IUSM-NW F12 1 The Upper Limb Ernest F. Talarico, Jr., Ph.D. Associate Director of Medical Education Associate Professor of Anatomy & Cell Biology Associate.

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The Upper Limb

Ernest F. Talarico, Jr., Ph.D.Associate Director of Medical Education

Associate Professor of Anatomy & Cell BiologyAssociate Faculty, Radiologic Sciences

Indiana University School of Medicine – Northwest Campus

Objectives

• To gain a comprehensive understanding of the osteology of the upper limb

• To understand and be able to discuss the anatomy/anatomical relationships of the upper limb (i.e., veins, arteries, compartments, muscles)

• To understand the brachial plexus• Apply the above to a case study of the

brachial plexus and medical imaging.

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Upper Limb Osteology

Brachium

Antebrachium

Carpus

Manus

Phalanges

Right Clavicle

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Fascia ☺ Compartment ☺ Lymphatics

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Veins and Lymphatics of the Upper Limb

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Muscles of the Brachiium

What is the view?

What is the innervation?

(anterior)

(Musculocutaneous n.)

Posterior

Radial n.

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Muscles of the Antebrachium

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Muscles of the Antebrachium

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Muscles of the Antebrachium

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Compartment & Muscles of the Manus

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An Area of Concern!

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Vessels

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(1) Lateral boarder of R1 and medial border of pectoralis minor m.• Superior (supreme) Thoracic a.

(2) Posterior to pectoralis minor m.• Thoracoacromial a. (Acromial, Clavicular,

Pectoral, Deltoid)• Lateral Thoracic a. (**** BREAST ****)

(3) Lateral border of pectoralis minor m. and the inferior border of teres major m.• Subscapular a. (largest)• Anterior & Posterior Circumflex Humeral aa.

(P > A)

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Anatomical Relationships - Vessels/Nerves

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The Brachial Plexus• Innervates all muscles of

superior extremity

• Sensory & motor nerves

• Anterior division fibers supply flexors

• Posterior division fibers supply extensors

Roots Trunks Divisions Cords BranchesRobert Taylor Drinks Cold Beer

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Spinal Nerves (31 pairs)Spinal Nerves (31 pairs) all are mixed nerves

(sensory and motor)

4 fiber components• Sensory

– GSA: general somatic afferent

– GVA: general visceral afferent

• Motor– GSE:

skeletal– GVE:

visceral

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Typical Thoracic

Spinal Nerve

31 pairs of spinal nerves:

8 cervical

12 thoracic

5 lumbar

5 sacral

1 coccygeal

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21

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Brachial Plexus: Major Branches

• Musculocutaneous (C5-7)

• Median Nerve (C6-T1)

• Ulnar Nerve (C8-T1)

• Axillary Nerve (C5-6)

• Radial Nerve (C7-8)

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Brachial Plexus: Major Branches

• Musculocutaneous (C5-7)

– Biceps Brachii (C5, C6)

– Coracobrachialis (C5, C6, C7)

– Brachialis (C5, C6)

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Brachial Plexus: Major Branches

• Median Nerve (C6-T1)

– Pronator teres– Flexor carpi radialis– Palmaris longus– Flexor digitorum profundus

(lateral)– Flexor digitorum superficialis– Flexor pollicus longus– Pronator quadratus– and hand mm.

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Brachial Plexus: Major Branches

• Ulnar Nerve (C8-T1, often C7)

+ 13 hand mm.

– Flexor digitorum profundus (medial)– Flexor carpi ulnaris

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Brachial Plexus: Major Branches

• Axillary Nerve (C5-6)

– Deltoid– Teres minor

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Brachial Plexus: Major Branches

• Radial Nerve (C5-T1) 12 + anconeus

– Brachioradialis– Triceps brachii (C6, C7, C8)– Extensor carpi radialis longus– and brevis– Extensor digitorum– Extensor digiti minimi– Extensor carpi ulnaris– Supinator– Abductor pollicus longus– Extensor pollicus longus and brevis– Extensor indicus

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Brachial Plexus: Other Nerves• Dorsal Scapular (C5)

– Rhomboideus major and minor– Levator scapulae

• Suprascapular (C5-6)

– Supraspinatus– Infraspinatus– Shoulder joint

• Subclavian (C5-6)

– Subclavius

• Lateral Pectoral (C5-C7)

– Pectoralis major and minor

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• Upper Subscapular (C5-6)

– Subcapularis

• Thoracodorsal (C6-8)

– Latissimus dorsi

• Lower Subscapular (C5-6)

– Teres major

• Long Thoracic (C5-7)

– Seratus anterior

• Medial Pectoral (C8-T1)

– Pectoralis minor and major

• Medial Brachial Cutaneous

• Medial Antebrachial Cutaneous

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Brachial Plexus

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Nerves of theUpper Limb

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CLNICAL CORRELATION

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Medical Imaging

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A swan neck deformity describes a finger with a hyperextended PIP joint and a flexed DIP joint.

Swan Neck Deformity

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How does this condition occur? Conditions that loosen the PIP joint and allow it to hyperextend can produce a swan neck deformity of the finger.

Rheumatoid arthritis (RA) is the most common disease affecting the PIP joint.

The small (intrinsic) muscles of the hand and fingers can tighten up from hand trauma.Various nerve disorders, such as cerebral palsy, Parkinson's disease, or stroke.

