1 Anatomy Review What makes us move? Anatomy Review What makes us move? Rennie Jacobs, PhD, LOTR, CHT 1 Objectives Objectives ¾ Provide a review of the anatomy pertinent to the field of occupational therapy. ¾ Provide knowledge pertaining to the neuromuscular system and vascular system, as well as osteokinematics and arthrokinematics associated with the upper quadrant. ¾ Provide clinical correlations that are rooted in anatomy, including where anatomical variations lead to clinical manifestations. 2 THE CADAVER IS THE BEST TOOL FOR LEARNING GROSS ANATOMY TO LEARN MORE ABOUT CADAVERS, READ 4 2 WAYS TO STUDY GROSS ANATOMY Regional Anatomy: Studying all the structures in an area together; e.g., the lower extremity includes bones, muscles, nerves, and vessels. Systemic Anatomy: Studying a complete system independent of region. •Skeletal (bones) •Muscular •Neurovascular •Cardiovascular (heart, blood) Regional Anatomy Regional Anatomy Head/neck Thorax Abdomen Pelvis/perineum Back Upper limb Lower limb Regions of the Body 6
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1
Anatomy ReviewWhat makes us move? Anatomy ReviewWhat makes us move?
Rennie Jacobs, PhD, LOTR, CHT
1
ObjectivesObjectivesProvide a review of the anatomy pertinent to the field of occupational therapy.
Provide knowledge pertaining to the neuromuscular system and vascular system, as well as osteokinematics and arthrokinematicsassociated with the upper quadrant.
Provide clinical correlations that are rooted in anatomy, including where anatomical variations lead to clinical manifestations.
2
THE CADAVER IS THE BEST TOOL FOR LEARNING GROSS ANATOMY
TO LEARN MORE ABOUT CADAVERS, READ4
2 WAYS TO STUDY GROSS ANATOMY
Regional Anatomy: Studying all the structures in an area together; e.g., the lower extremity includes bones, muscles, nerves, and vessels.
Systemic Anatomy: Studying a complete system independent of region.•Skeletal (bones)•Muscular •Neurovascular•Cardiovascular (heart, blood)
Regional AnatomyRegional AnatomyHead/neck
Thorax
Abdomen
Pelvis/perineum
Back
Upper limb
Lower limb
Regions of the Body
6
2
Clinical AnatomyClinical Anatomy
• Relationship of structure and function
• Clinical correlations emphasized throughout presentation
7
CC
Anatomical PositionAnatomical Position• Head, eyes, and toes
directed forward (anteriorly).
• Upper limbs by the sides;
palms facing anteriorly.
• Lower limbs together; toes
directed anteriorly.
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The Upper LimbThe Upper Limb
Function: Movement
Parts:• Shoulder• Arm (brachium)• Forearm (antebrachium)• Hand (manus)
• Elbow joint• Radioulnar joints• Wrist joints• Hand joints
Innervation of the Upper LimbBrachial Plexus
Innervation of the Upper LimbBrachial Plexus
Formed by ventral rami of C5-T1spinal nerves.
Nerves contain somatic motor and sensory fibers and post-synaptic sympathetics from cervical ganglia.
11
Roots
C5
C6
C7
C8
T1
BRACHIAL PLEXUSBRACHIAL PLEXUS
Dorsal scapular
Long thoracic12
3
Roots
C5
C6
C7
C8
T1
Trunks
Upper
Middle
Lower
Suprascapular
N. to Subclavius
BRACHIAL PLEXUSBRACHIAL PLEXUS
DS
LT13
Roots
C5
C6
C7
C8
T1
TrunksDivisions
Anterior
Posterior
Anterior
BRACHIAL PLEXUSBRACHIAL PLEXUS
DS
LT
SS
N to SUpper
Middle
Lower
14**No branches come off the divisions
Roots
C5
C6
C7
C8
T1
TrunksDivisionsCords
Lateral
Posterior
Medial
LP
USSLSS TD
MPMAC
LP: Lateral Pectoral
MP: Medial Pectoral
MBC: Medial Brachial Cutaneous n.
MAC: Medial AntebrachialCutaneous n.
