The ExtremitiesThe ExtremitiesUpper and Lower ExtremitiesUpper and Lower Extremities

By Bien Eli Nillos, MDBy Bien Eli Nillos, MD

THE SCAPULATHE SCAPULA

TRIANGLE OF AUSCULTATIONTRIANGLE OF AUSCULTATION

►On the medial back, it is an area of On the medial back, it is an area of little muscle and hence a good place little 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, laterally Lateral Border: Teres Major, laterally

and deep.and deep.► Inferior Border (base): Latissimus DorsiInferior Border (base): Latissimus Dorsi

QUADRANGULAR SPACEQUADRANGULAR SPACE

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

► Inferior border: Teres Major Inferior border: Teres Major (anteriorly)(anteriorly)

► Lateral border: Lateral head Lateral border: Lateral head of the Tricepsof the Triceps

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

► CONTENTS: can be damaged CONTENTS: can be damaged with a fracture of the neck of with a fracture of the neck of the humerus.the humerus.

► Axillary NerveAxillary Nerve► Posterior Circumflex Humeral Posterior Circumflex Humeral

ArteryArtery

TRIANGULAR SPACETRIANGULAR SPACE

►Anterior aspect, medial to the neck of Anterior aspect, medial to the neck of the humerus. the 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: Circumflex Scapular CONTENTS: Circumflex Scapular Branch of the subscapular artery.Branch of the subscapular artery.

►From top to bottom, order of the From top to bottom, order of the Scapular MusclesScapular Muscles SupraspinatusSupraspinatus InfraspinatusInfraspinatus Teres MinorTeres Minor Teres MajorTeres Major

►WINGED SCAPULA: WINGED SCAPULA: Both the Serratus Both the Serratus Anterior and Anterior and Rhomboids insert Rhomboids insert on the medial on the medial aspect of the aspect of the scapula. If you lose scapula. If you lose this insertion, you this insertion, you can get winged can get winged scapula, where the scapula, where the scapula does not scapula does not stay in place and is stay in place and is raised a bit from raised a bit from the posterior wall.the posterior wall.

GLENOHUMERAL JOINTGLENOHUMERAL JOINT

►ROTATOR CUFF: The tendons of the ROTATOR CUFF: The tendons of the muscles surrounding the shoulder muscles surrounding the shoulder joint. They rotate the shoulder.joint. They rotate the shoulder. Anterior Border: Anterior Border: SubscapularisSubscapularis Superolateral Border: Head of the bicepsSuperolateral Border: Head of the biceps Posterior Border: Posterior Border: Infraspinatus and Infraspinatus and

Teres MinorTeres Minor Superior Border: Superior Border: SupraspinatusSupraspinatus

► The joint is covered on all sides except The joint is covered on all sides except inferiorly. Hence shoulder dislocations tend inferiorly. Hence shoulder dislocations tend to occur inferiorly.to occur inferiorly.

► In this case you have to watch for In this case you have to watch for damage damage to the axillary nerve and Posterior to the axillary nerve and Posterior Circumflex Humeral ArteryCircumflex Humeral Artery, both of which , both of which are directly inferior, in the Quadrangular are directly inferior, in the Quadrangular Space, because this is straight below the Space, because this is straight below the shoulder joint.shoulder joint.

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

Deltoid MuscleDeltoid Muscle

► It inserts on It inserts on the Deltoid the Deltoid Tuberosity Tuberosity of the of the humerus humerus and has and has multiple multiple actionsactions

►Anterior partAnterior part flexes and medially flexes and medially rotates the arm.rotates the arm.

►Posterior partPosterior part extends and laterally extends and laterally rotates the arm.rotates the arm.

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

PECTORALIS MAJORPECTORALIS MAJOR

►Clavicular Clavicular Head: It flexes Head: It flexes the arm.the arm.

►Sternocostal Sternocostal Head: It Head: It extends the extends the arm.arm.

THE AXILLATHE AXILLA

►Anterior Border:Anterior Border: The pectoralis major and The pectoralis major and minor, and the subclavius, plus investing fascia minor, and the subclavius, plus investing fascia (Clavipectoral fascia).(Clavipectoral fascia).

►Base of the Axilla:Base of the Axilla: The skin of the armpit, The skin of the armpit, superficial fascia.superficial fascia.

►Apex of the AxillaApex of the Axilla: The root of the neck, : The root of the neck, through which the brachial plexus of nerves and through which the brachial plexus of nerves and vessels travels.vessels travels.

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

► Posterior BorderPosterior Border: Subscapularis, Latissimus : Subscapularis, Latissimus Dorsi, and Teres Minor.Dorsi, and Teres Minor.

