introduction to upper limb - aiims, rishikesh
TRANSCRIPT
![Page 1: Introduction to Upper limb - AIIMS, Rishikesh](https://reader030.vdocument.in/reader030/viewer/2022012514/618e72edf2f72b435c47c258/html5/thumbnails/1.jpg)
Introduction to
Upper limbDr Brijendra Singh
MBBS,MS,DNB,MNAMS
Professor & HoD Anatomy
AIIMS Rishikesh
1
![Page 2: Introduction to Upper limb - AIIMS, Rishikesh](https://reader030.vdocument.in/reader030/viewer/2022012514/618e72edf2f72b435c47c258/html5/thumbnails/2.jpg)
Learning objectives
At end of this session, students should be able to:
DESCRIBE
Contents of ant & post compartment of arm ,
Brachial plexus
Nerves ,blood vessels & their anatomical Relations with
clinical importance
2
![Page 3: Introduction to Upper limb - AIIMS, Rishikesh](https://reader030.vdocument.in/reader030/viewer/2022012514/618e72edf2f72b435c47c258/html5/thumbnails/3.jpg)
3
Week 5
RULE -Limbs are outgrowths of the ventral body wall that undergo distal growth and differentiation…5th Week
Week 7
and rotation…7th week
![Page 4: Introduction to Upper limb - AIIMS, Rishikesh](https://reader030.vdocument.in/reader030/viewer/2022012514/618e72edf2f72b435c47c258/html5/thumbnails/4.jpg)
Anterior
Humerus
Posterior
Radius
Anterior
Posterior
5th metacarpal
Anterior
Forearm
Hand
Arm
Ulnar
4
Upper LimbMuscle
Compartments
Stern Essential of Gross Anatom
y
![Page 5: Introduction to Upper limb - AIIMS, Rishikesh](https://reader030.vdocument.in/reader030/viewer/2022012514/618e72edf2f72b435c47c258/html5/thumbnails/5.jpg)
Anterior
Humerus
Posterior
Radius
Anterior
Posterior
5th metacarpal
Anterior
Forearm
Hand
Arm
Ulnar
5
Stern Essential of Gross Anatom
y
No posterior compartment in the hand
Few muscles of posterior compartment are present in anterolateral aspect of forearm (*brachioradialis, supinator)
*
![Page 6: Introduction to Upper limb - AIIMS, Rishikesh](https://reader030.vdocument.in/reader030/viewer/2022012514/618e72edf2f72b435c47c258/html5/thumbnails/6.jpg)
AnteriorMusculocutaneous n.
Humerus
Radial n.
UlnaRadius
Median n. & Ulnar n.
Radial n.
5th metacarpal
Ulnar n. & Median n.
Anterior
Anterior
Posterior
Posterior
Posterior
Motor innervationMuscle Compartments
Stern Essential of Gross Anatom
y
![Page 7: Introduction to Upper limb - AIIMS, Rishikesh](https://reader030.vdocument.in/reader030/viewer/2022012514/618e72edf2f72b435c47c258/html5/thumbnails/7.jpg)
*
7
Developmentally-ventral muscles:• Lie anterior to the long bones in anatomical position
Developmentally-dorsal muscles: • Lie posterior to the long bones in anatomical position (* exceptions)
Stern Essential of Gross Anatom
y
RULE : Ventral vs. dorsal limb mm.
![Page 8: Introduction to Upper limb - AIIMS, Rishikesh](https://reader030.vdocument.in/reader030/viewer/2022012514/618e72edf2f72b435c47c258/html5/thumbnails/8.jpg)
Brachial Plexus(right side; simplified)
TerminalBranches
“Roots of BP”
(=ventral rami)C5C6
C7
C8
T1
Trunks
U
M
L
Cord
LatPost
Med
Divisions
Anterior (ventral) division
Posterior (dorsal) division8
Stern Essential of Gross Anatom
y
![Page 9: Introduction to Upper limb - AIIMS, Rishikesh](https://reader030.vdocument.in/reader030/viewer/2022012514/618e72edf2f72b435c47c258/html5/thumbnails/9.jpg)
Brachial Plexus(right side; simplified)
TerminalBranches
“Roots of BP”
(=ventral rami)C5C6
C7
C8
T1
Trunks
U
M
L
Cord
LatPost
Med
Divisions
Anterior (ventral) division
Posterior (dorsal) division9
Stern Essential of Gross Anatom
y
Radial n.
