Exam 4 Flashcards
(295 cards)
1
Q
What are the five functions of the skin?
**BRETS
A
1- BARRIER (btw inside and outside environment)
2- REGULATION of BODY TEMPERATURE (sweating, changes in vessels diameters)
3- EXCRETION (water, sodium salts, urea, nitrogenous waste)
4- TRANSMITS SENSORY INFORMATION (touch, pain, pressure, temperature changes)
5- SYNTHESIS of VITAMIN D (when exposed to sun)
2
Q
By doing the following, what is the skin acting as ?
- resist mechanical abrasion
- protection against invasion of pathogens
- prevents dehydration (Impermeable to water)
- protects against damage from UV irradiation (melanocytes in skin)
A
BARRIER
3
Q
Skin is the LARGEST organ in the body. What are the layers (3) and appendages (3) of skin?
A
LAYERS
1) Epidermis
- stratified squamous keratinized epithelium
- AVASCULAR
- Derived from ECTODERM
2) Dermis
- dense irregular CT with blood vessels, nerves, glands and hair follicles, upper layer has loose irregular CT
- VASCULAR
- Derived from MESODERM
3) Hypodermis (layer below dermis)
- CT and fat
- superficial fascia
- subcutaneous layer
APPENDAGES
- Glands
- Hair
- Nails
4
Q
What are the parts of the dermis and what CT is each made of?
1-Basement membrane separates the dermis from the epidermis
- the SUPERFICIAL layer in the dermis
- dermal papillae and epidermal ridges form EVAGINATIONS and INTERDIGITATIONS
- connective tissue filled with fibers, cells and blood vessels
- MEISSNER corpuscles present in dermal papillae of dermis
2- The DEEPER and THICKER layer in dermis
- Few cells present
- TYPE I COLLAGEN
- Blends inferiorly with hypodermis or subcutaneous layer (hypodermis) of superficial fascia
- contains ARTERIOVENOUS ANASTOMOSES (numerous in thick skin of fingers and toes, either bypass capillary to form AV or artery form thick wall called GLOMUS-shunt)
- contains PACINIAN CORPUSCLES (concentric lamellae of collagen fibers surround myelinated axons in pacinian corpuscles)
A
1) PAPILLARY layer (has dermal papillae, blood vessels, meissner corpuscles)
- LOOSE irregular CT
- has MEISSNER CORPUSCLES
2) RETICULAR layer
- DENSE irregular CT (TYPE 1)
- has PACINIAN CORPUSCLES
**There is no distinct boundary btw papillary and reticular layers
5
Q
What part of skin form fingerprint?
A
EPIDERMAL RIDGE of epidermis
- made of stratified squamous keratinizing epithelium
- AVASCULAR
- Derived from ectoderm
6
Q
Skin can be differentiated into thick vs thin skin. Identify which this is :
- palms of hands and soles of feet
- thick stratum corneum
- stratum LUCIDUM is present
- thicker strata SPINOSUM and GRANULOSUM
- All 5 layers of epidermis present and VISIBLE (corneum, lucidum, granulosum, spinosum, Basale)
- contains sweat glands
- LACKS SMOOTH MUSCLE
A
THICK SKIN
- Elaborate dermal elevations in thick skin (epidermal ridge)
- Increased bonding btw epidermal basement and dermis PROTECTS thick skin from ABRASION and increased wear compared to thin skin
7
Q
Skin can be differentiated into thick vs thin skin. Identify which this is :
- All other skin
- thin stratum corneum
- stratum LUCIDUM is ABSENT
- thinner strata spinosum and granulosum
- has basale for production of new skin cells
- only 4 layers of epidermis present
- has arrector pili SMOOTH MUSCLE
A
THIN SKIN
- dermal papillae (papillary dermis) is not as pronounced
- hair follicles, sebaceous glands and sweat glands are present
8
Q
Skin is the largest organ of the body and composed of 3 layers (epidermis, dermis and hypodermis) . Epidermis is the top most layer, Derived from ectoderm, is AVASCULAR and has stratified squamous keratinized epithelium. What are the 5 layers of epidermis? (Bottom to top most layer)
A
1- Stratum basale 2- stratum spinosum 3- stratum granulosum 4- stratum lucidum 5- stratum corneum
From 5 - 1 (Come, Let’s Get Sun Burned)
9
Q
There are 5 layers of the epidermis. Identify this:
1) Consist of single layer of COLUMNAR to CUBOIDAL CELLS
2) Made up of BASAL cells that has :
- keratinocyte stem cells (increased mitotic activity)
- Melanocytes
- Langerhans cells
- Merkel Cells (sensory receptor cells in skin)
- What connects adjacent cells to each other?
- What connects basal cell to basement membrane ?
A
STRATUM BASALE
- HEMIDESMOSOMES connect basal cell to basement membrane
- DESMOSOMES connect adjacent basal cells to each other
10
Q
There are 5 layers of the epidermis. What is the layer and what makes up the layer
- consists of 4-6 rows of cells
- cells SYNTHESIZE KERATIN FILAMENTS that become assembled into tonofilaments
- Spine represent states of Desmosomes attachments to keratin tonofilaments
A
STRATUM SPINOSUM which is made up of
KERATINOCYTES
- produce keratin (bundles of tonofilament) and LAMELLAR bodies containing lipids
- Take in melanin (pigment) from melanocyte cytoplasmic processes
** DESMOSOMES attach adjacent keratinocytes giving cell a “spiny” appearance
11
Q
Identify structure
- form junctions btw keratinocytes
- hold keratinocytes together at cytoplasmic extensions
- gives resistance to distortion and abrasion
- connect to intracellular tonofilaments (keratin filament)
A
DESMoSOMES
12
Q
There are 5 layers of epidermis . Identify this:
- keratinocytes becomes FLATTENED (squamous)
- DYING CELLS start to lose organelles, nucleus, and melanin granules
- KERATOHYALIN granules accumulate (keratohyalin are aggregates of keratin forming tonofilaments)
- Lamellar bodies (granules) containing lipids released into extracellular space forms WATER BARRIER and seals the skin
A
STRATUM GRANULOSUM
- 3-5 layers of FLATTENED cells
- secretory granules are not surrounded by a membrane by consist of a protein called FILAGGRIN
- *FILAGGRIN associates and cross-links with bundles of keratin tonofilaments
- Combination of keratin tonofilaments with FILAGGRIN of keratohyalin granules produces keratin through KERATINIZATION
- *KERATIN produced in this process is the soft keratin of skin
- Hydrolytic enzymes disrupt the nucleus and all cytoplasmic organelles which disappear as cells fill with keratin
13
Q
There are 5 layers of epidermis. Identify this:
- Only found in THICK SKIN
- Dead, flattened keratinocytes filled with KERATIN and devoid of organelles and nucleus
- Translucent and barely visible
- densely packed keratin filaments
A
STRATUM LUCIDUM
14
Q
There are 5 layers of epidermis. Identify this:
- Dead keratinocytes are now called SQUAMES (or flakes) COMPLETELY FILLED with KERATIN aggregated by FILAGGRIN
- Surface squames are shed (desquamation) with abrasion and replaced with new cells arising from the deep stratum basale
- MOST SUPERFICIAL layer of skin
- ALL nuclei and organelles have disappeared from cells
A
STRATUM CORNEUM
15
Q
How many epidermal cell types are there? What are they?