USS: Upper Subscapular
TD: Thoracodorsal
LSS: Lower Subscapular
BRACHIAL PLEXUSBRACHIAL PLEXUS
DS
LT
SS
N to S
Anterior
Posterior
Anterior
Upper
Middle
Lower
MBC
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Roots
C5
C6
C7
C8
T1
TrunksDivisionsCords
Lateral
PosteriorAxillary
Musculocutaneous
Median
Terminal BranchesBRACHIAL PLEXUSBRACHIAL PLEXUS
DS
LT
SS
N to S
Anterior
Posterior
Anterior
LP
USSLSS TD
MPMBC
MAC
Medial
Upper
Middle
Lower
Ulnar Radial
In PCTIn Axilla 16
**Median nerve contributions vary from textbook to textbook….
**
ERB-DUCHENNE PALSYThe Erb-Duchenne syndrome results from a lesion of the C5 and C6 ventral rami in the superior trunk of the plexus
Proximal musculature in the upper limb is mainly affected, thus, muscles acting at the shoulder and at the elbow will be weakened.
In patients with this syndrome, the upper limb is held in a “waiter’s tip” position
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CC KLUMPKE’S PARALYSIS
- results from compression or stretching of the C8 and T1 fibers in the inferior trunk of the brachial plexus
Distal muscles in the upper limb that are innervated by the C8 and T1 fibers in the lower trunk will be primarily affected.
Patients experience weakness of the intrinsic muscles of the hand innervated by C8 or T1 fibers in the median and ulnar nerves, resulting in a combination of a full ape hand or a claw hand. 18
CC
4
Musculocutaneous Nerve
Musculocutaneous Nerve
(C5,6,7) Innervates anterior arm muscles.
Cutaneous innervation
19
Median NerveMedian Nerve(C6,7,8,T1) Innervates anterior forearm muscles (except 1½) and intrinsic thumb muscles.
(C5,6) Innervates deltoid and teres minor muscles.
Cutaneous innervation
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Radial NerveRadial Nerve(C5,6,7,8,T1) Innervates posterior arm and forearm muscles.
Cutaneous innervation
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Dermatomes of the Upper
Limb
Dermatomes of the Upper
Limb
Anterior
Posterior
Areas used to determine sensation in a particular dermatome:• C4: Skin over acromion.• C5: Skin over lower deltoid m.• C6: Tip of thumb.• C7: Tip of index or middle finger.• C8: Tip of little finger.• T1: Skin over medial side of elbow.• T2: Skin in axilla. 24
Part 1:• Vertebral a.• Internal thoracic a.• Thyrocervical trunk
– Inferior thyroid a.» Ascend. cervical a.
– Transverse cervical a.– Suprascapular a.
SUBCLAVIAN ARTERYSUBCLAVIAN ARTERYPart 2:
• Costocervical trunk
Part 3:• Dorsal scapular a.
**Named according to relationship to Anterior Scalene muscle, extends to first rib
27
Axillary ArteryAxillary ArteryContinuation of subclavian artery from lateral border of rib 1 to inferior border of teres major m. Divided into 3 parts relative to the pectoralis minor m.
Part 2: (posterior)
1. Thoracoacromial a.
2. Lateral thoracic a.
Part 3: (lateral)
1. Subscapular a.
2. Ant. circumflex humeral a.
3. Post. circumflex humeral a.
Part 1: (medial)1. Superior thoracic a.
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** Extends out to the lateral border of the teres major muscle
Arteries of the ArmArteries of the Arm
Brachial artery– Profunda brachii a. (deep
brachial a.)To posterior arm, and anterior and posterior lateral elbow
– Superior and inferior ulnar collateral aa.
To anterior and posterior medial elbow
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Arteries of the Forearm
Arteries of the Forearm
• Radial artery– Pulse point at the lateral wrist.– Also courses through snuff box.
• Ulnar artery– Common interosseous a.
• Anterior interosseous a. to deep anterior forearm. (accompanies anterior interosseous n. from median n.)
• Posterior interosseous a. to deep posterior forearm. (accompanies posterior interosseous n. from radial n.)
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Arteries of the HandArteries of the Hand
• Ulnar artery– Superficial palmar arch
3 common palmar digital aa.Proper palmar digital aa. (to adjacent sides of digits 2-4).Deep palmar br. (anastomoses with deep palmar arch).
• Radial artery– Deep palmar arch
Radialis indicis a. (to 2nd digit)Princeps pollicis a. (to thumb)Palmar metacarpal aa.Superficial palmar br. (anastomoses with superficial palmar arch).
