Functional anatomy of the Functional anatomy of the upper limb (guide to learning)upper limb (guide to learning)

23rd Sept 201423rd Sept 2014

MihMiháály, A., MD, PhD, DScly, A., MD, PhD, DSc

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Surface anatomy of the upper limb (UL)Surface anatomy of the upper limb (UL)

•• The importance of palpable anatomical The importance of palpable anatomical structures during medical examination.structures during medical examination.

•• Clavicula, acromion, coracoid processClavicula, acromion, coracoid process•• Epicondyles of the humerus, olecranonEpicondyles of the humerus, olecranon•• Styloid processes (ulna, radius)Styloid processes (ulna, radius)•• Os pisiforme, tuberculum ossis scaphoideiOs pisiforme, tuberculum ossis scaphoidei•• Metacarpal bones, phalangesMetacarpal bones, phalanges•• Arteria brachialis: pulsation on the arm Arteria brachialis: pulsation on the arm

(medial side)(medial side)•• Arteria radialis: pulsation at the wristArteria radialis: pulsation at the wrist•• Tendons: biceps, extensor carpi radialis, Tendons: biceps, extensor carpi radialis,

extensor carpi ulnaris, abductor pollicis extensor carpi ulnaris, abductor pollicis longus, extensor pollicis brevis, finger longus, extensor pollicis brevis, finger flexors and extensorsflexors and extensors 2

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Surface projection of Surface projection of the vessels of the ULthe vessels of the UL

Surface projection of the musclesSurface projection of the musclesand tendons of the handand tendons of the hand

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Main points of the lectureMain points of the lecture

•• Which are the anatomical regions connecting Which are the anatomical regions connecting the trunk to the upper limb ?the trunk to the upper limb ?

•• The origin of the large vessels and nerves The origin of the large vessels and nerves supplying the UL: significance of the axillary supplying the UL: significance of the axillary fossa.fossa.

•• Region on the UL where vessels and nerves Region on the UL where vessels and nerves are further distributed from the arm to the are further distributed from the arm to the forearm: the anatomy of the elbow region.forearm: the anatomy of the elbow region.

•• Region where vessels and nerves reach the Region where vessels and nerves reach the hand: the anatomy of the wrist.hand: the anatomy of the wrist.

•• Structure of the hand: the palm, the dorsum Structure of the hand: the palm, the dorsum and the fingers.and the fingers.

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Vessels and nerves of the UL come from the Vessels and nerves of the UL come from the neck and from the thoracic cavity: anatomical neck and from the thoracic cavity: anatomical

routes towards the free ULroutes towards the free UL

1.1. Hiatus scaleni (scalene triangle):Hiatus scaleni (scalene triangle):between the anterior and middle between the anterior and middle scalenus muscles (brachial plexus).scalenus muscles (brachial plexus).

2.2. The space between the clavicle and The space between the clavicle and first ribfirst rib (subclavian vein, artery, (subclavian vein, artery, brachial plexus).brachial plexus).

3.3. Vessels and nerves run through the Vessels and nerves run through the axillary fossaaxillary fossa in order to reach the UL.in order to reach the UL.

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THE SCALENE TRIANGLETHE SCALENE TRIANGLE(SCALENUS HIATUS)(SCALENUS HIATUS)

SCALENUS HIATUS: TRIANGULAR SPACESCALENUS HIATUS: TRIANGULAR SPACEBETWEEN THE SCALENUS ANTERIOR ANDBETWEEN THE SCALENUS ANTERIOR AND

SCALENUS MEDIUS MUSCLES, ON THE SCALENUS MEDIUS MUSCLES, ON THE NECK. BOTH MUSCLES ORIGINATE ON NECK. BOTH MUSCLES ORIGINATE ON

CERVICAL VERTEBRAE AND INSERT TO CERVICAL VERTEBRAE AND INSERT TO THE FIRST RIB, LEAVING A SPACE THE FIRST RIB, LEAVING A SPACE

BETWEEN THEM. THE SCALENUS HIATUS BETWEEN THEM. THE SCALENUS HIATUS CONTAINS THE TRUNKS OF THE BRACHIAL CONTAINS THE TRUNKS OF THE BRACHIAL

PLEXUS (BP) AND THE SUBCLAVIAN PLEXUS (BP) AND THE SUBCLAVIAN ARTERY. THE HIATUS IS PART OF THE ARTERY. THE HIATUS IS PART OF THE POSTERIOR TRIANGLE OF THE NECK POSTERIOR TRIANGLE OF THE NECK

(BEHIND THE STERNOCLEIDOMASTOIDEUS (BEHIND THE STERNOCLEIDOMASTOIDEUS MUSCLE).MUSCLE).

