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Bones and Muscles and regional anatomy of the upper limb part1

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1 Bones and Muscles and regional anatomy of the upper limb part1
Lecturer: Dr. M. Samsam University of Central Florida, Orlando, Pictures from Platzer atlas and textbook of human anatomy and K. Moore anatomy and Netter atlas of human anatomy

2 Bones of the upper limb: Scapula:
Surfaces Borders Angles Spine of scapula Acromion process 13- glenoid cavity 14- supraglenoid tubercle 16- neck of scapula 17- coracoid process 18- Scapular notch

3 Clavicle: S shape, Medial 2/3 is convex anteriorly and lateral 1/3 is concave anteriorly. 1- sternal end 2- acromial end Surfaces Lower surface: 5- costoclavicular impression 6- conoid tubercle 7- trapezoid line 8- Costoclavicular ligament 10- anterior sternoclavicular lig. 11- interclavicular lig. 14- Trapezoid ligament 15- Conoid ligament Fractures of clavicle Cleidocranial dysostosis C- Sternoclavicular joint E- Acromioclavicular joint

4 Humerus: Has a shaft and 2 ends. Proximal end: 1- head
2- Anatomical neck 8- Surgical neck 3- Greater tubercle 4- Lesser tubercle 5- intertubercular sulcus 9- Deltoid tuberosity (lateral) 11- medial border 13- lateral border 14- Sulcus for radial nerve (post. Surface) Distal end: Condyles: 17- Trochlea, 18- capitulum Epicondyles: 15- medial, 16- lateral 19- Radial fossa 20- Coronoid fossa 21- Sulcus for Ulnar nerve 22- Olecranon fossa

5 *Fractures of the Humerus:
*Fractures of the surgical neck: injury to the Axillary nerve. *Fractures of the middle of the shaft: may cause injury to the radial nerve: Wrist drop Fractures of the distal end of humerus: injury to the Median nerve. Fractures to the medial epicondyle: injury to the ulnar nerve. *Traumatic separation of the proximal epiphysis under years. Also in younger children since the capsule is stronger. * Dislocation of the shoulder joint

6 Radius and Ulna bones Radius: 1- Body, 2- Head, 3- Articular fovea
4- Articular circumference 5- Neck 6- Radial tuberosity 7- Interosseous margin 8- Anterior surface, 9- Ant. Margin, 10- Lat. surface 11- Post. Margin, 12- Post. Surface 13- Pronator tuberosity, 14- Styloid process 15- Ulnar notch, 16- Carpal articular surface 17- Sulcus for tendon of Abd. Pollicis longus and ext. Pollicis brevis 18- Sulcus for tendon of Ext. carpi radialis longus and brevis 19- and 20-) sulci for Extensor pollicis longus, extensor digitorum and Ext. indicis. 21- Dorsal tubercle

7 Radius and Ulna bones Ulna: 22- Shaft of Ulna, 23- Olecranon process
24- Trochlear notch, 25- Coronoid process 26- Radial notch, 27- Ulnar tuberosity 28- Supinator crest, 29- Interosseous margin 30- Anterior surface, 31- Ant. Margin 32- Medial surface, 33- Post. Surface 34- Post. Margin, 35- Nutrient foramen 36- Head of Ulna, 37- Articular circumference 38- Styloid process *Colles’ Fracture: fracture of the distal end of the radius, posterior displacement. Falling on hand with extended arm (eg.: falling on ice). May be accompanied by avulsion of ulnar styloid process.

8 Carpal Bones: Proximal row: Distal row: 2 rows, each row has 4 bones
Lateral Medial Carpal Bones: 2 rows, each row has 4 bones Proximal row: 1- Scaphoid (largest in this row) 2- Tubercle of scaphoid 3- Lunate 4- Triquetrum 5- Articular facet for Pisiform 6- Pisiform Distal row: 7- Trapezium 8- Tubercle of trapezium 9- Groove for flexor carpi radialis tendon 10- Articular facet for first metacarpal bone 11- Trapezoid 12- Capitate (bigest in 2nd row) 13- Hamate 14- Hamulus (hook of Hamate) *Scaphoid bone is the most frequent bone to fracture among the carpal bones. *Lunate is the most dislocated carpal bone.

9 Carpal tunnel: The 2 rows of the carpal bones produce the carpal groove which is concave anteriorly. *Flexor Retinaculum: Is a double layer of membrane covering the carpal groove anteriorly and produces the carpal tunnel for transmission of flexor muscles and median nerve. *Points of insertion of flexor retinaculum: Tubercle of scaphoid, pisiform, tubercle of Trapezium and hook of Hamate. *Carpal Tunnel Syndrome: Compression to the median nerve in the tunnel due to hypothyroidism, rheumatoid arthritis, pregnancy, Amyloidosis etc. It is a very painful condition. Lateral Medial

10 Metacarpal and phalangeal bones: 1- Head of the metacarpal bone
2- Body 3- Base 4- Styloid process of the 3rd metacarpal B. 5, 6, 7- Phalanx (digital bones) 8- Body 9- Head or trochlea 10- Base 11- Tuberosity of distal phalanx Sesamoid bones at 1st metacarpo-phalangeal J.

