Upper limb mehrdad - short notes from Moore\'s Anatomy text book PDF

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Mehrdad Jahangiri

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UPPER LIMB BY MEHRDAD JAHANGIRI UNIVERSITY OF DEBRECEN FACULTY OF MEDICINE

Mehrdad Jahangiri  Bones of upper limb  Pectoral gridle:  Clavicle  Scapula  Humerus  Ulna  Radius  Carpal bones  Metacarpals  Phalanges:  Proximal  Middle  Distal  Pectoral gridle  Formed by clavicle and scapula.  Connects the axial skeleton to appendicular skeleton.

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Clavicle:  Shaft of the clavicle has double curve in a horizontal plane.  Medial half is convex anteriorly.  Sternal end to form sternoclavicular joint.  Lateral half is concave laterally.  Acromial end is flat which articulates with acromion to form acromioclavicular joint.  Superior surface:  Is smooth as its lying deep to skin and platysma(subcutaneous neck muscle).  Inferior surface:  Is rough because strong ligament attachments .  Conoid tubercle.  Trapezoid line.  Subclavian groove.  Impression for the costoclavicular ligament.

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Scapula  Triangular flat bone that lies on the posterolateral aspect of thorax.  Overlying the 2nd -7th ribs.  Costal surface:  Subsclapular fossa  Posterior surface:  Spine of scapula  Supraspinous fossa  Infraspinous fossa  Deltoid tubercle  Acromion  Suprascapular notch  Lateralally:  Glenoid cavity  Supragelnoid tubercle  Infraglenoid tubercle  Coracoid process is located superior to glenoid cavity  Head  Neck

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Humerus  Largest bone of upper limb.  Articulates with scapula at glenohumeral joint and the radius and ulna at Elbow joint.  Proximally:  Head  Anatomical neck  Surgical neck  Greater tubercle  Lesser tubercle  Intertubercular (bicipital) groove  Shaft of humerus:  Deltoid tuberosity (laterally)  Radial groove (posteriorly)  Distally (inferior end):  Medial and lateral supraepicondylar ridges  Medial and lateral epicondyles  Condyle of humerus: o Trochlea o Capitulum o Olecranon fossa o Coronoid fossa o Radial fossa

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Mehrdad Jahangiri  Bones of forearm  Ulna  Radius  Ulna  Is stabilizing bone of forearm  Longer of two forearm bones  Proximally  Olecranon  Coronoid process  Trochlear notch  Tuberosity of ulna  Radial notch  Supinator crest  Supinator fossa  Distally  Head of ulna  Ulnar styloid process  Articular circumference  Shaft  Anterior border  Posterior border  Lateral border

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Radius  Proximally  Head  Neck  Radial tuberosity  Distally  Ulnar notch  Radial styloid process  Grooves for extensor tendons  Dorsal tubercle  Carpal articular surface

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 Bones of the hand: wrist or carpus is composed of 8 carpal bones arranged in proximal and distal rows of four.  Carpal bones  Proximal row:  Scaphoid o Boat shaped o Scaphoid tubercle  Lunate  Triquetrum  Pisiform  Distal row:

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Trapezium Trapezoid Capitate Hammate o Hook of hammate on palmar surface. Metacarpus: forms skeleton of palm of the hand between carpus and the phalanges.  Metacarpal bones  Each metacarpal consists of base,shaft and head  Base of metacarpals articulates with carpal bones  Heads of metacarpals articulate with proximal phalanges  1st metacarpal (of the thumb) is the thickest and shortest of these bones  3rd metacarpal is distinguished by a styloid process on the lateral side of its base  Phalanges  Each digit has 3 phalanges except for the first(the thumb) .  Each phalanx has: o Base o Shaft o Head  Proximal phalanges are the largest.  Middle phalanges are intermediate in size.  Distal phalanges are the smallest.