THE SCALENUS THE SCALENUS HIATUS AND HIATUS AND CONTENTS CONTENTS

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Anterior scalenus

First rib

BP

First rib

Scalenus hiatus and contentsScalenus hiatus and contents(from: Int. J. Shoulder Surgery; 2010)(from: Int. J. Shoulder Surgery; 2010)

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SA: subclavian arterySV: subclavian veinVA: vertebral artery

IJ: internal jugular veinCA: common carotid

artery7: scalenus anterior4: scalenus medius

6: scalenus posterior13: brachial plexus

The space between the clavicle The space between the clavicle and the first rib contains:and the first rib contains:

•• Subclavius muscle;Subclavius muscle;

•• Insertion of the scalenus anterior (SA) Insertion of the scalenus anterior (SA) muscle;muscle;

•• Insertion of the scalenus medius (SM) Insertion of the scalenus medius (SM) muscle;muscle;

•• Subclavian artery (posterior to the SA);Subclavian artery (posterior to the SA);

•• Subclavian vein (anterior to the SA);Subclavian vein (anterior to the SA);

•• Brachial plexus (in front of SM).Brachial plexus (in front of SM).10

Scalenus hiatus and the space between Scalenus hiatus and the space between the clavicle and the first rib the clavicle and the first rib

(from: Int. J. Shoulder Surgery; 2010)(from: Int. J. Shoulder Surgery; 2010)

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1: scalenus medius

2: scalenus anterior

5: phrenic nerve6: brachial

plexus7: dorsal

scapular artery8: suprascapular

artery9: thyrocervical

trunkSA: subclavian

arterySV: subclavian

veinRight clavicle dissected

ANOMALIES OF THE HIATUS: (A) THE SUBCLAVIAN ARTERY ISANOMALIES OF THE HIATUS: (A) THE SUBCLAVIAN ARTERY ISPIERCING THROUGH THE SA MUSCLE; (B) THE UPPER TRUNKPIERCING THROUGH THE SA MUSCLE; (B) THE UPPER TRUNK

OF THE BRACHIAL PLEXUS IS EMBEDDED INTO THE SA MUSCLEOF THE BRACHIAL PLEXUS IS EMBEDDED INTO THE SA MUSCLE

Thoracic outlet syndrome: compression of the Thoracic outlet syndrome: compression of the right subclavian artery between the clavicle right subclavian artery between the clavicle

and first rib during elevation of the arm and first rib during elevation of the arm (from: Gaillard F. and D(from: Gaillard F. and D’’Souza D., in free radiology tutorials)Souza D., in free radiology tutorials)

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Axillary fossa: walls and contentAxillary fossa: walls and content

•• Anterior and posterior axillary folds (m. pectoralis Anterior and posterior axillary folds (m. pectoralis major & m. latissimus dorsi, teres major).major & m. latissimus dorsi, teres major).

•• Medial wall: thoracic wall with serratus anterior.Medial wall: thoracic wall with serratus anterior.

•• Lateral wall: humerus, m. coracobrachialis, m. Lateral wall: humerus, m. coracobrachialis, m. biceps caput breve.biceps caput breve.

•• Posteriorly: subscapular fossa with subscapularis Posteriorly: subscapular fossa with subscapularis muscle.muscle.

•• Fascia axillaris: extension of the deep fascia, Fascia axillaris: extension of the deep fascia, covering the basis of the fossa.covering the basis of the fossa.

•• Contents: arteria & vena axillaris and branches; Contents: arteria & vena axillaris and branches; cords of the plexus brachialis and branches.cords of the plexus brachialis and branches.