Musculocutaneous n.
Median n.
Ulnar n.
![Page 10: Introduction to Upper limb - AIIMS, Rishikesh](https://reader030.vdocument.in/reader030/viewer/2022012514/618e72edf2f72b435c47c258/html5/thumbnails/10.jpg)
Brachial plexus - cords
Lateral cord – LML – Lateral Pectoral n,
Musculocutaneous n, lateral root of Median n
Medial cord – MMMMU – Medial pectoral n, Medial
cutaneous n of forearm, Medial cutaneous n of arm ,
Ulnar n & Medial root of median n.
Posterior cord – LUNAR – Lower subscapular n, Upper
subscapular n , Nerve to latissimus dorsi, Axillary n
& Radial n.10
![Page 11: Introduction to Upper limb - AIIMS, Rishikesh](https://reader030.vdocument.in/reader030/viewer/2022012514/618e72edf2f72b435c47c258/html5/thumbnails/11.jpg)
Brachial plexus – supraclavicular branches
- roots & trunks
Branch to Phrenic nerve –C5 –anterior to sclaneus
anterior
Dorsal scapular n – C5 – pierces sclaneus medius,
supplies rhomboids & levator scapulae
Long thoracic n – C5C6C7 – (C7 – may be absent) upper
two roots C5C6 pierce sclaneus medius , runs b/w
sclaneus ant & medius – Supply - serratus anterior.
TRUNKS – Upper
Nerve to subclavius – Erb’s Point - C5 C6 –subclavius (
gives - accessory phrenic nerve –C5)
Suprascapular n- C5C6 – supra & infraspinatus , articular
– shoulder, acromioclavicular,11
![Page 12: Introduction to Upper limb - AIIMS, Rishikesh](https://reader030.vdocument.in/reader030/viewer/2022012514/618e72edf2f72b435c47c258/html5/thumbnails/12.jpg)
Brachial plexus-
Lateral pectoral n- C5C6C7 – LC -larger, pierces
clavipectoral fascia ,ant to axillary art- pectoralis
major & minor.
Medial pectoral n- C8T1-MC- , pierces pectoralis
minor & supplies both pectoralis major & minor.
Upper sub scapular n- smaller – frequently
double.
Lower sub scapular n- subscapularis & teres
major.
Axillary n- ant branch –deltoid & post branch- has
pseudoganglion supplies teres minor ,cutaneous –
as- upper lateral cutaneous nerve of arm .12
![Page 13: Introduction to Upper limb - AIIMS, Rishikesh](https://reader030.vdocument.in/reader030/viewer/2022012514/618e72edf2f72b435c47c258/html5/thumbnails/13.jpg)
C5
C7
C6
C8
T1
**
*suprascapular n.supraspinatus
& infraspinatus mm.
axillary n.
deltoid & teres minor mm.
upper subscapular n.thoracodorsal n.lower subscapular n.
subscapularis m.latissimus dorsi m.subscapularis & teres major mm.
Brachial Plexus(branches)
Stern Essential of Gross Anatom
y
![Page 14: Introduction to Upper limb - AIIMS, Rishikesh](https://reader030.vdocument.in/reader030/viewer/2022012514/618e72edf2f72b435c47c258/html5/thumbnails/14.jpg)
C5
C7
C6
C8
T1
radial n.
axillary n.
medial n.
musculoskeletal n.
suprascapular n.
upper subscapular n.thoracodorsal n.lower subscapular n.
medial pectoral n.
lateral pectoral n.
long thoracic n.
dorsal scapular n.
**
*
ulnar n.
rhomboid mm.
pectoralis mm.
pectoralis mm.
serratus anterior m.
Brachial Plexus(branches)
14
Stern Essential of Gross Anatom
y
![Page 15: Introduction to Upper limb - AIIMS, Rishikesh](https://reader030.vdocument.in/reader030/viewer/2022012514/618e72edf2f72b435c47c258/html5/thumbnails/15.jpg)
C5
C7
C6
C8
T1
Radial n.
Axillary n.
Medial n.
Musculoskeletal n.
Suprascapular n.
