The Upper Extremity Lecture Presentation

The Upper Extremity
Bones, Muscles, Vessels,
Bones

• 30 bones!!!!
• Appendicular skeleton
• Pectoral girdle
• Glenoid cavity
• Allows for mobility
• Attachments
• Upper extremity:
• Arm
• humerus
• Forearm
• Radius, ulna (interosseous membrane)
• Hand
• Carpals, metacarpals, phalanges
• Review bones and landmarks studied in lab!!!

Joints of Upper Extremity

• Sternoclavicular
• Synovial-saddle
• Diarthrosis
• Acromioclavicular
• Synovial-plane
• Diarthrosis
• Glenohumeral joint
• Synovial-ball&socket
• Diarthrosis
• Many ligaments
• Muscle reinforcement
• Great Mobility

Joints of the Upper Extremity

• Elbow Joint
• Synovial – hinge
• Diarthrosis
• Articulations
• Humerus & Ulna
• Humerus & Radius
• Many Ligaments

Joints of Upper Extremity

• Proximal Radioulnar joint
• Synovial -  pivot
• Diarthrosis
• Distal Radioulnar joint
• Synovial – pivot
• Diarthrosis
• Allows pronation and supination of forearm

Joints of the Upper Extremity

• Radiocarpal joint
• Synovial-condyloid
• Distal radius with proximal row of carpals
• Intercarpal joints
• Synovial-plane
• Carpal-metacarpal (2-5)
• Synovial-plane
• Trapezium-metacarpal 1
• Synovial-saddle
• Metacarpal-phalangeal
• Synovial-condyloid
• Interphalangeal
• Synovial-hinge
• ALL DIARTHROSES

Review of Naming…..

• What do the following names TELL you about the muscle?
• Naming
• Flexor carpi ulnaris
• Flexor digitorum superficialis
• Flexor pollicis longus
• Pronator quadratus
• Extensor carpi radialis brevis

Scapula Muscles

• If the origin is on the scapula – moves the arm
• Subscapularis
• Supraspinatus
• Infraspinatus
• Teres Minor
• Teres Major
• Latissimus Dorsi (partial attachment)
• Coracobrachialis

Scapula Muscles

• If the insertion is on the scapula – moves the scapula
• Rhomboids
• Trapezius
• Pectoralis Minor
• Serratus Ventralis
• Levator Scapulae

Innervation of Muscles Moving Arm

Muscle		Innervation
Subscapularis Teres Major		Subscapular  N.
Infraspinatus Supraspinatus		Suprascapular N.
Teres Minor		Axillary N.
Coracobrachialis		Musculocutaneous N.

Arm Muscles

• Arm Compartments
• Anterior Compartment (3 muscles)
• Flexors of forearm and arm
• Posterior Compartment (1 muscle)
• Extensor of forearm and arm

Arm Muscles

• Anterior compartment
• Brachialis
• Coracobrachialis
• Biceps brachii
• Long head
• Short head

Arm Muscles

• Posterior compartment
• Triceps brachii
• Long head
• Medial head
• Lateral head

Forearm Muscles

• Cross elbow, wrist and finger joints
• Movement of hand and fingers
• Proximally are fleshy
• Distally have long tendons
• Flexor and extensor retinacula
• “wristbands”
• Keep tendons from jumping outwards when tensed

Forearm Muscles

• Anterior compartment
• Superficial and Deep layers
• Flexors of hand and fingers
• Most flexors have common origin on medial epicondyle
• Contains 2 pronator muscles
• Posterior compartment
• Superficial and Deep layers
• Extensors of hand and fingers
• Most extensors have common origin on lateral epicondyle
• Contains a supinator muscle

Anterior Compartment of Forearm
Muscles                                                                         Nerves

•       Superficial
• Flexor digitorum superficialis                 Median
• Flexor carpi radialis                                          Median
• Pronator teres                                       Median
• Palmaris longus                                     Median
• Flexor carpi ulnaris                                           Ulnar
•       Deep
• Pronator quadratus                                           Median
• Flexor pollicis longus                             Median
• Flexor digitorum profundus                   Ulnar (med 1/2)                                                                                    Median (lat 1/2)

Posterior Compartment of Forearm
Muscles                                                                                         Nerves

• Superficial
• Brachioradialis                                      Radial
• Anconeus                                                         Radial
• Extensor carpi radialis longus & brevis              Radial
• Extensor digitorum                                            Radial
• Extensor carpi ulnaris                            Radial
• Extensor digiti minimi                            Radial
• Deep
• Supinator                                                          Radial
• Abductor pollicis longus                                    Radial
• Extensor pollicis longus + brevis                        Radial
• Extensor indicus                                                Radial

Hand Bonesac

• Carpus (8)
• “True” wrist
• Distal to radius/ulna
• Metacarpus (5)
• Distal to carpus
• Phalanges (14)
• Distal to metacarpus

Intrinsic  Muscles of the Hand
Muscle                                                 Nerve

• Pinky = Hypothenar muscles
• All digiti minimi                                     Ulnar                            (Flexor, Abductor, Opponens)
• Thumb = Thenar muscles
• Abductor pollicis brevis                                    Median
• Flexor pollicis brevis                                         Median
• Opponens pollicis                                              Median
• Adductor pollicis                                              Ulnar
• Other Intrinsic Muscles
• Palmar + Dorsal Interossei                                Ulnar
• Lumbricals                                                        Median, Ulnar

Blood Supply - Arteries

• Subclavian (neck)
• Axillary (armpit)
• Subscapular
• Circumflex humeral arteries
• Brachial (arm)
• Deep brachial
• Radial (forearm)
• Ulnar (forearm)
• Common Interosseous
• Superficial & Deep Palmar arches
• Digital