•• Lymph nodes (20Lymph nodes (20--30) and fat tissue.30) and fat tissue.14

Region of the deltopectoral trigone; axillary fossa (deep fasciaRegion of the deltopectoral trigone; axillary fossa (deep fascia)) 15

Deltopectoral trigone

The axillary fossa: anteriorlyThe axillary fossa: anteriorly-- and and posteriorly directed tissue spacesposteriorly directed tissue spaces

•• Deltopectoral trigone:Deltopectoral trigone: space between the deltoid space between the deltoid and pectoralis major muscles, beneath the and pectoralis major muscles, beneath the clavicle. The cephalic vein pierces through and clavicle. The cephalic vein pierces through and discharges into the axillary vein. discharges into the axillary vein. Site of venous Site of venous cannulation.cannulation.

•• Quadrangular space:Quadrangular space: humerus, teres major, teres humerus, teres major, teres minor, long head of triceps. Contents: circumflex minor, long head of triceps. Contents: circumflex vessels of the humerus, axillary nerve.vessels of the humerus, axillary nerve.

•• Triangular space:Triangular space: long head of the triceps, teres long head of the triceps, teres major, teres minor. The circumflex vessels of the major, teres minor. The circumflex vessels of the scapula are transmitted here.scapula are transmitted here.

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Right side: deltopectoral trigonevisible (arrow).

Left side: pectoralis major cut, pectoralis minor revealed.

Pectoralis minor

Serratus anterior

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Deltopectoral trigone dissected: the site where the cephalic veiDeltopectoral trigone dissected: the site where the cephalic veinndischarges into the axillary veindischarges into the axillary vein 18

Fasciculus posteriorFasciculus posterior

Nervi subscapularesNervi subscapulares

Fasciculus medialisFasciculus medialis

FasciculusFasciculuslateralislateralis

Ventral aspectVentral aspect

Triangular spaceTriangular space

Quadrangular spaceQuadrangular space

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SCAPULAR ANASTOMOSES:SCAPULAR ANASTOMOSES:The scapular anastomoses help the circulation aroundThe scapular anastomoses help the circulation aroundthe shoulder when the blood flow in the axillarythe shoulder when the blood flow in the axillary-- or or distal subclavian artery is compromised.distal subclavian artery is compromised.

S: A. SUBCLAVIAS: A. SUBCLAVIAAX: A. AXILLARISAX: A. AXILLARIS

1.1. Tr. thyrocervicalisTr. thyrocervicalis2.2. A. transversa colliA. transversa colli3.3. A. suprascapularisA. suprascapularis4.4. A. dorsalis scapulaeA. dorsalis scapulae5.5. A. subscapularisA. subscapularis6.6. A. circumflexa humeri a., p.A. circumflexa humeri a., p.

Arrowhead: circumflex scapular artery, runningArrowhead: circumflex scapular artery, runningin the triangular space.in the triangular space.

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OBSTRUCTION OF THE AXILLARY OBSTRUCTION OF THE AXILLARY AARTERY: AXILLARYRTERY: AXILLARYBYPASSBYPASS SURGERYSURGERY USING BASILIC VEIN GRAFTUSING BASILIC VEIN GRAFT

Before surgeryBefore surgery

Obstruction of Obstruction of the axillary the axillary artery visible onartery visible onangiographicangiographicpicturepicture

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During surgeryDuring surgery: : nervus medianusnervus medianus ((blueblue) ) and and the thrombotised axillary arterythe thrombotised axillary artery ((redred))..

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The thrombotised section of the arteryThe thrombotised section of the artery23

Arrow points to the basilic vein graftArrow points to the basilic vein graft24

End of surgery: the vein is suturedEnd of surgery: the vein is suturedto the artery endto the artery end--piecespieces

Grafted veinGrafted vein

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PostPost--surgery angiography: good blood flow in the graftsurgery angiography: good blood flow in the graft 26

Axillary arteryAxillary artery

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The cubital region distributes nerves The cubital region distributes nerves and vessels to the forearmand vessels to the forearm

••The cubital fossa: medially bordered by the flexors (pronator teThe cubital fossa: medially bordered by the flexors (pronator teres, flexor res, flexor carpi radialis, carpi radialis, etcetc……; laterally bordered by the brachioradialis, extensor ; laterally bordered by the brachioradialis, extensor carpi radialis longus, brevis. Floor: brachialis, supinator. Palcarpi radialis longus, brevis. Floor: brachialis, supinator. Palpable item: pable item: tendon of the biceps brachii.tendon of the biceps brachii.