A
There are 5 cell types
1- keratinocytes 2- melanocytes 3- Langerhan’s Cells 4- Merkel Cells 5- Stem Cells
16
Q
Name the epidermal cell types
- primary cell type from base to surface
- produce keratin from tonofilaments and keratohyalin granules
- becomes squames in cornfield layer
**How do the epidermal cells go from stem cells to squamous cells over the progression of diff layer?
A
KERATINOCYTES
**Progression/differentiation of keratinocytes through the layers
1- stratum BASALE; basal stem cells divde by mitosis to create new keratinocytes
2- stratum SPINOSUM; differentiating cells move away from basement membrane into spinosum
-lamella bodies and tonofilaments begin to form
3- stratum GRANULOSUM; nucleus degenerates and other organelles lost,
- keratohyalin graules with filagrin form keratin aggregates,
- lamella bodies with lipids exocytosis to form water barrier
4- stratum CORNEUM; squamous cells on surface have only keratin
17
Q
Name the epidermal cell type
- Derived from NEURAL CREST (in basal layer)
- CLEAR cell cytoplasm
- ONLY IN BASAL LAYER
- mostly in THIN SKIN
- located btw stratum basale and stratum spinosum (bottom 2)
- LONG IRREGULAR cytoplasmic or dendritic extensions branch into epidermis
A
MELANOCYTES
- *PRODUCE MELANIN that is transferred to keratinocytes
- Tyrosinase made by rER, packaged into vesicles by Golgi, and fuse with melanosome vesicles
- Tyrosine - DOPA - Melanin via tyrosinase which is activated by UV light
- Melanin stored in membrane bound granules
- Melanin granules in cytoplasmic processes that insinuate btw keratinocytes
** Tanning INCREASES melanin PRODUCTION, NOT the NUMBER of MELANOCYTES
18
Q
What is the fate of melanin granules?
What is the difference in melanin in light vs dark skin?
A
**Melanin granules are transferred to keratinocytes
- melanocytes have cytoplasmic processes btw keratinocytes
- melanin granules phagocytosed into keratinocytes
- melanin granules degraded over time
1) Light skin; melanin is more rapidly DEGRADED, not found in upper layers of spinosum
2) Dark skin; PLENTIFUL MELANIN found in granulosum and may still be found in CORNEUM
19
Q
Name the epidermal cell type;
- ANTIGEN PRESENTING cell of IMMUNE system
- clear cell cytoplasm
- found in ALL LAYERS ; reside primarily in STRATUM SPINOSUM
A
LANGERHAN’S CELLS
- dendritic-type cells
- originate from BONE MARROW
- Migrate via blood to skin
20
Q
Name the epidermal stem cell;
- discriminative touch receptor (mechanoreceptors for sensation)
- clear cell cytoplasm
- ONLY IN BASAL LAYER OF THICK SKIN
- NOT IN THIN SKIN AT ALL
A
MERKEL CELLS
**If you find merkel cells, know you are in THICK not THIN skin
21
Q
there are 5 types of epidermal cells. what would stem cells look like and where found?
A
-dividing stem cell in basal layer of ALL skin (look for MITOTIC FIGURES but rare)
**The 5 epidermal cell types are; keratinocytes, melanocytes, Langerhan’s cells, merkel cells (THICK SKIN ONLY), stem cells
22
Q
What are the 4 appendages and 2 sensory receptors of skin
A
**
1- HAIR (develop from surface epithelium of EPIDERMIS and reside in DERMIS)
2- SEBACEOUS GLANDS (produce oily secretion called SEBUM when cells die in sebaceous glands_
- Develop from EPIDERMAL CELLS
- located btw hair follicle and arrector pili muscle
- SEBUM OILS; keep skin smooth, waterproof skin, prevent skin from drying. Give skin some antebacterial protection)
- Numerous glands associated with each hair follicle
3- SWEAT GLANDS
4- NAILS (fingernails are just a specialized region of skin where the stratum CORNEUM is hard keratin)
**
5- Meissner’s cprpuscles
6- Pacinian corpuscles
23
Q
There are 6 total (appendages and sensory receptors) of the skin.
Be specific
What has arrector pili muscle?
What is over most of body?
What is found in scalp/axilla/pubic?
A
HAIR 1- Pilosebaceous unit -hair follicle; shaft, bulb, papilla -sebaceous gland -ARRECTOR PILLI MUSCLE (smooth muscle that make hair erect); controlled by the AUTONOMIC NERVOUS SYSTEM, CONTRACT during strong EMOTIONS of fear and cold, contraction erects hair shaft, depresses skin where it inserts and produces a small bump on the surface of skin called GOOSE BUMP, contraction also forces SEBUM from sebaceous gland onto the hair follicle and skin)
2- TERMINAL HAIR
-thick in SCALP, AXILLA, pubic area
3- VELLUS HAIR
-fine, short and silky; OVER MOST OF the BODY
24
Q
Hair is one of the appendages of skin. It can be differentiated into pilosebaceous unit, terminal and vellus hair. Pilosebaceous unit is made up of hair follicle, sebaceous gland and arrector pili muscle. The structure of hair follicle is made of a shaft, bulb and papilla.
What are the 5 layers of hair follicle /(from outermost to innermost layer)
A
1- CTS (connective tissue sheath)
2- GLASSY membrane (thick basement membrane for external root sheath)
3- ERS (external root sheath)
- downgrowth of the epidermis
4- IRS (internal root sheath)
- surrounds the beginning of the hair shaft at the hair bulb
- ends at the level of the sebaceous glands
5- SHAFT (has cuticle, cortex and medulla)
25
Hair is one of the appendages of skin. It can be differentiated into pilosebaceous unit, terminal and vellus hair. Pilosebaceous unit is made up of hair follicle, sebaceous gland and arrector pili muscle. The structure of hair follicle is made of a shaft, bulb and papilla.
What gives rise to the shaft of the hair?
HAIR BULB
-MATRIX (root) that gives rise to the SHAFT of the hair
*Stem cells divide and differentiate into cells of the shaft and internal root sheath (increases the length of the hair shaft)
*Keratinocytes produce hard KERATIN
*Melanocyte produce hair COLOR
(Graying of hair due to loss of tyrosinase production)
26
Hair is one of the appendages of skin. It can be differentiated into pilosebaceous unit, terminal and vellus hair. Pilosebaceous unit is made up of hair follicle, sebaceous gland and arrector pili muscle. The structure of hair follicle is made of a shaft, bulb and papilla.
What supplies nutrients to the hair bulb?
HAIR PAPILLA
- loose CT containing blood vessel
* *SUPPLY NUTRIENTS to hair BULB (brings essential nutrients to hair follicle cells)
27
Hair is one of the appendages of skin. It can be differentiated into pilosebaceous unit, terminal and vellus hair. Pilosebaceous unit is made up of hair follicle, sebaceous gland and arrector pili muscle. The structure of hair follicle is made of a shaft, bulb and papilla.
What are the parts of hair shaft?
3 parts
1) Cuticle - layer of overlapping DEAD SQUAMOUS cells
2) Cortex
- CUBOIDAL cells
- KERATINIZED portion of the hair shaft
- contains MELANOSOMES
3) Medulla
- found only in THICK HAIR
- large vacuolated cells
28
Name the stages of the hair growth cycle
1- ANAGEN/growing phase
- up to 85% of hair in this phase at one time
- can last 2-5 years
2- CATAGEN/Involuting phase
-lasts 3-6 weeks
3- TELOGEN/resting phase
- Up to 15% of hair in this phase at one time
- can last 3-5 months
29
Sweat gland is one of the appendages of the skin. What are the 2 types of sweat gland and their secretions and types?