11 Brachial Plexus

12 Axillary region: (Pyramidal shape)
Borders: Pectoralis Major, Latis dorsi, ribs and intercostal muscles, humerus and coracobrachialis Atlas: only look at the items

13 (1-2)- Supraspinatus: Abductor of the arm,
Shoulder muscles inserted to Humerus: Dorsal group: (1-2)- Supraspinatus: Abductor of the arm, belongs to the rotator cuff muscle group. NN: Suprascapular N. (C4-C6) (4-5)- Infraspinatus: Lateral rotator of the arm NN: Suprascapular N. (C5-C6) (8-9)- Teres minor: Lateral rotator of the arm, Rotator cuff group, NN: Axillary (circumflex) N. C5-C6 Pathology: tendinopathy of supraspinatus (baseball), calcification, pain, tendon rupture >40 y and in younger people, avulsion of greater tub. Rotator cuff function: help to maintain the stability of the shoulder joint. 11- Deltoid: Origin: 12: clavicular, 13: acromial, and 14: spinal parts. Insertion: Deltoid tuberosity. NN: Axillary N. (C5- C6). Function: Most important abductor of the arm up to 90 degree. Ant. Part: flexes (anteversion) the arm+ medial rotation of the arm Middle part: abducts the arm Post. Part: extends (retroversion) + lateral rotation

14 Arm adduction and medial rotation, NN: Subscapular N. (C5,C6,C7)
(1-2)– Subscapularis M: Arm adduction and medial rotation, NN: Subscapular N. (C5,C6,C7) Insertion: lesser tubercle (3) Pathology: paralysis cause maximal lat. Rotation Rotator cuff muscles: supra+ infra spinatus, teres minor and subscapularis (9-10)- Teres major M: NN: Lower subscapular N. (C6-C7) moore 12- Latissimus dorsi M: (coughing M) Origin:13:vertebral part, 14:thoracolumbar part, 15:iliac part and 16:costal part Insertion: crest of the lesser tubercle Function: Adduction and medial rotation and extension of the arm, NN: Thoracodorsal N. (C6, C7, C8).

15 Ventral Muscle group: 1- Coracobrachialis M: Origin: coracoid process (2). Insertion: medial surface of the humerus Flexion (anteversion) and adduction of arm, Musculocutaneous N. (C5,C6,C7). 4- Pectoralis Minor M: Origin: 3-5th ribs Insertion: coracoid process It lowers and rotates the scapula, Medial pectoral N. (C8- T1). 7- Pectoralis major M: Origin: 8:clavicular part, 9:sternocostal part, 11:abdominal part Insertion: crest of the greater tubercle. F: Adduction and medial rotation of humerus NN: lateral and medial pectoral N.(C5-T1).l

16 **Elevation of the arm over 90o
Dorsal muscle group Serratus anterior M: Origin: 1st-9th ribs ( ) Insertion: From superior to inferior angle and the medial border of the scapula. Function: **Elevation of the arm over 90o Protracts the scapula and holds it against the thoracic wall and rotates the scapula laterally to elevate the arm **Long thoracic N. (C5- C6- C7) **Paralysis: Winged scapula: lifting the arm beyond 90o is not possible Differential diagnosis: Rhomboid M injury, Here you have winged scapula as well, but arm elevation is normal. 1 and 4 in A are Rhomboid muscles

17 Subclavious M: Number 1 (blue) Origin: 1st rib
Ventral muscle group Subclavious M: Number 1 (blue) Origin: 1st rib Insertion: sulcus for the subclavian muscle on the lower surface of clavicle. F: it pulls the clavicle towards the sternum Nerve to the Subclavious (C5- C6) 2-4) Omohyoid muscle Cranial muscle inserted on the Shoulder girdle: 6- Trapezius M 11- Sternocleidomastoid M

18 Muscles of the arm Biceps M (4): Acts on 2 joints: Brachialis M (1):
Origin: coracoid process (8) and supraglenoid tubercle (6). Insertion: Radial tuberosity (9) and forearm fascia. Acts on 2 joints: Long head (5): abductor and medial rotator of the arm Short head (7): adductor of the arm Both heads flex (anteroversion) shoulder joint On elbow joint: flexor and strong supinator of the forearm. NN: Musculocutaneous N. (C5- C6) **Biceps Jerk: C5- C6 Brachialis M (1): Origin: distal half of humerus anteriorly (2) Insertion: ulnar tuberosity (3)/ coronoid process. Powerful flexor of the elbow joint and radial nerve to some of its lateral part Coracobrachialis M (repeated): Origin: coracoid process. Insertion: medial surface of the humerus Flexor of the arm. Musculocutaneous N. (C5,C6,C7).