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Special Test for Peripheral Circulation
Special Test for Peripheral Circulation
Allen’s Test Capillary Nail Blanch Test
32
CC
Raynaud’s PhenomenonRaynaud’s Phenomenon
• The pathophysiologic event of loss of arterial inflow to the digits
• Condition associated w/ vasospasm• Usually triggered by cold or stress
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CC Superficial Veins of the UESuperficial Veins of the UE
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THE BACKTHE BACK
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The BackDermatomes & Cutaneous Nerves
The BackDermatomes & Cutaneous Nerves
Medial brs of dorsal rami of spinal nerves
Lateral brs of dorsal rami of spinal nerves
36
Dorsal ramus
Ventral ramus
7
MUSCLES OF THE BACK
MUSCLES OF THE BACK
• Extrinsic muscles– Superficial muscles
move the upper limb – Intermediate muscles
weak assist in respiration
• Intrinsic muscles:– Move the axial skeleton
37
Extrinsic Back MusclesSuperficial Muscles
• Trapezius m.• Latissimus dorsi m.• Levator scapulae m.• Rhomboid minor m.• Rhomboid major m.
Movement of the upper limb
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Superficial Back MusclesTrapezius
• Attachments
• Nerve supplyMotor: Accessory n. (CN XI).
• ActionsElevates and depresses,
retracts & laterally rotates the scapula.
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• Nerve supply Thoracodorsal n. (C6, C7, C8).
• ActionsExtends, adducts, &
medially rotates the humerus at the shoulder. Raises trunk on fixed limbs.
• Attachments
Superficial Back MusclesLatissimus Dorsi
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Floor of intertubercular groove
Spinous process of T7-T12, thoracolumbar fascia, iliac
crest, inferior 3 or 4 ribs
• Nerve supplyDorsal scapular n. (C5) and C3 & C4 nn.
vertebral column.• Maintain posture.• Chief extensors of
the vertebral column with a bilateral contraction.
-All Innervated by dorsal rami of spinal nerves
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SCAPULAR and PECTORAL REGIONS
45 46
The Pectoral RegionDermatomes & Cutaneous Nerves
The Pectoral RegionDermatomes & Cutaneous Nerves
T2T3
T4
T5T6T7T8T9T10T11T12
Dermatomes (C4, T2-T6,7)
Anterior cutaneous branches med. & lat.
Lateral cutaneous branches ant. & post.
Intercostal nerves
(ant. rami)
Cutaneous Nerves
Intercostobrachial
nerve C4
Bones of the Shoulder RegionBones of the Shoulder Region
• Pectoral (shoulder) girdle:For attachment of the upper limb to the trunk. Provides strength, support, and mobility for the upper limb.Clavicle: Articulates with the axial
skeleton (sternum).Articulates with the scapula (acromion).
Scapula: Attached to axial skeleton (ribs) by muscles.Articulates with the clavicle and with the head of the humerus.
Humerus
ClavicleScapula
Humerus (arm bone): Articulates with the glenoid fossa of the scapula. 47
ClavicleClavicle
48
No surgery, full range of
motion…
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ScapulaScapula
Anterior
Posterior 49
Movements of the ScapulaMovements of the Scapula
Elevation
Depression
Protraction
Retraction
Medial rotation
Internal/downward
Lateral rotation
External/upward50
Movements of the ScapulaMovements of the Scapula• Elevation
1. Trapezius (upper fibers)2. Levator scapulae3. Rhomboid major & minor
-Designated as ‘anterior’ or ‘posterior’ depending on relation to the glenoid fossa. Anterior most common.
-Axillary nerve vulnerable – What muscles would be affected????
Axillary n.Axillary n.
Radial n.Radial n.
Axillary n.Axillary n.
Radial n.Radial n.
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CC
Bursae of the ShoulderBursae of the ShoulderBursa: Sac-like structure containing a film of synovial fluid, located between tendons and bone, ligaments, or other tendons, or where skin moves over a bony prominence.
Subscapular bursa
Between subscapularis tendon and neck of scapula.
Subacromial-subdeltoid bursa
Between acromion-deltoid m. and supraspinatus tendon.
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Subacromial BursitisSubacromial BursitisIrritation and inflammation of the subacromial bursa. Can be due to bone spurs on the inferior surface of acromion, calcification of the supraspinatus tendon, or general irritation from overuse.
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CC
Scapular RegionScapular Region
65
• Deltoid m.• Supraspinatus m.• Infraspinatus m.• Teres minor m.• Teres major m.• Subscapularis m.
Scapulohumeral Muscles(Scapular Region)
Scapulohumeral Muscles(Scapular Region)
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12
DeltoidNerve: Axillary n.
