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Upper Limb #3: Elbow Christopher Ramnanan, Ph.D. November 5 th, 2015 - Identify the bony structures of the humerus, radius and ulna.

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Presentation on theme: "Upper Limb #3: Elbow Christopher Ramnanan, Ph.D. November 5 th, 2015 - Identify the bony structures of the humerus, radius and ulna."— Presentation transcript:

1 Upper Limb #3: Elbow Christopher Ramnanan, Ph.D. cramnana@uottawa.ca November 5 th, 2015 - Identify the bony structures of the humerus, radius and ulna. - Describe the movements of the elbow joint and between the radius and ulna. - Identify and describe the function of the muscles in the anterior and posterior compartment of the arm. - Describe the course of the neurovascular structures in the arm (brachial artery and vein, and median, ulnar and radial nerves).

2 Osteology: Humerus (Focus Distally) Anatomical Neck Greater Tubercle Lesser Tubercle Surgical Neck Bicipital Groove (Intertubercular sulcus) Capitulum Trochlea Lateral/Medial Epicondyles Spiral (Radial) Groove Olecranon fossa Lateral/Medial Epicondyles Posterior Anterior Trochlea

3 Lateral view Medial view Capitulum Trochlear notch of ulna Head of radius Trochlea Osteology: Ulna and Radius (Focus Proximally) Capitulum Head of radius Trochlear notch of ulna Trochlea Olecrenon of ulna Coronoid Process Radial tuberosity

4 Capitulum Head of radius Trochlear notch of ulna Trochlea Elbow Joint -Hinge synovial joint (flexion/extension) -Articulation (2 sites; humeroulnar is primary): Humeroulnar (trochlea of humerus; trochlear notch of ulna) Humeroradial (capitulum of humerus; head of radius)

5 Articular cartilage Ulnar Collateral Ligament Synovial membrane Joint Capsule Radial Collateral Ligament Lateral view Medial view Radial Collateral Ligament Anterior view Elbow Joint

6

7 Radio-Ulnar Joints Distal (Pivot Synovial) Proximal (Pivot Synovial) Intermediate (Syndesmosis Joint) Note in lab: Interosseous membrane The pivoting of the radius about the ulna at the proximal and distal radio- ulnar joints results in pronation/supination Supination Pronation

8 Proximal Radio-Ulnar Joint -Pivot synovial joint -Articulation: head of radius, radial notch of ulna -Note: this joint is located within loose fibrous capsule of elbow joint; synovial membrane is extension of that of elbow joint -Ligament: Anular Ligament of Radius (allow rotation of radius about the ulna) Clinical correlation: nursemaid`s elbow in children (subluxation of head of radius)

9 All three anterior arm muscles supplied by musculocutaneous nerve Biceps brachii: supination + flexion (shoulder, elbow) Coracobrachialis: weak flexion / adduction (shoulder) Brachialis: flexes at the elbow, but does not cross the shoulder joint and therefore does not function at shoulder Anterior Arm Compartment: Flexors of Shoulder and Elbow Biceps brachii Coracobrachialis Brachialis

10 Posterior Arm Compartment: Extensors of Shoulder and Elbow All three heads of triceps brachii muscles supplied by radial nerve, and extend at the elbow Only the Long head crosses the shoulder joint and can extend the shoulder; the lateral and medial heads only cross the elbow the joint Clinical Note: The radial nerve runs in the radial (spiral) groove as it innervates the triceps, and is subject to injury due to bony fractures at this point in its course. Long head Lateral head Medial head (observed when lateral head has been resected) Radial N Axillary N

11 Anterior Forearm Compartment: Wrist/Digit Flexors, Forearm Pronators Note: Muscles organized into a Superficial layer (4) and the Deep layers (4) Muscles will flex at any joint that they cross (wrist and/or digits) Dominant Nerve of compartment: Median Nerve Exception: flexor carpi ulnaris and the ulnar half of the flexor digitorum profundus are innervated by the ulnar nerve

12 Common Flexor Tendon Superficial Layer of Anterior Forearm Muscles (4) Pronator Teres Palmaris Longus Flexor Carpi Radialis Flexor Carpi Ulnaris Note: -Common Flexor Tendon and PFPF orientation will help you ID these muscles in lab -Pronator Teres is relatively short,and only pronates forearm (does not cross/function at the wrist) -Palmaris Longus attaches to palmar aponeurosis; important in cats, but not so much in humans (wrinkles skin over palm; may be absent) -Note brachioradialis, a muscle that flexes at the ELBOW but belongs to the posterior compartment (radial nerve innervation; physically located with extensor group)

13 Clinical Note: medial epicondylitis (Golfer’s elbow) involves wear of the common flexor tendon

14 Flexor Digitorum Superficialis (FDS): extends to middle phalanx of digits 2-5, will flex proximal interphalangeal (PIP) joint Flexor Digitorum Profundus (FDP): extends to distal phalanx; will flex both proximal and distal interphalangeal joints (PIP, DIP) Flexor pollicis longus (FPL): flexes IP joint of thumb Pronator quadratus: pronates at distal radio-ulnar joint Deep Layers of Anterior Forearm Muscles (4)