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Mallet Finger

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How do these injuries of the DIP joint occur?

A mallet finger results when the extensor tendon is cut or torn from the attachment on the bone. Sometimes, a small fragment of bone may be pulled, or avulsed, from the distal phalanx. The result is the same in both cases: the end of the finger droops down and cannot be straightened.

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Boutonniere Injury

Boutonnière deformity (buttonhole deformity) is a deformity in which the middle finger joint is bent in a fixed position inward (toward the palm) and the outermost finger joint is bent excessively outward (away from the palm).

This disorder most often results from rheumatoid arthritis but can also occur from injury (such as deep cuts, joint dislocation, or fractures) or osteoarthritis

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• A 34-year-old, African-American male, falls from the roof of a new home under construction and lands on a cement boulder with impact on the right, proximal one-third of the humeral diaphysis. Medical history is significant for HTN, diabetes, and hypercholesterolemia. Examination in the ER is remarkable for BP 168/90; T 99.9; P 90; R 28. Bone is evident topographically near the deltoid tuberosity, and there is bleeding. Inflammatory response is active and there is decreased ROM; flexor and extensor reflexes are intact. CT reveals shattered humeral diaphysis with displacement. Surgical intervention is consistent with internal fixation and bone grafting using osseous tissue from the ilium ground and mixed with sea coral. The anterior and posterior circumflex humeral arteries were noted to be intact, and were clamped during surgery to facilitate repair. Three weeks post-surgery, the patient complains of significant pain near the site of injury. MRI reveals AVN of the proximal humeral diaphysis. Which of the following selections best explains the patient’s condition?

A. nonunion of bone fragmentsB. malpractice on the part of the surgeonC. diabetes D. muscle injuryE. neuropathy

• A 34-year-old, African-American male, falls from the roof of a new home under construction and lands on a cement boulder with impact on the right, proximal one-third of the humeral diaphysis. Medical history is significant for HTN, diabetes, and hypercholesterolemia. Examination in the ER is remarkable for BP 168/90; T 99.9; P 90; R 28. Bone is evident topographically near the deltoid tuberosity, and there is bleeding. Inflammatory response is active and there is decreased ROM; flexor and extensor reflexes are intact. CT reveals shattered humeral diaphysis with displacement. Surgical intervention is consistent with internal fixation and bone grafting using osseous tissue from the ilium ground and mixed with sea coral. The anterior and posterior circumflex humeral arteries were noted to be intact, and were clamped during surgery to facilitate repair. Three weeks post-surgery, the patient complains of significant pain near the site of injury. MRI reveals AVN of the proximal humeral diaphysis. Which of the following selections best explains the patient’s condition?

A. nonunion of bone fragmentsB. malpractice on the part of the surgeonC. diabetes D. muscle injuryE. neuropathy

Based on your knowledge of anatomy of the upper limb, what is the most likely cause of the AVN and the patient’s pain?

Question

• A 34-year-old, African-American male, falls from the roof of a new home under construction and lands on a cement bolder with impact on the right, proximal one-third of the humeral diaphysis. Medial history is significant for HTN, diabetes, and hypercholesterolemia. Examination in the ER is remarkable for BP 168/90; T 99.9; P 90; R 28. Bone is evident topographically near the deltoid tuberosity, and there is bleeding. Inflammatory response is active and there is decreased ROM; flexor and extensor reflexes are intact. CT reveals shattered humeral diaphysis with displacement. Surgical intervention is consistent with internal fixation and bone grafting using osseous tissue from the ilium ground and mixed with sea coral. The anterior and posterior circumflex humeral arteries were noted to be intact, and were clamped during surgery to facilitate repair. Three weeks post-surgery, the patient complains of significant pain near the site of injury. MRI reveals AVN of the proximal humeral diaphysis. Which of the following selections best explains the patient’s condition?

A. nonunion of bone fragmentsB. malpractice on the part of the surgeonC. diabetes D. muscle injuryE. neuropathy

Based on your knowledge of anatomy of the upper limb, what is the most likely cause of the AVN and the patient’s pain?Question

Objective: Is to test the student doctor’s understanding of anatomical and vascular relationships of the upper limb.

• A 34-year-old, African-American male, falls from the roof of a new home under construction and lands on a cement boulder with impact on the right, proximal one-third of the humeral diaphysis. Medical history is significant for HTN, diabetes, and hypercholesterolemia. Examination in the ER is remarkable for BP 168/90; T 99.9; P 90; R 28. Bone is evident topographically near the deltoid tuberosity, and there is bleeding. Inflammatory response is active and there is decreased ROM; flexor and extensor reflexes are intact. CT reveals shattered humeral diaphysis with displacement. Surgical intervention is consistent with internal fixation and bone grafting using osseous tissue from the ilium ground and mixed with sea coral. The anterior and posterior circumflex humeral arteries were noted to be intact, and were clamped during surgery to facilitate repair. Three weeks post-surgery, the patient complains of significant pain near the site of injury. MRI reveals AVN of the proximal humeral diaphysis. Which of the following selections explains the patients condition?

A. nonunion of bone fragmentsB. malpractice on the part of the surgeonC. diabetes D. muscle injuryE. neuropathy

Based on you knowledge of anatomy of the upper limb, what is the most likely cause of the AVN and the patient’s pain?Question

Objective: Is to test the student doctor’s understanding of anatomical and vascular relationships of the upper limb.

Elimination

ReasoningConfirmation