►CONTENTS:CONTENTS: The axillary arteryThe axillary artery The axillary veinThe axillary vein The Brachial PlexusThe Brachial Plexus The Axillary group of lymph nodesThe Axillary group of lymph nodes

AXILLARY ARTERYAXILLARY ARTERY

►1st Part of Axillary 1st Part of Axillary ArteryArtery: Above the : Above the pectoralis minor. Has pectoralis minor. Has 1 branch.1 branch. Superior Thoracic Superior Thoracic

ArteryArtery

►2nd Part of Axillary Artery2nd Part of Axillary Artery: Directly : Directly deep to the Pectoralis Minor. Has 2 deep to the Pectoralis Minor. Has 2 branches.branches. Thoracoacromial Artery (pierces Thoracoacromial Artery (pierces

clavipectoral fascia)clavipectoral fascia)►Deltoid Branch of ThoracoacromialDeltoid Branch of Thoracoacromial►Pectoralis Branch of Thoracoacromial.Pectoralis Branch of Thoracoacromial.

Lateral Thoracic Artery (aka External Lateral Thoracic Artery (aka External Mammary Artery) -- important source of Mammary Artery) -- important source of blood for mammary glands.blood for mammary glands.

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

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

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

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

Subscapular Artery -- largest branch which Subscapular Artery -- largest branch which supplies muscles of posterior wall (scapula)supplies muscles of posterior wall (scapula)►Circumflex Scapular Artery branches off and proceeds Circumflex Scapular Artery branches off and proceeds

posteriorly through the triangular space.posteriorly through the triangular space.►Thoracodorsal Artery travels along with thoracodorsal Thoracodorsal Artery travels along with thoracodorsal

nerve.nerve.

AXILLARY LYMPH NODESAXILLARY LYMPH NODES

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

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

► Pectoral Group:Pectoral Group: Drains the anterior thorax and Drains the anterior thorax and some of mammary glands. Assoc. with lateral some of mammary glands. Assoc. with lateral thoracic artery.thoracic artery.

► CENTRAL GROUP:CENTRAL GROUP: It receives the lymph from the It receives the lymph from the previous three groups. It forms the largest group previous three groups. It forms the largest group and is often palpable upon examination.and is often palpable upon examination.

► APICAL GROUP:APICAL GROUP: The only one above the pectoralis The only one above the pectoralis minor. It receives lymph from the central group as minor. It receives lymph from the central group as well as other locales, and dumps into the well as other locales, and dumps into the subclavian trunk.subclavian trunk.

The ArmThe ArmUpper ExtremitiesUpper Extremities

The HumerusThe Humerus

►Radial Groove: Radial Groove: The region of the The region of the humerus along humerus along which the radial which the radial nerve travels, just nerve travels, just posteroinferior to posteroinferior to the Deltoid the Deltoid TuberosityTuberosity

►CONTENTS of CONTENTS of Radial GrooveRadial Groove:: Radial NerveRadial Nerve Deep Brachial ArteryDeep Brachial Artery

►Surgical Neck of the HumerusSurgical Neck of the Humerus: The : The Axillary Nerve wraps around the Axillary Nerve wraps around the surgical neck of the humerus. Thus surgical neck of the humerus. Thus injuries to the neck can damage that injuries to the neck can damage that nervenerve

Cutaneous Innervation of the Cutaneous Innervation of the ArmArm

►Axillary NerveAxillary Nerve: Supplies the skin over the : Supplies the skin over the deltoid muscle.deltoid muscle.

►Radial NerveRadial Nerve: Posterior of arm and : Posterior of arm and forearm.forearm. The lateral dorsal aspect of the hand (posterior The lateral dorsal aspect of the hand (posterior

of thumb and index finger up to the DIP joint).of thumb and index finger up to the DIP joint).

►Medial Antebrachial Cutaneous NerveMedial Antebrachial Cutaneous Nerve: : Supplies much of the anterior skin of arm.Supplies much of the anterior skin of arm.

ForearmForearm

ANATOMICAL SNUFFBOXANATOMICAL SNUFFBOX

► In between the Extensor Pollicis Longus In between the Extensor Pollicis Longus and Extensor Pollicis Brevis. The Abductor and Extensor Pollicis Brevis. The Abductor Pollicis Longus is directly lateral to it.Pollicis Longus is directly lateral to it.

►The Radial Nerve runs over the superficial The Radial Nerve runs over the superficial part of the anatomical snuffbox, to part of the anatomical snuffbox, to innervate the lateral cutaneous hand.innervate the lateral cutaneous hand.

