The Extremities

8/14/2019 The Extremities

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The ExtremitiesThe ExtremitiesUpper and Lower ExtremitiesUpper and Lower ExtremitiesBy Bien Eli Nillos, MDBy Bien Eli Nillos, MD


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THE SCAPULATHE SCAPULA


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TRIANGLE OF AUSCULTATIONTRIANGLE OF AUSCULTATION

On the medial back, it is an area ofOn the medial back, it is an area of

little muscle and hence a good placelittle muscle and hence a good place

to listen to the lungs.to listen to the lungs.

Medial Border: Trapezius muscleMedial Border: Trapezius muscle

Lateral Border: Teres Major, laterallyLateral Border: Teres Major, laterally

and deep.and deep.

Inferior Border (base): Latissimus DorsiInferior Border (base): Latissimus Dorsi


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TRIANGULAR SPACETRIANGULAR SPACE

Anterior aspect, medial to the neck ofAnterior aspect, medial to the neck of

the humerus.the humerus. Lateral border: Long head of the triceps.Lateral border: Long head of the triceps.

Upper border: Teres MinorUpper border: Teres Minor

Lower border: Teres MajorLower border: Teres Major

CONTENTS: Circumflex ScapularCONTENTS: Circumflex Scapular

Branch of the subscapular artery.Branch of the subscapular artery.


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From top to bottom, order of theFrom top to bottom, order of the

Scapular MusclesScapular Muscles SupraspinatusSupraspinatus

InfraspinatusInfraspinatus

Teres MinorTeres Minor

Teres MajorTeres Major


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WINGED SCAPULA:WINGED SCAPULA:Both the SerratusBoth the SerratusAnterior andAnterior andRhomboids insertRhomboids insert

on the medialon the medialaspect of theaspect of thescapula. If you losescapula. If you losethis insertion, youthis insertion, youcan get wingedcan get winged

scapula, where thescapula, where thescapula does notscapula does notstay in place and isstay in place and israised a bit fromraised a bit fromthe posterior wall.the posterior wall.


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GLENOHUMERAL JOINTGLENOHUMERAL JOINT

ROTATOR CUFF: The tendons of theROTATOR CUFF: The tendons of the

muscles surrounding the shouldermuscles surrounding the shoulder

joint. They rotate the shoulder.joint. They rotate the shoulder. Anterior Border:Anterior Border: SubscapularisSubscapularis

Superolateral Border: Head of the bicepsSuperolateral Border: Head of the biceps

Posterior Border:Posterior Border: Infraspinatus andInfraspinatus and

Teres MinorTeres Minor Superior Border:Superior Border: SupraspinatusSupraspinatus


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The joint is covered on all sides exceptThe joint is covered on all sides exceptinferiorly. Hence shoulder dislocations tendinferiorly. Hence shoulder dislocations tendto occur inferiorly.to occur inferiorly.

In this case you have to watch forIn this case you have to watch for damagedamageto the axillary nerve and Posteriorto the axillary nerve and PosteriorCircumflex Humeral ArteryCircumflex Humeral Artery, both of which, both of whichare directly inferior, in the Quadrangularare directly inferior, in the QuadrangularSpace, because this is straight below theSpace, because this is straight below theshoulder joint.shoulder joint.

TEST for Axillary Nerve damage: CutaneousTEST for Axillary Nerve damage: Cutaneoussensation in the Deltoid regionsensation in the Deltoid region


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Deltoid MuscleDeltoid Muscle

It inserts onIt inserts on

the Deltoidthe Deltoid

TuberosityTuberosity

of theof thehumerushumerus

and hasand has

multiplemultipleactionsactions


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Anterior partAnterior part flexes and mediallyflexes and medially

rotates the arm.rotates the arm.

Posterior partPosterior part extends and laterallyextends and laterally

rotates the arm.rotates the arm.

Lateral fibersLateral fibers abduct the arm.abduct the arm.