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 Brachial plexus  Main nerves in the upper limb arise from the brachial plexus  Is divided into  Supraclavicular part  Infraclavicular part  Almost all branches of brachial plexus arises in the axilla (except 4 supraclavicular branches)  Its formed by union of amterior rami of last 4 cervical (C5-C8) and 1st thoracic neve (T1)  Parts of brachial plexus:  Roots(C5-T1) pass through scalenus hiatus(space btw anterior and middle scalene muscles). o Branches arising from the roots:  Dorsal scapular nerve.  Long thoracic nerve.  Trunks formed by union of roots o Superior trunk  Suprascapular nerve.  Nerve to subclavius. o Middle trunk o Inferior trunk  Divisions as the plexus passes through cervicoaxillary canal posterior to clavicle.  Each trunk divides to: o Anterior division. o Posterior division.  Cords  Formed by union of divisions.  Located in axilla.  Bear the relationship with axillary artery that indicates their names. o Lateral cord:  Lateral pectoral nerve. o Medial cord:  Medial pectoral nerve.  Medial cutaneous nerve of arm (medial brachial cutaneous nerve).  Medial cutaneous nerve of forearm (medical antebrachial cutaneous nerve). o Posterior cord:  Upper subscapular nerve.  Thoraco dorsal nerve.  Lower subscapular nerve.  Terminal branches: o Ulnar nerve (medial cord). o Median nerve (formed by union of medial and lateral roots from medial and lateral cords). o Musculocutaneous nerve (lateral cord). o Radial nerve (posterior cord). o Axillary nerve (posterior cord).

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Mehrdad Jahangiri  Axioappendicular muscles are muscles that attach the axial skeleton to upper appendicular skeleton.  Anterior axioappendicular muscles move pectoral gridle  Pectoralis major  Pectoralis minor  Serratus anterior  Subclavius

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Posterior axioappendicular muscles  Superficial muscles  Trapezius  Latissimus dorsi

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Deep muscles  Levator scapulae  Rhomboid major  Rhomboid minor

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 Movements of scapula  Elevation  Trapezius,descending part  Levator scapulae  10-12cm  Depression  Gravity  Trapezius,ascending part  Latissimus dorsi  10-12cm  Protraction  Serratus anterior  40-45 degrees  Retraction  Trapezius,middle part  40-45 degrees  Upward rotation  Trapezius,descending part  Serratus anterior  60 degrees  Downward rotation  Latissimus dorsi  60 degrees  Scapulohumeral (intrinsic shoulder) muscles  6 muscles that pass from scapula to the humerus.  Muscles:  Deltoid  Supraspinatus  Infraspinatus  Teres minor  Teres major  Subscapularis  ROTATOR CUFF MUSCLES  SUPRASPINATUS  INFRASPINATUS  TERES MINOR  SUBSCAPULARIS  These muscles form a musculotendinous rotator cuff around glenohumeral joint which protects the joint and gives it stability.

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Mehrdad Jahangiri  Muscles of Arm  Anterior muscles are flexors 1. Biceps brachii 2. Brachialis 3. Coracobrachialis  Posterior muscles are extensors 1. Triceps brachii 2. Anconeus

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Mehrdad Jahangiri  Muscles of Forearm 1.

Anterior muscles  are flexors of wrist and digits and pronators of forearm  Located in 3 layers 1. Superficial layer (pronator teres,flexor carpi radialis,palmaris longus,flexor carpi ulnaris) 2. Intermediate layer (flexor digitorum superficialis) 3. Deep layer (flexor digitorum profundus,flexor pollicis longus,pronator quadratus)

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Posterior muscles  are extensors of wrist and digits and supinator of forearm  Located in 2 layers 1. Superficial layer (brachioradialis,extensor carpi radialis longus,extensor carpi radialis brevis,extensor digitorum,extensor digiti minimi,extensor carpi ulnaris) 2. Deep layer ( supinator,extensor indicis,abductor pollicis longus,extensor pollicis longus,extensor pollicis brevis)

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Mehrdad Jahangiri  Muscles of Hand  Intrinsic muscles of the hand are Located in 5 compartments: 1. Thenar compartment (abductor pollicis brevis,flexor pollicis brevis,opponens pollicis). 2. Adductor compartment (adductor pollicis). 3. Hypothenar compartment (abductor digiti minimi,flexor digiti minimi brevis,opponens digiti minimi). 4. Central compartment (lumbricals and long flexor tendons). 5. Interosseous compartment (palmar and dorsal interossei muscles).

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ARTERIAL SUPPLY AND VENOUS DRAINAGE AND LYMPHATIC DRAINAGE OF UPPER LIMB

 SUBCLAVIAN ARTERY AND VEIN  Is the major artery of lateral cervical region.  The left subclavian artery arises from the arch of aorta directly.  The right subclavian artery arises from the brachiocephalic trunk (branch of arch of aorta).  The branches which are related to the upper limb are:  The suprascapular artery (either arises from the thyrocervical trunk or the 3rd part of subclavian artery directly).  The dorsal scapular artery (either arises from the transverse cervical artery or the 3rd part of subclavian artery directly).

