shoulder and pectoral region

8/14/2019 Shoulder and Pectoral Region

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Shoulder and PectoralShoulder and Pectoral

regionregion



THE SCAPULA THE SCAPULA

► Supraspinatus Fossa:Supraspinatus Fossa: Depression in theDepression in thescapula, above the scapular spine.scapula, above the scapular spine.

►

Infraspinatus Fossa:Infraspinatus Fossa: Depression in theDepression in thescapula, below the scapular spine.scapula, below the scapular spine.

► TRAPEZIUS MUSCLE: It is innervated by the TRAPEZIUS MUSCLE: It is innervated by thespinal accessory nerve. Hence with aspinal accessory nerve. Hence with acervical neck fracture, some people can stillcervical neck fracture, some people can still

shrug their shoulders, even though they'veshrug their shoulders, even though they'velost upper-limb innervation, due to residuallost upper-limb innervation, due to residualinnervation from this nerve.innervation from this nerve.



TRIANGLE OFTRIANGLE OF

AUSCULTATIONAUSCULTATION

►On the medial back, it is an area of On the medial back, it is an area of

little muscle and hence a good placelittle muscle and hence a good place

to listen to the lungs.to listen to the lungs.

►Medial Border: Trapezius muscleMedial Border: Trapezius muscle

►Lateral Border: Teres Major, laterallyLateral Border: Teres Major, laterally

and deep.and deep.

► Inferior Border (base): Latissimus DorsiInferior Border (base): Latissimus Dorsi



QUADRANGULAR SPACEQUADRANGULAR SPACE

► Just medial to the surgical neck of the humerus Just medial to the surgical neck of the humeruson the posterior side.on the posterior side.

► Superior border: Teres Minor (posteriorly)Superior border: Teres Minor (posteriorly)

►

Inferior border: Teres Major (anteriorly)Inferior border: Teres Major (anteriorly)► Lateral border: Lateral head of the TricepsLateral border: Lateral head of the Triceps

► Medial border: Long head of the TricepsMedial border: Long head of the Triceps

► CONTENTS: These guys can be damaged with aCONTENTS: These guys can be damaged with a

fracture of the neck of the humerus.fracture of the neck of the humerus. Axillary NerveAxillary Nerve

Posterior Circumflex Humeral ArteryPosterior Circumflex Humeral Artery



TRIANGULAR SPACETRIANGULAR SPACE

►Anterior aspect, medial to the neck of theAnterior aspect, medial to the neck of the

humerus.humerus.

►Lateral border: Long head of the triceps.Lateral border: Long head of the triceps.

►Upper border: Teres MinorUpper border: Teres Minor

►Lower border: Teres MajorLower border: Teres Major

►CONTENTS:CONTENTS: Circumflex Scapular BranchCircumflex Scapular Branch

of the subscapular artery.of the subscapular artery.



TRIANGULAR INTERVAL TRIANGULAR INTERVAL

►Between the two heads of the tricepsBetween the two heads of the triceps

muscle, inferior to the teres major.muscle, inferior to the teres major.

►

CONTENTS:CONTENTS:

Deep Brachial ArteryDeep Brachial Artery

andand Radial NerveRadial Nerve, both of which, both of which

continue along the radial groove of thecontinue along the radial groove of the

humerus.humerus.



SCAPULASCAPULA: The shoulder: The shoulder

blade.blade.► From top to bottom, order of the Scapular Muscles:From top to bottom, order of the Scapular Muscles:

SupraspinatusSupraspinatus

InfraspinatusInfraspinatus

Teres Minor Teres Minor

Teres Major Teres Major

► WINGED SCAPULAWINGED SCAPULA: Both the Serratus Anterior and: Both the Serratus Anterior andRhomboids insert on the medial aspect of theRhomboids insert on the medial aspect of thescapula. If you lose this insertion, you can get wingedscapula. If you lose this insertion, you can get wingedscapula, where the scapula does not stay in place andscapula, where the scapula does not stay in place and

is raised a bit from the posterior wall.is raised a bit from the posterior wall.



Deltoid MuscleDeltoid Muscle

► It inserts on the Deltoid Tuberosity of It inserts on the Deltoid Tuberosity of

the humerus and has multiple actionsthe humerus and has multiple actions

►

Anterior part flexes and mediallyAnterior part flexes and medially

rotates the arm.rotates the arm.

►Posterior part extends and laterallyPosterior part extends and laterally

rotates the arm.rotates the arm.

►Lateral fibers abduct the arm.Lateral fibers abduct the arm.



Abduction of the ArmAbduction of the Arm

►STEP I: Movement of supraspinatus andSTEP I: Movement of supraspinatus and

deltoid muscles, until the angle is about 80 atdeltoid muscles, until the angle is about 80 at

which point the acromion and greaterwhich point the acromion and greater

tubercle hit each other.tubercle hit each other.►STEP II:STEP II: Rotation of the ScapulaRotation of the Scapula, to get the, to get the

acromion process out of the way. Theacromion process out of the way. The

Serratus Anterior and Trapezius move theSerratus Anterior and Trapezius move the

inferior border of the scapula laterally.inferior border of the scapula laterally.



PECTORALIS MAJORPECTORALIS MAJOR

►Aids in both flexing and extending theAids in both flexing and extending the

arm, depending on part of muscle.arm, depending on part of muscle.

►

Clavicular HeadClavicular Head

: It flexes the arm.: It flexes the arm.

►Sternocostal Head:Sternocostal Head: It extends theIt extends the

arm.arm.



CLAVIPECTORAL FASCIACLAVIPECTORAL FASCIA

► Fascia separating the pectoralis major from pectoralisFascia separating the pectoralis major from pectoralisminor, and overlying the pecs, the serratus anterior,minor, and overlying the pecs, the serratus anterior,and latissimus dorsi muscles. It goes from the pec-and latissimus dorsi muscles. It goes from the pec-minor to the clavicle.minor to the clavicle.

► Perforations:Perforations: The The Cephalic VeinCephalic Vein goes through the membrane to becomegoes through the membrane to become

the axillary vein.the axillary vein. The The Thoracoacromial ArteryThoracoacromial Artery comes from axillary artery andcomes from axillary artery and

perfuses the deltoid and pec-minor muscles.perfuses the deltoid and pec-minor muscles.

► The subclavius muscle is completely invested by the The subclavius muscle is completely invested by thefascia, both anteriorly and posteriorly.fascia, both anteriorly and posteriorly.

► Costocoracoid LigamentCostocoracoid Ligament is the strongest part of theis the strongest part of thefascia, going from the 1st rib to the coracoid process.fascia, going from the 1st rib to the coracoid process.It travels along the lower border of the subclavius.It travels along the lower border of the subclavius.



CEPHALIC VEIN (CEPHALIC VEIN (CLINICAL)CLINICAL)

►A surgeon may pass a fine tubeA surgeon may pass a fine tube

through the Cephalic Vein ------>through the Cephalic Vein ------>

Axillary Vein ------> Subclavvian ------>Axillary Vein ------> Subclavvian ------>

SVC ------> Heart to withdraw blood.SVC ------> Heart to withdraw blood.



THE AXILLATHE AXILLA

► Borders of the Axilla:Borders of the Axilla: Anterior Border: The pectoralis major and minor, and theAnterior Border: The pectoralis major and minor, and the

subclavius, plus investing fascia (Clavipectoral fascia).subclavius, plus investing fascia (Clavipectoral fascia).

Base of the Axilla: The skin of the armpit, superficialBase of the Axilla: The skin of the armpit, superficial

fascia.fascia. Apex of the Axilla: The root of the neck, through which theApex of the Axilla: The root of the neck, through which the

brachial plexus of nerves and vessels travels.brachial plexus of nerves and vessels travels.

Medial Border: Serratus Anterior and intercostal muscles.Medial Border: Serratus Anterior and intercostal muscles.

Posterior Border: Subscapularis, Latissimus Dorsi, andPosterior Border: Subscapularis, Latissimus Dorsi, and

Teres Minor. Teres Minor.



THE AXILLATHE AXILLA

►CONTENTS:CONTENTS: The axillary artery The axillary artery

The axillary vein The axillary vein

The Brachial Plexus The Brachial Plexus

The Axillary group of lymph nodes The Axillary group of lymph nodes



AXILLARY ARTERY AXILLARY ARTERY

► Branches of the Axillary Artery.Branches of the Axillary Artery.► 1st Part of Axillary Artery:1st Part of Axillary Artery: Above the pectoralisAbove the pectoralis

minor. Has 1 branch.minor. Has 1 branch. Superior Thoracic ArterySuperior Thoracic Artery

► 2nd Part of Axillary Artery:2nd Part of Axillary Artery: Directly deep to theDirectly deep to thePectoralis Minor. Has 2 branches.Pectoralis Minor. Has 2 branches. Thoracoacromial ArteryThoracoacromial Artery (pierces clavipectoral fascia)(pierces clavipectoral fascia)

►Deltoid Branch of ThoracoacromialDeltoid Branch of Thoracoacromial ►Pectoralis Branch of ThoracoacromialPectoralis Branch of Thoracoacromial..

Lateral Thoracic ArteryLateral Thoracic Artery (aka External Mammary(aka External MammaryArtery) -- important source of blood for mammaryArtery) -- important source of blood for mammaryglands.glands.



AXILLARY ARTERY……AXILLARY ARTERY……

► 3rd Part of Axillary Artery:3rd Part of Axillary Artery: Below the pectoralisBelow the pectoralisminor. Has 3 branches.minor. Has 3 branches. Anterior Circumflex Humeral ArteryAnterior Circumflex Humeral Artery Posterior Circumflex Humeral ArteryPosterior Circumflex Humeral Artery -- passes through-- passes through

Quadrangular space along with the axillary nerve.Quadrangular space along with the axillary nerve.► And anterior and posterior circumflex humerals anastomoseAnd anterior and posterior circumflex humerals anastomose

with each other around the lateral neck of the humerus.with each other around the lateral neck of the humerus.