►The Radial Artery is the "floor" of the The Radial Artery is the "floor" of the snuffbox, snugged right on top of the snuffbox, snugged right on top of the Scaphoid bone.Scaphoid bone.

THE HANDTHE HAND

►The bones of the Carpus consist of the The bones of the Carpus consist of the Scaphoid, Lunate, Triquetral, Pisiform, Scaphoid, Lunate, Triquetral, Pisiform, Hamate, Capitate, Trapezoid, and the Hamate, Capitate, Trapezoid, and the Trapezium.Trapezium.

► A. LunateA. Lunate

Articulates with the Articulates with the Triquetral, Scaphoid, Triquetral, Scaphoid, Hamate, Capitate, and Hamate, Capitate, and Radius.Radius.

► B. TriquetralB. Triquetral

Articulates with the Articulates with the Hamate, Lunate, Hamate, Lunate, Pisiform, and the Ulna.Pisiform, and the Ulna.

► C. PisiformC. Pisiform

Articulates directly with Articulates directly with Triquetral bone, and Triquetral bone, and indirectly via cartilage indirectly via cartilage with the Ulna. with the Ulna.

► D. HamateD. Hamate

Also known as the Unciform Also known as the Unciform bone, it articulates with the bone, it articulates with the fourth an fifth metacarpals fourth an fifth metacarpals and the Triquetral.and the Triquetral.

► E. CapitateE. Capitate

The largest bone of the The largest bone of the wrist, it articulates with the wrist, it articulates with the Trapezoid, Hamate, Trapezoid, Hamate, Scaphoid, Lunate, and the Scaphoid, Lunate, and the second, third and fourth second, third and fourth Metacarpals.Metacarpals.

► F. TrapezoidF. Trapezoid

Articulates with the second Articulates with the second Metacarpal, Trapezium, Metacarpal, Trapezium, Capitate, and the Scaphoid.Capitate, and the Scaphoid.

►G. TrapeziumG. Trapezium

Articulates with the Articulates with the first and second first and second Metacarpal, Metacarpal, Trapezoid, and the Trapezoid, and the Scaphoid. Scaphoid.

►H. ScaphoidH. Scaphoid

Articulates with the Articulates with the Radius, Trapezius, Radius, Trapezius, Trapezoid, Capitate, Trapezoid, Capitate, and Lunate.and Lunate.

► Metacarpals (Palm)Metacarpals (Palm)

The Metacarpals join the wrist with the The Metacarpals join the wrist with the fingers. They are numbered 1 - 5 fingers. They are numbered 1 - 5 starting on the thumb side. They starting on the thumb side. They articulate with the Proximal Phalanges articulate with the Proximal Phalanges and when you clench your fist, it is the and when you clench your fist, it is the head of the Metacarpal that sticks out head of the Metacarpal that sticks out (knuckles).(knuckles).

► J. Proximal PhalangeJ. Proximal Phalange

This bone articulates with the Middle This bone articulates with the Middle Phalange (Distal in the Pollex) and the Phalange (Distal in the Pollex) and the Metatarsal. It can be found at the start Metatarsal. It can be found at the start of our finger.of our finger.

► K. Middle PhalangeK. Middle Phalange

The Middle Phalange can be found just The Middle Phalange can be found just below the Distal Phalange. Each finger below the Distal Phalange. Each finger has one except the Pollex (thumb) has one except the Pollex (thumb) which only has a distal and proximal.which only has a distal and proximal.

► L. Distal PhalangeL. Distal Phalange

The Distal Phalange is found at the end The Distal Phalange is found at the end of each finger.of each finger.

Lab ExerciseLab Exercise

► I. Tabulate all of the Muscles of the I. Tabulate all of the Muscles of the Upper Extremities: Describe according Upper Extremities: Describe according to ORIGIN, INSERTION, ACTION AND to ORIGIN, INSERTION, ACTION AND NERVE SUPPLYNERVE SUPPLY

► II. Draw the Antecubital Fossa, and II. Draw the Antecubital Fossa, and label the BOUNDARIES. Describe the label the BOUNDARIES. Describe the CONTENTS and their importance. CONTENTS and their importance.

► III. Be able to Describe the following III. Be able to Describe the following types of FRACTURES (DRAW each type)types of FRACTURES (DRAW each type) TransverseTransverse ObliqueOblique SpiralSpiral LongitudinalLongitudinal Segmental Fracture Segmental Fracture Open FractureOpen Fracture Close FractureClose Fracture

► IV. Describe what is Carpal Tunnel IV. Describe what is Carpal Tunnel Syndrome.Syndrome.

END OF LECTUREEND OF LECTURE