1- CONTAINS 2 cell types ; CLEAR cells (NO secretory GRANULES, WATERY/electrolyte secretion) and darK cells (has secretory granules with MUCUS secretion)
- Myoepithelial cells; surround basal region of the secretory portion of each sweat gland, contraction of these cells expels the secretion/sweat from sweat glands
- Most numerous in thick skin (palm and sole)
- Assist in temperature regulation (through evaporation of water from sweat on body surfaces)
- Excrete water, sodium salts, ammonia, Uric acid and urea
2- FOUND IN DERMIS
- primarily limited to ; axilla, anus, areolar regions of breast
- also develop down growth of epidermis
- larger than eccrine sweat glands
- ducts open into hair follicle Canal
- becomes functional at puberty when sex hormones are produced
- produces VISCOUS SECRETION; acquires a distinct and unpleasant odor after bacterial decomposition
2 types of sweat gland
1) ECCRINE sweat gland (simple coiled tubular glands)- produce watery secretion
A- ducts; coiled stratified cuboidal epithelium of DARK stained cells,
-SMALL OD.
-leads to skin surface (ascends, straightens and penetrates epidermis)
B- secretory units; simple to stratified cuboidal epithelium of LIGHT stained cells
-LARGE OD
-Found deep in DERMIS
2) APOCRINE sweat gland - produce protein/lipid secretion
30
Nails is one of the appendages of skin.
FINGER NAILS are just a specialized region of skin where hard keratin is the stratum corneum.
```
What does the following nail terminology mean
1- Eponychium
2-Nail plate
3- Hyponychium
4- Nail matrix
```
1- Eponychium (cuticle); not so hard keratin
2- Nail plate (finger nail); lies on the nail bed/epidermis
3- Hyponychium; hurts when you cut your finger too close
4- Nail matrix; region that generated hard keratin, is seen through the nail as the lighter colored lunula
31
How is the skin developed?
- EPIDERMIS is derived from surface ectoderm
- division of the surface ectoderm cells creates a surface layer f squamous cells called the PERIDERM and a BASAL LAYER of cells (Periderm cells are shed into the amniotic fluid)
- The BASAL LAYER continues to divide and creates INTERMEDIATE LAYERS that become the SPONGIOSUM/SPINOSUM
- All layers established by the END OF 4 MONTHS
- Neural crest cells migrate into the basal layer and become MELANOCYTES
- Proliferation of the basal cells produces the epidermal ridges (form the fingerprints)
- DERMIS forms primarily from MESODERM
* Paraxial- dermis of back
* Somatic lateral plate - dermis of limbs and body wall
- NEURAL CREST forms dermis of face and neck
32
What is this/
- White paste that covers the skin at birth
- mixture of desquamated epidermal cells, sebum and other secretions
- protects skin from amniotic fluid
VERNIX CASEOSA
33
How does hair develop?
1) Proliferation of basal layer into the dermis forms a HAIR BUD
* becomes the EPIDERMAL ROOT SHEATH
* small bud on the side of the bud forms the SEBACEOUS GLAND
2) Hair bud continue to migrate into the dermis and forms the hair bulb
* surrounding mesenchyme forms the DERMAL ROOT SHEATH
3) MESENCHYME invades the hair bulb to form the PAPILLA
4) ARRECTOR PILI MUSCLE forms from MESENCHYME
5) FIRST HAIR is called LANUGO (eyebrows form first)
- soft, fine and light pigment
- plentiful by week 17-20
34
The muscles of the back are complex but divisible into 3 groups, what are they and their importance/associations
```
A. SUPERFICIAL GROUP; associated with upper extremity (SCAPULA attached to vertebrae by this group)
1-Trapezius
2-Latissimus dorsi
3-Levator scapulae
4-Rhomboideus minor
5-Rhomboideus major
```
B. INTERMEDIATE GROUP; associated with respiration
1-Levatores costarum
2-Serratus posterior superior
3- Serratus posterior inferior
C. DEEP GROUP; associated with movement of the trunk and back, support body weight
1- Splenius muscles (crevicis and capitis)
2-Erector Spinae (Iliocostalis, longissimus, spinalis)
3- Transversospinalis (semispinalis, multifidus, rotatores)
35
The muscles of the back are complex but divisible into 3 groups: superficial, intermediate and deep group.
```
TRAPEZIUS
Group
Origin
Insertion
Action
Nerve
```
Group; Superficial
Origin
SKULL - External occipital protuberance
FASCIA - LIGAMENTUM nuchae
VERTEBRAE - spines of C7, T1-12
Action
- BOTH elevates upper fibers and depress lower fibers of the shoulder
- Retracts scapula
- Extends head
Nerve
- ACCESSORY NERVE (CRANIAL NERVE XI)
* *can test shrug shoulders
36
The muscles of the back are complex but divisible into 3 groups: superficial, intermediate and deep group.
```
LARTISSIMUS DORSI (large in swimmers)
Group
Origin
Insertion
Action
Nerve
```
Group; superficial
origin
- VERTEBRAE; spines of T6–T12
- FASCIA; thoracolumbar fascia
- PELVIC BONE; iliac crest
Insertion
HUMERUS; Intertubercular (bicipital) groove
Action
-Adducts, Extends and medially rotates arm
Nerve
THORACODORSAL NERVE
37
The muscles of the back are complex but divisible into 3 groups: superficial, intermediate and deep group.
```
LEVATOR SCAPULAE
Group
Origin
Insertion
Action
Nerve
```
Group; superficial
Origin
VERTEBRA - Transverse processes of C1-C4
Insertion
SCAPULA; superior angle and medial border
Action
-elevates and adducts scapula
Nerve
-DORSAL SCAPULAR NERVE
38
The muscles of the back are complex but divisible into 3 groups: superficial, intermediate and deep group.
```
RHOMBOID MINOR
Group
Origin
Insertion
Action
Nerve
```
Group; Superficial
Origin
VERTEBRAE; spines of C7, T1
Insertion
SCAPULA; medial border
Action
Elevates and adducts scapula
Nerve
DORSAL SCAPULAR NERVE
39
The muscles of the back are complex but divisible into 3 groups: superficial, intermediate and deep group.
```
RHOMBOID MAJOR
Group
Origin
Insertion
Action
Nerve
```
Group; Superficial
Origin
Vertebrae; spines of T2-T5
Insertion
SCAPULA; Medial border to inferior angle
Action
Elevates and adducts scapula
Nerve
DORSAL SCAPULAR NERVE
40
The muscles of the back are complex but divisible into 3 groups: superficial, intermediate and deep group.
```
LEVATORES COSTARUM
Group
Origin
Insertion
Action
Nerve
```
Group; Intermediate group
Origin
- VETEBRAE; Transverse processes of C7, T1-11
Insertion
-RIBS; inferior to origin
Action
-Raise ribs in inspiration
Nerve
-DORSAL RAMI OF THORACIC SPINAL NERVES
41
The muscles of the back are complex but divisible into 3 groups: superficial, intermediate and deep group.