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PECTORALIS MAJORPECTORALIS MAJOR

ClavicularClavicular

Head: It flexesHead: It flexes

the arm.the arm.

SternocostalSternocostal

Head: ItHead: It

extends theextends the

arm.arm.


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THE AXILLATHE AXILLA


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Anterior Border:Anterior Border: The pectoralis major and minor,The pectoralis major and minor,and the subclavius, plus investing fasciaand the subclavius, plus investing fascia(Clavipectoral fascia).(Clavipectoral fascia).

Base of the Axilla:Base of the Axilla: The skin of the armpit,The skin of the armpit,

superficial fascia.superficial fascia. Apex of the AxillaApex of the Axilla: The root of the neck, through: The root of the neck, through

which the brachial plexus of nerves and vesselswhich the brachial plexus of nerves and vesselstravels.travels.

Medial BorderMedial Border: Serratus Anterior and intercostal: Serratus Anterior and intercostalmuscles.muscles.

Posterior BorderPosterior Border: Subscapularis, Latissimus: Subscapularis, LatissimusDorsi, and Teres Minor.Dorsi, and Teres Minor.


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CONTENTS:CONTENTS:The axillary arteryThe axillary artery

The axillary veinThe axillary vein

The Brachial PlexusThe Brachial Plexus

The Axillary group of lymph nodesThe Axillary group of lymph nodes


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AXILLARY ARTERYAXILLARY ARTERY

1st Part of Axillary1st Part of Axillary

ArteryArtery: Above the: Above the

pectoralis minor. Haspectoralis minor. Has

1 branch.1 branch. Superior ThoracicSuperior Thoracic

ArteryArtery


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2nd Part of Axillary Artery2nd Part of Axillary Artery: Directly: Directly

deep to the Pectoralis Minor. Has 2deep to the Pectoralis Minor. Has 2

branches.branches.

Thoracoacromial Artery (pierces clavipectoralThoracoacromial Artery (pierces clavipectoralfascia)fascia)Deltoid Branch of ThoracoacromialDeltoid Branch of Thoracoacromial

Pectoralis Branch of Thoracoacromial.Pectoralis Branch of Thoracoacromial.

Lateral Thoracic Artery (aka ExternalLateral Thoracic Artery (aka External

Mammary Artery) -- important source ofMammary Artery) -- important source of

blood for mammary glands.blood for mammary glands.


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3rd Part of Axillary Artery: Below the pectoralis3rd Part of Axillary Artery: Below the pectoralis

minor. Has 3 branches.minor. Has 3 branches.

Anterior Circumflex Humeral ArteryAnterior Circumflex Humeral Artery Posterior Circumflex Humeral Artery -- passesPosterior Circumflex Humeral Artery -- passes

through Quadrangular space along with the axillarythrough Quadrangular space along with the axillary

nerve.nerve.

And anterior and posterior circumflex humerals anastomoseAnd anterior and posterior circumflex humerals anastomosewith each other around the lateral neck of the humerus.with each other around the lateral neck of the humerus.

The posterior circumflex also anastomoses with the deepThe posterior circumflex also anastomoses with the deep

brachial artery.brachial artery.

Subscapular Artery -- largest branch which suppliesSubscapular Artery -- largest branch which supplies

muscles of posterior wall (scapula)muscles of posterior wall (scapula)Circumflex Scapular Artery branches off and proceedsCircumflex Scapular Artery branches off and proceeds

posteriorly through the triangular space.posteriorly through the triangular space.

Thoracodorsal Artery travels along with thoracodorsalThoracodorsal Artery travels along with thoracodorsal

nerve.nerve.


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AXILLARY LYMPH NODESAXILLARY LYMPH NODES

Lateral Group:Lateral Group: Drains the upper limb. Located nearDrains the upper limb. Located nearbrachial artery.brachial artery.