► The posterior circumflex also anastomoses with the deep The posterior circumflex also anastomoses with the deepbrachial artery.brachial artery.

Subscapular ArterySubscapular Artery -- largest branch which supplies-- largest branch which supplies

muscles of posterior wall (scapula)muscles of posterior wall (scapula)► Circumflex Scapular ArteryCircumflex Scapular Artery branches off and proceedsbranches off and proceeds

posteriorly through theposteriorly through the triangular spacetriangular space..

► Thoracodorsal ArteryThoracodorsal Artery travels along with thoracodorsal nerve.travels along with thoracodorsal nerve.



AXILLARY VEINAXILLARY VEIN

► The union of the basilic and deep brachial The union of the basilic and deep brachialveins. It then joins with the Cephalic Veinveins. It then joins with the Cephalic Veinto become the Subclavian Vein.to become the Subclavian Vein.

► It travels along theIt travels along the medial sidemedial side of theof theaxillary artery.axillary artery.

►Commonly receives tributaries from theCommonly receives tributaries from theThoraco-Epigastric VeinsThoraco-Epigastric Veins, an important, an important

collateral route for venous return, if thecollateral route for venous return, if theIVC becomes obstructed.IVC becomes obstructed.



THYROCERVICAL TRUNK THYROCERVICAL TRUNK

► An arterial branch that comes off the subclavian artery,An arterial branch that comes off the subclavian artery,before it turns into the Axillary Artery. It has the followingbefore it turns into the Axillary Artery. It has the followingbranches:branches:

► Transverse Cervical Artery:Transverse Cervical Artery: Turns into the Dorsal Turns into the DorsalScapular Artery.Scapular Artery. Dorsal Scapular Artery:Dorsal Scapular Artery: Branch on the posterior side, where itBranch on the posterior side, where it

supplies the Levator Scapulae and Rhomboids, along with thesupplies the Levator Scapulae and Rhomboids, along with theDorsal Scapular N.Dorsal Scapular N.

► The Suprascapular Artery:The Suprascapular Artery: Heads around the scapularHeads around the scapularnotch and anastomoses with thenotch and anastomoses with the circumflex artery circumflex artery to formto form

one of the main collateral channels around the scapula.one of the main collateral channels around the scapula. Suprascapular N. follows the suprascapular artery to supply to theSuprascapular N. follows the suprascapular artery to supply to the

supraspinatus and infraspinatus.supraspinatus and infraspinatus.



AXILLARY LYMPH NODESAXILLARY LYMPH NODES

► The apical group is the most crucial for The apical group is the most crucial forspreading of breast cancer. If it has gotten tospreading of breast cancer. If it has gotten tothe axillary group, you is in trouble.the axillary group, you is in trouble.

► Lateral Group:Lateral Group: Drains the upper limb.Drains the upper limb.Located near brachial artery.Located near brachial artery.

► Subscapular Group:Subscapular Group: Drains the scapularDrains the scapularregion and posterior thoracic wall.region and posterior thoracic wall.

►

Pectoral Group:Pectoral Group: Drains the anterior thoraxDrains the anterior thorax

and some of mammary glands. Assoc. withand some of mammary glands. Assoc. withlateral thoracic artery.lateral thoracic artery.



AXILLARY LYMPH NODES….AXILLARY LYMPH NODES….

►CENTRAL GROUP:CENTRAL GROUP: It receives the lymphIt receives the lymph

from the previous three groups. It forms thefrom the previous three groups. It forms the

largest group and is often palpable uponlargest group and is often palpable upon

examination.examination.►APICAL GROUP:APICAL GROUP: The only one above the The only one above the

pectoralis minor. It receives lymph from thepectoralis minor. It receives lymph from the

central group as well as other locales, andcentral group as well as other locales, and

dumps into the subclavian trunk.dumps into the subclavian trunk.



THE BRACHIAL PLEXUS OF THE BRACHIAL PLEXUS OF

NERVESNERVES

►CERVICAL ROOTS of the Plexus:CERVICAL ROOTS of the Plexus: Dorsal Scapular (C5)Dorsal Scapular (C5)

Long Thoracic Nerve (C5,C6,C7)Long Thoracic Nerve (C5,C6,C7)..►Runs along the Serratus Anterior superficially. YouRuns along the Serratus Anterior superficially. You

gotta watch it during a mastectomy -- it could be cutgotta watch it during a mastectomy -- it could be cutaccidentally.accidentally.

►CLINICAL -- if the Long Thoracic is accidentally cut,CLINICAL -- if the Long Thoracic is accidentally cut,

You will get You will get Winged ScapulaWinged Scapula. The long Thoracic will. The long Thoracic willno longer hold the Scapula in place, via Rhomboidsno longer hold the Scapula in place, via Rhomboidsand Serratus Anterior.and Serratus Anterior.




NERVESNERVES

►SUPERIOR TRUNK -- C5, C6, part of C4SUPERIOR TRUNK -- C5, C6, part of C4 Direct BranchesDirect Branches

►Suprascapular Nerve (C5,C6)Suprascapular Nerve (C5,C6)

►Subclavius Nerve (C5,C6)Subclavius Nerve (C5,C6)

ANTERIOR DIVISION ------> LATERAL CORDANTERIOR DIVISION ------> LATERAL CORD

POSTERIOR DIVISION ------> POSTERIORPOSTERIOR DIVISION ------> POSTERIOR

CORDCORD




NERVESNERVES

►MIDDLE TRUNK -- C7MIDDLE TRUNK -- C7 ANTERIOR DIVISION ------> LATERAL CORDANTERIOR DIVISION ------> LATERAL CORD


CORDCORD




NERVESNERVES

► INFERIOR TRUNK -- C8, L1INFERIOR TRUNK -- C8, L1 ANTERIOR DIVISION ------> MEDIAL CORDANTERIOR DIVISION ------> MEDIAL CORD


CORDCORD




NERVESNERVES

►LATERAL CORDLATERAL CORD Gives off theGives off the Lateral Pectoral Nerve.Lateral Pectoral Nerve.

(mammary glands)(mammary glands)

Becomes theBecomes the MUSCULOCUTANEOUSMUSCULOCUTANEOUSNERVE (C5,C6,C7).NERVE (C5,C6,C7).

Forms a branch with the medial cord, toForms a branch with the medial cord, to

form the Median Nerve.form the Median Nerve.




NERVESNERVES

►MEDIAL CORDMEDIAL CORD

Gives off the Medial Pectoral,Gives off the Medial Pectoral, MedialMedial

BrachiocutaneousBrachiocutaneous, and, and MedialMedial

Antebrachial CutaneousAntebrachial Cutaneous Nerves. (medialNerves. (medialaspect of arm)aspect of arm)

Forms a branch with the Lateral Cord, to formForms a branch with the Lateral Cord, to form

the Median Nerve.the Median Nerve.

Becomes theBecomes the ULNAR NERVE (C8,T1, someULNAR NERVE (C8,T1, someC7).C7).




NERVESNERVES

►POSTERIOR CORDPOSTERIOR CORD Gives off the Upper and LowerGives off the Upper and Lower

Subscapular Nerves, and theSubscapular Nerves, and the

Thoracodorsal NerveThoracodorsal Nerve.. Forms theForms the AXILLARY NERVE (C5,C6)AXILLARY NERVE (C5,C6)..

Becomes theBecomes the RADIAL NERVERADIAL NERVE

(C5,C6,C7,C8)(C5,C6,C7,C8)




NERVESNERVES

►MEDIAN NERVE:MEDIAN NERVE: Formed by theFormed by the

union of the anterior divisions of theunion of the anterior divisions of the

lateral and medial cords. It is thelateral and medial cords. It is the

bottom-middle part of the "M"bottom-middle part of the "M"




NERVES (clinical)NERVES (clinical)► DUCHENNE-ERB PARALYSIS:DUCHENNE-ERB PARALYSIS: Damage to theDamage to the

Upper Trunk of the Brachial PlexusUpper Trunk of the Brachial Plexus► Excessive downward traction of the arm during birth,Excessive downward traction of the arm during birth,

which can tear the upper trunk at its root.which can tear the upper trunk at its root.► This cuts off the suprascapular and subclavius This cuts off the suprascapular and subclavius

completely, as well as most of axillary nerve. Youcompletely, as well as most of axillary nerve. Youlose shoulder movement.lose shoulder movement.

► Symptom: The arm just droops there, mediallySymptom: The arm just droops there, mediallyrotated, elbow extended, shoulder adducted,rotated, elbow extended, shoulder adducted,forearm pronated.forearm pronated. Waiter's Tip Position.Waiter's Tip Position.

► Erb's Point:Erb's Point: The location of the superior trunk, The location of the superior trunk,where C5 and C6 unite, and where the Suprascapularwhere C5 and C6 unite, and where the Suprascapularand Subclavius are given off.and Subclavius are given off.




NERVES (clinical)NERVES (clinical)► KLUMPKE'S PARALYSIS:KLUMPKE'S PARALYSIS: Damage to the lowerDamage to the lower

trunk (C8-T1).trunk (C8-T1).► Loss of most of median and especiallyLoss of most of median and especially ulnar ulnar nerves.nerves.► Symptoms:Symptoms:

Clawed hands due to loss of innervation of intrinsicClawed hands due to loss of innervation of intrinsicmuscles (T1) of the hand.muscles (T1) of the hand.

Loss of sensation on medial aspect of arm, forearm, andLoss of sensation on medial aspect of arm, forearm, andhand (due to loss of ulnar nerve).hand (due to loss of ulnar nerve).

