UPPER LIMB

Parts of upper limb

Shoulder region

• Pectoral / breast region

• Axilla / armpit

• Scapular region

Arm / brachium

Forearm / antebrachium

Hand

• Carpus / wrist

• Metacarpus / hand proper

• Digits

PECTORAL REGION

THE BREAST / MAMMARY GLAND

Mammary bed

Blood supply of Mammary Gland

Breast cancer may spread to the clavicle, humerus & cervical vertebrae by retrograde venous flow

Venous drainage of Mammary Gland

Lymphatic drainage of Mammary Gland

Those draining parenchyma of breast including areola and nipple

Subareolar plexus of Sappey

Those draining overlying skin excluding areola & nipple

Krukenberg’s tumour

Lymphatic drainage of Mammary Gland…

Milk Line

Amastia : bilateral agenesis of

mammary gland, a rare anomaly

Polymastia : accessory breast

Polythelia : supernumery nipples

Witch milk : fat free fluid in first one or

two weeks after birth by infant’s breast, due to

maternal oestrogen & foetal prolactin

Carcinoma of breast usually arises from

larger ductal epithelium, whereas distal

smaller ducts are the site of benign

fibro-adenoma

Accessory breast

Peau d’ orange – a condition where hoir follicles appear to be retrected &

caused by obstruction of cutaneous lymphatics with stagnation of lymph & oedema of skin around the hair follicle resembles skin of an orange

Clavicle

The female clavicle is shorter,

thinner, less curved and

smoother, and its acromial end

is carried lower than the sternal

in comparison with the male

Muscles of pectoral region

Structures piercing Clavipectoral fascia :

Cephalic vein

Lateral pectoral nerve

Thoraco-acromial vessels

Lymphatics

Scapula

Muscles of Scapular Region

Intermuscular spaces

Superficial muscle of back

AXILLA (armpit)

BRACHIAL PLEXUS

Spinal Nerve

Brachial plexus injury

Erb’s Palsy

Klumpke’ Palsy

• Horner’s syndrome :

Ptosis

Miosis

Anhydrosis

Enophthalmos

Loss of ciliospinal reflex

Winging of scapula

Winging of right scapula

Arm

(or circumflex nerve)

(pseudoganglion)

RADIAL NERVE

Radian Nerve Injury:

In Axilla

• Crutch palsy

• Saturday night palsy

In Spiral groove

• # shaft humerus

• Prolonged application of torniquet

Wrist drop

MEDIAN NERVE (Labourer’s nerve)

Median Nerve Injury:

• Carpal tunnel syndrome

• Ape thumb deformity

• Pointing Index

ULNAR NERVE (Musician Nerve)

Ulnar claw hand

Blood supply to upper limb

( Radial artery )

( Ulnar artery )

Cubital fossa

A triangular depressed area in front of elbow

Boundries:

• Medial • Lateral • Base • Apex • Floor-brachialis & supinator • Roof

CONTENTS (ML)

• Median nerve • Bifurcation of brachial artery • Biceps tendon • Radial nerve

(lateral)

(medial)

FLEXOR REINACULUM

Skeleton of Hand

SHOULDER JOINT

Closed packed with full congruency of articulating bone in abduction & lateral

rotation

Ligaments

Glenoid labrum

Fibrous capsule

Gleno- humeral ligament

Coraco-humeral ligament

Transverse humeral ligiment

Arterial supply :

• Anterior & postetior circumflex humeral arteries

• Suprascapular artery

Nerve supply:

• Axillary (circumflex) nerve - lower & anterior part

• Suprascapular nerve - upper & posterior part

• Lateral pectoral nerve - upper & anterior part

Movemets:

Flexion, extension, abduction, adduction, Medial & lateral rotation,

circumduction

Stability of shoulder joint

Static stability: superior capsule

superior GH ligament

coraco-humeral ligament

Dynamic stability : SITS muscles keep the ball in contact with the socket (guardian of the joint)

In abduction of arm , lower weak part of capsule is supported by long

head of triceps

Glenoid labrum deepens the socket & prevent skidding of ball from its

socket

Upward displacement of humeral head is prevented by long tendon of

biceps & coracoacromial arch

Upper Limb- Applied Anatomy

Supracondylar fracture:

• Common in children

• Due to fall on out-streached hand

• Lower fragment often tilted backward

• Injury to brachial artery Volkmann’s ischemic contracture

Tennis elbow:

Abrupt pronation during tennis play may produce sprain or partial tear of

radial collateral ligament (ECRB) & manifested by pain and tenderness

over lateral condyle of humerus

Golfer’s Elbow: medial epicondylitis

Pulled elbow:

• Dislocation of head of radius through annular ligament

• Due to sudden traction on wrist or hand when forearm is semi-pronated

• Affects the children under six

Colles’ Fracture: • A # of distal end of radius, lower fragment

displaces upward & backward

• Due to fall on outstreached hand

• Produces a classical dinner fork deformity

Smith’s fracture: • Reverse of colles’ #

• Due to fall on back on hand

• Distal fragment displaces upward & forward

Bennett’s fracture • # of base of 1st metacarpal

• caused when thumb is forcefully abducted

• # is oblique & enters CMC joint of thumb causing joint instability

Dupuytren contracture :

• Contracture of palmar aponeurosis

• Flexion deformity of one or more finger due to

thickening & shortening of palmar aponeurosis

• Ring finger is most commonly affected (flexion at

MCP & PIP joints)

de Quervain’s tenovaginitis : (affected

tendon sheath)

• Inflammation of common sheath of AbPL & EPB

tendon

• Pain & swelling over radial styloid process

Common test in Upper Limb

1. Hawkins Kennedy impingment test :

Test – impingment for supraspinatus tendon

Procedure – patient sitting/standing. Forward flex shoulder to 90° & flex

elbow to 90°. Apply passive medial rotation

Positive sign – reproduction of symptoms

2. Pinch grip test :

Test – anterior interosseous nerve entrapment

Procedure - patient pinches tips of index finger & thumb together

Positive sign – inability to pinch the tip

3. Finkelstein test :

Test – tenosynovitis of AbPL & EPB tendons (de Quervain’s

tenosynovitis)

Procedure – patient make a fist with thumb inside. Passively

move wrist into ulnar deviation

Positive sign – reproduction of symptoms

4. Froment’s sign :

Test – ulnar nerve paralysis

Procedure – grip piece of paper b/w index finger & thumb. Pull

paper away

Positive sign – flexion of IP thumb joint as paper pulled away

5. Phalen’s (wrist flexion) test :

Test – median nerve pathology ; carpal tunnel syndrome

Procedure– place dorsal aspect of hand together with wrist flexed.

Hold for 1 min.

Positive sign – tingling in distribution of median nerve

6. Reverse phalen’ stest :

Test – median nerve pathology

Procedure – place palms of hands together with wrist extended.

Hold for 1 min.

Positive sign - tingling in distribution of median nerve