```
SERRATUS POSTERIOR SUPERIOR
Group
Origin
Insertion
Action
Nerve
```
Group; Intermediate
Origin
VERTEBRAE; spines of cervical and upper thoracic vertebrae
Insertion
-RIBS
Action
Raise ribs in inspiration
Nerve
INTERCOSTAL NERVES
42
The muscles of the back are complex but divisible into 3 groups: superficial, intermediate and deep group.
```
SERRATUS POSTERIOR INFERIOR
Group
Origin
Insertion
Action
Nerve
```
Group; Intermediate
Origin
-VERTEBRAE; spines of upper lumbar and lower thoracic vertebrae
Insertion
RIBS
Action
LOWER ribs in expiration
Nerve
INTERCOSTAL NERVES
43
The muscles of the back are complex but divisible into 3 groups: superficial, intermediate and deep group.
```
SPLENIUS
Group
Origin
Insertion
Action
Nerve
```
Group; Deep group
Origin
VERTEBRAE; spines of T1-T4
Insertion
SPLENIUS CAPITIS TO SKULL; occipital and temporal bones
SPLENIUS CERVICIS TO VERTEBRAE; transverse processes of C2-C3
Action
Extend neck and head (rotate in unilateral action)
Nerve
DORSAL RAMI OF SPINAL NERVES
44
The muscles of the back are complex but divisible into 3 groups: superficial, intermediate and deep group.
```
ERECTOR SPINAE
Group
Origin
Insertion
Action
Nerve
```
Deep group
Origin
1- ILIOCOSTALIS -from ilium and ribs
2- LONGISSIMUS - from transverse processes of vertebrae
3- SPINALIS - from spinous processes
Insertion
1-ILIOCOSTALIS to ribs and transverse process
2- LONGISSIMUS to transverse process of vertebrae
3- SPINALIS to spinous process
Action
Extend trunk and vertebral column
Nerve
DORSAL RAMI OF SPINAL NERVES
45
The muscles of the back are complex but divisible into 3 groups: superficial, intermediate and deep group.
```
TRANSVERSOSPINALIS
Group
Origin
Insertion
Action
Nerve
```
```
Deep group
Muscle has ((semispinalis, multifidus, rotatores)
```
Origin
TRANSVERSE PROCESS OF VERTEBRAE
Insertion
All insert upon SPINES OF VERTEBRAE SUPERIOR TO ORIGIN: Differ in how many vertebrae they extend across
1) SEMISPINALIS extend across 5 or 6 vertebrae
2) MULTIFIDUS extend across 3 or 4 vertebrae
3) ROTATORES extend across 1 or 2 vertebrae
Action
All extend trunk in bilateral action and rotate vertebral column in unilateral action
Nerve
DORSAL RAMI OF SPINAL NERVES
46
1) What is the only bony link to skeleton in the upper extremity
1- CLAVICLE
Scapula is linked to skeleton ANTERIORLY by CLAVICLE
**CLAVICLE is the most frequently BROKEN BONE in the body
47
Scapula articulates with humerus where?
- How does scapula attach to vertebrae?
- What does this allow for?
scapula articulates with humerus at the GLENOHUMERAL JOINT (ball and socket)
**scapula attach to vertebrae by muscles; the glenohumeral joint allows for other muscles to act on arm
48
What is this
**covers deep muscles of the back
- attaches MEDIALLY to spines of the vertebrae
- attached INFERIORLY to ilium (pelvic bone)
**Provides For Muscle attachment
FUNCTION; bilateral force, weight distribution
THORACOLUMBAR (LUMBAR) FASCIA
**orientation of CROSSING collagen fibers MAY HELP SUPPORT BODY WEIGHT when you lift opposite leg
**Collagen fibers CROSS IN MIDLINE above the sacrum
**POTENTIAL USE AS SURGICAL LANDMARK
49
What are the 3 muscles that
ACTION; All ELEVATE and ADDUCT scapula
Innervation; All by DORSAL SCAPULAR NERVE
LEVATOR SCAPULAE
RHOMBOID MINOR
RHOMBOID MAJOR
50
- What overlies the 6th intercostal space; floor has no large muscles - good place for listening with stethoscope ?
- What are the boundaries?
TRIANGLE OF AUSCULTATION
-Medial to scapula
BOUNDARIES
Inferior - Latissimus dorsi
Superior - Trapezius
Lateral - Rhomboid major
51
- What is the intermediate group associated with?
- where do they all originate form?
- Insertion
- Associated with RESPIRATION
- ALL ORIGIN is VERTEBRAE
- ALL insert to RIBS
52
What innervated the Serratus posterior superior and Serratus posterior inferior
INTERCOSTAL NERVES
53
NAME THE GROUP
- all extend trunk of neck when act bilaterally
- all located dorsal to vertebral column
- all innervated by DORSAL RAMI OF SPINAL NERVES
DEEP GROUP OF MUSCLES OF THE BACK
- Splenius
- Erector Spinae (Iliocostalis, longissimus, spinalis)
- Transversospinalis (semispinalis, multifidus, rotatores)
54
What is this?
1) Sensory and motor axons to REGION OF BACK; sensory to skin of back and posterior neck, motor axons to deep muscles of back and neck
2) Sensory and motor axons to OTHER PARTS of the BODY; sensory to skin of extremities (arm, leg) and anterior and lateral regions of trunk; motor to muscles of extremities and anterior and lateral regions of trunk
1- DORSAL RAMUS (AKA DRSAL PRIMARY RAMUS)
2- VENTRAL RAMUS (AKA VENTRAL PRIMARY RAMUS)
55
The PECTORAL REGION has how many muscles? List them
```
4 muscles
1- PECTORALIS MAJOR
2- PECTORALIS MINOR
3- SERRATUS ANTERIOR
4- SUBCLAVIUS
```
56
There are 4 muscles of the pectoral region
```
PECTORALIS MAJOR
Origin
Insertion
Action
Nerve
```
Origin;
- clavicular head; MEDIAL half of CLAVICLE
- sternocostal head; STERNUM and upper six costal cartilages
Insertion
-lateral lip of bicipital groove (intertubercular sulcus)
Action
- ADDUCTS and MEDIALLY rotates the arm
- FLEXES arm
Nerve
-MEDIAL and LATERAL pectoral nerves
57
There are 4 muscles of the pectoral region
```
PECTORALIS MINOR
Origin
Insertion
Action
Nerve
```
Origin
3rd to 5th ribs near cartilages
Insertion
Coracoid process of scapula
Action
- DEPRESSES scapula
- ELEVATES ribs of origin for deep inspiration
Nerve
MEDIAL PECTORAL
58
There are 4 muscles of the pectoral region
```
SERRATUS ANTERIOR
Origin
Insertion
Action
Nerve
```
Origin
Upper eight ribs
Insertion
-Medial (vertebral) border of scapula
Action
- rotates scapula
- Draws scapula forward around thoracic wall (protraction)
- Holds scapula against thoracic wall
Nerve
LONG THORACIC NERVE
59
There are 4 muscles of the pectoral region
```
SUBCLAVIUS
Origin
Insertion
Action
Nerve
```
Origin
1st costal cartilage
Insertion
CLAVICLE
Action
ANCHORS and DEPRESSES clavicle during upper limb movements
Nerve
NERVE TO SUBCLAVIUS
60
There are 6 total muscles of the shoulder. 4 muscles make up the ROTATOR CUFF. Name them
what is the function of rotator cuff?