► Horner's Syndrome:Horner's Syndrome: Associated problem; cervicalAssociated problem; cervical

sympathetic paralysis, resulting in:sympathetic paralysis, resulting in: Constriction of pupils.Constriction of pupils.

► Enophthalmos -- apparent recession of eyeballs.Enophthalmos -- apparent recession of eyeballs.



THE ARMTHE ARM

► THE HUMERUSTHE HUMERUS► Radial Groove:Radial Groove: The region of the humerus along which the radial nerve The region of the humerus along which the radial nerve

travels, just posteroinferior to the Deltoid Tuberosity.travels, just posteroinferior to the Deltoid Tuberosity. CLINICAL: Thus a fracture in the middle of the radius could easily damage theCLINICAL: Thus a fracture in the middle of the radius could easily damage the

radial nerve.radial nerve. CONTENTS of Radial Groove:CONTENTS of Radial Groove:

► Radial NerveRadial Nerve ► Deep Brachial ArteryDeep Brachial Artery

► Surgical Neck of the Humerus:Surgical Neck of the Humerus: The The Axillary NerveAxillary Nerve wraps aroundwraps aroundthe surgical neck of the humerus. Thus injuries to the neck can damagethe surgical neck of the humerus. Thus injuries to the neck can damagethat nerve.that nerve.

► Cutaneous Innervation of the ArmCutaneous Innervation of the Arm► Axillary Nerve:Axillary Nerve: Supplies the skin over the deltoid muscle.Supplies the skin over the deltoid muscle.►

Radial Nerve:Radial Nerve: Posterior of arm and forearm.Posterior of arm and forearm. The lateral dorsal aspect of the hand (posterior of thumb and index finger up The lateral dorsal aspect of the hand (posterior of thumb and index finger upto the DIP joint).to the DIP joint).

► Medial Antebrachial Cutaneous Nerve:Medial Antebrachial Cutaneous Nerve: Supplies much of theSupplies much of theanterior skin of arm.anterior skin of arm.



THE ARMTHE ARM

► BRACHIAL ARTERY:BRACHIAL ARTERY: Supplies the arm.Supplies the arm.

► The The Deep Brachial ArteryDeep Brachial Artery comes off the brachialcomes off the brachial

artery to curl around the back of the humerus,artery to curl around the back of the humerus,

along the radial groove, to supply to the Triceps.along the radial groove, to supply to the Triceps.

Posterior Circumflex Humeral:Posterior Circumflex Humeral: Deep Brachial gives off Deep Brachial gives off

this branch, which goes back up arm to the Quadrangularthis branch, which goes back up arm to the Quadrangular

space.space.

Radial CollateralRadial Collateral andand Middle Collateral ArteriesMiddle Collateral Arteries

which join up with Radial Recurrent to form elbowwhich join up with Radial Recurrent to form elbowanastomoses.anastomoses.



THE ARMTHE ARM

►MUSCULOCUTANEOUS NERVEMUSCULOCUTANEOUS NERVE: The: Themajor innervator of the arm.major innervator of the arm.

► It goes straight through theIt goes straight through the

coracobrachialis muscle to innervate thecoracobrachialis muscle to innervate theanterior aspect of the brachialis.anterior aspect of the brachialis.

►Lateral Antebrachial CutaneousLateral Antebrachial CutaneousNerve:Nerve: After innervating the brachialis, itAfter innervating the brachialis, it

goes to the anterior arm to innervate thegoes to the anterior arm to innervate theskin of the anterior arm.skin of the anterior arm.



ARTERIAL ANASTOMOSESARTERIAL ANASTOMOSES

AROUND ELBOWAROUND ELBOW► Collateral Branches off the Ulnar ArteryCollateral Branches off the Ulnar Artery

Posterior Ulnar Recurrent Artery:Posterior Ulnar Recurrent Artery: Medial anastomoses withMedial anastomoses withInferior Ulnar Collateral.Inferior Ulnar Collateral.

Anterior Ulnar Recurrent Artery:Anterior Ulnar Recurrent Artery: Medial anastomoses withMedial anastomoses withSuperior Ulnar Collateral.Superior Ulnar Collateral.

► Collateral Branches off the Radial ArteryCollateral Branches off the Radial Artery Radial Recurrent Artery:Radial Recurrent Artery: Lateral anastomoses with RadialLateral anastomoses with Radial

CollateralCollateral► Collateral Branches off the Brachial Artery:Collateral Branches off the Brachial Artery:

Inferior Ulnar Collateral:Inferior Ulnar Collateral: (Ulnar Recurrent)(Ulnar Recurrent) Superior Ulnar Collateral:Superior Ulnar Collateral: (Ulnar Recurrent)(Ulnar Recurrent)

► Collateral Branches off the Deep Brachial Artery:Collateral Branches off the Deep Brachial Artery: Radial Collateral Artery:Radial Collateral Artery: (Radial Recurrent)(Radial Recurrent) Middle Collateral Artery:Middle Collateral Artery: Anastomoses with InterosseusAnastomoses with Interosseus

Recurrent, but there is variety.Recurrent, but there is variety.



ULNAR ARTERYULNAR ARTERY

►One of the terminal branches of theOne of the terminal branches of theBrachial Artery.Brachial Artery.

►Gives off theGives off the Common InterosseusCommon Interosseus

ArteryArtery, a short stub which divides into, a short stub which divides intotwo parts:two parts: Anterior Interosseus Artery:Anterior Interosseus Artery: SuppliesSupplies

the deep muscles of the flexor forearm.the deep muscles of the flexor forearm.

Posterior Interosseus Artery:Posterior Interosseus Artery: SuppliesSuppliesthe entire extensor forearm.the entire extensor forearm.



BREAK TIMEBREAK TIME



THE EXTENSOR FOREARMTHE EXTENSOR FOREARM

► BRACHIORADIALIS: CLINICAL -- it may become damagedBRACHIORADIALIS: CLINICAL -- it may become damagedduring a distal radial fracture, because it inserts on theduring a distal radial fracture, because it inserts on thestyloid process of the radius.styloid process of the radius.

► COMMON EXTENSOR TENDON:COMMON EXTENSOR TENDON: The origin of the The origin of thesuperficialsuperficial extensor forearm muscles. It hooks onto theextensor forearm muscles. It hooks onto the

lateral epicondylelateral epicondyle andand supracondylar ridgesupracondylar ridge of theof thehumerus.humerus.► POSTERIOR INTEROSSEUS NERVE:POSTERIOR INTEROSSEUS NERVE: The Deep Branch The Deep Branch

of the Radial Nerve. It innervates most muscles of theof the Radial Nerve. It innervates most muscles of theextensor forearm.extensor forearm.

► It pierces the supinator muscle to come into theIt pierces the supinator muscle to come into the

posterior forearm.posterior forearm.► It travels between the superficial and deep groups of It travels between the superficial and deep groups of

muscles in the posterior forearm.muscles in the posterior forearm.



THE EXTENSOR FOREARMTHE EXTENSOR FOREARM

►POSTERIOR INTEROSSEUSPOSTERIOR INTEROSSEUS

ARTERY:ARTERY: Supplies the extensorSupplies the extensor

forearm muscles and travels with theforearm muscles and travels with the

Posterior Interosseus Nerve. It is aPosterior Interosseus Nerve. It is abranch of the Common Interosseusbranch of the Common Interosseus

Artery, which comes from the UlnarArtery, which comes from the Ulnar

Artery.Artery.



EXTENSOR RETINACULUMEXTENSOR RETINACULUM

► The sheath that covers all of the extensor The sheath that covers all of the extensortendons going into the wrist.tendons going into the wrist.

► ORDER OF EXTENSOR TENDONS GOINGORDER OF EXTENSOR TENDONS GOINGINTO THE WRISTINTO THE WRIST Extensor Pollicis BrevisExtensor Pollicis Brevis Extensor Pollicis LongusExtensor Pollicis Longus Extensor Carpi Radialis LongusExtensor Carpi Radialis Longus Extensor Carpi Radialis BrevisExtensor Carpi Radialis Brevis

(Extensor Indices, concurrent with and deep to(Extensor Indices, concurrent with and deep toExtensor Digitorum)Extensor Digitorum) Extensor DigitorumExtensor Digitorum

► Extensor Digiti MinimiExtensor Digiti Minimi



ANATOMICAL SNUFFBOXANATOMICAL SNUFFBOX::

► In between theIn between the Extensor Pollicis LongusExtensor Pollicis Longus andand

Extensor Pollicis BrevisExtensor Pollicis Brevis. The. The Abductor Pollicis Abductor Pollicis

LongusLongus is directly lateral to it.is directly lateral to it.

►

The The

Radial NerveRadial Nerve

runs over the superficial partruns over the superficial part

of the anatomical snuffbox, to innervate theof the anatomical snuffbox, to innervate the

lateral cutaneous hand.lateral cutaneous hand.

► The The Radial ArteryRadial Artery is the "floor" of the snuffbox,is the "floor" of the snuffbox,

snugged right on top of the Scaphoid bone.snugged right on top of the Scaphoid bone. You can take a pulse in anatomical snuffbox, by You can take a pulse in anatomical snuffbox, by

palpating the radial artery against the Scaphoid bone.palpating the radial artery against the Scaphoid bone.