••This is the region where the brachial artery gives main branchesThis is the region where the brachial artery gives main branches: the : the radial and the ulnar arteries. Location of the brachial artery: radial and the ulnar arteries. Location of the brachial artery: medial to the medial to the biceps tendon. The ulnar artery will give the common interosseoubiceps tendon. The ulnar artery will give the common interosseous artery.s artery.

••This is the region where the large nerves of the UL are distribuThis is the region where the large nerves of the UL are distributed again: ted again: median nerve in the middle (medial to the brachial artery), ulnamedian nerve in the middle (medial to the brachial artery), ulnar nerve on r nerve on the medial side (behind the medial epicondyle), radial nerve deethe medial side (behind the medial epicondyle), radial nerve deep on the p on the lateral side. Nerves are related to muscles: flexor carpi ulnarilateral side. Nerves are related to muscles: flexor carpi ulnaris (UN), s (UN), pronator teres (MN), supinator (RN).pronator teres (MN), supinator (RN).

••The region contains the elbow anastomoses of the arteries and thThe region contains the elbow anastomoses of the arteries and the veins.e veins.

••Posterior surface of the cubital region: olecranon and epicondylPosterior surface of the cubital region: olecranon and epicondyles (bursa es (bursa olecrani). Short segment of the ulnar nerve.olecrani). Short segment of the ulnar nerve.

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V. mediana cubiti

V. mediana cephalica cubiti

V. mediana basilica cubiti

V. mediana antebrachii

Anastomotic superficial veinsAnastomotic superficial veins

Significance of the veins in cannulations, taking blood samples,Significance of the veins in cannulations, taking blood samples, etcetc…… 29

Rete cubiti: the arterial anastomoses Rete cubiti: the arterial anastomoses of the elbowof the elbow

•• Brachial artery:Brachial artery: superior and inferior superior and inferior ulnar collateral arteriesulnar collateral arteries

•• Profunda brachii artery:Profunda brachii artery: medial and medial and radial collateral arteriesradial collateral arteries

•• Radial artery:Radial artery: radial recurrent arteryradial recurrent artery

•• Ulnar artery:Ulnar artery: ulnar recurrent artery,ulnar recurrent artery,recurrent interosseous artery recurrent interosseous artery (from (from posterior interosseous arteryposterior interosseous artery))

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The significance of this anastomosis system: a possibility of coThe significance of this anastomosis system: a possibility of collateralllateralcirculation in cases of injury or obliteration of the brachial acirculation in cases of injury or obliteration of the brachial artery. Thertery. The

collateral branches will supply the distal forearm structures wicollateral branches will supply the distal forearm structures with blood.th blood.

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N. cutaneus antibrachii medialisN. cutaneus antibrachii medialis

N. cutaneus antibrachii lateralis (from musculocutaneus nerve)N. cutaneus antibrachii lateralis (from musculocutaneus nerve)

Superficial nerves innervating the Superficial nerves innervating the elbow region and the forearmelbow region and the forearm

Knowledge on the nerves is important when cannulating superficiaKnowledge on the nerves is important when cannulating superficial veins.l veins.

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Biceps brachii tendonBiceps brachii tendon

PtPt

N. cutaneus antebrachii lateralisN. cutaneus antebrachii lateralisN. medianusN. medianus

N. ulnarisN. ulnaris

BicBic

FcUFcU

FcRFcR

Medial aspect of the elbowMedial aspect of the elbow

Brachial arteryBrachial artery

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PtPt

Lateral cutaneous nerve of forearmLateral cutaneous nerve of forearm Median nerveMedian nerve

Ulnar nerveUlnar nerve

BicBic

FcUFcU

FcRFcR

Two muscular Two muscular „„tunnelstunnels”” in the elbow region: 1. the median nerve runs through the in the elbow region: 1. the median nerve runs through the two heads of the pronator teres muscle; 2. the ulnar nerve runs two heads of the pronator teres muscle; 2. the ulnar nerve runs between the two heads between the two heads of the flexor carpi ulnaris muscle (the medial epicondyle may caof the flexor carpi ulnaris muscle (the medial epicondyle may cause compression, too.use compression, too.

