Bones of Upper Limb

• Appendicular Skeleton• Pectoral Girdle =

scapula,clavicle• Upperlimb – Arm: humerus– Forearm: radius, ulna• Interosseus membrane

– Hand: carpals, metacarpals, phalanges

Joints of Upper Extremity• Sternoclavicular– Synovial of saddle– Diarthrosis

• Acromioclavicular– Synovialof plane– Diarthrosis

• Shoulder joint (Glenohumeral j )– Synovial of ball&socket– Many ligaments– Muscle reinforcement– Great Mobility !

Joints of the Upper Limb• Elbow Joint :

Synovial of hinge

• Articulations–Humerus with

Ulna & Radius

• Collateral Ligaments

Joints of Upper Limb

• Sup.Radioulnar joint– Synovial of pivot

• Inf. Radioulnar joint– Synovial – pivot

• Allows pronation and supination of forearm

Joints of the Upper Limb

• Radiocarpal joint– Synovial of condyloid– Distal radius with

scaphoid and Lunate• Intercarpal joints– Synovial of plane

• Carpometacarpal (2-5)– Synovial of plane

• Trapezium-metacarpal 1– Synovial of saddle

• Metacarpo-phalangeal– Synovial of condyloid

• Interphalangeal– Synovial of hinge

Review of Naming

• Naming–Flexor carpi ulnaris–Flexor digitorum superficialis–Flexor pollicis longus–Pronator quadratus–Extensor carpi radialis brevis

What do the following names TELL you about the muscle?

Muscles of Scapula

• If ORIGIN on scapula = Move Arm– Subscapularis– Supraspinatus– Infraspinatus– Teres Minor– Teres Major– Latissimus Dorsi (partial O on scap)– Coracobrachialis

• If INSERTION on scapula = Move If INSERTION on scapula = Move • scapulascapula– Rhomboids– Trapezius– Pectoralis Minor– Serratus Ventralis– Levator Scapulae

Rotator Cuff

Nerve supply of Scapula Muscles• Origin on Scapula:– Latissimus dorsi = Thoracodorsal nerve– Subscapularis, Teres Major = Subscapular nerves– Supraspinatus, Infraspinatus = Suprascapular nerves– Teres Minor = Axillary nerve

• Insertion on Scapula– Levator Scapular, Rhomboids = Dorsal Scapular nerve– Pectoralis Minor = Pectoral n.– Serratus Ventralis = Long Thoracic n.– Trapezius = Accessory n.

Muscles of Arm: Cross elbow, Move forearm• 2 Compartments

– Anterior: Flexors of forearm– Posterior: Extensors of forearm

• Anterior Compartment– Biceps brachii = MC nerve– Brachialis = MC nerve– Brachioradialis = Radial nerve

• Coracobrachialis = MC nerve– O = coracoid process of scapula– I = medial side humeral shaft– A = flex, adduct arm

• Posterior Compartment– Triceps brachii = Radial nerve– Anconeus = Radial nerve

N.B. MC = musclocutaneous nerve

Muscles of forearm: Cross wrist & finger joints, flexes hand &

fingers• Cross Wrist = flex, extend, abduct, adduct hand• Cross Fingers = flex, extend fingers• Most muscles fleshy proximally, long tendons distally• Flexor + Extensor Retinacula :– The retinaculum is a thick band of deep fascia has bony

attachment ; it keeps tendons in position during movements– Under the retinaculum, tendons are surrounded by synovial

sheathes

Compartments of the forearm : 1.Anterior Flexor Compartment : (Superficial + Deep layers)Most of superficial flexors originate by a common origin from medial epicondyleContains 2 pronators, are supplied by Median and Ulnar nerves2.Posterior Extensor Compartment : (Superficial + Deep layers) Are supplied by Radial and post. Interosseus nerves

Anterior Compartment of Forearm s

• Superficial Muscles– Flexor digitorum superficialis Median– Flexor carpi radialis Median– Pronator teres Median– Palmaris longus Median– Flexor carpi ulnaris Ulnar

• Deep Muscles– Pronator quadratus Median– Flexor pollicis longus Median– Flexor digitorum profundus Ulnar (med 1/2)

Median (lat 1/2)

Muscle Nerve

Anterior Compartment Forearm

Flexor Carpi Radialis

Flexor Retinaculum

Medial Epicondyle

Flexor Digitorum Superficialis is deep to other flexors

Flexor Carpi Ulnaris

BrachioradialisPronator Teres

Anterior View

Posterior Compartment of Forearm

• Superficial– Extensor carpi radialis longus Radial– Extensor digitorum Radial– Extensor carpi ulnaris Radial

• Deep– Supinator Radial– Abductor pollicis longus Radial– Extensor pollicis longus + brevis Radial– Extensor indicus Radial

Muscle Nerve

Posterior Compartment of Forearm

Extensor digitorum

Extensor carpi ulnaris Ext Carpi Radialis Longus

Brachioradialis

Lateral Epicondyle

Posterior View

Muscles of Hand

• Pinky (little finger)– All digiti minimi Ulnar

(Flexor, Abductor, Opponens)

• Thumb– Abductor pollicis brevis Median– Flexor pollicis brevis Median– Opponens pollicis Median– Adductor pollicis Ulnar

• Other Intrinsic Muscles– Palmar & Dorsal Interossei Ulnar– 4 Lumbricals Median, Ulnar