19 Long head (2) originates from infraglenoid tubercle (5).
Triceps M: Has 3 heads. Long head (2) originates from infraglenoid tubercle (5). Lateral and medial heads originate from humerus Insertion: Olecranon process Function: Chief extensor of elbow joint Long head acts on 2 joints: Retroversion and adduction of the arm Radial N. (C6- C7- C8) Triceps Jerk: C7- C8 Anconeus M: Assists triceps Radial N.(C7- C8- T1)

20 Plexus syndromes and mononeuropathies (the upper limb)
Upper brachial plexus lesion: Erb-Duchenne paralysis (C5-C6): Traction on the arm at birth or falling on the shoulder may damage the upper part of the plexus (roots may be pulled out of spinal cord) Signs: Deltoid and supraspinatus are paralyzed (no arm abduction) Infraspinatus paralysis leads to medial rotation of the arm. Biceps and Brachialis are also paralyzed (no elbow flexion) . Loss of Biceps and supinator (weak supination) Adductors of shoulder are mildly affected (pectoralis major and Latissimus dorsi)

21 Plexus syndromes and mononeuropathies (the upper limb)
Lower brachial plexus lesion: Not as common as upper plexus injuries. Paralysis of the intrinsic muscle of hand (small muscles) with anesthesia. Results from sudden upward pull of the shoulder. Klumpke’s paralysis (C8-T1): Injury to C8-T1 roots following forced abduction of the shoulder. Signs: Atrophic paralysis of the forearm and small muscles of hand (Claw hand) and often a sympathetic palsy: eg: a Horner’s syndrome

22 Damage to axillary nerve

23 Ventral Forearm Muscles: Superficial layer: 1- 4) Pronator Teres
Humeral and ulnar heads Function: pronation of forearm and flexion at elbow NN: Median N. (C6- C7) 14- Palmaris longus Flexes the hand toward the palm, tenses the palmar aponeurosis, Median N. (C7-C8) 15- Palmar Aponeurosis 12- 13) Flexor carpi radialis Runs in the carpal canal in a groove on trapezium. F: Palmar flexion and Radial abduction of hand 5-10) Flexor digitorum superficialis Strong flexors of the finger (4 medial) joints; also flexes the wrist , Runs in the carpal tunnel NN: Median N. (C7, C8, T1) 16- Flexor carpi ulnaris Humeral and Ulnar (from Olecranon) heads. F: Hand (palmar) flexion and adduction Runs outside of carpal tunnel. NN: Ulnar N. (C7- C8) 18- Pisiform bone

24 Ventral Forearm Muscles: Deep layer 4-6) Flexor digitorum Profundus
Runs through the carpal tunnel Function: it is a flexor of the wrist, midcarpal, metacarpophalangeal and phalangeal joints NN: Median N. (ant. Interosseous branch) laterally (C8 and T1), Ulnar N. medially (C8- T1) 8- 10) Flexor pollicis longus Has it’s own tendon sheath Flexor of the terminal phalanx (thumb) NN: Median N. (ant. Interosseous branch) C8- T1 1- 3) Pronator quadratus Pronates the forearm (with Pronator Teres) Median N. (ant. Interosseous branch) C8- T1

25 Carpal tunnel: Produced by flexor retinaculum (9) over
the carpal bones anteriorly. *Structures passing into the tunnel: Flexor digitorum superficialis (12) and profundus, Flexor pollicis longus (11) and Median nerve. Flexor carpi radialis (10) has its own canal in the groove of trapezium. *Carpal Tunnel Syndrome: Compression to the median nerve in the tunnel due to hypothyroidism, rheumatoid arthritis, pregnancy, Amyloidosis etc. It is a very painful condition. Palmarcarpal tendon sheaths (green)

26 Forearm Muscles: Radial group 7-9) Brachioradialis (beer drinking M.)
It brings the forearm into midposition between pronation and supination; in this position it acts as a flexor (forearm flexor) NN: Radial N. (C5- C6 and C7) 4-6) Extensor carpi radialis longus Extensor and abductor of hand at wrist joint NN: Radial N. (C6- C7) 1-3) Extensor carpi radialis brevis Extensor and abductor of the hand at wrist joint NN: Radial N. (deep branch) (C7- C8) Elbow tendinitis (lateral epicondylitis) or (tennis/golfer’s elbow): periosteal irritation, pain 10- Extesor digitorum 11- Ext. digiti minimi 12- Ext. carpi ulnaris 13- Ext. pollicis longus 14- Ext. pollicis brevis 15- Abductor pollicis longus 16- Ulna 17- Radius