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The subclavian vein is the major venous channel draining the upper limb. It unites with the Internal jugular vein to form the brachiocephalic vein, posterior to the medial end of the clavicle.

 AXILLARY ARTERY AND VEIN  The axillary artery begins at the lateral border of the 1st rib as the continuation of the subclavian artery and ends at the inferior border of the teres major (it becomes the brachial artery when it passes the inferior border of the teres major).  For descriptive purposes, the axillary artery is divided into three parts by the pectoralis minor as it passes posterior to it (the part number also indicates the number of its branches): 1. The first part of the axillary artery is located between the lateral border of the 1st rib and the medial border of the pectoralis minor and has one branch—the superior thoracic artery. 2. The second part of the axillary artery lies posterior to pectoralis minor and has two branches—the thoracoacromial and lateral thoracic arteries—which pass medial and lateral to the muscle, respectively. o The thoracoacromial artery divides into 4 branches (deltoid,pectoral,clavicular and acromial).

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The third part of the axillary artery extends from the lateral border of pectoralis minor to the inferior border of teres major and has three branches. o The subscapular artery (is the largest branch of the axillary artery).  The circumflex scapular artery (passing posteriorly between the subscapularis and the teres major [the triangular space] to supply muscles on the dorsum of the scapula.  Anastomoses with branches of the suprascapular artery.  The thoraco dorsal artery. o The anterior circumflex humeral and posterior circumflex humeral arteries (sometimes by means of a common trunk).  The larger posterior circumflex humeral artery passes medially through the posterior wall of the axilla via the quadrangular space with the axillary nerve.  These arteries anastomos aruond the surgical neck of humerus.

The axillary vein is formed by the union of the brachial vein (the accompanying veins of the brachial artery) and the basilic vein at the inferior border of the teres major. The axillary vein ends at the lateral border of the 1st rib, where it becomes the subclavian vein.

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 BRACHIAL ARTERY AND VEINS OF ARM 

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The brachial artery begins at the inferior border of the teres major and ends in the cubital fossa opposite the neck of the radius where, under cover of the bicipital aponeurosis, it divides into the radial and ulnar arteries. At first it lies medial to the humerus where its pulsations are palpable in the medial bicipital groove. During its course through the arm, the brachial artery gives rise to many unnamed muscular branches and the humeral nutrient artery. The main named branches of the brachial artery arising from its medial aspect are the deep artery of the arm and the superior and inferior ulnar collateral arteries. The collateral arteries help form the periarticular arterial anastomoses of the elbow region.

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DEEP ARTERY OF ARM:  The deep artery of the arm (L. arteria profunda brachii) is the largest branch of the brachial artery and has the most superior origin.  The deep artery accompanies the radial nerve along the radial groove.  The deep artery terminates by dividing into middle and radial collateral arteries (which participate in the periarticular arterial anastomoses around the elbow). o The radial collateral artery anastomoses with the recurrent radial artery (branch of radial artery). o The middle (medial) collateral artery anastomoses with the recurrent interosseous artery.

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HUMERAL NUTRIENT ARTERY:  It enters the nutrient canal on the anteromedial surface of the humerus.

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SUPERIOR ULNAR COLLATERAL ARTERY:  It accompanies the ulnar nerve posterior to the medial epicondyle of the humerus.  Here it anastomoses with the posterior ulnar recurrent artery and the inferior ulnar collateral artery (participating in the periarticular arterial anastomoses of the elbow).

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INFERIOR ULNAR COLLATERAL ARTERY  The inferior ulnar collateral artery arises from the brachial artery approximately 5 cm proximal to the elbow crease.  It passes anterior to the medial epicondyle of the humerus and anastomoses with the anterior ulnar recurrent artery.

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Veins of Arm:  The superficial veins are in the subcutaneous tissue, and the deep veins accompany the arteries.  Both sets of veins have valves.  SUPERFICIAL VEINS: o The two main superficial veins of the arm, the cephalic and basilic veins.  DEEP VEINS: o Paired deep veins, collectively constituting the brachial vein, accompany the brachial artery. o The brachial vein begins at the elbow by union of the accompanying veins of the ulnar and radial arteries and ends by merging with the basilic vein to form the axillary vein.