O OTHE FLEXOR FOREARM



THE FLEXOR FOREARMTHE FLEXOR FOREARM

► THE FLEXOR FOREARMTHE FLEXOR FOREARM► MEDIAN NERVE:MEDIAN NERVE: Lies in between theLies in between the flexor digitorumflexor digitorum

superficialissuperficialis andand flexor digitorum profundusflexor digitorum profundus in the forearm.in the forearm.► Travels into the hand deep to the Travels into the hand deep to the palmaris longus palmaris longus (right in the(right in the

middle, anterior surface), traveling through the carpal tunnel.middle, anterior surface), traveling through the carpal tunnel.► Supplies all of flexor forearm EXCEPT theSupplies all of flexor forearm EXCEPT the Flexor Carpi UlnarisFlexor Carpi Ulnaris andand

the medial half of thethe medial half of the Flexor Digitorum ProfundusFlexor Digitorum Profundus..► INJURY: Can be injured in wrist slashing and carpal tunnelINJURY: Can be injured in wrist slashing and carpal tunnel

syndrome.syndrome. Lost sensation to area supplied by median nerve in hand.Lost sensation to area supplied by median nerve in hand. Paralysis of long flexors of wrist (except the two ulnar flexors)Paralysis of long flexors of wrist (except the two ulnar flexors) Thenar muscles atrophy, with the result that opposition of thumb is Thenar muscles atrophy, with the result that opposition of thumb is

lost.lost.

Loss of pronation, depending on where the severance occurs (wrist orLoss of pronation, depending on where the severance occurs (wrist orelbow)elbow)

► SUMMARY OF INJURY: Very crippling: loss of action of thumb andSUMMARY OF INJURY: Very crippling: loss of action of thumb andcutaneous sensation on palm of hand.cutaneous sensation on palm of hand.



ULNAR NERVEULNAR NERVE

► In the forearm, it supplies theIn the forearm, it supplies the Flexor CarpiFlexor CarpiUlnarisUlnaris and the medial half of theand the medial half of the Flexor Flexor Digitorum ProfundusDigitorum Profundus..

► It passesIt passes superficialsuperficial to the flexor retinaculum.to the flexor retinaculum.►

INJURY: Commonly injured around the posteriorINJURY: Commonly injured around the posteriorof the medial epicondyle -- right where the funnyof the medial epicondyle -- right where the funnybone is.bone is. Claw-Hand:Claw-Hand: Paralysis of small muscles of handParalysis of small muscles of hand

supplied by Ulnar Nerve. This is the result of loss of supplied by Ulnar Nerve. This is the result of loss of control over intrinsic hand muscles, which supply thecontrol over intrinsic hand muscles, which supply the"balance" between the long flexor and extensor"balance" between the long flexor and extensortendons. Result is over-flexion of distal phalanges andtendons. Result is over-flexion of distal phalanges andextension of proximal phalanges.extension of proximal phalanges.



RADIAL NERVERADIAL NERVE

► Enters the forearm by traveling over the lateralEnters the forearm by traveling over the lateralepicondyle. Splits into two branches.epicondyle. Splits into two branches.

► Superficial Branch of the Radial Nerve:Superficial Branch of the Radial Nerve: Travels Travelsdeep to the brachioradialisdeep to the brachioradialis to go to the hand.to go to the hand.

► Deep Branch of the Radial Nerve --Deep Branch of the Radial Nerve -- Goes deepGoes deepback to posterior compartment, where it isback to posterior compartment, where it isPosterior Interosseus Nerve.Posterior Interosseus Nerve. thethe

► INJURY:INJURY: Wrist-DropWrist-Drop is the sign of radial nerveis the sign of radial nerveinjury.injury. It is the most frequently injured, due to breaks in theIt is the most frequently injured, due to breaks in the

middle of the humerus.middle of the humerus. Paralysis of the long extensors of the fingers.Paralysis of the long extensors of the fingers. Lateral (radial deviation) of hand is difficult.Lateral (radial deviation) of hand is difficult. Movement (extension and abduction) of thumb is difficult.Movement (extension and abduction) of thumb is difficult.



Intrinsic hand musclesIntrinsic hand muscles

► T1: INTRINSIC MUSCLEST1: INTRINSIC MUSCLES -- All intrinsic-- All intrinsicmuscles of the hand are supplied by T1 fibers,muscles of the hand are supplied by T1 fibers,whether from the Ulnar or Radial nerves.whether from the Ulnar or Radial nerves.

► LATERAL ANTEBRACHIAL CUTANEOUSLATERAL ANTEBRACHIAL CUTANEOUS

NERVE:NERVE: From the Musculocutaneous Nerve, itFrom the Musculocutaneous Nerve, itinnervates the lateral part of the anteriorinnervates the lateral part of the anteriorforearm.forearm.

► MEDIAL ANTEBRACHIAL CUTANEOUSMEDIAL ANTEBRACHIAL CUTANEOUS

NERVE:NERVE: From the medial cord of the brachialFrom the medial cord of the brachialplexus, it innervates the medial part of theplexus, it innervates the medial part of thecutaneous flexor forearm.cutaneous flexor forearm.



Arterial supplyArterial supply

► RADIAL ARTERY:RADIAL ARTERY: One of the terminal branches of the BrachialOne of the terminal branches of the BrachialArtery.Artery.

► Gives off the Deep Palmar Arch.Gives off the Deep Palmar Arch.

► Gives off the Dorsalis Pollicis and Dorsalis Indices Arteries.Gives off the Dorsalis Pollicis and Dorsalis Indices Arteries.

► CLINICAL --CLINICAL -- RADIAL PULSERADIAL PULSE: On the palmar lateral wrist, at the: On the palmar lateral wrist, at the

location of thelocation of the Radial TrioRadial Trio, you can feel the pulse., you can feel the pulse. The Radial Artery is found lateral to the The Radial Artery is found lateral to the Flexor Carpi RadialisFlexor Carpi Radialis andand FlexorFlexor

Pollicis LongusPollicis Longus tendons at this location in the wrist. Those are thetendons at this location in the wrist. Those are thecomponents of the radial trio.components of the radial trio.

► PATH: Then the radial artery goes to the floor of the anatomicalPATH: Then the radial artery goes to the floor of the anatomicalsnuffbox ------> through the adductor pollicis and dorsalsnuffbox ------> through the adductor pollicis and dorsal

interosseus muscles ------> deep palmar arch.interosseus muscles ------> deep palmar arch.



Arterial supplyArterial supply

►ULNAR ARTERY:ULNAR ARTERY: One of the terminalOne of the terminal

branches of the Brachial Artery.branches of the Brachial Artery.

►Does not Does not pass through the Flexorpass through the Flexor

Retinaculum.Retinaculum.

►Gives off the Superficial Palmar Arch.Gives off the Superficial Palmar Arch.



FLEXOR RETINACULUMFLEXOR RETINACULUM

► The sheath that contains the flexor tendons on The sheath that contains the flexor tendons onthe anterior wrist.the anterior wrist.

► Goes from the Trapezium to the Scaphoid.Goes from the Trapezium to the Scaphoid.

►CARPAL TUNNEL SYNDROME:CARPAL TUNNEL SYNDROME: The The MedianMedianNerveNerve passes deep to the flexor retinaculum. If passes deep to the flexor retinaculum. If it is entrapped, carpal tunnel syndrome results.it is entrapped, carpal tunnel syndrome results. Causes numbness and tingling in the lateral part of Causes numbness and tingling in the lateral part of

the hand supplied by the median nerve, and somethe hand supplied by the median nerve, and some

motor dysfunction.motor dysfunction. Treatment: Cut the flexor retinaculum and relieve Treatment: Cut the flexor retinaculum and relieve

the pressure.the pressure.



Flexor ……..Flexor ……..

► MOBILE WAD:MOBILE WAD: The lateral compartment of The lateral compartment of

the flexor forearm, which is more looselythe flexor forearm, which is more loosely

connected than the other compartments. Itconnected than the other compartments. It

contains two muscles:contains two muscles:

► BrachioradialisBrachioradialis

► Extensor Carpi Radialis LongusExtensor Carpi Radialis Longus

► PALMARIS LONGUS MUSCLE: Absent in aboutPALMARIS LONGUS MUSCLE: Absent in about

30% of people, and a good candidate for30% of people, and a good candidate forsurgicalsurgical tendon transferstendon transfers when it iswhen it is

present.present.



Flexors ……Flexors ……

► FLEXOR DIGITORUM:FLEXOR DIGITORUM: Acts differently than the extensorActs differently than the extensordigitorum.digitorum.

► Superficial Flexor Digitorum:Superficial Flexor Digitorum: Inserts on the distal phalanxInserts on the distal phalanxand crosses over the DIP joint.and crosses over the DIP joint.

► Profunda Flexor Digitorum:Profunda Flexor Digitorum: Inserts on the proximalInserts on the proximalphalanx and crosses over the PIP joint.phalanx and crosses over the PIP joint.

► SPACE OF PARONA:SPACE OF PARONA: The potential space between the The potential space between thesuperficial and deep groups of anterior muscles -- essentiallysuperficial and deep groups of anterior muscles -- essentiallybetween the Flexor Digitorum Superficialis and Flexorbetween the Flexor Digitorum Superficialis and FlexorDigitorum Profundus.Digitorum Profundus.

► FASCIA ANTEBRACHIALIS:FASCIA ANTEBRACHIALIS: Thick fascial plane over the Thick fascial plane over theanterior forearm.anterior forearm.

► INTEROSSEUS MEMBRANE:INTEROSSEUS MEMBRANE: Between the radius and ulna,Between the radius and ulna,the posterior limit to the anterior compartment. The Anteriorthe posterior limit to the anterior compartment. The AnteriorInterosseus Nerve and Artery, and the Flexor DigitorumInterosseus Nerve and Artery, and the Flexor DigitorumProfundus, are directly superficial to it.Profundus, are directly superficial to it.

JOINTS OF THE UPPERJOINTS OF THE UPPER



JOINTS OF THE UPPER JOINTS OF THE UPPER

EXTREMITY EXTREMITY ► Types of Joints: Joints are structures that connects bones Types of Joints: Joints are structures that connects bones

together.together.► Fibrous Joints:Fibrous Joints: Collagen joints.Collagen joints.