Upper & lower subscapular nn.Thoracodorsal n.
Medial pectoral n.
Lateral pectoral n.
Long thoracic n.
Dorsal scapular n.
**
*
Ulnar n.
Brachial Plexus(all branches)
* Nerve to subclavius** Medial brachial & antebrachial cutaneous nn.
15
Stern Essential of Gross Anatom
y
![Page 16: Introduction to Upper limb - AIIMS, Rishikesh](https://reader030.vdocument.in/reader030/viewer/2022012514/618e72edf2f72b435c47c258/html5/thumbnails/16.jpg)
Brachial plexus - cords
Lateral cord – LML – Lateral Pectoral n,
Musculocutaneous n, lateral root of Median n
Medial cord – MMMMU – Medial pectoral n, Medial
cutaneous n of forearm, Medial cutaneous n of arm ,
Ulnar n & Medial root of median n.
Posterior cord – LUNAR – Lower subscapular n, Upper
subscapular n , Nerve to latissimus dorsi, Axillary n
& Radial n.16
![Page 17: Introduction to Upper limb - AIIMS, Rishikesh](https://reader030.vdocument.in/reader030/viewer/2022012514/618e72edf2f72b435c47c258/html5/thumbnails/17.jpg)
Nerve supply of Scapula Muscles
Origin on Scapula:
Latissimus dorsi = Thoracodorsal nerve
Subscapularis, Teres Major = Subscapular nerves
Supraspinatus, Infraspinatus = Suprascapular nerves
Teres Minor = Axillary nerve
Insertion on Scapula
Levator Scapular, Rhomboids = Dorsal Scapular nerve
Pectoralis Minor = Pectoral n.
Serratus anterior = Long Thoracic n.
Trapezius = Accessory n.
![Page 18: Introduction to Upper limb - AIIMS, Rishikesh](https://reader030.vdocument.in/reader030/viewer/2022012514/618e72edf2f72b435c47c258/html5/thumbnails/18.jpg)
Branches of the Posterior Cord (continued)
Axillary Nerve ( w . Circumflex vs..)
Supplies:
Deltoid and Teres minor (motor supply )
Capsule of shoulder
skin of lower part covering deltoid (sensory
supply)
Subscapular Nerves {branches of C5 + C6 rami}
Innervates: Subscapularis, Teres major
Thoracodorsal Nerve (runs w. thoracodorsal vs)
supplies: Latissimus dorsi
![Page 19: Introduction to Upper limb - AIIMS, Rishikesh](https://reader030.vdocument.in/reader030/viewer/2022012514/618e72edf2f72b435c47c258/html5/thumbnails/19.jpg)
Muscles of Arm: Cross elbow, Move forearm
Two compartments 1. Anterior: Flexors of forearm &
2. Posterior: Extensors of forearm
Anterior Compartment – MCN +AA & BA
Biceps brachii = MC nerve
Brachialis = MC nerve
Coracobrachialis = MC nerve &
Brachioradialis = Radial nerve
Posterior Compartment – RN + PBA
Triceps brachii = Radial nerve
Anconeus = Radial nerve
![Page 20: Introduction to Upper limb - AIIMS, Rishikesh](https://reader030.vdocument.in/reader030/viewer/2022012514/618e72edf2f72b435c47c258/html5/thumbnails/20.jpg)
![Page 21: Introduction to Upper limb - AIIMS, Rishikesh](https://reader030.vdocument.in/reader030/viewer/2022012514/618e72edf2f72b435c47c258/html5/thumbnails/21.jpg)
![Page 22: Introduction to Upper limb - AIIMS, Rishikesh](https://reader030.vdocument.in/reader030/viewer/2022012514/618e72edf2f72b435c47c258/html5/thumbnails/22.jpg)
Muscles of
Scapula
• If ORIGIN on scapula =
• Move Arm
– Subscapularis
– Supraspinatus
– Infraspinatus
– Teres Minor
– Teres Major
– Latissimus Dorsi (partial O on scapula)
– Coracobrachialis
• If INSERTION on scapula =
• Move scapula
– Rhomboids
– Trapezius
– Pectoralis Minor
– Serratus Ventralis
– Levator Scapulae
Rotator Cuff
![Page 23: Introduction to Upper limb - AIIMS, Rishikesh](https://reader030.vdocument.in/reader030/viewer/2022012514/618e72edf2f72b435c47c258/html5/thumbnails/23.jpg)
Compartments of the forearm :
Flexor Compartment : Anterior
(Superficial + Deep layers)
Most of superficial flexors originate by a
common origin from medial epicondyle
Contains 2 pronators, are supplied by
Median, AIN and Ulnar nerves
2.Posterior Extensor Compartment : Posterior
(Superficial + Deep layers)
Are supplied by Radial and Posterior
interosseous nerve.