Actions: Abducts, flexes, extends, medially and laterally rotates the humerusat the shoulder.
Scapular Region MusclesScapular Region MusclesClavicle
Acromion
Spine of scapula
67Deltoid tuberosity
Scapular Region MusclesScapular Region Muscles• Supraspinatus
Nerve: Suprascapular n.
Actions: Stabilizes shoulder joint; initiates and assists with abduction of the humerus.
• InfraspinatusNerve: Suprascapular n.
Actions: Laterally rotates humerus.
Supraspinous fossa
Superior facet of greater tubercle of humerus
Supraspinatus
Infraspinous fossa
Middle facet of greater tubercle of humerus
Infraspinatus
68Posterior View
Scapular Region MusclesScapular Region Muscles• Teres minor
Inferior-lateral border of scapula Medial lip of bicipital
groove of humerus
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Scapular Region MusclesScapular Region Muscles
SubscapularisNerve: Upper & lower
subscapular nn.
Actions: Stabilizes shoulder joint; medially rotates the humerus.
Lesser tubercle of humerus
Subscapular fossa of scapula
70Anterior View
Rotator Cuff MusclesRotator Cuff MusclesBlend with articular capsule; stabilize shoulder joint.
Teres minor
SupraspinatusInfraspinatus
Subscapularis
“S I T S”muscles
Anterior
Posterior
S
SI
T
Supraspinatus
Infraspinatus
Teres minor
Subscapularis
71
Rotator Cuff Tear
Rotator Cuff Tear
72
-In addition to trauma, both cumulative and acute, either from internal or external sources, RTC tears can be due to calcification of supraspinatus tendon > tendinitis > tear
CC
Subacromialbursa
13
Pectoral Region Pectoral Region
• Pectoralis major m.• Pectoralis minor m.• Serratus anterior m.
Pectoral Region MusclesPectoral Region Muscles
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Pectoral Region MusclesPectoral Region Muscles
• Pectoralis major m. (clavicular and sternocostal heads)Nerve: Medial and lateral pectoral nn.Actions: Flexes, adducts, and
medially rotates the humerus at the shoulder.
Clavicle (med. ½)
Sternocostal head
Bicipital groove
75
Pectoralis minor
Coracoid process
Pectoral Region MusclesPectoral Region Muscles
• Pectoralis minorNerve: Medial (and lateral) pectoral nn.Actions: Protracts the scapula and
depresses shoulder.3
4
5
76
Pectoral Region MusclesPectoral Region Muscles
• Serratus anterior m.Nerve: Long thoracic n.Actions: Protracts scapula; laterally
rotates scapula.
Paralysis of the long thoracic nerve results in “winging of the scapula”
Medial border
Inferior angle
12
3
4
5
6
7
8
9 CC
Axilla (Armpit)Axilla (Armpit)Pyramid-shaped space that provides a passageway for vessels and nerves (brachial plexus) going to and from the upper limb.
Note narrow opening!
78
14
Thoracic Outlet SyndromeThoracic Outlet Syndrome
Cervical Rib or Rudimentary First Thoracic Rib
79
CC
ARM(Brachium)
ARM(Brachium)
80
HumerusHumerusPosteriorAnterior
Bone of the Arm
Greater tubercle
Lesser tubercle
Greater tubercle
Head Head
Intertubercular groove
Capitulum Trochlea Trochlea
Olecranon fossa
Coronoid fossa
Radial fossa
Deltoid tuberosity Spiral (radial)
groove
Lateral supracondylar ridge
Lateral lip
Medial lip
81
Movements at the Elbow JointMovements at the Elbow Joint
• Anterior Arm Compartment1. Biceps brachii m.2. Coracobrachialis m.3. Brachialis m.
Posterior Arm Compartment1. Triceps brachii m.2. Anconeus m.
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Anterior Arm MusclesAnterior Arm Muscles
• Biceps brachii (short and long heads)Nerve: Musculocutaneous n.Actions: Short head: Weak flexor of the humerus at the shoulder; Long and short heads: Strong flexor of the elbow and supinator of the forearm.
Long head
Short head
Biceps brachii
Supraglenoid tubercle
Coracoid process
Radial tuberosity
Bicipital aponeurosis
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15
Biceps Tendon RuptureBiceps Tendon Rupture• Commonly caused by degenerative changes
within the tendon– Long head of bicep– Distal tendon
• Non-operative treatment for long head of bicep gives good results (loss of power only ~10-20%)
• Distal tendon rupture can cause up to 40% loss of flexion and supination. Surgery more important. 85
Thickened deep fascia holds tendons of long flexors at the wrist.