Blood Supply - Veins

• Deep veins
• Deep palmar venous arches
• Radial - forearm
• Ulnar - forearm
• Brachial – arm/elbow
• Axillary – axilla
• Subclavian - neck

• Superficial Veins
• Digital
• Superficial palmar venous arches
• Median – forearm
• Median cubital – elbow
• Blood draws!!
• Cephalic – arm/forearm
• Basilic – arm/forearm

Axilla

• Armpit!!
• Boundaries
• Ventral
• Pectoral muscles
• Dorsal
• Latissimus dorsi, teres major, subscapularis
• Medial
• Serratus ventralis
• Lateral
• Intertubercular (Bicipital) groove of humerus
• Contents
• axillary lymph nodes, axillary vessels, brachial plexus

Surface Anatomy of Arm

• Cephalic Vein
• Biceps brachii
• Triceps brachii
• Olecrenon Process
• Medial Epicondyle
• Lateral Epicondyle

Surface Anatomy of Elbow

• Cubital Fossa
• Anterior surface elbow
• Contents          
• Median Cubital Vein
• Brachial Artery
• Median Nerve
• Boundaries
• Medial= Pronator teres
• Lateral= Brachioradialis
• Superior= Line between epicondyles

Surface Anatomy of Hand

• Carpal Tunnel
• Carpals concave anteriorly
• Carpal ligament covers it
• Contains: long tendons, Median nerve
• Inflammation of tendons = compression of Median nerve
• Anatomical Snuffbox
• Lateral = E.pollicis brevis
• Medial = E. pollicis longus
• Floor = scaphoid, styloid of radius
• Contains Radial Artery (pulse)

Brachial Plexus

• Nerve plexus
• Lies partly in neck and partly in axilla
• Gives rise to almost all nerves that supply upper limb
• Formed by intermixing of ventral rami of spinal nerves C5-C8 and T1

Brachial Plexus

• Really Tired? Drink Coffee Buddy!

• R = RAMI (ventral) (5)
• T = TRUNKS (3)
• D = DIVISIONS (2)
• C = CORDS (3)
• B = BRANCHES (Many!!)

Rami join to form Trunks! (in neck)
Ventral Rami                                Trunks

• C5                                           Upper Trunk
• C6

• C7                                           Middle Trunk

• C8
• T1                                            Lower Trunk

Trunks Split to form Divisions! (in neck)
Trunks                                            Divisions

• Upper                                      Anterior                                                                                                                        Posterior

• Middle                         Anterior                                                                                                                        Posterior

• Lower                                      Anterior                                                                                                                        Posterior

Divisions Join to form Cords! (in axilla)
Trunks       Division                               Cords
U                                 A                                             Lateral
P
M                                 A                                             Medial
P
L                                  A                                             Posterior
P
Cords Give off Branches!! (in axilla)

• Lateral                                      Musculocutaneous                                                                                                                                                                              

                                                                          Median

• Medial                                                     Ulnar

• Posterior                                                  Radial                                                                                                                           Axillary                                                                                                                 Thoracodorsal                                                                                                               Subscapulars

Lateral Cord

• Musculocutaneous nerve
• Off lateral cord
• Course:
• Anterior arm
• Becomes cutaneous and gives skin sensation to lateral forearm
• Innervates:
• Corocobrachialis (motor)
• Biceps brachii (motor)
• Brachialis (motor)
• Skin distal to the elbow (sensory)

Medial Cord

• Ulnar nerve
• Course:
• Comes off medial cord
• Descends along medial side of arm
• Passes posterior to medial epicondyle
• Follows the ulna
• Superficial to carpal tunnel into hand
• Branches to supply intrinsics and skin
• Innervates:
• Flexor carpi ulnaris (motor)
• Flexor digitorum profundus (motor)
• Most intrinsic hand muscles (motor)
• Dorsal branch supplies skin of medial 2/3 of hand (sensory)

Both Medial and Lateral Cords

• Median nerve
• Course:
• Middle of brachial plexus (from lateral and medial cords)
• Does not branch in arm
• Distal to elbow provides many branches to most forearm flexors
• Passes through carpal tunnel to hand to lateral palmar intrinsics
• Innervates:
• Anterior forearm (motor)
• Most flexors, some intrinsics (thumb)
• 2/3 Lateral palm (sensory)
• Dorsum of fingers 2 and 3 (sensory)

Posterior Cord

• Radial nerve
• Largest branch of brachial plexus
• Comes from posterior cord
• Course:
• Through arm
• Around humerus
• Around lateral epicondyle (then divides)
• Innervates:
• Posterior muscles of arm and forearm
• Triceps brachii, anconeus, brachioradialis
• Divides in forearm:
• Superficial
• Skin of arm and dorsolateral surface of hand
• Deep
• Supinator & Extensor muscles of forearm (eg ext. carpi radialis L + B)

Posterior Cord (continued)

• Axillary nerve
• Branches off posterior cord
• Course:
• Runs posterior to humerus
• Runs with caudal humeral circumflex artery
• Innervates:
• Deltoid and teres minor (motor)
• Capsule of shoulder, skin of shoulder (sensory)
• Subscapular nerve
• Innervates:
• Subscapularis, Teres major
• Thoracodorsal nerve
• Course:
• Runs with thoracodorsal artery and vein
• Innervates:
• Latissimus dorsi

Nerve Damage

• Ulnar nerve
• “Claw hand”
• Inability to extend fingers at interphalangeal joints, results in permanent flexion of hand = claw
• Median nerve
• “Ape hand”
• Inability to oppose thumb
• Radial nerve
• “Wrist drop”
• Inability to extend the hand, inability to fully extend forearm

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