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Anatomy Review Session

Anatomy Review Session. Summer 2009. Approach to Anatomy. Osteology Arthrology Nerves Vessels Approaches Questions. References. Miller Self assessment exams OITE References Primary articles Hoppenfeld. Upper extremity Shoulder Arm Forearm Wrist Spine. Lower extremity Hip

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Anatomy Review Session

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  1. Anatomy Review Session Summer 2009

  2. Approach to Anatomy • Osteology • Arthrology • Nerves • Vessels • Approaches • Questions

  3. References • Miller • Self assessment exams • OITE References • Primary articles • Hoppenfeld

  4. Upper extremity Shoulder Arm Forearm Wrist Spine Lower extremity Hip Thigh Knee and leg Ankle and foot Format

  5. Shoulder

  6. Osteology • Clavicle • First bone to ossify (5 weeks) • Last to fuse (medial epiphysis at 25 years old) • Fracture of clavicle  most common birth injury

  7. Osteology • Scapula • Glenoid retroverted 5 degrees • Humerus retroverted 30 degrees • Attachments: 17 muscles, 4 ligaments

  8. Coracoid • Coracoid attachments • Coracoacromial ligament • Coracoclavicular ligs • Conoid (medial) • Trapezoid (lateral) • Conjoined tendon • Coracobrachialis • Short head of biceps • Pec Minor

  9. Notches • Suprascapular notch • Superior transverse scapular ligament • Nerve below • Artery above • Spinoglenoid notch • Inferior transverse scapular ligament • Nerve and artery below ** Compression (ganglion/cyst) = infraspinatus atrophy

  10. Arthrology • Glenohumeral joint • Key stabilizers

  11. Static Articular anatomy Glenoid Labrum Negative Pressure Capsule Ligaments Dynamic Rotator cuff Biceps tendon Scapulothoracic motion Static/Dynamic restraints

  12. Arthrology • Acromioclavicular joint • Incomplete intra-articular disc (arthritis) • AC ligaments provide A-P stability • CC ligaments provide sup-inf stability • Sternoclavicular joint • Complete intra-articular disc • Rotates 30 deg w/shoulder flexion

  13. Arthrology • Scapulothoracic joint • 2:1 ratio of GH:ST motion • Coracoacromial ligament – superior-anterior restraint in rotator cuff deficient shoulder • Acromial branch of thoracoacromial artery runs on the medial aspect of the CA lig (caution during subacromial decompression)

  14. Muscles • Greater tuberosity • Supraspinatus (ant) • Infraspinatus (mid) • Teres minor (post) • Lesser tuberosity • Subscapularis • IR stronger than ER • Posterior shoulder dislocations occur with seizures/electrical shock

  15. Brachial Plexus • Ventral rami C5-T1 • Under clavicle between scalenus anterior and scalenus medius • Roots (5) / Trunks (3) / Divisions (6) / Cords (3) / Branches (“Ron Taylor Drinks Cold Beer”) • 4 preclavicular branches • Dorsal Scapular nerve • Long Thoracic nerve • Suprascapular nerve • Nerve to the subclavius

  16. Brachial Plexus

  17. Cord terminations • Lateral • Musculocutaneous • Posterior • Radial and axillary nerve • Medial • Ulnar nerve • Medial and Lateral • Median nerve

  18. Brachial Plexus Palsies • Erb-Duchenne Palsy • Roots C5-6 • Deficit: Deltoid, RTC, elbow flexors, wrist/hand extensors (“Waiter’s tip”) • Klumpke Palsy • Roots C8-T1 • Deficit: Wrist flexors/intrinsic Horner’s syndrome • Total plexus • C5-T1 • Deficit: flaccid arm

  19. Scapular winging • Scapular trapezius winging (lateral) • Injury to the spinal accessory nerve • Shoulder depression, scapular translation laterally • Inferior angle rotated laterally due to unopposed pull of serratus anterior • Serratus anterior scapular winging (medial) • Injury to the long thoracic nerve • Shoulder elevation, scapular translation medially • Inferior angle rotated medially

  20. Axillary artery • 3 parts based on relationship to pec minor

  21. Axillary artery • Part 1 • Supreme thoracic- medial • Part 2 • Thoracoacromial (four branches) • deltoid, acromial (SAD at CA lig), pectoral, clavicular • Lateral thoracic • Part 3 (Most vulnerable to traumatic injury) • Subscapular (2 branches) • Thoracodorsal • Circumflex scapular triangular space • Anterior humeral circumflex: main supply to humeral head • Posterior humeral circumflex – with axillary nerve in quadrangular space

  22. Axillary Artery

  23. Shoulder Approaches • Anterior approach • Deltopectoral (Interval: Axillary nerve and Med/Lat Pectoral nerves) • Axillary nerve along inferior border of subscap • Musculocutaneous nerve: 5-8cm below coracoid – terminal branch is lateral antebrachial cutaneous • Adduction/ER of arm protects axillary nerve • Lateral approach • Deltoid split • Axillary nerve is 5 cm below tip of acromion

  24. Shoulder Approaches • Posterior approach • Between infraspinatus (suprascapular n.) and teres minor (axillary n.) • Quadrangular space • Axillary nerve, posterior humeral circumflex artery • Triangular space • Circumflex scapular artery • Triangular interval • Radial nerve, Profunda Brachii artery

  25. Axillary nerve Post humeral circumflex artery Circumflex scapular artery Radial nerve Profunda Brachii artery

  26. Elbow

  27. Osteology • Spiral groove 13cm above articular surface of trochlea • Normal carrying angle of elbow • 7 degrees valgus • Maximal distension of capsule at 70-80 deg flexion