ROTATOR CUFF
- Supraspinatus
- Infraspinatus
- Teres minor
- Subscapularis
* Function; hold the head of the humerus against the glenoid cavity while the limb is being moved
Others
- Deltoid
- Teres major
61
There are 6 muscles in the shoulders. 4 are rotator cuff muscles.
```
DELTOID
Origin
Insertion
Action
Nerve
```
Origin
-Lateral clavicle, acromion process and spine of scapula
Insertion
-Deltoid tuberosity of humerus
Action
ANTERIOR part; flexes and medially rotates arm
MIDDLE part; abducts arm
POSTERIOR part; extends and laterally rotates arm
Nerve
AXILLARY
62
There are 6 muscles in the shoulders. 4 are rotator cuff muscles.
```
SUPRASPINATUS
Origin
Insertion
Action
Nerve
```
Origin
SUPRASPINOUS fossa of scapula
Insertion
Greater tubercle of humerus
Action
Initiates abduction of arm; stabilizes shoulder joint
Nerve
SUPRASCAPULAR
63
There are 6 muscles in the shoulders. 4 are rotator cuff muscles.
```
INFRASPINATUS
Origin
Insertion
Action
Nerve
```
Origin
Infraspinous fossa of scapula
Insertion
Greater tubercle of humerus
Action
Laterally rotates arm; stabilizes shoulder joint
Nerve
SUPRASCAPULAR
64
There are 6 muscles in the shoulders. 4 are rotator cuff muscles.
```
TERES MINOR
Origin
Insertion
Action
Nerve
```
Origin
Lateral border of scapula
Insertion
Greater tubercle of humerus
Action
Laterally rotates arm; stabilizes shoulder joint
Nerve
AXILLARY NERVE
65
There are 6 muscles in the shoulders. 4 are rotator cuff muscles.
```
SUBSCAPULARIS
Origin
Insertion
Action
Nerve
```
Origin
Subscapular fossa of scapula
Insertion
Lesser tubercle of humerus
Action
Medially rotates arm; stabilizes shoulder joint
Nerve
UPPER AND LOWER SUBSCAPULAR NERVE
66
There are 6 muscles in the shoulders. 4 are rotator cuff muscles.
```
TERES MAJOR
Origin
Insertion
Action
Nerve
```
Origin
Inferior angle of scapula
Insertion
Medial lip of the intertubercular groove (bicipital groove) of humerus
Action
Medially rotates and ADDUCTS arm
Nerve
LOWER SUBSCAPULAR NERVE
67
Name this
- modified sweat gland located in superficial fascia
- AXILLARY tail of gland (tail of spence) extends into armpit
MAMMARY GLAND
*TAIL of Spence is removed in modified radical or radical mastectomy
68
What ligaments in mammary gland acts as walls to separate breast into 15-20 lobes/compartments?
-Each lobe contains milk glans via LACTIFEROUS DUCT to nipple
What is the removal of a single lobe?
SUSPENSORY/COOPER’S LIGAMENTS
Lobectomy is removal of a single lobe
69
In a SAGITTAL section of mammary gland, what is the layer of loose CT separating breast from deep fascia?
- potential space that allows movement of breast over underlying structures
- tumor can invade deep fascia and pectoralis major leading to fixation of breast to thoracic wall
RETROMAMMARY SPACE
70
What is the arterial supply of the mammary gland? (3)
1- Internal thoracic artery from subclavian artery
2- Thoracoacromial artery from AXILLARY artery
3- Lateral thoracic artery from AXILLARY artery
71
Lymph fluid is formed from interstitial/tissue fluids and lymph nodes filter pathogens and cancerous cells from lymph.
What is the lymphatic drainage of the mammary gland and how (4)
Why is the lymphatic drainage system of breast important?
**Drains into AXILLARY LYMPH NODES in superficial fascia
1) Pectoral/anterior AXILLARY nodes;
- drains LATERAL breast
- receive approx. 75% of lymph from breast
2) Parasternal nodes (adjacent to internal thoracic vessels)
- drain MEDIAL breast
- receive MOST of the REMAINING lymph from breast
3) Abdomen nodes
- LOWER quadrants of breast
4) Other breast
**Breast lymph drainage system is important since tumor cells can spread from breast to other bodily regions via lymphatic vessels
72
What causes WINGED SCAPULA?
Damage to the LONG THORACIC NERVE
* Serratus anterior muscle no longer holds scapula to thoracic wall
* *Medial border and inferior angle of the scapula thrust POSTERIORLY when patient pushes hand against wall
73
The fascia of the pectoral region invests the four pectoral muscles ; which is which
1) covers the pectoralis MAJOR
2)
- encloses the pectoralis MINOR and SUBCLAVIUS and attaches to the clavicle
- protects the underlying neurovascular structures that supply upper limb (e.g BRACHIAL PLEXUS and AXILLARY VESSELS)
1) PECTORAL FASCIA
| 2) CLAVIPECTORAL FASCIA
74
What is the clavipectoral fascia pierces by? (3)
1- CEPHALIC VEIN
-drains lateral side f superficial aspect of upper limb, enters deltopectoral triangle and pierces clavipectoral fascia to join the AXILLARY vein
2- THORACOACROMIAL ARTERY
-A branch of the AXILLARY artery
3- LATERAL PECTORAL NERVE
-A branch of the lateral cord of the brachial plexus (beside pectoralis minor- medial)
75
What is the triangular depression Inferior to the lateral part of the clavicle called?
What are the borders and contents?
DELTOPECTORAL/CLAVIPECTORAL TRIANGLE
BORDERS;
- Superiorly; Clavicle
- Laterally; Deltoid
- Medially; Pectoralis major
CONTENTS
- CEPHALIC vein (superficial)
- Tip of coracoid process (Deep; can palpate - like a RAVEN’S PEAK)
76
WHAT IS THIS
- pyramidal shaped area btw the arm and upper thorax
- passageway for the neurovascular supply to the upper limb
What are the borders?
AXILLA/ARMPIT
BORDERS
1- Anterior wall
-Pectoralis major and minor muscles
2-Posterior wall
-scapula, subscapular is, latissimus dorsi (insertion) and Teres major
3- Medial wall
-Upper 4 ribs, intercostal muscles btw ribs and Serratus anterior
4- Lateral wall
-Intertubercular groove of humerus
77
The contents of the axilla is made of neurovascular bundle enveloped by sheath of connective tissue, the AXILLARY SHEATH.
What are the 3 contents of axilla
1- AXILLARY ARTERY (STLSAP- sixties teens loved sex and pot)
2- AXILLARY VEIN
3- AXILLARY LYMPH NODES
78
The AXILLARY artery is the continuation of what artery?
