Lecturer: Dr. M. Samsam University of Central Florida, Orlando, Pictures from Platzer atlas and textbook of human anatomy and K. Moore anatomy and Netter.

Lecturer: Dr. M. SamsamUniversity of Central Florida, Orlando,

Pictures from Platzer atlas and textbook

of human anatomy and K. Moore anatomy and Netter atlas of human anatomy

Bones and Muscles and regional anatomy of the upper limb part2

Damage to the Radial nerveInjury proximal to the origin of Triceps:

*No extension of elbow (elbow is flexed)*No triceps reflex*Wrist drop (all extensor muscles and the Supinator are paralyzed), thumb is flexedand adductedSensory loss: dorsolateral lower brachial region, posterior surface of forearm, dorsum of the hand and radial side ofproximal phalanges

Injury of the nerve in radial groove:In fractures of humerusTriceps muscle is usually functioningWirst drop and sensory loss in dorsolateral aspect of the forearm and handPlus all other problems mentioned above

Nerve injury in forearm:Here the deep radial nerve is injured (wrist drop)Extension of the thumb and metacarpal joints is disturbed. Sensation is usually preserved

Median Nerve injury:Above the elbow:Muscles in the arm are not affectedForearm and hand muscles are affected1- All flexors of the wrist are paralyzed except:2- Flexor carpi ulnaris and ulnar part of Flexor digitorum profundus.

3- Thumb flexors and abductor paralyzed but not Adductor (ulnar N.) (ape hand)4- Flexion at metacarpophalangeal joints possible (intact interossei MM, ulnar N.)6- 1st and 2nd Lumbricals lost function and all together, inability to fully flex index and middle finger (HAND OF PAPAL BENEDICTION)Pronation of forearm paralyzed and sensory loss over the median N. area

Injury at wrist Joint: (suicide or injury e.g.: hand out of car’s window) Short muscles of the thumb paralyzed, not adductor.Thenar muscles atrophy (flattened, ape hand)Flexor pollicis longus functioningSensory loss over Medial N. area

Ulnar nerve injury:

At wrist1- Fingers are hyperextended at metacarpophalangeal joints and flexed at interphalangeal joints (paralysis of interossei MM and 2 medial lumbricals (Claw hand)2- Tendon of flexor digitorum perfundus (2 medial ones) paralyzed, Therefore flexion of the ring and little fingeris not possible at distal phalangeal joints3- Small muscles of the little finger are paralyzed4- Abduction and Adduction of the fingers are impaired( paralysis of interossei MM, piano playing, writing.. Impaired)5- Sensory loss over ulnar innervating area.

Injury at elbow:1- Paralysis of flexor carpi ulnaris and medial portion ofFlexor digitorum profundus2- Ulnar deviation of the wrist is weakened, hand is abducted and extendedPlus problem number 4 and 5 from above

Regional AnatomyAtlas: only look at the itemsInfraclavicular region(Deltopectoral triangle)

Borders: 1- Clavicle, 2- Deltoid, 3- Pectoralis majorSkin innervation: medial, intermediate and Lateral supraclavicular nerves (cervical plexus)On deltoid region: innervation by axillary nerve

6- Pectoralis minor M.7- Clavipectoral fascia8-Cephalic vein9- Axillary vein10- Thoracoacromial artery (11-clavicular, 12-acromial, 13-deltoid, 14-pectoral parts)15- Pectoral nerve16- Subclavius M.17- Axillary artery18- lateral cord19- Posterior cord20- Medial cord21- Suprascapular nerve and vessels

Axillary region: (Pyramidal shape)Borders: Pectoralis Major, Latis dorsi, ribs andintercostal muscles, humerus and coracobrachialis

Atlas: only look at the items

Brachial Plexus

Arteries of the shoulder and Upper arm:

**Arterial Blood pressure Measurements using a sphygmometer

*Brachial artery occlusion/Laceration:Deep flexor paralysis,

*Volkmann’s ischemic contracture

Moore

Veins of the shoulder And upper arm:

Moore

Lymph nodes of the Axillary region:

Arranged in 5 groups:Pectoral, medial, apical, central and subscapularDrainage: subclavian lymphatic trunk to right lymphatic duct to right venous angle

**Importance: Breast Cancers maygive metastasis to the axillarylymph node (75% of breast’s lymphatics drain here). Removal of the lymph nodesmay be necessary.Mastectomy: removal of the breast.

*Lymphangitis

Regional anatomy:Atlas: Only look at the itemsAnterior Brachial region:

1- Brachial fascia2- Cephalic vein3- Basilic vein4- Basilic hiatus5- Medial antebrachial cutaneous N.6- the same nerve as 57- lymph nodes8- Medial brachial cutaneous N.9- Intercostobrachial N.

Anterior Brachial region

Medial bicipital groove:Between biceps and intermuscular septa

Contents:Median N, Brachial artery and veins andbasilic vein, medial cutaneous antebrachialnerve and ulnar N. medially.

Deep in this region, proximally , the radial nerve takes a posterior direction.

Axillary spaces:

Quaderangular spaceTriangular Spaces

1- Teres Minor2- Teres Major3- Humerus4- Long head of Triceps

Radial nerve is found deep in the posterior brachial region in radial groove of humerus accompaniedby deep brachial A and V.

Regional anatomy:Atlas: Only look at the items

Cubital fossa: Superficial

1- Basilic vein2- Antebrachial Basilic vein5- Cephalic and7- Median cubital vein4- Medial cutaneous antebrachial nerve6- lateral antebrachial cutaneous nerve(branch of musculocutaneous N.)

Cubital fossa (deep):Atlas: Only look at the items

1- Biceps Brachii M.2- Bicipital aponeurosis3- Brachialis M4- Pronator teres5- Brachioradialis6- Radial artery and veins7- recurrent radial A.8- Median N.9- Ulnar nerve10- Radial N.11- Superficial Radial N.12- Deep radial N.13- Supinator muscle

Arteries of the forearm and hand:

1- brachial artery2- Radial artery3- Ulnar artery6- Deep palmar arch8- Principal artery of the thumb13- Superficial palmar arch14- the 3 common digital arteries15- the 2 common palmar digital arteries16- Dorsal carpal branch

Anterior antebrachial region:Atlas: Only look at the items

2 and 6- Anastomoses between cephalic and basilic antebrachial veins

7- Medial cutaneous antebrachial N.11- Radial artery and veins14- Superficial Radial N.21- Ulnar N22 and 23- Ulnar artery and veins

Anterior carpal region:

1- Antebrachial fascia, 2- Deep layer3- tendon of palmaris longus4- Pronator quadratus5- Radial A.6- Flexor carpi radialis9- Median N.10- Ulnar artery11- Ulnar nerve12- Flexor carpi ulnaris13- Palmar aponeurosis

Palm of the hand:

1- Superficial palmar arch18- Deep palmar arch11- median nerve9- ulnar nerve

Dorsum of the Hand:Radial artery (9) enters the Snuffbox andgives a dorsal branch which produces thedorsal arterial arch of the hand.Then it gives the principal artery of the thumband then a main branch to join the deep palmar arch.

Snuffbox: borders:Tendon of extensor pollicis longus (superior)tendons of the ext. pollicis brevis and abductor pollicis longus (inferiorly).

Contents of snuffbox:9- Radial artery8- Superficial radial N.