![Page 24: Introduction to Upper limb - AIIMS, Rishikesh](https://reader030.vdocument.in/reader030/viewer/2022012514/618e72edf2f72b435c47c258/html5/thumbnails/24.jpg)
![Page 25: Introduction to Upper limb - AIIMS, Rishikesh](https://reader030.vdocument.in/reader030/viewer/2022012514/618e72edf2f72b435c47c258/html5/thumbnails/25.jpg)
Anterior Compartment of Forearm
Superficial Muscles
Flexor digitorum superficialis Median
Flexor carpi radialis Median
Pronator teres Median
Palmaris longus Median
Flexor carpi ulnaris Ulnar
Deep Muscles
Pronator quadratus Ant.int N - Median
Flexor pollicis longus Ant.int.N - Median
Flexor digitorum profundus Ulnar (med 1/2)
Flexor digitorum profundus Ant.int.N - Median (lat 1/2)
Muscle Nerve
![Page 26: Introduction to Upper limb - AIIMS, Rishikesh](https://reader030.vdocument.in/reader030/viewer/2022012514/618e72edf2f72b435c47c258/html5/thumbnails/26.jpg)
Anterior Compartment Forearm
Flexor Carpi Radialis
Flexor Retinaculum
Medial Epicondyle
Flexor Digitorum Superficialis is deep to other flexors
Flexor Carpi Ulnaris
BrachioradialisPronator Teres
Anterior View
![Page 27: Introduction to Upper limb - AIIMS, Rishikesh](https://reader030.vdocument.in/reader030/viewer/2022012514/618e72edf2f72b435c47c258/html5/thumbnails/27.jpg)
Posterior Compartment of Forearm
Superficial
Extensor carpi radialis Longus & Brevis RN
Extensor digitorum (communis) RN
Extensor digiti minimi RN
Extensor carpi ulnaris RN
Deep (post gp) - PIN
Supinator Radial n + PIN
Abductor pollicis longus PIN
Extensor pollicis longus + brevis PIN
Extensor indicis PIN
Muscle Nerve
![Page 28: Introduction to Upper limb - AIIMS, Rishikesh](https://reader030.vdocument.in/reader030/viewer/2022012514/618e72edf2f72b435c47c258/html5/thumbnails/28.jpg)
Posterior Compartment of Forearm
Extensor digitorum
Extensor carpi ulnaris Ext Carpi Radialis Longus
Brachioradialis
Lateral Epicondyle
Posterior View
![Page 29: Introduction to Upper limb - AIIMS, Rishikesh](https://reader030.vdocument.in/reader030/viewer/2022012514/618e72edf2f72b435c47c258/html5/thumbnails/29.jpg)
![Page 30: Introduction to Upper limb - AIIMS, Rishikesh](https://reader030.vdocument.in/reader030/viewer/2022012514/618e72edf2f72b435c47c258/html5/thumbnails/30.jpg)
Muscles of Hand
Pinky (little finger)
All digiti minimi Ulnar
(Flexor, Abductor, Opponens)
Thumb
Abductor pollicis brevis Median
Flexor pollicis brevis Median
Opponens pollicis Median
Adductor pollicis Ulnar- deep br
Other Intrinsic Muscles
Palmar & Dorsal Interossei Ulnar
4 Lumbricals Median, Ulnar
Muscle Nerve
![Page 31: Introduction to Upper limb - AIIMS, Rishikesh](https://reader030.vdocument.in/reader030/viewer/2022012514/618e72edf2f72b435c47c258/html5/thumbnails/31.jpg)
Muscles of Hand
ABduction
Palmar Interossei
Lumbricals
ADDuction
1st
2nd
3rd
4th
Dorsal Interossei
Interossei help the lumbricals to extend I P joints and flex MC-P joints
![Page 32: Introduction to Upper limb - AIIMS, Rishikesh](https://reader030.vdocument.in/reader030/viewer/2022012514/618e72edf2f72b435c47c258/html5/thumbnails/32.jpg)