Flexor retinaculum (transverse carpal ligament)
Antebrachial fascia and palmarcarpal ligament
129
Carpal TunnelCarpal Tunnel
Flexor retinaculum is attached laterally to the scaphoid and trapezium, and medially to the pisiform and hamate.
Carpal tunnel is a fibro-osseous passageway under the flexor retinaculum and over a deep arch formed by the carpal bones.
130
S
T
Carpal TunnelContents
Carpal TunnelContents
234
5
Flexor retinaculum
Median n.
Flexor digitorumsuperficialis tendons
Flexor digitorumprofundus tendons
Flexor pollicis longustendon
∗ Flexor carpi radialis tendon (not in carpal tunnel)
∗
131
Median nerve compression
Carpal tunnel
Median n.
Carpal Tunnel SyndromeCarpal Tunnel SyndromeCC
23
Pillar PainPillar Pain
o Temporary tenderness on each side of the palm where the ligament is attached to the bones (trapezial ridge and hook of hamate). Usually tender for at least four to six weeks after a carpal tunnel release.
133
CC Ulnar Tunnel SyndromeUlnar Tunnel Syndrome
• Compression at Guyon’s canal– “hypothenar hammer
syndrome”– “handlebar palsy”
• Tunnel formed by ligament that connects pisiform and hook of hamate
Attachments:From 2nd, 4th, and 5th metacarpals to lateral band of extensor expansion of digits 2, 4, and 5.
Nerve:Deep ulnar n.
Actions:(PAD) Adduct fingers 2, 4, and 5 and extend at IP joints.
153
Intrinsic Hand MusclesMid-palmar Muscles
Intrinsic Hand MusclesMid-palmar Muscles
• Dorsal interossei (4)Attachments:
From adjacent metacarpals to lateral band of extensor expansion of digits 2, 3, and 4.
Nerve:Deep ulnar n.
Actions:(DAB) Abduct digits 2, 3, and 4 and extend at IP joints.
154
Innervation of Intrinsic Hand Muscles
Innervation of Intrinsic Hand Muscles
Median Nerve:o Recurrent br. to thenar muscles; digital
brs. to lumbricals #1 and #2.
Ulnar Nerve:o Deep br. to all other hand muscles.
155
Cutaneous Nerves of the HandPalmar Side
Cutaneous Nerves of the HandPalmar Side
Median n:• Palmar cutaneousbr.
• Common and proper digital brs.
Ulnar n: (superficial to flexor retinaculum)
• Palmar cutaneous br.
• Superficial ulnar n.
• Common and proper digital brs.
Radial n:• Sup. radial n.
156
Note: Palmar cutaneous br. of median nerve does not go through carpal tunnel, sensation is spared.
27
Cutaneous Nerves of the HandDorsal Side
Cutaneous Nerves of the HandDorsal Side
Ulnar n:• Dorsal br.
• Dorsal digital brs.
Radial n:• Superficial radial n.
• Dorsal digital brs.
Median n:
•Digital brs.
157
ReferencesReferences• Agur, A. M. R. & Dalley, A. F. (2009). Grant’s Atlas of Anatomy, 12th ed.
Maryland: Lippincott Williams & Wilkins.• Burke, S. L, Higgins. J. P., McClinton, M. A., Saunders, R. J., &
Valdata, L. (2006). Hand and Upper Extremity Rehabilitation. A Practical Guide. Missouri: Elsevier.
• Gilroy, A. M., MacPherson, B. R., & Ross, L. M. (2008). Atlas of Anatomy. New York: Thieme.
• Skirven, T. M., Osterman, A. L., Fedorczyk, J. M., & Amadio. P. C. (2011). Rehabilitation of the Hand and Upper Extremity, 6th ed. PA: Mosby.
• Moore, K. L., Dalley, A. F., & Agur, A. M. R. (2010). Clinically Oriented Anatomy, 6th ed. Maryland: Lippincott Williams & Wilkins.
• Pearl, M. L., Bessos, K., Wong, K. (1998). Strength deficits related to distal biceps tendon rupture and repair. American Journal of Sports Medicine, 26, 295-296.Michael L. Pearl
• Spriggs, L., Whitworth, R., & Swartz, W. Presentations from Medical Gross and Allied Health Gross Anatomy courses, LSUHSC, New Orleans, LA.