SUBCLAVIAN ARTERY
*Begins at the lateral border of rib 1 and ends at the inferior border of the Teres major (inferior border of axilla) where it becomes brachial artery
subclavian artery - AXILLARY artery - brachial artery
79
What are the branches of the AXILLARY artery
3 parts
PART 1
1- Superior thoracic artery
PART 2
2- Thoracoacromial artery
3- Lateral thoracic artery
PART 3
4- Anterior circumflex numeral artery
-small artery; winds ANTERIORLY around surgical neck of humerus
5- Posterior circumflex artery
-winds POSTERIORLY around surgical neck of humerus
6- Subscapular artery (largest branch
-courses along LATERAL border of scapula
80
NAME THIS
- located medial the AXILLARY artery
- begins as a continuation of the basilica vein from the arm
- receives tributaries that correspond to the AXILLARY artery and the CEPHALIC vein
AXILLARY VEIN
81
NAME THIS
- group of nodes located in the connective tissue
- receive lymph from the upper limb and breast
- drain into the subclavian lymph trunks, which drain into the right lymphatic duct (right side of body) and thoracic duct (left side of body)
What are the drainage patterns
AXILLARY LYMPH NODES
1- HUMERAL nodes; drain the UPPER LIMB
2- SUBSCAPULAR/POSTERIOR NODES; drain POSTERIOR wall of axilla
3- Pectoral/anterior nodes; drain anterior wall of axilla, including the lateral breast
4- Central nodes; receive lymph from humeral, subscapular and pectoral nodes
5- Apical nodes; receive lymph from central node
6- Supraclavicuar nodes; receive lymph from apical nodes and drain into the subclavian lymph trunk
82
The brachial plexus is divided into 2 parts. One in neck and other in axilla. What are they called? And there further divisions
1- Supraclavicular part IN NECK
- VENTRAL RAMI (spina nerves C5-T1)
- TRUNK
- DIVISIONS
2- Infraclavicular part IN AXILLA
- CORDS
- TERMINAL BRANCHES
**PNEMONIC
Randy Travis Drinks Cold Beer
83
How many trunks in the brachial plexus? What are they and the spinal nerves??
3 trunks
1- SUPERIOR (C5 and C6)
2- MIDDLE (C7)
3-INFERIOR (C8 and T1); Located on rib 1
84
What do the anterior and posterior divisions of the brachial plexus supply?
ANTERIOR division; supply anterior compartments (FLEXORS) of the arm and forearm e.g lateral cord-musculocutaneous nerve
- formed by superior and middle trunks C5, C6,C7
- formed by inferior trunk C8,T1
POSTERIOR division; supply the posterior compartment (EXTENSOR) of the arm and forearm e.g radial and AXILLARY nerve
85
How are cords formed and how are they named?
- formed by the union of divisions
- named in their relationship TO THE AXILLARY ARTERY e.g posterior cord is posterior to the AXILLARY artery, lateral cord is lateral to the AXILLARY artery and medial cord is medial to the AXILLARY artery
86
What are the terminal branches of the posterior cord? And spinal nerves/
which is which branch
1- innervated deltoid and Teres minor muscles and sensory fibers to skin of UPPER LATERAL ARM
2-LARGEST branch
- motor to extensors of posterior arm and posterior forearm
- sensory to skin of posterior arm, posterior forearm, dorsolateral hand and dorsal side of proximal part of lateral 3.5 digits
-formed by the union of all 3 posterior divisions (C5-T1)
1- AXILLARY nerve (C5, C6)
-innervated deltoid and Teres minor muscles and sensory fibers to skin of UPPER LATERAL ARM
2- RADIAL NEERVE (C5-C8, T1)
-LARGEST branch
-motor to extensors of posterior arm and posterior forearm
-sensory to skin of posterior arm, posterior forearm, dorsolateral hand and dorsal side of proximal part of lateral 3.5 digits
87
There are 3 SIDE branches of the posterior cord. Name them
1- innervates subscapularis
2-innervates latissimus dorsi
3- innervates suubscapularis and Teres major
1- UPPER SUBSCAPULAR NERVE
2- THORACODORSAL NERVE
3- LOWER SUBSCAPULAR NERVE
88
Name the cord
-formed by the union of the anterior divisions of the upper and middle trunk (mostly C5-C7)
WHAT ARE THE TERMINAL BRANCES
LATERAL CORD
TERMINAL BRANCHES
1- Musculocutaneous nerve (C5-C7)
Key landmark;Nerve pierces corrracobrachialis muscle of arm
-innervates anterior arm muscles (coracobrachialis, biceps brachii and brachialis)
-is a CUTANEOUS nerve to lateral forearm
2- LATERAL PART OF MEDIAN NERVE (C5-C7)
-joins a similar contribution from the medial cord to form the median nerve
89
Name the side branch of lateral cord
-innervates pectoralis major
LATERAL PECTORAL NERVE
-is names lateral for the cord it branches from and not in relation to the medial pectoral nerve (medial pectoral nerve is lateral to lateral pectoral nerve)
90
What cord is the continuation of the anterior division of the lower trunk (C8 and T1)
What are the branches?
MEDIAL CORD
TERMINAL BRANCHES
1- ULNAR NERVE (C8, T1)
-innervates medial 1.5 muscles of forearm (flexor Capri ulnaris and medial part of flexor digitorum profunda) and most intrinsic muscles of hand
-cutaneous branches to medial 1/3rd of palm and dorsum of hand and medial 1.5 fingers (little finger and medial side of ring finger)
2-MEDIAL PART OF MEDIAN NERVE
-joins the lateral part of the median nerve from the lateral cord to form the median nerve
91
What are the side branches of the medial cord
1- Medial pectoral nerve ; innervate the pectoralis major and minor
2- Medial cutaneous nerve of arm
3- Medial cutaneous nerve of forearm
92
Name the nerve
-medial to most muscles of anterior compartment, thenar muscles to thumb and lateral 2 lumbricals of palm of hand
What is exception/
MEDIAN NERVE
Exception
- flexor Carpi ulnaris and medial art of flexor digitorum profundus and most intrinsic muscles of palm of the hand
- sensory to skin of lateral 2/3rds of palm of hand, palmar side and nail beds of lateral 3.5 fingers
93
Name the branches of ventral rami respectively;
1
- branch of the ventral RAMUS of C5
- innervate LEVATOR scapulae, rhomboid major and rhomboid minor muscles that attach to medial border of scapula
2- branch of the ventral rami of C5-C7
1- DORSAL SCAPULAR NERVE
2- LONG THORACIC NERVE (nerve to Serratus anterior)
94
Name the side branches from upper trunk
Which one innervates supraspinatus and Infraspinatus muscles
1- SUPRASCAPULAR NERVE (C5 and C6)
-innervates supraspinatus and Infraspinatus muscles
2- Nerve to SUBCLAVIUS
-innervates subclavius
95
Tell me about the anterior compartment in general
Muscles
Action
Innervation
Muscles; Biceps brachii, brachialis, coracobrachialis
Action; Major FLEXOR at elbow joint and supination of forearm at superior and inferior radioulnar joints
Innervation; MUSCULOCUTANEOUS NERVE
96
There are 4 muscles of the arm. 3 of the anterior compartment and 1 posterior compartment
Name them
Anterior
1- Biceps brachii (long head and short head)
2- Coracobrachialis
3- Brachialis
Posterior
1-Triceps brachii (long, lateral and medial head)
97
There are 4 muscles of the arm. 3 of the anterior compartment and 1 posterior compartment
BICEPS BRACHII
Long head
Short head
Origin
Long head- Supraglenoid tubercle
Short head - Coracoid process
Insertion - Radial tuberosity
Action-
- Powerful flexor of forearm at elbow joint
- Powerful supination of forearm
- Weak flexor of arm at glenohumeral joint
Nerve
MUSCULOCUTANEOUS NERVE
98
There are 4 muscles of the arm. 3 of the anterior compartment and 1 posterior compartment
CORACOBRACHIALIS
Origin - Coracoid process
Insertion - Mid-shaft humerus
Action- FLEXION of arm at glenohumeral/shoulder joint
Nerve -MUSCULOCUTANEOUS NERVE
99
There are 4 muscles of the arm. 3 of the anterior compartment and 1 posterior compartment
BRACHIALIS
Origin- Anterior humerus
Insertion- Ulnar tuberosity
Action - Flexes forearm
Nerve - MUSCULOCUTANEOUS NERVE
100
There are 4 muscles of the arm. 3 of the anterior compartment and 1 posterior compartment
TRICEPS BRACHII
Long head
Lateral head
Medial head
Origin
Long head; Infraglenoid tubercle
Lateral head; posterior lateral surface of humerus
Medial head; posterior medial surface of humerus
Insertion
Olecranon of ulna
Action
Extends forearm
Nerve
RADIAL NERVE
101
What is the clinical condition
-Flexing elbow results in prominent bulge of the muscle belly (popeye’s sign)
Rupture of Long head of biceps brachii
102
- What artery changes to what artery at the lower border of Teres major/ axilla into the anterior arm
- also terminates just below elbow joint as what arteries?
