Bones and Muscles and regional anatomy of the upper limb part2 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

Damage to the Radial nerve Injury proximal to the origin of Triceps: *No extension of elbow (elbow is flexed) *No triceps reflex *Wrist drop (all extensor muscles and the Supinator are paralyzed), thumb is flexed and adducted Sensory loss: dorsolateral lower brachial region, posterior surface of forearm, dorsum of the hand and radial side of proximal phalanges Injury of the nerve in radial groove: In fractures of humerus Triceps muscle is usually functioning Wirst drop and sensory loss in dorsolateral aspect of the forearm and hand Plus all other problems mentioned above Nerve injury in forearm: Here the deep radial nerve is injured (wrist drop) Extension of the thumb and metacarpal joints is disturbed. Sensation is usually preserved

(suicide or injury e.g.: hand out of car’s window) Median Nerve injury: Above the elbow: Muscles in the arm are not affected Forearm and hand muscles are affected 1- All flexors of the wrist are paralyzed except: 2- Flexor carpi ulnaris and ulnar part of Flexor digitorum profundus. 3- Thumb flexors and abductor paralyzed but not Adductor (ulnar N.) (ape hand) 4- Flexion at metacarpophalangeal joints possible (intact interossei MM, ulnar N.) 6- 1st and 2nd Lumbricals lost function and all together, inability to fully flex index and middle finger (HAND OF PAPAL BENEDICTION) Pronation of forearm paralyzed and sensory loss over the median N. area Injury at wrist Joint: (suicide or injury e.g.: hand out of car’s window) Short muscles of the thumb paralyzed, not adductor. Thenar muscles atrophy (flattened, ape hand) Flexor pollicis longus functioning Sensory loss over Medial N. area

Ulnar nerve injury: At wrist Injury at elbow: 1- Fingers are hyperextended at metacarpophalangeal joints and flexed at interphalangeal joints (paralysis of interossei MM and 2 medial lumbricals (Claw hand) 2- Tendon of flexor digitorum perfundus (2 medial ones) paralyzed, Therefore flexion of the ring and little finger is not possible at distal phalangeal joints 3- Small muscles of the little finger are paralyzed 4- Abduction and Adduction of the fingers are impaired ( paralysis of interossei MM, piano playing, writing.. Impaired) 5- Sensory loss over ulnar innervating area. Injury at elbow: 1- Paralysis of flexor carpi ulnaris and medial portion of Flexor digitorum profundus 2- Ulnar deviation of the wrist is weakened, hand is abducted and extended Plus problem number 4 and 5 from above

Atlas: only look at the items Regional Anatomy Atlas: only look at the items Infraclavicular region (Deltopectoral triangle) Borders: 1- Clavicle, 2- Deltoid, 3- Pectoralis major Skin innervation: medial, intermediate and Lateral supraclavicular nerves (cervical plexus) On deltoid region: innervation by axillary nerve 6- Pectoralis minor M. 7- Clavipectoral fascia 8-Cephalic vein 9- Axillary vein 10- Thoracoacromial artery (11-clavicular, 12-acromial, 13-deltoid, 14-pectoral parts) 15- Pectoral nerve 16- Subclavius M. 17- Axillary artery 18- lateral cord 19- Posterior cord 20- Medial cord 21- Suprascapular nerve and vessels

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

Brachial Plexus

Arteries of the shoulder and Upper arm: **Arterial Blood pressure Measurements using a sphygmometer *Brachial artery occlusion/Laceration: Deep flexor paralysis, *Volkmann’s ischemic contracture

Veins of the shoulder And upper arm: Moore

Lymph nodes of the Axillary region: Arranged in 5 groups: Pectoral, medial, apical, central and subscapular Drainage: subclavian lymphatic trunk to right lymphatic duct to right venous angle **Importance: Breast Cancers may give metastasis to the axillary lymph node (75% of breast’s lymphatics drain here). Removal of the lymph nodes may be necessary. Mastectomy: removal of the breast. *Lymphangitis Moore

Regional anatomy: Atlas: Only look at the items Anterior Brachial region: 1- Brachial fascia 2- Cephalic vein 3- Basilic vein 4- Basilic hiatus 5- Medial antebrachial cutaneous N. 6- the same nerve as 5 7- lymph nodes 8- Medial brachial cutaneous N. 9- Intercostobrachial N.

Anterior Brachial region Medial bicipital groove: Between biceps and intermuscular septa Contents: Median N, Brachial artery and veins and basilic vein, medial cutaneous antebrachial nerve and ulnar N. medially. Deep in this region, proximally , the radial nerve takes a posterior direction.

Axillary spaces: Quaderangular space Triangular Spaces 1- Teres Minor 2- Teres Major 3- Humerus 4- Long head of Triceps Radial nerve is found deep in the posterior brachial region in radial groove of humerus accompanied by deep brachial A and V.

Regional anatomy: Atlas: Only look at the items Cubital fossa: Superficial 1- Basilic vein 2- Antebrachial Basilic vein 5- Cephalic and 7- Median cubital vein 4- Medial cutaneous antebrachial nerve 6- lateral antebrachial cutaneous nerve (branch of musculocutaneous N.)

Cubital fossa (deep): Atlas: Only look at the items 1- Biceps Brachii M. 2- Bicipital aponeurosis 3- Brachialis M 4- Pronator teres 5- Brachioradialis 6- Radial artery and veins 7- recurrent radial A. 8- Median N. 9- Ulnar nerve 10- Radial N. 11- Superficial Radial N. 12- Deep radial N. 13- Supinator muscle

Arteries of the forearm and hand: 1- brachial artery 2- Radial artery 3- Ulnar artery 6- Deep palmar arch 8- Principal artery of the thumb 13- Superficial palmar arch 14- the 3 common digital arteries 15- the 2 common palmar digital arteries 16- Dorsal carpal branch

Anterior antebrachial region: Atlas: Only look at the items 2 and 6- Anastomoses between cephalic and basilic antebrachial veins 7- Medial cutaneous antebrachial N. 11- Radial artery and veins 14- Superficial Radial N. 21- Ulnar N 22 and 23- Ulnar artery and veins

Anterior carpal region: 1- Antebrachial fascia, 2- Deep layer 3- tendon of palmaris longus 4- Pronator quadratus 5- Radial A. 6- Flexor carpi radialis 9- Median N. 10- Ulnar artery 11- Ulnar nerve 12- Flexor carpi ulnaris 13- Palmar aponeurosis

Palm of the hand: 1- Superficial palmar arch 18- Deep palmar arch 11- median nerve 9- ulnar nerve

Dorsum of the Hand: Radial artery (9) enters the Snuffbox and gives a dorsal branch which produces the dorsal arterial arch of the hand. Then it gives the principal artery of the thumb and then a main branch to join the deep palmar arch. Snuffbox: borders: Tendon of extensor pollicis longus (superior) tendons of the ext. pollicis brevis and abductor pollicis longus (inferiorly). Contents of snuffbox: 9- Radial artery 8- Superficial radial N.