Subscapular Group:Subscapular Group: Drains the scapular region andDrains the scapular region andposterior thoracic wall.posterior thoracic wall.

Pectoral Group:Pectoral Group: Drains the anterior thorax andDrains the anterior thorax andsome of mammary glands. Assoc. with lateralsome of mammary glands. Assoc. with lateralthoracic artery.thoracic artery.

CENTRAL GROUP:CENTRAL GROUP: It receives the lymph from theIt receives the lymph from theprevious three groups. It forms the largest group andprevious three groups. It forms the largest group and

is often palpable upon examination.is often palpable upon examination. APICAL GROUP:APICAL GROUP: The only one above the pectoralisThe only one above the pectoralis

minor. It receives lymph from the central group asminor. It receives lymph from the central group aswell as other locales, and dumps into the subclavianwell as other locales, and dumps into the subclaviantrunk.trunk.


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The ArmThe ArmUpper ExtremitiesUpper Extremities


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The HumerusThe Humerus

Radial Groove:Radial Groove:

The region of theThe region of the

humerus alonghumerus along

which the radialwhich the radialnerve travels, justnerve travels, just

posteroinferior toposteroinferior to

the Deltoidthe DeltoidTuberosityTuberosity


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CONTENTS ofCONTENTS ofRadial GrooveRadial Groove:: Radial NerveRadial Nerve

Deep Brachial ArteryDeep Brachial Artery

Surgical Neck of the HumerusSurgical Neck of the Humerus: The: The

Axillary Nerve wraps around theAxillary Nerve wraps around the

surgical neck of the humerus. Thussurgical neck of the humerus. Thus

injuries to the neck can damage thatinjuries to the neck can damage thatnervenerve


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Cutaneous Innervation of theCutaneous Innervation of the

ArmArm

Axillary NerveAxillary Nerve: Supplies the skin over the: Supplies the skin over the

deltoid muscle.deltoid muscle.

Radial NerveRadial Nerve: Posterior of arm and: Posterior of arm and

forearm.forearm.The lateral dorsal aspect of the hand (posteriorThe lateral dorsal aspect of the hand (posterior

of thumb and index finger up to the DIP joint).of thumb and index finger up to the DIP joint).

Medial Antebrachial Cutaneous NerveMedial Antebrachial Cutaneous Nerve::

Supplies much of the anterior skin of arm.Supplies much of the anterior skin of arm.


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ForearmForearm


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ANATOMICAL SNUFFBOXANATOMICAL SNUFFBOX

In between the Extensor Pollicis Longus andIn between the Extensor Pollicis Longus andExtensor Pollicis Brevis. The Abductor PollicisExtensor Pollicis Brevis. The Abductor PollicisLongus is directly lateral to it.Longus is directly lateral to it.

The Radial Nerve runs over the superficialThe Radial Nerve runs over the superficialpart of the anatomical snuffbox, to innervatepart of the anatomical snuffbox, to innervatethe lateral cutaneous hand.the lateral cutaneous hand.

The Radial Artery is the "floor" of theThe Radial Artery is the "floor" of the

snuffbox, snugged right on top of thesnuffbox, snugged right on top of theScaphoid bone.Scaphoid bone.


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THE HANDTHE HAND


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The bones of the Carpus consist of theThe bones of the Carpus consist of the

Scaphoid, Lunate, Triquetral, Pisiform,Scaphoid, Lunate, Triquetral, Pisiform,

Hamate, Capitate, Trapezoid, and theHamate, Capitate, Trapezoid, and the

Trapezium.Trapezium.


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A. LunateA. Lunate

Articulates with theArticulates with theTriquetral, Scaphoid,Triquetral, Scaphoid,Hamate, Capitate, andHamate, Capitate, andRadius.Radius.

B. TriquetralB. Triquetral

Articulates with theArticulates with theHamate, Lunate,Hamate, Lunate,Pisiform, and the Ulna.Pisiform, and the Ulna.