15 Flexion at the PIP can be produced by the FDS or the FDP Flexion at the DIP can only be produced by the FDP

16 Posterior Forearm Compartment: Wrist Extensors, Forearm Supinator Note: Muscles organized into a Superficial layer (6) and a Deep layer (5) Muscles will generally extend at any joint they cross (wrist and/or digits) Dominant Nerve of compartment: Radial Nerve

17 Superficial Layer of Posterior Forearm Muscles (6) Branchoradialis: innervated by radial nerve, but flexes at the ELBOW Extensor carpi radialis longus: originates above the common extensor tendon Extensor carpi radialis brevis Extensor digitorum: splits into four tendons, will extend four digits Extensor minimi: muscle associated with belly of extensor digitorum, extends 5 th digit Extensor carpi ulnaris Common Extensor Tendon Note: Brachioradialis and Extensor carpi radialis longus originate above the common extensor tendon Wear of the common extensor tendon (lateral epicondylitis) is termed tennis elbow

18 Deep Layer of Posterior Forearm Muscles (5) Abductor Pollicis Longus Extensor Pollicis Brevis Extensor Pollicis Longus Extensor indicis Supinator: deep muscle that wraps around proximal radius

19 Pronated View Supinated View Biceps: powerful supinator, tendon attaches to radial tuberosity; musculocutaneous n. Pronator Teres: pronator, median nerve Pronator Quadratus: median nerve Supinator: supinator, radial nerve

20 Arteries of the Upper Limb Brachial A. Axillary A. (continuation of Subclavian A.) Radial A. Ulnar A. Cephalic V. (lateral, long) Basilic V. (medial, short) Median Cubital V. Note: Deep veins in limbs run retrograde with, and named for, partner arteries (venae comitantes); limb veins are valved

21 Arteries of the Forearm The Radial A. travels along the deep (medial) surface of the brachioradialis with the superficial branch of the radial nerve. The Ulnar A. runs along the deep (medial) surface of the flexor carpi ulnaris with the ulnar nerve.

22 Boundaries Superior: Imaginary line b/w medial and lateral epicondyles of humerus Medial: Lateral border of pronator teres Lateral: medial border of brachioradialis Roof: superficial and deep fascia (including biceps aponeurosis) Floor: (not shown) supinator, brachialis muscles As the biceps tendon progresses to the radial tuberosity, some fibers fan out to form biceps aponeurosis that helps protect the cubital fossa Contents Brachial A. bifurcation* into Radial A and Ulnar A. *note: location of bifurcation may be variable Median Nerve Biceps tendon Brachial A. Median N. The Cubital Fossa

23 Note: Radial Nerve bifurcation and median cubital vein are near the cubital fossa, but usually not considered formally in the cubital fossa. The deep branch of the radial nerve dives into the supinator on its way to the posterior compartment of the forearm.

24 Motor to the anterior arm compartment (3 muscles; typically dives into coracobranchialis proximally) Sensory to skin on lateral forearm (after innervating the arm muscles, emerges as the lateral cutaneous nerve of the forearm) The Musculocutaneous Nerve

25 The Median Nerve Dominant motor nerve of the anterior forearm compartment (except 1.5 muscles); minor motor nerve of the hand (thenar compartment and thumb-side lumbricals) Sensory to most of skin on palmar surface of hand (lateral 3.5 digits) and dorsal aspects of lateral 3.5 fingertips

26 The Ulnar Nerve Minor motor nerve of the anterior forearm compartment (1.5 muscles, including the flexor carpi ulnaris and the ulnar half of the flexor digitorum profundus); dominant motor nerve of the hand Sensory to medial (ulnar-side) 1.5 digits (palmar and dorsal surfaces)

27 The Radial Nerve Motor nerve to the posterior arm and posterior forearm muscles Sensory to posterior arm, posterior forearm, and most of posterior hand (exception: medial 1.5 digits, all finger tips)

28 LAB 8 CHECKLIST - ELBOW LIGAMENTS and CARTILAGE -Interosseus membrane -Annular ligament -Radial collateral ligament -Ulnar collateral ligament BONES -Humerus -Lateral epicondyle -Medial epicondyle -Trochlea -Capitulum -Olecrenon fossa -Radius -Head of radius -Tuberosity MUSCLES Anterior Upper Arm -Biceps brachii -Brachialis -Coracobrachialis Posterior Upper Arm -Triceps – long, lateral and medial Superficial Anterior Forearm (4) -Pronator teres -Flexor carpi radialis -Palmaris longus -Flexor carpi ulnaris Deep Anterior Forearm (4) -Flexor digitorum superficialis -Pronator quadratus -Flexor digitorum profundus -Flexor pollicis longus Superficial Posterior Forearm (6) -Brachioradialis -Extensor carpi radialis longus -Extensor carpi radialis brevis -Extensor digitorum -Extensor digiti minimi -Extensor carpi ulnaris Deep Posterior Forearm (5) -Extensor pollicis longus -Extensor pollicis brevis -Extensor indicis -Abductor pollicis longus -Supinator ARTERIES -Brachial artery -Radial artery -Ulnar artery VEINS -Axillary vein -Median cubital vein -Cephalic vein -Basilic vein -Brachial vein SPACES - Cubital fossa NB: Items italicized are conceptual, those denoted with a * are FYI -Ulna -Olecrenon -Coronoid process -Trochlear notch


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