Suture of the skull.Suture of the skull. The The interosseus membraneinterosseus membrane between the radius and ulna. This is abetween the radius and ulna. This is a

type of type of syndesmosissyndesmosis -- i.e. a sheet of fibrous tissue.-- i.e. a sheet of fibrous tissue.

► Cartilaginous Joints:Cartilaginous Joints: Examples:Examples:

► Epiphyseal PlatesEpiphyseal Plates► Costochondral JointsCostochondral Joints► Intervertebral DiscIntervertebral Disc► Pubic SymphysisPubic Symphysis

Primary Cartilaginous Joints:Primary Cartilaginous Joints: SynchondrosesSynchondroses -- hyaline cartilage.-- hyaline cartilage. Secondary Cartilaginous Joints:Secondary Cartilaginous Joints: SymphysisSymphysis -- hyaline cartilage-- hyaline cartilage

along with fibrous tissue or fibrous cartilage.along with fibrous tissue or fibrous cartilage.



Joints of Upper extremity Joints of Upper extremity

► Types of Joints: Joints are structures that connects bones Types of Joints: Joints are structures that connects bonestogether.together.

► Fibrous Joints:Fibrous Joints: Collagen joints.Collagen joints. Suture of the skull.Suture of the skull. The The interosseus membraneinterosseus membrane between the radius and ulna. This is abetween the radius and ulna. This is a

type of type of syndesmosissyndesmosis -- i.e. a sheet of fibrous tissue.-- i.e. a sheet of fibrous tissue.

► Cartilaginous Joints:Cartilaginous Joints: Examples:Examples:

► Epiphyseal PlatesEpiphyseal Plates► Costochondral JointsCostochondral Joints► Intervertebral DiscIntervertebral Disc► Pubic SymphysisPubic Symphysis

Primary Cartilaginous Joints:Primary Cartilaginous Joints: SynchondrosesSynchondroses -- hyaline cartilage.-- hyaline cartilage. Secondary Cartilaginous Joints:Secondary Cartilaginous Joints: SymphysisSymphysis -- hyaline cartilage-- hyaline cartilage

along with fibrous tissue or fibrous cartilage.along with fibrous tissue or fibrous cartilage.



Joints of upper extremity Joints of upper extremity

► Synovial Joints:Synovial Joints: Characterized by four things.Characterized by four things.

► AA joint cavity joint cavity , filled with a viscous lubricant substance -- synovial fluid., filled with a viscous lubricant substance -- synovial fluid.► AA synovial membranesynovial membrane, which produces the synovial fluid to fill the joint, which produces the synovial fluid to fill the joint

cavity.cavity.► Articular cartilage Articular cartilage ►

\Fibrous Capsule\Fibrous Capsule Types of Synovial Joints Types of Synovial Joints

► Plane Joint Plane Joint -- moveable only in one axis, in one plane.-- moveable only in one axis, in one plane.► Hinge Joint Hinge Joint -- moveable only in one axis -- i.e. flexion and extension.-- moveable only in one axis -- i.e. flexion and extension.► Pivot Joint Pivot Joint -- moveable only in one axis -- i.e. rotation.-- moveable only in one axis -- i.e. rotation.► Condyloid Joint Condyloid Joint -- moveable in two axes -- i.e. flexion-extension, or-- moveable in two axes -- i.e. flexion-extension, or

abduction-adduction.abduction-adduction.

It is usually ellipsoid in shape.It is usually ellipsoid in shape.► Saddle Joint Saddle Joint -- two axes.-- two axes.► Ball and Socket Joint Ball and Socket Joint -- Multi-axis movement.-- Multi-axis movement.



Movements of jointsMovements of joints

► Synovial Joints:Synovial Joints: Characterized by four things.Characterized by four things.

► AA joint cavity joint cavity , filled with a viscous lubricant substance -- synovial fluid., filled with a viscous lubricant substance -- synovial fluid.► AA synovial membranesynovial membrane, which produces the synovial fluid to fill the joint, which produces the synovial fluid to fill the joint

cavity.cavity.► Articular cartilage Articular cartilage ►

\Fibrous Capsule\Fibrous Capsule Types of Synovial Joints Types of Synovial Joints

► Plane Joint Plane Joint -- moveable only in one axis, in one plane.-- moveable only in one axis, in one plane.► Hinge Joint Hinge Joint -- moveable only in one axis -- i.e. flexion and extension.-- moveable only in one axis -- i.e. flexion and extension.► Pivot Joint Pivot Joint -- moveable only in one axis -- i.e. rotation.-- moveable only in one axis -- i.e. rotation.► Condyloid Joint Condyloid Joint -- moveable in two axes -- i.e. flexion-extension, or-- moveable in two axes -- i.e. flexion-extension, or

abduction-adduction.abduction-adduction.

It is usually ellipsoid in shape.It is usually ellipsoid in shape.► Saddle Joint Saddle Joint -- two axes.-- two axes.► Ball and Socket Joint Ball and Socket Joint -- Multi-axis movement.-- Multi-axis movement.



Clinical….Clinical….

► CLINICAL -- Injuries / Diseases of the Joints:CLINICAL -- Injuries / Diseases of the Joints:► Dislocation:Dislocation: Complete loss of apposition betweenComplete loss of apposition between

two articular surfaces.two articular surfaces.► Subluxation:Subluxation: Partial dislocation; partial loss of Partial dislocation; partial loss of

apposition between two articular surfaces.apposition between two articular surfaces.► Osteoarthritis:Osteoarthritis: Degeneration of articular cartilageDegeneration of articular cartilage

and/or surfaces in weight-bearing joints, resultingand/or surfaces in weight-bearing joints, resultingfrom age and/or trauma.from age and/or trauma.

► Rheumatoid Arthritis:Rheumatoid Arthritis: Connective tissue disorderConnective tissue disorderaffecting the whole body, mainly affecting the smallaffecting the whole body, mainly affecting the small

joints in terms of joints. joints in terms of joints.► Gout:Gout: Painful inflammation of the joint from excessPainful inflammation of the joint from excess

uric acid, resulting sodium biurate deposits in joints.uric acid, resulting sodium biurate deposits in joints.



Movements of joints….Movements of joints….

► CONJUNCT ROTATION: Instinctive orCONJUNCT ROTATION: Instinctive or

automatic rotation of the forearm, asautomatic rotation of the forearm, as

demonstrated by Codman's paradox, wheredemonstrated by Codman's paradox, where

you hold your palm to your side, abduct it,you hold your palm to your side, abduct it,rotate it anteriorly, and bring it back to yourrotate it anteriorly, and bring it back to your

body, to discover that it is now facing thebody, to discover that it is now facing the

other way.other way.

► ADJUNCT ROTATION: Deliberate rotation of ADJUNCT ROTATION: Deliberate rotation of the joint, such as when you point your handsthe joint, such as when you point your hands

laterally and then try to abduct your arm.laterally and then try to abduct your arm.



GLENOHUMERAL JOINT:GLENOHUMERAL JOINT:

► ROTATOR CUFFROTATOR CUFF: The tendons of the muscles surrounding the shoulder: The tendons of the muscles surrounding the shoulder joint. They rotate the shoulder. joint. They rotate the shoulder. Anterior Border: SubscapularisAnterior Border: Subscapularis Superolateral Border: Head of the bicepsSuperolateral Border: Head of the biceps Posterior Border: Infraspinatus and Teres MinorPosterior Border: Infraspinatus and Teres Minor Superior Border: SupraspinatusSuperior Border: Supraspinatus

► CLINICAL: The joint is covered on all sides except inferiorly. HenceCLINICAL: The joint is covered on all sides except inferiorly. Henceshoulder dislocations tend to occur inferiorly.shoulder dislocations tend to occur inferiorly. In this case you have to watch for damage to theIn this case you have to watch for damage to the axillary nerveaxillary nerve andand

Posterior Circumflex Humeral ArteryPosterior Circumflex Humeral Artery, both of which are directly inferior,, both of which are directly inferior,in the Quadrangular Space, because this is straight below the shoulder joint.in the Quadrangular Space, because this is straight below the shoulder joint.

TEST for Axillary Nerve damage: Cutaneous sensation in the Deltoid region TEST for Axillary Nerve damage: Cutaneous sensation in the Deltoid region

► THREE DEGREES OF FREEDOM: Circumduction + Rotation. Hence it is a THREE DEGREES OF FREEDOM: Circumduction + Rotation. Hence it is amobile but unstable joint.mobile but unstable joint. The glenohumeral joint is an The glenohumeral joint is an incongruent incongruent joint -- note that the head of the joint -- note that the head of the

humerus does not fit in perfectly with the Glenoid Cavity of the Scapula.humerus does not fit in perfectly with the Glenoid Cavity of the Scapula.

► STABILIZING MUSCLES: TheSTABILIZING MUSCLES: The deltoid deltoid andand bicepsbiceps help stabilize thehelp stabilize theshoulder, due to the incongruence of the joint.shoulder, due to the incongruence of the joint.

ULNOHUMERAL JOINTULNOHUMERAL JOINT



ULNOHUMERAL JOINTULNOHUMERAL JOINT

(ELBOW)(ELBOW)

► Has higher stability and lower mobility: only one degreeHas higher stability and lower mobility: only one degreeof freedom (flexion / extension).of freedom (flexion / extension).

► The Humerus articulates only with the Ulna -- the radiusThe Humerus articulates only with the Ulna -- the radiushas nothing to do with it!has nothing to do with it!

► Radial Collateral LigamentRadial Collateral Ligament -- Lateral ligament support.-- Lateral ligament support.

► Ulnar Collateral LigamentUlnar Collateral Ligament -- Medial ligament support.-- Medial ligament support.