Brachial arteryBrachial artery

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CHRONIC, UNTREATED OCCLUSION OF THE BRACHIAL ARTERYCHRONIC, UNTREATED OCCLUSION OF THE BRACHIAL ARTERYIN THE FOSSA CUBITI CAUSED ISCHEMIC DEGENERATION OF THEIN THE FOSSA CUBITI CAUSED ISCHEMIC DEGENERATION OF THE

FOREARM MUSCLES: VOLKMANNFOREARM MUSCLES: VOLKMANN’’S ISCHEMIC CONTRACTURES ISCHEMIC CONTRACTURE

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The wrist is the junction between The wrist is the junction between the forearm and the handthe forearm and the hand

•• The wrist has two surfaces: dorsal and palmar.The wrist has two surfaces: dorsal and palmar.

•• These surfaces guide the tendons to the hand.These surfaces guide the tendons to the hand.

•• The wrist also guides the nerves and blood The wrist also guides the nerves and blood vessels to the hand.vessels to the hand.

•• These functions are achieved through These functions are achieved through osteofascial compartments: the carpal tunnel on osteofascial compartments: the carpal tunnel on the anterior surface, and the dorsal tendon the anterior surface, and the dorsal tendon compartments on the posterior side. Tendons compartments on the posterior side. Tendons are surrounded by tendon sheaths.are surrounded by tendon sheaths.

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12

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56 2

Intertendinous junctions

Dorsal carpal Dorsal carpal tendon tendon

compartmentscompartmentsand sheathsand sheaths

1Retinaculum extensorum

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Dorsal carpal tendon sheathsDorsal carpal tendon sheaths(in six fascia compartments)(in six fascia compartments)

1

26

3 54

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Dorsal carpal tendon sheaths on the wrist, forming sixDorsal carpal tendon sheaths on the wrist, forming sixtendontendon--compartments, fixed by the extensor retinaculum.compartments, fixed by the extensor retinaculum.

RetinaculumRetinaculumextensorumextensorum

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2233

4455

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Radial arteryRadial artery

Cephalic veinCephalic vein

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Tendons and tendon sheaths on Tendons and tendon sheaths on the back of the wrist (R the back of the wrist (R →→ U)U)

•• M. abductor pollicis longus & extensor M. abductor pollicis longus & extensor pollicis brevis sheaths.pollicis brevis sheaths.

•• M. extensor carpi radialis longus & M. extensor carpi radialis longus & brevis sheaths.brevis sheaths.

•• M. extensor pollicis longus sheath.M. extensor pollicis longus sheath.

•• M. extensor digitorum & extensor M. extensor digitorum & extensor indicis: common sheath.indicis: common sheath.

•• M. extensor digiti minimi sheath.M. extensor digiti minimi sheath.

•• M. extensor carpi ulnaris sheath.M. extensor carpi ulnaris sheath.40

The anterior (volar) wrist regionThe anterior (volar) wrist region•• The wrist is bordered laterally by the flexor carpi radialis The wrist is bordered laterally by the flexor carpi radialis

(FCR) tendon; medially by the flexor carpi ulnaris (FCU) (FCR) tendon; medially by the flexor carpi ulnaris (FCU) tendon. In the middle we find the palmaris longus tendon. In the middle we find the palmaris longus (superficially) and the superficial and deep flexor digitorum (superficially) and the superficial and deep flexor digitorum (FD) tendons. Flexor pollicis longus (FPL) tendon runs (FD) tendons. Flexor pollicis longus (FPL) tendon runs deep on the radial side. The tendons, except FCU run in the deep on the radial side. The tendons, except FCU run in the carpal tunnel in their tendon sheaths.carpal tunnel in their tendon sheaths.

•• Median nerveMedian nerve: runs in the tunnel. Carpal tunnel syndrome !: runs in the tunnel. Carpal tunnel syndrome !

•• Ulnar nerve Ulnar nerve and and ulnar artery ulnar artery run medially, superficial to the run medially, superficial to the flexor retinaculum.flexor retinaculum.