Muscle Nerve

Muscles of Hand

ABduction

Palmar Interossei

Lumbricals

ADDuction

1st

2nd

3rd

4th

Dorsal Interossei

Interossei help the lumbricals to extend I P joints and flex MC-P joints

Blood Supply of U.L: 1. The Veins

•Cephalic (arm-forearm)•Basilic (arm-forearm)

•Median Cubital (elbow)•Median Vein

•SF. Palmar Venous Arch•Digital

SUPERFICIAL

•Subclavian (neck)•Axillary (axilla)

•Brachial (arm-elbow)

•Radial (forearm)•Ulnar (forearm)•Deep Palmous Venous arch

DEEP

Blood Supply of the U.L: 2.Arteries• Subclavian A (neck)• Axillary A (armpit)– Subscapular A

• Brachial A (arm)– Deep brachial

• Radial A (forearm)• Ulnar A (forearm)

Common Interosseous A

• Superficial & Deep Palmar arches

Axilla = Armpit• Region between arm and chest• Boundaries– Ventral - pectoral muscles– Dorsal = latissimus dorsi, teres major

subscapularis– Medial = serratus ventralis– Lateral = bicipital groove of humerus

• Contents– Axillary lymph nodes, Axillary vessels

Brachial Plexus

The Axilla

Surface Anatomy of Upper Limb• Biceps + Triceps brachii• Olecrenon Process• Medial Epicondyle• 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 Upper Limb

• 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• Network of nerves starts in

in the neck, then to the axilla

• Is motor to muscles of upper limb except trapezius

• Sensory to skin of U.L except tip of shoulder & upper part of skin covers deltoid.

• Root value : C5,6,7,8,T1

Where Ventral Rami Come FromDorsal Root

Ventral Root

spinal nerve

Dorsal Ramus of spinal nerve

Ventral Ramus of spinal nerve

Structure of the Spinal nerve

Parts of Brachial Plexus

• Really Tired? Drink Coffee Buddy!

• R = ROOTS (ventral rami)• T = TRUNKS• D = DIVISIONS• C = CORDS• B = BRANCHES

Roots 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 AnteriorPosterior

• Middle Anterior

Posterior

• Lower Anterior Posterior

Divisions Join to form Cords! (in axilla)

U A P

M A P

L A P POSTERIOR CORD

LATERAL CORD

MEDIAL CORD

Trunks Divisions Cords

Cords Give off Branches!! (in axilla)

• Lateral Musculocutaneous

Median

• Medial Ulnar

• Posterior RadialAxillary(thoracodorsal)(subscapular)

Parts of the brachial plexus…..

Injury of the brachial plexus

Branches of the Posterior Cord• Radial Nerve : • ( is the largest branch of the post. cord) – Course: Through arm, spiral groove of the humerus, then in

front of lat. epicondyle, then divides :– Divides in the forearm to give : • Superficial = skin of arm and dorsolateral surface of hand• Deep ( post interosseus nerve ) = extensor muscles of

forearm (eg E. carpi radialis L , B., …)

– Innervates: posterior muscles of arm Triceps brachii, anconeus, supinator, brachioradialis

– Sensory :……, skin of back

The Radial nerve• 1.from post. cord• 2.artificai triangular

space• 3.spiral groove• 4.pireces lat. I.M.S• 5.in front of lat.

epicondyle, and divides into : ……..

Damage to Radial Nerve = wrist dropInability to extend the hand

Branches of the Posterior Cord (continued)

• Axillary Nerve ( w . Circumflex vs..)– Supplies: • Deltoid and Teres minor (motor supply )• Capsule of shoulder• skin of lower part covering deltoid (sensory supply)

• Subscapular Nerves {branches of C5 + C6 rami}

– Innervates: Subscapularis, Teres major

• Thoracodorsal Nerve (runs w. thoracodorsal vs) supplies: Latissimus dorsi

The brachial plexus

The Lateral Cord gives :• .Lat. Root of median nerve• .Lat.pectoral nerve• Musculocutaneous :–Course: branches to arm, distal to

elbow becomes cutaneous :sensory to skin of lateral side of forearm .–Motor :• Biceps brachii, brachialis, coracobrachialis

The Median nerve• The Median nerve : is formed by 2 roots :…..– Course: middle of brachial plexus, distal to elbow provides

many branches to most forearm flexors, passes through carpal tunnel to hand to lateral palmar intrinsics

– Motor supply to: most muscles of anterior of the forearm flexors

thenar eminence (thumb), lat.2 Lumbrichals

– Sensory : skin of lateral 2/3 of palm ,lat. Three & half fingers to back of middle phalanges

– Nerve Damage = “Ape” Hand• Inability to Oppose Thumb

The median nerve

The median nerve : C5,6,7,8,T1

.Is formed by 2 roots

.Has 3 relations w. brachial A

.Enters forearm by piercing pronator teres( supplies it 1st )

.Enters hand deep to flexor retinaculum ( Carpal tunnel )

. In the it gives deep & superficial branches

The median nerve

Branches of the Medial Cord : 5 • The Ulnar nerve :– Course: runs along medial side of arm, behind medial

epicondyle ( site of its injury )– Enters the hand :superficial to flexor retinaculum .

– Supplies : • Motor :FCU and medial part of FDP (in forearm1 1/2) Ms. Of hand except 5• Skin of medial 1/3 of hand Ant +Post + medial one &

half fingers• Nerve Damage: Partial Claw hand• Inability to extend fingers at interphalangeal joints,

results in permanent flexion = claw

The Ulnar nerve C7,8,T1

Ulnar nerve injury : Partial Claw hand

Dermatomal supply of the hand