C. PisiformC. Pisiform

Articulates directly withArticulates directly withTriquetral bone, andTriquetral bone, andindirectly via cartilageindirectly via cartilagewith the Ulna.with the Ulna.


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D. HamateD. Hamate

Also known as the UnciformAlso known as the Unciformbone, it articulates with thebone, it articulates with thefourth an fifth metacarpalsfourth an fifth metacarpalsand the Triquetral.and the Triquetral.

E. CapitateE. Capitate

The largest bone of theThe largest bone of thewrist, it articulates with thewrist, it articulates with theTrapezoid, Hamate,Trapezoid, Hamate,Scaphoid, Lunate, and theScaphoid, Lunate, and thesecond, third and fourthsecond, third and fourthMetacarpals.Metacarpals.

F. TrapezoidF. Trapezoid

Articulates with the secondArticulates with the secondMetacarpal, Trapezium,Metacarpal, Trapezium,Capitate, and the Scaphoid.Capitate, and the Scaphoid.


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G. TrapeziumG. Trapezium

Articulates with theArticulates with thefirst and secondfirst and secondMetacarpal, Trapezoid,Metacarpal, Trapezoid,and the Scaphoid.and the Scaphoid.

H. ScaphoidH. Scaphoid

Articulates with theArticulates with the

Radius, Trapezius,Radius, Trapezius,Trapezoid, Capitate,Trapezoid, Capitate,and Lunate.and Lunate.

Metacarpals (Palm)Metacarpals (Palm)


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Metacarpals (Palm)Metacarpals (Palm)

The Metacarpals join the wrist with theThe Metacarpals join the wrist with thefingers. They are numbered 1 - 5fingers. They are numbered 1 - 5starting on the thumb side. Theystarting on the thumb side. Theyarticulate with the Proximal Phalangesarticulate with the Proximal Phalanges

and when you clench your fist, it is theand when you clench your fist, it is thehead of the Metacarpal that sticks outhead of the Metacarpal that sticks out(knuckles).(knuckles).

J. Proximal PhalangeJ. Proximal Phalange

This bone articulates with the MiddleThis bone articulates with the Middle

Phalange (Distal in the Pollex) and thePhalange (Distal in the Pollex) and theMetatarsal. It can be found at the startMetatarsal. It can be found at the startof our finger.of our finger.

K. Middle PhalangeK. Middle Phalange

The Middle Phalange can be found justThe Middle Phalange can be found just

below the Distal Phalange. Each fingerbelow the Distal Phalange. Each fingerhas one except the Pollex (thumb) whichhas one except the Pollex (thumb) whichonly has a distal and proximal.only has a distal and proximal.

L. Distal PhalangeL. Distal Phalange

The Distal Phalange is found at the endThe Distal Phalange is found at the end

of each finger.of each finger.


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Lab ExerciseLab Exercise

I. Tabulate all of the Muscles of theI. Tabulate all of the Muscles of the

Upper Extremities: Describe accordingUpper Extremities: Describe according

to ORIGIN, INSERTION, ACTION ANDto ORIGIN, INSERTION, ACTION AND

NERVE SUPPLYNERVE SUPPLY II. Draw the Antecubital Fossa, andII. Draw the Antecubital Fossa, and

label the BOUNDARIES. Describe thelabel the BOUNDARIES. Describe the

CONTENTS and their importance.CONTENTS and their importance.


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III. Be able to Describe the followingIII. Be able to Describe the followingtypes of FRACTURES (DRAW each type)types of FRACTURES (DRAW each type)TransverseTransverse

ObliqueOblique SpiralSpiral

LongitudinalLongitudinal

Segmental FractureSegmental Fracture

Open FractureOpen Fracture Close FractureClose Fracture


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IV. Describe what is Carpal TunnelIV. Describe what is Carpal Tunnel

Syndrome.Syndrome.


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END OF LECTUREEND OF LECTURE

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