•• Radial artery Radial artery and and nervenerve branches run laterally and dorsally branches run laterally and dorsally around the distal end of the radius through the foveola around the distal end of the radius through the foveola radialis (anatomical snuffradialis (anatomical snuff--box) towards the first dorsal box) towards the first dorsal interosseous space.interosseous space.

•• Minor medial structure is the Minor medial structure is the GuyonGuyon--tunneltunnel, which is , which is superficial, compared to the carpal tunnel.superficial, compared to the carpal tunnel. 41

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THE CARPAL TUNNELTHE CARPAL TUNNEL

The GuyonThe Guyon--tunneltunnel

•• The superficial branch of the ulnar The superficial branch of the ulnar nerve and the ulnar artery run together nerve and the ulnar artery run together radial to the pisiform bone. The are radial to the pisiform bone. The are protected by fibrous tissue of the protected by fibrous tissue of the palmar aponeurosis and also by the palmar aponeurosis and also by the palmaris brevis musclepalmaris brevis muscle. This space is . This space is the Guyonthe Guyon’’s tunnel. Injuries to the s tunnel. Injuries to the aponeurosis or to the muscle may aponeurosis or to the muscle may damage the artery and nerve.damage the artery and nerve.

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m. palmaris brevism. palmaris brevis

The location of GuyonThe location of Guyon’’s tunnel (ulnar nerve, s tunnel (ulnar nerve, ulnar artery; arrows)ulnar artery; arrows)

NNAA

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The structure of the palm and fingersThe structure of the palm and fingers

•• The hand and the fingers have palmar and dorsal The hand and the fingers have palmar and dorsal surfaces.surfaces.

•• The palmar surface consists of important tissue The palmar surface consists of important tissue layers: these layers are observable mainly in the layers: these layers are observable mainly in the mesothenar.mesothenar.

•• The muscles of the hand form muscular The muscles of the hand form muscular eminences: thenar and hypothenar; which eminences: thenar and hypothenar; which contain the muscles acting on the fingers.contain the muscles acting on the fingers.

•• Nerves give several thin branches (U, M, R).Nerves give several thin branches (U, M, R).•• Arteries are form the superficialArteries are form the superficial-- and deep and deep

palmar arches, and from a dorsal weaker artery palmar arches, and from a dorsal weaker artery system.system.

•• Veins form a palmar venous plexus.Veins form a palmar venous plexus.45

Palma manus: layersPalma manus: layers

Aponeurosis palmarisAponeurosis palmaris

Hypothenar Hypothenar

ThenarThenar

Dorsal extensor tendonsDorsal extensor tendons

abpb

fpb op

add

abdm

fdmb

op

io

ioio

io

io

ioio

lu

The skin of the palmThe skin of the palmis thick, connected tois thick, connected tothe aponeurosis bythe aponeurosis by

connective tissue bundles.connective tissue bundles.The skin is containing fatThe skin is containing fattissue, richly vascularizedtissue, richly vascularized

and innervated.and innervated.

Dorsal deep fasciaDorsal deep fascia

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Angiography: arterial phaseAngiography: arterial phase Angiography: venous phaseAngiography: venous phase

Ulnar a.Ulnar a.Radial a.Radial a.

Cephalic veinCephalic vein

Basilic veinBasilic vein

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Anatomical layers on the palm: (1) skin; (2) palmar aponeurosis;Anatomical layers on the palm: (1) skin; (2) palmar aponeurosis; (3) (3) superficial palmar arch and common digital nerves; (4) flexor tesuperficial palmar arch and common digital nerves; (4) flexor tendons and ndons and lumbrical muscles; (5) deep palmar arch, deep branch of the ulnalumbrical muscles; (5) deep palmar arch, deep branch of the ulnar nerve; r nerve;

(6) interosseus muscles and adductor pollicis muscle(6) interosseus muscles and adductor pollicis muscle

Aponeurosis palmarisAponeurosis palmaris Arcus palmaris superficialisArcus palmaris superficialis48

Palmar aponeurosis

Palmaris brevis muscle

Palmaris longus muscle

LAYERS OF THE PALM:LAYERS OF THE PALM:LAYER I.: Deep fascia and LAYER I.: Deep fascia and palmar aponeurosispalmar aponeurosis

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Common sheath of the flexors

Vagina tendinis musculi flexoris pollicis longi

Vagina tendinis musculi flexoris carpi radialis

Tendon sheaths

Layer II.:Layer II.:muscles and muscles and

tendonstendons

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Tendons and tendon sheathsTendons and tendon sheathson the palmar sideon the palmar side

•• M. flexor digitorum spfc. + profundus M. flexor digitorum spfc. + profundus common sheath: the sheath is continuous to common sheath: the sheath is continuous to the 5th finger, the other 3 sheaths commence the 5th finger, the other 3 sheaths commence again at the root of the fingers.again at the root of the fingers.

