9Brachial Plexus Injuries Shoulder AdductedMedially rotated armExtend ElbowInjuries to the brachial plexus affects movement and cutaneous sensations in the upper limb.Erb-Duchenne Palsy: Upper Trunk or C5,6 Roots – results in waiters tip.
10Brachial Plexus Injuries Compression of cords of the brachial plexus from prolonged hyperabduction of the arm. Results in pain radiating down the arm with hand weakness.
11Brachial Plexus Injuries Klumpke Palsy: Less common, inferior brachial plexus injury(C8-T1), may be from trying to break a fall. Intrinsic muscle of the hand affected, develops claw hand.
12Brachial Plexus Injuries Injuries to the brachial plexus affects movement and cutaneous sensations in the upper limb.Erb-Duchenne Palsy: Upper Trunk or C5,6 Roots – results in waiters tip.Compression of cords of the brachial plexus from prolonged hyperabduction of the arm. Results in pain radiating down the arm with hand weakness.Klumpke Palsy: Less common, inferior brachial plexus injury(C8-T1), may be from trying to break a fall. Intrinsic muscle of the hand affected, develops claw hand.Acute Brachial Plexus Neuritis (Parsonage Turner Syndrome): sudden on set of severe shoulder pain then is followed by weakness. Inflammation is often preceded by some event (URI, Vaccination or Non-specific Trauma)
14Biceps Brachii Musculocutaneous (C5,C6) (bi, two + L. caput, head) – 2 headsShort headTip of coracoid processLong headSupraglenoid tubercle of scapulaSingle distal tendon attached to Radius with biceps tendonBicipital aponeurosis runs from biceps tendon across the cubital fossaProtects structures of cubital fossaNo attachment to Humerus“Three joint muscle”Glenohumeral jointElbow jointRadioulnar jointWhen elbow is extended – flexor of elbowElbow 90o :Supinated – flexorPronated – primary supinator of the armSemiprone – active with resistance only
15Bicipital Myotatic Reflex Deep Tendon Reflex / Muscle Stretch Reflex – C5Biceps TendonitisWear and tear, usually long head of the bicepsSpeed’s test – flexion pain at insertionYergason test – elbow 90o resisted supination
16Rupture of the Tendon usually long head, rare distally.
17Brachialis LAB Musculocutaneous C5, C6 Flexes forearm all positions – not effected by positionMAIN flexor of the forearm
18Coracobrachialis LAB Musculocutaneous C5, C6, C7 Flexes arm Helps arm adductionStabilizes glenohumeral joint from inferior dislocationCarrying suitcase
20Triceps brachii LAB Radial nerve (C6,C7, C8) 3 heads Long head Crosses glenohumeral jointHelps Adduct and extend ArmStabilizes inferior dislocationMedial headWorkhorse of forearm extensionLateral headStrongest but is recruited against resistance
21AnconeusRadial C7, C8, T1Tenses the capsule of the elbow joint preventing its being pinched during extension.
22Muscles of the forearm flexor The flexors are arranged in three layersSuperficial layer4 musclesCrosses elbowIntermediate layer1 muscleDeep layer3 musclesCrosses wrist and phalanges
25Superficial Layer – forearm LAB Palmaris LongusMedian nerveAbsent in 14% of people (usually left)Tendon passes superficial to the flexor retinaculumAttaches to palmar aponeurosisMedian nerve runs lateral to tendonCTS Injection - medial
26Superficial Layer – forearm LAB Flexor Carpi UlnarisMost medial flexorFlexes and adducts the wrist if acting aloneUlnar C7, C8
27Intermediate layer – forearm LAB Flexor digitorum superficialisDistal end four tendons go through carpal tunnel to middle phalangesFlexes four fingersPIPMCP – strongerMedian C7, C8, T1Test – one finger flexed PIP, others extended
29Deep Layer – forearm LAB Flexor Digitorum ProfundusOnly muscle that flex the DIPMedial part – Ulnar C8, T1Lateral part - Median (anterior interosseous) C8, T1Flexor Pollicis LongusOnly muscle to flex the 1st IP, MCP and CMC jointsMedian (anterior interosseous) C8, T1
30Deep Layer – forearm LAB Pronator quadratusDeepest muscle of anterior forearmSometimes considered fourth layerMedian (anterior interosseous) C8, T1
31Posterior muscle of the forearm Superficial layerDeep layer and Outcropping muscles of deep layer
32Extensor muscle of the forearm Divided into 3 functional groupsExtend, abduct, adduct the hand at the wristExtensor carpi radialis longusExtensor carpi radialis brevisExtensor carpi ulnarisExtend the medial four fingersExtensor digitorumExtensor indicisExtensor digiti minimiExtend or abduct the thumbAbductor pollicis longusExtensor pollicis brevisExtensor pollicis longus
34Superficial LAB Extensor digitorum Extensor digiti minimi Four tendons to extensor hood of 4 fingersExtensor digiti minimi5th fingerExtensor carpi ulnarisExtend and adducts wrist jointRadial nerve C7, C8 (posterior interosseous nerve)
35Deep Layer LAB Supinator Extensor indicis Prime supinator with arm extendedRadial (deep branch)Extensor indicisIndependent extensor of 2nd fingerRadial C7, C8 – (PI)
36Deep Layer - Outcropping LAB Abductor pollicis longusBase of 1st metacarpalExtensor pollicis brevisBase of 1st proximal phalanxDe Quervain’s TenosynovitisExtensor pollicis longusBase of 1st distal phalanxRadial nerve C7, C8
37Medial & Lateral Epicondylitis Medial – Common Flexor TendonPitcher’s (Little League) ElbowLateral – Common Extensor TendonTennis ElbowTreatmentSplintPhysical TherapyNSAIDsSteroids OralSteroid Injection at the common flex/ext tendon
38Intrinsic muscle of the hand Thenar muscleAbductor pollicis brevisMedian nerve C8, T1Flexor pollicis brevisSuperficial head – Median C8, T1Deep head – Ulnar C8, T1
39Intrinsic muscle of the hand Thenar muscleOpposes thumbMedian nerve C8, T1Adductor pollicisUlnar nerve C8, T1
40Intrinsic muscle of the hand Hypothenar muscleAbductor digiti minimiFlexor digiti minimiOpponens digiti minimiUlnar nerve C8, T1
41Intrinsic muscle of the hand Short MusclesLumbricals – UlnarFlex fingers at the MCP jointExtend fingers at IP jointInterosseiDorsal – Abduct from axial linePalmar – Adduct to axial lineDAB with a PAD
47Nursemaid’s Elbow Preschool children Particularly girls Transient subluxationTreatment consists of manipulating the child's arm so that the annular ligament and radial head return to their normal anatomic positions.Immobilize the elbow and palpate the region of the radial head with one hand.The other hand applies axial compression at the wrist while supinating the forearm and flexing the elbow.As the arm is manipulated, a click or snap can be felt at the radial head.
48Next Week Should know Great to know Must know Fig 5.15 – Pectinues Adductor brevisSuperior gemellusObturator internusInferior gemellusObturator externusGreat to knowTable 5.1Must know559 - Bones of the LEFig 5.6, 5.7, 5.8 and 5.9Dermatomes Fig 5.13Fig 5.15 – Tensor fascia lataSartoriusRectus FemorisAdductor longusVastus medialis / lateralisGracilisFig 5.17 – Neurovascular structureFig 2.3 – Gluteal RegionBiceps femorisSemi-tendinosusSemi-mebranosusGluteus Medius / MaximusPiriformisPopliteal fossaTibial nervePopliteal veinPopliteral arteryCommon fibular (peroneal) nerveSural nerve