  28. Coranoid attachments • Anterior bundle of MCL (18mm distal to tip) • Brachialis (11mm distal to tip) • Anterior capsule (6mm distal to tip) • Coranoid is intra-articular

  29. Elbow ligaments • MCL • Anteroinferior portion of medial epicondyle to sublime tubercle • Anterior bundle: most important in resisting valgus force • **Valgus stability w/arm pronated = intact anterior bundle of MCL • LCL: most important is the LUCL • Deficiency = posterolateral rotatory instability • From lateral epicondyle to ulna crista supinatoris

  30. Elbow Ligaments LATERAL MEDIAL

  31. Nerves • Musculocutaneous – pierces CB 5-8cm below insertion, LABC • Radial – 21cm from medial epicondyle and 14cm from lateral • Found at the BR/ brachial interval • Dual innervation to brachialis (MC/radial) • Median – crosses lateral to medial over brachial artery, no branches in the arm • Ulnar- no branches to arm

  32. Surgical Approaches • Anterolateral approach to humerus: splits brachialis • Dual innervation (Radial and MC) • Radial n. (Brachialis and BR interval) • Kocher approach • Ancones (radial n.) and ECU (PIN) • Pronate arm to protect PIN • 38mm in pronation / 22mm in supination

  33. Elbow arthroscopy • Direct lateral portal • “soft spot” in triangle (joint insufflation) • Anterolateral portal • 2-3cm distal to lateral epicondyle and 1cm anteriorly • WATCH FOR RADIAL NERVE/PIN • Medial portal • 2cm distal and 2cm anterior to medial epicondyle • WATCH FOR MEDIAL ANTEBRACHIAL CUTANEOUS NERVE • Posterior portal • 3cm prox to tip of olecranon and 2cm lateral • Pohling portals • 2cm proximal and anterior to medial epicondyle (anterior to septum)

  34. FOREARM

  35. Osteology/Arthrology • Radius is convex laterally • Restoration of radial bow important in ORIF of shaft fractures • DRUJ most stable in supination • Volar wrist ligaments stronger than dorsal • Radial styloid and radial tuberosity are 180 deg rotated from one another

  36. TFCC • TFCC • Dorsal and volar radioulnar ligaments • Articular disc • Meniscal homologue • UCL (ulnolunate/ulnotriquetral) • ECU

  37. Radial nerve • Between BR and brachialis • Supplies BR, ECRL, ECRB (mobile wad) • PIN supplies the rest • Order of reinnervation • Supinator, ECU, EDC, EDM, APL, EPL, EPB, EIP last to return w/PIN palsy (most distally innervated) • Wartenberg’s syndrome – pain from radial sensory nerve entrapment at wrist • Superficial radial nerve: between BR & ECRL

  38. PIN compression • Potential sites of PIN compression (FREAS) • Fibrous bands • Recurrent leash of Henry • ECRB (site of tennis elbow) • Arcade of Frohse (proximal edge supinator) • Supinator distal margin

  39. Median nerve • Splits two heads of the pronator teres • Runs between FDS and FDP • Supplies PT, FCR, PL, FDS, thenars, FPB (supinator head), 1st and 2nd lumbrical

  40. AIN • Runs between FPL and FDP • Supplies PQ, FPL and FDP to index and long

  41. AIN compression • Potential sites of AIN Compression • Deep head of PT • FDS • Aberrant vessels • Gantzer’s muscle (accessory FPL)

  42. Ulnar nerve • Cubital tunnel (ulnar groove, fascial arch, muscles of FCU) • Between FCU and FDP (supplies ulnar ½) • Distally at Guyon’s—more superficial • Supplies FCU, ulnar ½ of FDP, hypothenars, 3rd and 4th lumbrical, deep head of FPB

  43. Ulnar nerve compression • Potential sites of ulnar nerve compression • Arcade of Struthers • band from medial head of triceps to medial IM septum8cm prox to med epicondyle • Medial IM septum • Medial epicondyle • Cubital tunnel • Proximal edge of FCU (Osborne’s fascia) • Deep flexor pronator aponeurosis

  44. Cutaneous nerves • LABC – continuation of musculocutaneous nerve, lateral to bicep at elbow • MABC – arises from medial cord, crosses 6cm proximal to 4cm distal from medial epicondyle • PABC – arises from radial nerve, crosses from posterior to anterior compartment

  45. Nerves splitting muscles • PIN splits supinator • Median nerve splits pronator teres • Ulnar nerve splits FCU

  46. Nerve anastomoses • Martin-Gruber anastomosis • Between median and ulnar nerve in forearm • Riches-Cannieu anastomosis • Between ulnar and median nerve in the palm

  47. Vessels • Radial artery • Splits at level of radial neck • Between BR and PT proximally and between BR and FCR distally • Ulnar artery • Between FDS and FDP proximally • On FDP between FDS and FCU distally

  48. Forearm approaches • Henry (anterior) • BR (radial n.) and PT (median n.) proximally • BR and FCR (median n.) distally • Elevate PQ off radius • Thompson (dorsal) • ECRB (radial n.) and EDC (PIN) proximally • ECRB and EPL (PIN) distally • Excessive retraction of the supinator can injure PIN

  49. Wrist and Hand

  50. Osteology • Carpal bones • Ossification begins at capitate (1 year of age) and runs counterclockwise • Pisiform (9 years) **Last to ossify

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