•• M. flexor pollicis longus sheath: continuous M. flexor pollicis longus sheath: continuous from the wrist to the tip of the pollex.from the wrist to the tip of the pollex.

•• M. flexor carpi radialis sheath: begins at the M. flexor carpi radialis sheath: begins at the wrist (carpal tunnel) ends at the insertion of wrist (carpal tunnel) ends at the insertion of the muscle.the muscle.

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Spfc. flexor tendons

Deep flexor tendons

Vincula tendinum

Layer III.: the bottom of the palm;Layer III.: the bottom of the palm;

the adductor pollicis and interosseithe adductor pollicis and interossei

Carpal tunnel open, structures dissected outCarpal tunnel open, structures dissected out

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DupuytrenDupuytren--contracture:contracture:degenerativedisease of degenerativedisease of the the palmar aponeurosispalmar aponeurosis. . Fibers running to the 4thFibers running to the 4thand 5th fingers are oftenand 5th fingers are oftenaffected. The fibrosisaffected. The fibrosispulls the finger intopulls the finger intoflexion.flexion.

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Structure of the fingersStructure of the fingers

•• Palmar surfacePalmar surface: : tendon sheaths for the flexor tendons tendon sheaths for the flexor tendons fixed to the phalanges. They end at the basis of the last fixed to the phalanges. They end at the basis of the last phalanx.phalanx.

•• Dorsal surfaceDorsal surface: flat tendons without sheaths, thin deep : flat tendons without sheaths, thin deep fascia and thin skin.fascia and thin skin.

•• Blood supplyBlood supply: proper digital arteries running on the : proper digital arteries running on the sides (with their veins).sides (with their veins).

•• Nerve supplyNerve supply: proper digital nerves (palmar and dorsal) : proper digital nerves (palmar and dorsal) running on the sides (U, M, R).running on the sides (U, M, R).

•• Pulp spacePulp space:: the tips of the fingers have connective the tips of the fingers have connective tissue septa from the skin to the deep fascia tissue septa from the skin to the deep fascia ––periosteum. Fat tissue is filling their spaces; very rich periosteum. Fat tissue is filling their spaces; very rich capillary network and rich sensory innervation with capillary network and rich sensory innervation with special, encapsulated nerve endings for discriminative special, encapsulated nerve endings for discriminative touch and pressure.touch and pressure. 54

Deep and superficial flexor tendonsDeep and superficial flexor tendons

The extensor tendonsThe extensor tendonsLocation of Location of pulp spacepulp space

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OBERSTOBERST--type anesthesiatype anesthesia(digital nerves)(digital nerves)

Maximilian OBERST (1849-1925) german

surgeon 56

Extensor tendonExtensor tendon

Osteofascial compartments on the ULOsteofascial compartments on the UL

•• Arm, Arm, fascia brachii: septum intermusculare mediale fascia brachii: septum intermusculare mediale & laterale.& laterale. Sulcus bicipitalis medialis & lateralis. Sulcus bicipitalis medialis & lateralis. Separation of flexor and extensor muscles.Separation of flexor and extensor muscles.

•• Forearm, Forearm, fascia antebrachii + membrana interossea:fascia antebrachii + membrana interossea:flexors, extensors, superficial and deep muscles are flexors, extensors, superficial and deep muscles are separated (no intermuscular septum).separated (no intermuscular septum).

•• Carpal tunnel (flexor retinaculum): Carpal tunnel (flexor retinaculum): m. flexor carpi m. flexor carpi radialis, m. flexor pollicis longus, m. flexor digitorum radialis, m. flexor pollicis longus, m. flexor digitorum spfc., m. flexor digitorum prof. + nervus medianus.spfc., m. flexor digitorum prof. + nervus medianus.