The Axilla
![Page 33: Introduction to Upper limb - AIIMS, Rishikesh](https://reader030.vdocument.in/reader030/viewer/2022012514/618e72edf2f72b435c47c258/html5/thumbnails/33.jpg)
Axilla = Armpit
Region between arm and chest
Boundaries
Anterior - pectoral muscles
Posterior = latissimus dorsi, teres major&
subscapularis
Medial = upper 4 ICS & serratus ant
Lateral = bicipital groove of humerus
Contents
Axillary lymph nodes, Axillary vessels ,Brachial
Plexus
![Page 34: Introduction to Upper limb - AIIMS, Rishikesh](https://reader030.vdocument.in/reader030/viewer/2022012514/618e72edf2f72b435c47c258/html5/thumbnails/34.jpg)
Upper Limb
![Page 35: Introduction to Upper limb - AIIMS, Rishikesh](https://reader030.vdocument.in/reader030/viewer/2022012514/618e72edf2f72b435c47c258/html5/thumbnails/35.jpg)
Upper Limb
Cubital Fossa
Contents
Median Cubital Vein
Brachial Artery
Median Nerve
Boundaries
Medial= Pronator teres
Lateral= Brachioradialis
Superior= Line between epicondyles
![Page 36: Introduction to Upper limb - AIIMS, Rishikesh](https://reader030.vdocument.in/reader030/viewer/2022012514/618e72edf2f72b435c47c258/html5/thumbnails/36.jpg)
![Page 37: Introduction to Upper limb - AIIMS, Rishikesh](https://reader030.vdocument.in/reader030/viewer/2022012514/618e72edf2f72b435c47c258/html5/thumbnails/37.jpg)
![Page 38: Introduction to Upper limb - AIIMS, Rishikesh](https://reader030.vdocument.in/reader030/viewer/2022012514/618e72edf2f72b435c47c258/html5/thumbnails/38.jpg)
Surface Anatomy
of Upper Limb
Anatomical Snuffbox
Lateral = APL & E
pol brevis
Medial = E. pollicis
longus
Floor = scaphoid,
styloid of radius
Contains Radial
Artery (pulse)
![Page 39: Introduction to Upper limb - AIIMS, Rishikesh](https://reader030.vdocument.in/reader030/viewer/2022012514/618e72edf2f72b435c47c258/html5/thumbnails/39.jpg)
UM
R
Test for Peripheral Nerve Sensory Function:
Ulnar n. – Tip of 5th digit (little finger)Median n. – Tip of 2nd digit (index finger)
Radial n. – Webbing b/w thumb & index finger (dorsum)
![Page 40: Introduction to Upper limb - AIIMS, Rishikesh](https://reader030.vdocument.in/reader030/viewer/2022012514/618e72edf2f72b435c47c258/html5/thumbnails/40.jpg)
40
M
U
R
C6
C7
C8
![Page 41: Introduction to Upper limb - AIIMS, Rishikesh](https://reader030.vdocument.in/reader030/viewer/2022012514/618e72edf2f72b435c47c258/html5/thumbnails/41.jpg)
Bicipital reflex (C6 cord level) Triceps reflex (C7 cord level)
acad
emic
.scr
anto
n.ed
u
Stretch Reflex
![Page 42: Introduction to Upper limb - AIIMS, Rishikesh](https://reader030.vdocument.in/reader030/viewer/2022012514/618e72edf2f72b435c47c258/html5/thumbnails/42.jpg)
IVD Root Sensory Loss Motor WeaknessC4-C5 C5 Shoulder Shoulder weakness
C5-C6 C6 Anterior upper arm, Forearm flexionLateral forearm, thumb Biceps reflex
C6-C7 C7 3rd digits Forearm extensionTriceps reflexWrist extensionHand grip
C7-C8 C8 5th digits Wrist flexionMedial forearm Intrinsic hand mm.
Source: Devinsky et al. Neurologic Pearls
UPPER LIMB RADICULAR SYNDROMES
Proximal
Distal
Cranial
Caudal