► CONGRUENCE: The Olecranon of the Ulna fits muchCONGRUENCE: The Olecranon of the Ulna fits muchbetter into the Olecranon Fossa of the Humerus, asbetter into the Olecranon Fossa of the Humerus, as

compared to the shoulder joint.compared to the shoulder joint.► Posterior Elbow: The joint capsule is lax on the posterior,Posterior Elbow: The joint capsule is lax on the posterior,

so that the elbow can flex and extend.so that the elbow can flex and extend.



ULNORADIAL JOINT (ELBOW)ULNORADIAL JOINT (ELBOW)

►Proximal Ulnoradial Joint:Proximal Ulnoradial Joint: AnnularAnnularLigamentLigament holds the Radial Head in placeholds the Radial Head in place

in the Radial Notch of the Ulna.in the Radial Notch of the Ulna.► Intermediate Ulnoradial Joint:Intermediate Ulnoradial Joint:

Interosseus MembraneInterosseus Membrane holds themholds themtogether along the shafts of both bones.together along the shafts of both bones.

►Distal Ulnoradial Joint:Distal Ulnoradial Joint: AnteriorAnterior andandPosterior Ulnoradial LigamentsPosterior Ulnoradial Ligaments..



RADIOCARPAL JOINT (WRIST)RADIOCARPAL JOINT (WRIST)

The Radius articulates with the Carpal Bones -- not the Ulna at all!The Radius articulates with the Carpal Bones -- not the Ulna at all! ► TWO DEGREES OF FREEDOM: We can circumduct the wrist. TWO DEGREES OF FREEDOM: We can circumduct the wrist.► Much of flexion (especially) and extension actually occurs at theMuch of flexion (especially) and extension actually occurs at the

Intercarpal JointsIntercarpal Joints between the two rows of Carpal Bones.between the two rows of Carpal Bones.► Joint of Knuckles and Fingers: Joint of Knuckles and Fingers:►

Carpometacarpal Joints:Carpometacarpal Joints:

Joints between distal row of carpal Joints between distal row of carpal

bones and metacarpals.bones and metacarpals.► Metacarpophalangeal (MCP) Joints:Metacarpophalangeal (MCP) Joints: The knuckles, between The knuckles, between

the metacarpals and proximal phalanges.the metacarpals and proximal phalanges.► Proximal Interphalangeal (PIP) Joints:Proximal Interphalangeal (PIP) Joints: Between theBetween the

proximal and middle phalanges.proximal and middle phalanges.►

Distal Interphalangeal (DIP) Joints:Distal Interphalangeal (DIP) Joints: Between the middleBetween the middleand distal phalanges (not present in thumb).and distal phalanges (not present in thumb).► THUMBTHUMB -- NOT A STABLE JOINT compared to the other fingers.-- NOT A STABLE JOINT compared to the other fingers.

The thumb has more mobility, too, to allow opposition. The thumb has more mobility, too, to allow opposition.



Break timeBreak time



THE HANDTHE HAND

► Movements of the Fingers:Movements of the Fingers:► Flexion and Extension of Fingers: Uses the fingernailsFlexion and Extension of Fingers: Uses the fingernails

as a fan.as a fan.

► Abduction and Adduction of Fingers: Uses theAbduction and Adduction of Fingers: Uses the

fingernails to slice through the air, centered aroundfingernails to slice through the air, centered aroundthe middle finger.the middle finger.

► THUMB: Same goes for thumb -- flexion, extension, THUMB: Same goes for thumb -- flexion, extension,abduction, and adduction are based on the position of abduction, and adduction are based on the position of the thumb-nail.the thumb-nail.

► Circumduction:Circumduction: The combination action of flexion, The combination action of flexion,extension, abduction, and adduction. Moving aroundextension, abduction, and adduction. Moving aroundin a circle, as you can do with your fingers, wrist, andin a circle, as you can do with your fingers, wrist, andshoulder.shoulder.

Force Transduction through theForce Transduction through the



Force Transduction through theForce Transduction through the

Hand and Arm:Hand and Arm:► Weight-bearing on the hand can beWeight-bearing on the hand can be

transmitted as follows:transmitted as follows: SCAPHOID ------> RadioCarpal joints ------> RADIUSSCAPHOID ------> RadioCarpal joints ------> RADIUS

------> Interosseus Membrane ------> ULNA ------>------> Interosseus Membrane ------> ULNA ------>Olecranon ------> HUMERUS ------> GlenohumeralOlecranon ------> HUMERUS ------> Glenohumeral

Joint ------> SCAPULA ------> Coracoclavicular Joint ------> SCAPULA ------> CoracoclavicularLigaments ------> CLAVICLELigaments ------> CLAVICLE

► The clavicle is the only bony articulationThe clavicle is the only bony articulationbetween the upper limb and trunk between the upper limb and trunk ..

►

Most common points of fracture in a fall:Most common points of fracture in a fall: The surgical neck of the humerus The surgical neck of the humerus The middle of the clavicle The middle of the clavicle



Common Wrist Fractures:Common Wrist Fractures:

►Colles Fracture:Colles Fracture: Fracture of theFracture of the

distal radius.distal radius.

►Scaphoid FracturesScaphoid Fractures: Fracture of the: Fracture of the

scaphoid bone.scaphoid bone.



Hand functions…Hand functions…

►Extrinsic Muscles of the Hands: MostlyExtrinsic Muscles of the Hands: Mostly

concerned with grip.concerned with grip.

► Intrinsic Muscles of the Hands: ConcernedIntrinsic Muscles of the Hands: Concerned

with manipulation of the digits. All of themwith manipulation of the digits. All of themare basically innervated by T1.are basically innervated by T1.

►PALMAR APONEUROSIS:PALMAR APONEUROSIS: Deep to the skinDeep to the skin

and fascia. It holds it down, so that the skinand fascia. It holds it down, so that the skin

on the palm is tight and hairless.on the palm is tight and hairless.



Clinical….Clinical….

►DUPUYTREN'S CONTRACTURE:DUPUYTREN'S CONTRACTURE:

Flexion of the 4th and 5th digits,Flexion of the 4th and 5th digits,

resulting from progressive shorteningresulting from progressive shortening

of the palmar aponeuroses, fromof the palmar aponeuroses, fromhypertrophy and hyperplasia.hypertrophy and hyperplasia.

Unknown cause.Unknown cause.



FIBROUS FLEXOR SHEATHSFIBROUS FLEXOR SHEATHS

►Strong sheath covering the long tendonsStrong sheath covering the long tendonsgoing into the hand, distal to the flexorgoing into the hand, distal to the flexorretinaculum.retinaculum.

►

The fibrous sheaths of the fingers The fibrous sheaths of the fingerscontain two tendons: The tendons of thecontain two tendons: The tendons of theFlexor Digitorum SuperficialisFlexor Digitorum Superficialis and theand theFlexor Digitorum ProfundusFlexor Digitorum Profundus..

► The fibrous sheath of the thumb The fibrous sheath of the thumbcontains one tendon: Thecontains one tendon: The Flexor PollicisFlexor PollicisLongus.Longus.



SYNOVIAL FLEXOR SHEATHSSYNOVIAL FLEXOR SHEATHS

►): The fibrous sheaths are enclosed in): The fibrous sheaths are enclosed in

synovial sheaths in areas where theresynovial sheaths in areas where there

is friction. Primarily:is friction. Primarily:

►Deep to the flexor retinaculum.Deep to the flexor retinaculum.

►Within the digits.Within the digits.

► There are NO SYNOVIAL SHEATHS in There are NO SYNOVIAL SHEATHS in

the central palm of the hand.the central palm of the hand.



Bursae…Bursae…

► RADIAL BURSA:RADIAL BURSA:

► Contains the Pollicis Longus tendon.Contains the Pollicis Longus tendon.

► Communicates with Ulnar Bursa in 50% of Communicates with Ulnar Bursa in 50% of

people.people.► ULNAR BURSA:ULNAR BURSA:

► Contains the Flexor Digitorum Superficialis andContains the Flexor Digitorum Superficialis and

Profundus tendons.Profundus tendons.

► Communicates with Radial Bursa in 50% of Communicates with Radial Bursa in 50% of people.people.



CLINICALCLINICAL

HORSESHOE INFECTION:HORSESHOE INFECTION: Infection spreadingInfection spreadingfrom little finger to thumb or vice versa, as afrom little finger to thumb or vice versa, as a

consequence of the communication between theconsequence of the communication between the

radial and ulnar bursae.radial and ulnar bursae.

DORSAL SUBCUTANEOUS SPACE will receiveDORSAL SUBCUTANEOUS SPACE will receive

lymph from the palmar aspect of the hand. Thuslymph from the palmar aspect of the hand. Thus

a hand-infection can easily result in swelling ona hand-infection can easily result in swelling on

posterior aspect of the hand, in which case itposterior aspect of the hand, in which case it

would be lymph -- not pus -- so don't incise it.would be lymph -- not pus -- so don't incise it.

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Arterial supply of handArterial supply of hand

►SUPERFICIAL PALMAR ARCH:SUPERFICIAL PALMAR ARCH: MainMainarterial supply to the hand.arterial supply to the hand.

►Literally it is formed by a continuationLiterally it is formed by a continuation

of the artery, and it anastomoses withof the artery, and it anastomoses withthe Superficial Palmar Branch of thethe Superficial Palmar Branch of theRadial Artery.Radial Artery.

► It gives off It gives off Common Palmar DigitalCommon Palmar DigitalArteries ------> Proper PalmarArteries ------> Proper PalmarDigital ArteriesDigital Arteries

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►DEEP PALMAR ARCH:DEEP PALMAR ARCH: Lies deep toLies deep to

the flexor retinaculum.the flexor retinaculum.