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 ARTERIES AND VEINS OF FOREARM  ULNAR ARTERY  Pulsations of the ulnar artery can be palpated on the lateral side of the FCU tendon, where it lies anterior to the ulnar head.  Branches of the ulnar artery: o The anterior and posterior ulnar recurrent arteries anastomose with the inferior and superior ulnar collateral arteries, respectivel (they may be present as anterior and posterior branches of a (common) ulnar recurrent artery). o The common interosseous artery, a short branch of the ulnar artery, divides almost immediately into anterior and posterior interosseous arteries. o The anterior interosseous artery , running directly on the anterior aspect of the interosseous membrane with the anterior interosseous nerve, whereas the posterior interosseous artery courses between the superficial and the deep layers of the extensor muscles in the company of the posterior interosseous nerve. o Unnamed muscular branches of the ulnar artery supply muscles on the medial side of the forearm.  RADIAL ARTERY  The pulsations of the radial artery can be felt easily in the distal part of forearm.  It crosses the floor of the anatomical snuff box (foveola radialis).  The radial recurrent artery participates in the periarticular arterial anastomoses around the elbow by anastomosing with the radial collateral artery, a branch of the deep artery of the arm.  The palmar and dorsal carpal branches of the radial artery o Participate in the periarticular arterial anastomosis around the wrist. o They are anastomosing with the corresponding branches of the ulnar artery and terminal branches of the anterior and posterior interosseous arteries, forming the palmar and dorsal carpal arches.  The unnamed muscular branches of the radial artery supply muscles in the adjacent (anterolateral) aspects of both the flexor and the extensor compartments.

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VEINS OF FOREARM  SUPERFICIAL VEINS o The main superficial veins of forearm are the basilic,ceohalic,median antebrachial and median cubital veins.  DEEP VEINS o Deep veins accompanying arteries in the forearm. o These accompanying veins (L. venae comitantes) arise from the anastomosing deep venous palmar arch in the hand. o From the lateral side of the arch, paired radial veins arise and accompany the radial artery. o From the medial side, paired ulnar veins arise and accompany the ulnar artery o The deep interosseous veins, which accompany the interosseous arteries, unite with the accompanying veins of the radial and ulnar arteries.

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 ARTERIES AND VEINS OF HAND  ULNAR ARTERY IN HAND  The ulnar artery enters the hand anterior to the flexor retinaculum between the pisiform and the hook of the hamate via the ulnar canal (Guyon canal).  The artery divides into two terminal branches, the superficial palmar arch and the deep palmar branch.  The superficial palmar arch (the main termination of the ulnar artery): o gives rise to three common palmar digital arteries that anastomose with the palmar metacarpal arteries from the deep palmar arch. o Each common palmar digital artery divides into pair of proper palmar digital arteries, which run along the adjacent sides of the 2nd–4th digits.  RADIAL ARTERY IN HAND  The radial artery curves dorsally around the scaphoid and trapezium and crosses the floor of the anatomical snuff box.  It enters the palm by passing between the heads of the 1st dorsal interosseous muscle.  The radial artery ends by anastomosing with the deep branch of the ulnar artery to form the deep palmar arch, which is formed mainly by the radial artery.  This arch lies across the metacarpals just distal to their bases.  The deep palmar arch gives rise to: o Three palmar metacarpal arteries. o The princeps pollicis artery.  The radialis indicis artery passes along the lateral side of the index finger (It usually arises from the radial artery, but it may originate from the princeps pollicis ).  VEINS OF HAND  Superficial and deep venous palmar arches, associated with the superficial and deep palmar (arterial) arches, drain into the deep veins of the forearm.  The dorsal digital veins drain into three dorsal metacarpal veins, which unite to form a dorsal venous network. o Superficial to the metacarpus, this network is prolonged proximally on the lateral side as the cephalic vein. o The basilic vein arises from the medial side of the dorsal venous network.

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VENOUS DRAINAGE OF UPPER LIMB  SUPERFICIAL VEINS OF UPPER LIMB  The main superficial veins of the upper limb, the cephalic and basilic veins, originate in the subcutaneous tissue on the dorsum of the hand from the dorsal venous network.  Perforating veins form communications between the superficial and deep veins.  The cephalic vein:  Ascends in the subcutaneous tissue from the lateral aspect of the dorsal venous network.  Anterior to the elbow, the cephalic vein communicates with the median cubital vein, which passes obliquely across the anterior aspect of the elbow in the cubital fossa and joins the basilic vein.  The cephalic vein courses superiorly between the deltoid and the pectoralis major muscles along the delto...