1) AXILLARY artery - BRACHIAL artery (from axilla to anterior arm- lower border of Teres major)
2) BRACHIAL artery - ULNAR and RADIAL arteries (just below elbow joint)
103
1) What artery descends the arm with the median nerve
2) What artery is palpable and can be compressed against the humerus in the in the proximal arm to stop hemorrhage?
3) Where is the site for placement of blood pressure cuff? What does it compress?
4) Where is the site where a stethoscope is place on what artery? Why?
1- BRACHIAL ARTERY
2- BRACHIAL ARTERY
3- MID-ARM, to compress BRACHIAL ARTERY
4- CUBITAL FOSSA, To listen for pulse during blood pressure measurement
104
What are the respective branches of the brachial artery
1- courses into posterior/radial groove (joins RADIAL NERVE here)
2- Courses with ULNAR NERVE to pass posterior to medial epicondyle and posterior to elbow joint
3- descends ANTERIOR to the ELBOW joint
1- DEEP (profunda) brachial artery
- go to posterior compartment of arm - joins RADIAL NERVE (in radial groove of humerus)
- TERMINAL BRANCHES; Radial collateral and middle collateral -participate in ARTERIAL ANASTOMOSIS at elbow joint
2- SUPERIOR ULNAR COLLATERAL ARTERY
- courses with ULNAR NERVE to pass posterior to the medial epicondyle of the humerus ad posterior to the elbow joint.
- Also do ARTERIAL ANASTOMOSIS at elbow joint
3- INFERIOR ULNAR COLLATERAL ARTERY
- Descends anterior to the elbow joint
- participates in the ARTERIAL ANASTOMOSIS at elbow joint
105
What are the branches of brachial artery that participate in ARTERIAL ANASTOMOSIS AT ELBOW JOINT
1- Radial and middle collateral artery (branches from deep/profunda brachial artery)
2- Superior ulnar collateral artery
3- Inferior ulnar collateral artery
* *All 3 branches of the Brachial artery
- So when brachial artery is compressed at mid-arm during hemorrhage, elbow anastomosis still allow blood flow to the forearm
106
Name the nerves
- pass along medial side of arm into anterior forearm
- do NOT innervate brachial muscles but innervate muscle of anterior forearm and hand
MEDIAN and ULNAR Nerves
107
Name the nerve
- is most medially located in arm
- passes POSTERIORLY to pierce medial inter muscular septum
- descends along posterior side of medial epicondyle of humerus
* *Site for damage by compression against bone (funny bone)
ULNAR NERVE
** DO NOT innervate any branches in the arm (just forearm/hand)
108
Name the nerve
- innervates the anterior compartment muscles of arm
- pierces and innervates the coracobrachialis
- passes POSTERIORLY to pierce medial intermuscular septum
- descends btw the brachialis and biceps brachii innervating these muscle
- emerges laterally above elbow joint as the lateral cutaneous nerve of forearm (anterbrachial) supplying skin of lateral forearm
MUSCULOCUTANEOUS NERVE
109
Name the nerve
- innervates the posterior compartment muscles of arm from nerve branches in the axilla
- gives off sensory nerves, the inferior lateral brachial cutaneous nerve and the posterior cutaneous nerves of arm and forearm
- descends diagonally in the radial groove of the humerus with the deep brachial artery btw the medial and lateral heads of the triceps
RADIAL NERVE
110
FRACTURE of the HUMERUS (shaft) at the radial groove can injure the radial nerve, which also innervates extensors of posterior compartment of forearm.
What is this called?
WRIST-DROP (Inability to extend the wrist and digits)
111
What are the artery/nerve associations of the following?
1- Ulnar nerve medial to what?
2- Ulnar nerve - with what artery above the medial epicondyle
3- Radial nerve - with what artery in radial groove
4- Median nerve with what artery
5- Radial collateral artery with at nerve at elbow joint?
1- Ulnar nerve; medial to brachial artery
2- Ulnar nerve - superior ulnar collateral artery above medial epicondyle (pierce medial intermuscular septum)
3- Radial nerve - profunda brachial artery in radial groove
4- Median nerve- brachial artery
5- Radial collateral artery - radial nerve above elbow
112
Radial nerve damage (in mid shaft/ radial groove of humerus) does not significantly affect what action?
-Does not significantly affect extension of arm at elbow joint
* *Most of Triceps brachii is innervated proximal to radial groove
- damage of radial nerve by fx of mid-shaft will not affect most of triceps brachii
- So extension of arm at elbow joint will not be significantly affected
113
Where is the cubital fossa and what are the borders and contents ?
USE?
**Median cubital vein is located in superficial fascia in the cubital fossa
-TRIANGULAR Depression is anterior to elbow
BORDERS
A. Horizontal plane btw medial and lateral epicondyle of humerus
B. Lateral border; BRACHIORADIALIS
C. Medial border; PRONATOR TERES
CONTENTS
1. Biceps brachii TENDON
2. Brachial ARTERY
3. Median NERVE
* *TAN
**CUBITAL FOSSA is site of stethoscope placement for blood pressure assessment
114
What nerve is deep to brachioradialis at lateral border of cubital fossa?
What are the terminal branches? (Which is motor? Sensory?)
RADIAL NERVE - deep to brachioradialis at lateral border of cubital fossa
BRANCHES
1- DEEP branch of radial nerve
- MOTOR nerve to posterior compartment of forearm, which extend hand at wrist
2- SUPERFICIAL branch of radial nerve
-SENSORY nerve innervation the dorsolateral hand and proximal part of lateral 3.5 digits
115
Venipuncture of what may inadvertently puncture underlying brachial artery?
What is it protected by?
MEDIAL CUBITAL VEIN
**Brachial artery Protected by bicipital aponeurosis
116
What are all the arteries of anatomosis at elbow joint?
| Use?
- allows blood flow distally into the forearm and hand if brachii artery is compressed by prolonged FLEXION of forearm at elbow joint or if the brachial artery is ligated to suppress hemorrhaging of lacerated artery
Above elbow joint (2 branches)
1- Branches of deep brachial artery
- Radial collateral a.
-Middle collateral a.
2- Branches of brachial a.
- Superior ulnar collateral a.
- Inferior ulnar collateral a.
Below elbow joint (3 branches)
1- Branch of radial a.
-Radial recurrent a.
2- Branch of common interosseous a.
-Interosseous recurrent a.