► This is formed by the radial artery, and This is formed by the radial artery, and

it anastomoses with the terminal ulnarit anastomoses with the terminal ulnarartery.artery.

► It gives off theIt gives off the Palmar MetacarpalPalmar Metacarpal

Arteries ------> Proper PalmarArteries ------> Proper PalmarDigital ArteriesDigital Arteries

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►DORSAL CARPAL ARCH:DORSAL CARPAL ARCH: From theFrom the

dorsal carpal branches of the Radialdorsal carpal branches of the Radial

and Ulnar arteries.and Ulnar arteries.

► It gives off theIt gives off the Dorsal MetacarpalDorsal MetacarpalArteries ------> Dorsal DigitalArteries ------> Dorsal Digital

ArteriesArteries..

hO h



Other parts …..Other parts …..

►THENAR SPACE:THENAR SPACE: The area deep to The area deep tothe 1st lumbrical muscle and the 2stthe 1st lumbrical muscle and the 2stflexor tendon, in the palm of the hand.flexor tendon, in the palm of the hand.

►MIDPALMAR SPACE:MIDPALMAR SPACE: The medial part The medial partof the deep palm of the hand, deep toof the deep palm of the hand, deep tothe rest of the flexor tendons. It is nextthe rest of the flexor tendons. It is nextto the Thenar Space.to the Thenar Space.

►A SEPTUM separates the Thenar fromA SEPTUM separates the Thenar fromMidPalmar spaces.MidPalmar spaces.

CUTANEOUS INNERVATION OFCUTANEOUS INNERVATION OF



CUTANEOUS INNERVATION OFCUTANEOUS INNERVATION OF

HAND, FOREARM, ARMHAND, FOREARM, ARM► Axillary N:Axillary N:

Shoulder and Deltoid regionsShoulder and Deltoid regions► Musculocutaneous N / Lateral Antebrachial Cutaneous N:Musculocutaneous N / Lateral Antebrachial Cutaneous N:

Lateral forearm (both posterior and anterior)Lateral forearm (both posterior and anterior)► Medial Antebrachial Cutaneous N:Medial Antebrachial Cutaneous N:

Medial Forearm (both posterior and anterior)Medial Forearm (both posterior and anterior)►

Radial N:Radial N: Central posterior arm and forearmCentral posterior arm and forearm Lateral 2/3 of posterior hand (up to middle of 4th digit or so) -- EXCEPT theLateral 2/3 of posterior hand (up to middle of 4th digit or so) -- EXCEPT the

finger tips!!finger tips!! Lateral part of the thumbLateral part of the thumb

► Median N:Median N: Lateral two thirds of anterior handLateral two thirds of anterior hand Fingertips of lateral 2/3 of posterior handFingertips of lateral 2/3 of posterior hand

► Ulnar N:Ulnar N: Medial third of the hand, both anterior and posterior.Medial third of the hand, both anterior and posterior.

LUMBRICALSLUMBRICALS



LUMBRICALS:LUMBRICALS:

► They provide stability to the digits. They provide stability to the digits.► They are They are anterior anterior to the Metacarpophalangeal (MCP) jointsto the Metacarpophalangeal (MCP) joints

(knuckles).(knuckles). So theySo they flex flex the knuckles.the knuckles.

► They are They are posterior posterior to the proximal and distal interphalangealto the proximal and distal interphalangeal(PIP and DIP) joints.(PIP and DIP) joints. So theySo they extend extend the distal phalanges.the distal phalanges.

► They originate from the tendon of the flexor digitorum They originate from the tendon of the flexor digitorumProfundus.Profundus.

► FUNCTION OF LUMBRICALS: They are rich inFUNCTION OF LUMBRICALS: They are rich in neuromuscularneuromuscularspindle organsspindle organs, and they are thought to give you, and they are thought to give youproprioceptionproprioception (spatial orientation) and(spatial orientation) and kinesthesiakinesthesia (sense(sense

of motion) of the digits, due to the tension placed on them byof motion) of the digits, due to the tension placed on them bythe digital tendons.the digital tendons.

► In other words, they allow you to know where your finger isIn other words, they allow you to know where your finger isand where it is going.and where it is going.

AND ENTRAPMENTAND ENTRAPMENT




NEUROPATHIESNEUROPATHIES

► SPACE OF PARONA COMPRESSION: Veins areSPACE OF PARONA COMPRESSION: Veins aresubject to compression when swelling orsubject to compression when swelling orfluid buildup occurs in any potential space.fluid buildup occurs in any potential space.

This causes blood to backflow, which causes This causes blood to backflow, which causes

the following course of events.the following course of events.► Ischemia ------> Necrosis ------> FibrosisIschemia ------> Necrosis ------> Fibrosis ► FASCIOTOMY:FASCIOTOMY: Cutting through the fasciaCutting through the fascia

which is causing the compartmentwhich is causing the compartmentsyndrome, thereby relieving the pressuresyndrome, thereby relieving the pressureand hopefully the compartment syndrome.and hopefully the compartment syndrome.

CLINICAL STUFF: FRACTURESCLINICAL STUFF: FRACTURESAND ENTRAPMENT




NEUROPATHIESNEUROPATHIES► SATURDAY NIGHT SYNDROME:SATURDAY NIGHT SYNDROME: Drunk person fallingDrunk person falling

asleep on elbow and hence on ulnar nerve. Wake up theasleep on elbow and hence on ulnar nerve. Wake up thenext morning and the ulnar nerve is dead.next morning and the ulnar nerve is dead.

► CORACOBRACHIALIS SYNDROME (N447):CORACOBRACHIALIS SYNDROME (N447): Loss of theLoss of theMusculocutaneous NerveMusculocutaneous Nerve where it runs through thewhere it runs through theCoracobrachialis MuscleCoracobrachialis Muscle. If the muscle dies, then nerve. If the muscle dies, then nerve

dies with it.dies with it.► YOU ALSO LOSE: YOU ALSO LOSE: Biceps, Brachialis, and LateralBiceps, Brachialis, and Lateral

Antebrachial Cutaneous Nerve Antebrachial Cutaneous Nerve..► LOST FUNCTION:LOST FUNCTION:

Lost flexion at elbow.Lost flexion at elbow. Weak supination due to supinator muscle.Weak supination due to supinator muscle.

► Lost sensation over lateral aspect of forearm (cutaneousLost sensation over lateral aspect of forearm (cutaneousinnervation of medial antebrachial cutaneous N.)innervation of medial antebrachial cutaneous N.)

CLINICAL STUFF: FRACTURESCLINICAL STUFF: FRACTURESAND ENTRAPMENT




NEUROPATHIESNEUROPATHIES► SUPINATOR CHANNEL SYNDROME:SUPINATOR CHANNEL SYNDROME:

Compression of theCompression of the Deep Branch of the RadialDeep Branch of the RadialNerveNerve between thebetween the Superficial and Deep Heads of Superficial and Deep Heads of the Supinator, and the Lateral Epicondyle.the Supinator, and the Lateral Epicondyle.

► This occurs right at the This occurs right at the lateral epicondylelateral epicondyle, where, where

the Radial Nerve gives off two branches (Deep andthe Radial Nerve gives off two branches (Deep andSuperficial) to innervate the forearm.Superficial) to innervate the forearm.

► Arcade of Frohn:Arcade of Frohn: Occurs in 20%-30% of Occurs in 20%-30% of population, where one head of the Supinator ispopulation, where one head of the Supinator isactually a sharp tendon inserting on the lateralactually a sharp tendon inserting on the lateral

epicondyle. This can also lead to Radial N.epicondyle. This can also lead to Radial N.damage.damage.

CLINICAL STUFF: FRACTURESCLINICAL STUFF: FRACTURESAND ENTRAPMENTAND ENTRAPMENT




NEUROPATHIESNEUROPATHIES► SUPRACONDYLAR SYNDROME:SUPRACONDYLAR SYNDROME: EntrapmentEntrapment

of theof the Median N.Median N. beneath thebeneath the Ligament of Ligament of StruthersStruthers,, which connects thewhich connects the Supracondylar Supracondylar ProcessProcess to theto the Medial Epicondyle.Medial Epicondyle.

► The Supracondylar Process is a bit of bone The Supracondylar Process is a bit of bonesticking out the medial aspect of the humerus. Itsticking out the medial aspect of the humerus. Itis only present in a small fraction of population.is only present in a small fraction of population.

► LOSS OF FUNCTION AND SENSATION: AnywhereLOSS OF FUNCTION AND SENSATION: Anywherethe median N. innervates.the median N. innervates.

Lateral 2/3 of palm of hand, lost cutaneous sensation.Lateral 2/3 of palm of hand, lost cutaneous sensation.

Lose motor to the palmar thenar muscles.Lose motor to the palmar thenar muscles. Lose motor to the first two lumbricals.Lose motor to the first two lumbricals.





NEUROPATHIESNEUROPATHIES► PRONATOR TERES SYNDROME:PRONATOR TERES SYNDROME: Entrapment of Entrapment of

Median N.Median N. passing between the Deep andpassing between the Deep andSuperficial Heads of the Pronator Teres.Superficial Heads of the Pronator Teres.

► The Median N. also passes deep to the Flexor The Median N. also passes deep to the Flexor

Digitorum Superficialis tendon, right after it getsDigitorum Superficialis tendon, right after it getspast the Pronator Teres. This can also causepast the Pronator Teres. This can also causetrouble.trouble.

► LOSS OF FUNCTION and SENSATION: Again,LOSS OF FUNCTION and SENSATION: Again,whatever would happen if you lose the Median N.whatever would happen if you lose the Median N.See above.See above.