•• Tendinous compartments on the dorsal side of the Tendinous compartments on the dorsal side of the wrist, with the wrist, with the extensor retinaculum.extensor retinaculum.

•• Palmar aponeurosis: deep fascia.Palmar aponeurosis: deep fascia.57

Arm CTArm CT

19: humerus19: humerus23,25,21: m. 23,25,21: m.

tricepstriceps5: a. brachialis5: a. brachialis2: v. basilica2: v. basilica

9: v. cephalica9: v. cephalica27: n. medianus27: n. medianus

39: n. ulnaris39: n. ulnaris3: m. biceps3: m. biceps

6: m. brachialis6: m. brachialis

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Computer tomography at the level of the carpometacarpal jointsComputer tomography at the level of the carpometacarpal joints(1: V. metacarpal basis; 31: metacarpal bases; 7: os hamatum; 4:(1: V. metacarpal basis; 31: metacarpal bases; 7: os hamatum; 4: os os

capitatum; 28: os trapezoideum; 27: os trapezium)capitatum; 28: os trapezoideum; 27: os trapezium)

Canalis Canalis carpicarpi

hypothenarhypothenar

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ERBERB--DUCHENNE PARALYSIS (C5, 6): supraspinatus, infraspinatus,DUCHENNE PARALYSIS (C5, 6): supraspinatus, infraspinatus,biceps, deltoideus, teres minor, brachialis muscular palsies. biceps, deltoideus, teres minor, brachialis muscular palsies.

Arm is rotated medially, hand is pronated (arrows). May happenArm is rotated medially, hand is pronated (arrows). May happenalso during childbirth (obstetric paralysis).also during childbirth (obstetric paralysis).

PLEXUS INJURYPLEXUS INJURY

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Serratus anterior paralysisSerratus anterior paralysis(winging of scapula)(winging of scapula)

Nervus thoracicus longus paralysis (C5,6,7)Nervus thoracicus longus paralysis (C5,6,7)

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The multisegmental innervation The multisegmental innervation of UL muscles (examples)of UL muscles (examples)

•• M. biceps brachii, m. brachialis: C 5,6M. biceps brachii, m. brachialis: C 5,6

•• M. triceps brachii: C 6,7,8M. triceps brachii: C 6,7,8

•• M. flexor carpi ulnaris: C 7,8M. flexor carpi ulnaris: C 7,8

•• M. flexor carpi radialis: C 6,7M. flexor carpi radialis: C 6,7

•• M. flexor digitorum spfc., prof.: C 7,8, T1M. flexor digitorum spfc., prof.: C 7,8, T1

•• M. flexor pollicis longus: C 8, T1M. flexor pollicis longus: C 8, T1

•• M. ext. carpi radialis longus, brevis: C 6,7M. ext. carpi radialis longus, brevis: C 6,7

•• M. extensor digitorum: C 7,8M. extensor digitorum: C 7,862

Images: Sobotta atlas

Radiological anatomy of the ULRadiological anatomy of the UL

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Severe trauma of the UL Severe trauma of the UL –– surgicalsurgicaltreatmenttreatment……

Forearm reconstruction after accidentForearm reconstruction after accident66

Picture sourcesPicture sources

•• SOBOTTA Atlas, Medicina, 2007SOBOTTA Atlas, Medicina, 2007

•• Abrahams, Craven, Lumley: Illustrated clinical Abrahams, Craven, Lumley: Illustrated clinical anatomy. Hodder Arnold, 2005anatomy. Hodder Arnold, 2005

•• Ihnatsenka B, Boezaart AP: Int J Shoulder Surg Ihnatsenka B, Boezaart AP: Int J Shoulder Surg 2010, 4: 632010, 4: 63--7070

•• Weir, Abrahams: Imaging atlas of human anatomy. Weir, Abrahams: Imaging atlas of human anatomy. MosbyMosby--Wolfe, 1997Wolfe, 1997

•• Thiel: Photographic atlas of practical anatomy. Thiel: Photographic atlas of practical anatomy. Springer, 1996Springer, 1996

•• Szeged Anatomy Department: anatomical figuresSzeged Anatomy Department: anatomical figures’’collectioncollection

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