27 Dorsal Forearm MM: superficial layer
1-3) Extensor digitorum Runs in 4th tendon compartment. Produces the dorsal aponeurosis (3) with intertendinous connections (5) Function: Extends the 4 medial fingers (metacarpophalangeal J.), strong dorsiflexor of the hand at wrist joint NN: Post. Interosseous branch of deep radial nerve C7- C8 6- Extensor digiti minimi Runs in the 5th tendon compartment Extension of the 5th digit and dorsiflexion of hand 7-8) Extensor carpi ulnaris Runs in the 6th tendon compartment Common head and ulnar head origin Inserted to the base of 5th metacarpal Extends and adducts the hands

28 Deep layer of dorsal forearm muscles: 1-4) Supinator
Encircles the radius and supinates forearm NN: Deep branch of radial N. C5- C6 5-9) Abductor pollicis longus Runs through 1st tendon compartment Abduction of the first thumb+ it’s extension at carpometacarpal joint 10-14) Extensor pollicis brevis Runs in the 1st tendon compartment Extension of the proximal phalanx at metacarpophalangeal joint. 15-18) Extensor pollicis longus Runs through 3rd tendon compartment Extends the thumb using the crest on radius as a fulcrum (at metacarpophalangeal and Interphalangeal joints). 19-21) Extensor indicis Runs through 4th compartment with Ext. digitorum Index extension and hand dorsiflexion All 4 muscles above are innervated by: Post. Interosseous branch of deep radial nerve C7- C8

29 Extensor retinaculum (1):
Covers the carpal bones dorsally and has septae which produce 6 tendon compartments through which tendon of the extensor muscles and the abductor pollicis longus pass. Dorsal tendon sheaths (green) Palmarcarpal tendon sheaths (green)

30 1- Abductor polloicis brevis:
Thenar Muscles: 1- Abductor polloicis brevis: Origin: scaphoid tubercle and Flexor retinaculum Insertion: radial sesamoid and proximal phalanx Abduction of thumb, Median N. C8-T1 6-7) Flexor pollicis brevis: Origin: superficial head from flexor retinaculum (3) deep head from trapezium (8), tarpezoid (9) and capitate (10) Insertion: sesamoid bone of metacarpophalangeal J. Flexes the thumb Superficial innervation by median N. C8-T1 Deep head by ulnar N. C8-T1 (not in Moore) Adductor Pollicis: 2 heads Transverse head (11) origin: 3rd metacarpal bone Oblique head: from capitate and other carpal and 2nd/3rd metacarpals Inserted into ulnar sesamoid bone (14). Thumb Adduction. Deep branch of Ulnar nerve C8-T1 Opponens pollicis (15) : Origin: tubercle of trapezium (16) and flexor retinaculum (3). Insertion: radial margin of 1st metacarpal bone. Thumb opposition. Median N. C8- T1

31 Abductor digiti minimi (9)
Palmar Aponeurosis Consists of Longitudinal (1) and transverse (2) Fascicles. Reach the tendon sheath of flexors (3) and deep transverse metacarpal ligaments. Dupuytren’s contracture: progressive fibrosis, thickening and shortening of the aponeurosis leads to partial flexion of the ring and small finger. Palmaris brevis in hypothenar eminence connect the skin of ulnar border to palmar aponeurosis and flexor retinaculum. Innervation: superficial branch of ulnar N. (C8- T1) Hypothenar Muscles: All innervated by: deep branch of ulnar N. C8- T1 Abductor digiti minimi (9) Origin: pisiform (12) pisohamate lig. (13), Flex. Ret (8) Insertion: base of proximal phalanx of 5th digit Abducts the 5th digit Flexor digiti minimi (10) Origin: Flexor retinaculum and hamate hamulus Flexes the 5th digit Opponens digiti minimi (11) Insertion: Ulnar margin of 5th metacarp Makes opposition of the 5th finger to thumb possible

32 Muscles of the Metacarpus: Interossei Muscles:
Palmar interosseous, 3 sigle-headed Dorsal interosseous, 4 double-headed Palmar interossei (1): 3 muscles Origin: 2nd, 4th and 5th metacarpals Insertion: corresponding proximal phalanges and dorsal aponeurosis Function: Adduction of digits, assist lumbricals Ulnar N. deep branch (C8-T1) Dorsal Interossei: 4 muscles Origin: adjacent sides of two metacarps Insertion: base of the 2nd-4th proximal phalanges Function: Abduction of digits Ulnar N. (deep branch) C8- T1 Lumbricals: 4 muscles 2 lateral (radial) and 2 medial (ulnar) Origin: tendon of flexor digitorum profundus Insertion: lateral sides of dorsal aponeurosis 2 lateral ones innervated by Median N. C8-T1 2 medial ones innervated by Ulnar N. C8-T1

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