NEUROPATHIESNEUROPATHIES►MARTIN-GRUBER ANASTOMOSIS:MARTIN-GRUBER ANASTOMOSIS: ConnectionConnection

between the Median and Ulnar nerves in the palmbetween the Median and Ulnar nerves in the palm

of the hand, in about 30% of population. Whenof the hand, in about 30% of population. When

the connection is there, it is mainly a motorthe connection is there, it is mainly a motor

connection.connection.►Result = people with Ulnar N. damage may stillResult = people with Ulnar N. damage may still

have cutaneous anesthesia, but they may keephave cutaneous anesthesia, but they may keep

some motor function in the hand.some motor function in the hand.





NEUROPATHIESNEUROPATHIES► CARPAL TUNNEL SYNDROME:CARPAL TUNNEL SYNDROME: The The Median NerveMedian Nerve

passes deep to the flexor retinaculum. If it is entrapped,passes deep to the flexor retinaculum. If it is entrapped,carpal tunnel syndrome results.carpal tunnel syndrome results.

► Carpus is actually U-Shaped.Carpus is actually U-Shaped.► LOSS OF FUNCTION:LOSS OF FUNCTION:

Causes numbness and tingling in the lateral part of the handCauses numbness and tingling in the lateral part of the handsupplied by the median nerve.supplied by the median nerve. Weakening and wasting of the Thenar muscles.Weakening and wasting of the Thenar muscles.

► TREATMENT: Cut the flexor retinaculum and relieve the TREATMENT: Cut the flexor retinaculum and relieve thepressure.pressure.

► Superficial Palmar Branch of Median NSuperficial Palmar Branch of Median N does not godoes not go

through the Carpal Tunnelthrough the Carpal Tunnel. It results in an area of skin in. It results in an area of skin inthe middle of the palm that is not affected by Carpelthe middle of the palm that is not affected by Carpel

Tunnel Syndrome. Tunnel Syndrome.





NEUROPATHIESNEUROPATHIES► CUBITAL TUNNEL SYNDROME:CUBITAL TUNNEL SYNDROME: Compression of Compression of

thethe Ulnar NerveUlnar Nerve between the two heads of originbetween the two heads of origin

of theof the Flexor Carpi UlnarisFlexor Carpi Ulnaris..

► The The Pisiform bonePisiform bone, distally, acts as a lever in, distally, acts as a lever in

allow the flexor carpi ulnaris to flex the fingersallow the flexor carpi ulnaris to flex the fingersmore strongly.more strongly.

► LOSS OF FUNCTION: Medial two heads of the flexorLOSS OF FUNCTION: Medial two heads of the flexor

digitorum profundus and most of the intrinsicdigitorum profundus and most of the intrinsic

muscles of the hand.muscles of the hand.





NEUROPATHIESNEUROPATHIES► GUYON'S CANAL SYNDROME :GUYON'S CANAL SYNDROME : Compression of theCompression of the

Ulnar NerveUlnar Nerve inin Guyon's CanalGuyon's Canal, between the, between the Volar CarpalVolar CarpalLigament Ligament and theand the Flexor RetinaculumFlexor Retinaculum..

► Volar Carpal Ligament:Volar Carpal Ligament: Is superficial to the flexorIs superficial to the flexorretinaculum. The ulnar artery and nerve pass superficial toretinaculum. The ulnar artery and nerve pass superficial tothe flexor retinaculum but deep to the volar carpalthe flexor retinaculum but deep to the volar carpal

ligament.ligament.► CUBITAL TUNNEL -VS- GUYON'S CANAL:CUBITAL TUNNEL -VS- GUYON'S CANAL: In Guyon's Canal,In Guyon's Canal,

only the intrinsic muscles of the hand are lost, whereas inonly the intrinsic muscles of the hand are lost, whereas inCubital Tunnel Syndrome you also lose the innervation of Cubital Tunnel Syndrome you also lose the innervation of the medial half of the flexor digitorum profundus.the medial half of the flexor digitorum profundus.





NEUROPATHIESNEUROPATHIES► DUPUYTREN'S CONTRACTURE:DUPUYTREN'S CONTRACTURE: ProgressiveProgressive

shortening of the palmar aponeuroses, fromshortening of the palmar aponeuroses, fromhypertrophy and hyperplasia. Unknown cause.hypertrophy and hyperplasia. Unknown cause.

► Found esp. in those who have done a lot of manualFound esp. in those who have done a lot of manuallabor.labor.

► SYMPTOM: Tends to bring the medial two fingers inSYMPTOM: Tends to bring the medial two fingers intoward the palm and flex them downward a bit.toward the palm and flex them downward a bit.

► LOSS OF FUNCTION: Blood vessels that reach the skinLOSS OF FUNCTION: Blood vessels that reach the skinthrough the palmar aponeurosis are compromised!!!through the palmar aponeurosis are compromised!!!

►

TREATMENT: If caught early enough, incise the TREATMENT: If caught early enough, incise theaponeurosis.aponeurosis.





NEUROPATHIESNEUROPATHIES► TENOSYNOVITIS:TENOSYNOVITIS: Not to be messed with.Not to be messed with.

Inflammation of the tendons in the synovial joints,Inflammation of the tendons in the synovial joints,which can spread proximally all the way to the elbow.which can spread proximally all the way to the elbow.

► INFECTION CAN SPREAD from theINFECTION CAN SPREAD from the Ulnar BursaUlnar Bursa------> Carpal Tunnel------> Carpal Tunnel (with secondary carpal tunnel(with secondary carpal tunnelsyndrome)syndrome) ------> Space of Parona ------> Cubital------> Space of Parona ------> CubitalFossaFossa..

► Tenosynovitis in the index finger flexor tendon can Tenosynovitis in the index finger flexor tendon canrupture and get into therupture and get into the Thenar SpaceThenar Space, causing a, causing a

compartment syndrome there as well.compartment syndrome there as well.





NEUROPATHIESNEUROPATHIES► DEQUERVAIN'S DISEASE:DEQUERVAIN'S DISEASE: A specificA specific

tenosynovitis of the first extensor compartment,tenosynovitis of the first extensor compartment,which transmits the Extensor Pollicis Longus andwhich transmits the Extensor Pollicis Longus andBrevis.Brevis.

► Found in people who use their thumb a lot andFound in people who use their thumb a lot and

are not used to it.are not used to it.► SYMPTOM: Dull pain around wrist and lack of SYMPTOM: Dull pain around wrist and lack of

desire to move the fingers.desire to move the fingers.► Dequervain's test:Dequervain's test: Make a fist like a child withMake a fist like a child with

the thumb inside, and then ulnar deviatethe thumb inside, and then ulnar deviate(adduct) the wrist. It hurts even without the(adduct) the wrist. It hurts even without thedisease!disease!





NEUROPATHIESNEUROPATHIES► SCAPHOID FRACTURE:SCAPHOID FRACTURE: If the scaphoid isIf the scaphoid is

fractured, there is potential for avascularfractured, there is potential for avascularnecrosis in 1/3 of all people, because bloodnecrosis in 1/3 of all people, because bloodcomes from only one place -- the distal end.comes from only one place -- the distal end.

► This will result in demineralization of the This will result in demineralization of theScaphoid from lack of use, and it will appearScaphoid from lack of use, and it will appeardark on the X-Ray as a result.dark on the X-Ray as a result.

► When the fracture occurs in theWhen the fracture occurs in the neck neck of theof the

Scaphoid, blood supply is cut off to theScaphoid, blood supply is cut off to theproximal part.proximal part.





NEUROPATHIESNEUROPATHIES►TRIGGER FINGER:TRIGGER FINGER: Swelling of the fibrousSwelling of the fibrous

sheaths going around the tendons, such that,sheaths going around the tendons, such that,

when the tendon is on one side of the swelling,when the tendon is on one side of the swelling,

such that the finger is flexed, it will stay thatsuch that the finger is flexed, it will stay that

way and you can't extend it. Then you can pullway and you can't extend it. Then you can pullreal hard to get the tendon past thereal hard to get the tendon past the

"bottleneck" to the other side of the swelling,"bottleneck" to the other side of the swelling,

such that the finger extends, and then yousuch that the finger extends, and then you

can't flex it again!can't flex it again!





NEUROPATHIESNEUROPATHIES►RAYNAUD'S DISEASE:RAYNAUD'S DISEASE: Vascular problemVascular problem

of too high of sympathetic tone, which canof too high of sympathetic tone, which cancause complications in the hand.cause complications in the hand.

►Spasmodic vasoconstriction at the wristSpasmodic vasoconstriction at the wristwill cause one or two fingers to becomewill cause one or two fingers to becomecyanotic and ischemic.cyanotic and ischemic.

► You could cut the sympathetic nerves at You could cut the sympathetic nerves at

the neck to try and treat it.the neck to try and treat it.► It is a very serious disease.It is a very serious disease.





NEUROPATHIESNEUROPATHIES►VARUS:VARUS: A bone-fracture that createsA bone-fracture that creates

angulationangulation toward the midline of thetoward the midline of the

body body ..

►VALGUS:VALGUS: A bone-fracture that createsA bone-fracture that createsangulationangulation away from the midline of away from the midline of

the body the body ..





NEUROPATHIESNEUROPATHIES► TYPES OF FRACTURES: TYPES OF FRACTURES:► Transverse Transverse

► ObliqueOblique

► SpiralSpiral

► LongitudinalLongitudinal► Segmental Fracture:Segmental Fracture: Broken bone in two or moreBroken bone in two or more

places, creating pieces of bone between the fractures.places, creating pieces of bone between the fractures.

► Open FractureOpen Fracture -- fracture within an exposed wound-- fracture within an exposed woundand hence vulnerable to infection.and hence vulnerable to infection.

► Close FractureClose Fracture -- not exposed by a wound and hence-- not exposed by a wound and hencenot susceptible to infection.not susceptible to infection.



Thank you Thank you

shoulder and pectoral region

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