3- Branches of ulnar
- Posterior ulnar recurrent a.
- Anterior ulnar recurrent a.
117
What are the elbow anatomosis?
1- Radial collateral a. (above elbow joint) to Radial recurrent a. (Below)
2- Middle collateral a. To Interosseous recurrent a.
3- Superior ulnar collateral a. To Posterior ulnar recurrent a.
4- Inferior ulnar collateral a. To Anterior ulnar recurrent a.
118
What are the extrinsic muscles of the shoulder?
Origin
Insertion
```
5 total
Superficial group
1- Trapezius
2- Latissimus dorsi
3- Serratus anterior
```
Deep group
1- LEVATOR scapulae
2- Rhomboid major and minor
119
Serratus anterior is one of the extrinsic muscles of the shoulder.
Identify
Origin
Insertion
Action
Nerve
**Clinical condition from nerve damage
Origin - Upper 8 ribs
Insertion - Medial border of scapular
Action
- Rotates scapula
- Draws scapula forward around thoracic wall (pronation) used when reaching anterior e.g throw a punch
- Holds scapula against thoracic wall
Nerve - LONG THORACIC NERVE
**Damage of long thoracic nerve result in WINGED SCAPULA
120
WHat group of muscles arise/originate from clavicle and scapula and insert on the humerus?
Name them
INTRINSIC MUSCLES OF SHOULDERS
```
ROTATOR CUFF
1-Supraspinatus
2-Infraspinatus
3-Teres minor
4-Subscapularis
```
**Pneumonic SITS
5- Deltoid
6- Teres major
121
Name the group of muscles
- attach the scapula to the humerus
- hold the head of the humerus against the glenoid fossa of the scapula and prevent dislocation of the shoulder joint
ROTATOR CUFF MUSCLES
* * have tendons that form a sheath or cuff, which blends with the fibrous capsule of shoulder joint. Cuff covers almost all the joint capsule except inferiorly
* *The head of the abducted humerus can be DISLOCATED INFERIORLY since the rotator cuff tendons are not present below the shoulder joint
122
There are 6 total intrinsic muscles of the shoulder. 4 of which are rotator cuff muscles
```
SUPRASPINATUS
Origin
Insertion
Action
Nerve
```
Origin - supraspinatus fossa of scapula
Insertion; Greater tubercle of humerus
Action;
- Initiates ABDUCTION of arm
- Stabilizes shoulder joint
Nerve
SUPRASCAPULAR NERVE
123
There are 6 total intrinsic muscles of the shoulder. 4 of which are rotator cuff muscles
```
INFRASPINATUS
Origin
Insertion
Action
Nerve
```
Origin - Infraspinous fossa of scapula
Insertion - Greater tubercle of humerus
Action
- Laterally rotate arm
- Stabilize shoulder joint
Nerve
SUPRASCAPULAR NERVE
124
There are 6 total intrinsic muscles of the shoulder. 4 of which are rotator cuff muscles
```
TERES MINOR
Origin
Insertion
Action
Nerve
```
Origin - Lateral border of scapula
Insertion - Greater tubercle of humerus
Action -
- Laterally rotate arm
- Stabilize shoulder joint
Nerve
AXILLARY NERVE
125
There are 6 total intrinsic muscles of the shoulder. 4 of which are rotator cuff muscles
```
SUBSCAPULARIS
Origin
Insertion
Action
Nerve
```
Origin - Subscapular fossa of scapula
Insertion - Lesser tubercle of humerus
Action
- Medially rotates arm
- Stabilize shoulder joint
Nerve
UPPER AND LOWER SUBSCAPULAR NERVE
126
There are 6 total intrinsic muscles of the shoulder. 4 of which are rotator cuff muscles
```
DELTOID
Origin
Insertion
Action
Nerve
```
Origin - Lateral clavicle, acromion process and spine of scapula
Insertion - Deltoid tuberosity of humerus
Action
Anterior part; flexes and medially rotates arm
Middle part; Abducts arm
Posterior part; Extends and laterally rotates arm
Nerve
AXILLARY NERVE
127
There are 6 total intrinsic muscles of the shoulder. 4 of which are rotator cuff muscles
```
TERES MAJOR
Origin
Insertion
Action
Nerve
```
Origin - Inferior angle of scapula
Insertion - Medial lip of the intertubercular groove (bicipital groove) of humerus
Action - Medial rotates and adducts arm
Nerve
LOWER SUBSCAPULAR NERVE
128
A BURSA is a synovial sac filled by a capillary film of synovial fluid. the sac is I usually located btw tendon and bone or tendon and another muscle to reduce friction btw these structures
Name the bursa
-lies btw supraspinatus tendon and acromion and deltoid muscle
What happens with inflammation?
SUBACROMIAL BURSA
***IF INFLAMMED (subacromial bursitis) - results in pain during abduction of arm from 70 - 120 degrees
**PAINFUL ARC SYNDROME
129
WHAT is the most commonly torn tendon of the rotator cuff muscles?
-Tear in tendon can cause dislocation of humerus
SUPRASPINATUS TENDON
- undergoes degenerative tendinitis in older people and can result in calcium deposited in tendon
- the tendon adheres to subacromial bursa due to calcium deposits
- degeneration of tendon and adjacent capsule of shoulder joint can result in communication between subacromial bursa and joint cavity
130
What muscles help with abduction of the arm?
What are the stages?
DELTOID, SUPRASPINATUS, (with assistance from Serratus anterior and trapezius)
1- SUPRASPINATUS
-initiates abduction (initial 15 degrees) from fully addicted position)
2- DELTOID
-continues abduction from 15 - 120 degrees at which point greater tubercle of humerus contacts acromion process
3- SERRATUS ANTERIOR AND TRAPEZIUS
-allows abduction of arm above your head by rotating the scapula so glenoid fossa faces superiorly and laterally
131
What is the rectangular space btw bone and muscles that allows for passage of neurovascular structures from axilla to posterior aspects of scapular region and arm?
What are the boundaries / and contents
QUANDRANGULAR SPACE
**Boundaries; Teres minor, Teres major, long head of triceps brachii, surgical neck of humerus
**Contents ; AXILLARY nerve and posterior circumflex humeral vessels
132
AXILLARY nerve and posterior circumflex humeral vessels are contents of the Quadrangular space.
Damage of AXILLARY nerve result in what?
what are the causes/
-Damage of AXILLARY nerve result in WEAK ABDUCTION OF ARM
**(AXILLARY nerve innervates deltoid)
Causes
1- Break of surgical neck of humerus
2- Inferior dislocation of shoulder
**Head of humerus pops out inferiorly from capsule of shoulder joint and damages AXILLARY nerve
133
what is the triangular space that allows for passage of neurovascular supply from axilla to post scapular and arm regions
What are the boundaries and contents
TRIANGULAR INTERVAL
BOUNDARIES
- Teres major
- long head or triceps
- lateral head of triceps
CONTENTS ; radial n. And deep brachial artery
**damage of radial nerve lead to wrist drop and sensory of hand
Damage occurs form break in mid-shaft of humerus
134
What artery provides blood supply to upper limb ?
-can be kinked during prolonged FLEXION of the arm
AXILLARY ARTERY
135
What makes up the arterial anastomosis at the around the shoulder joint?
**Function to create a bypass around a potentially kinked or blocked AXILLARY artery.
1- Branches thyrocervical trunk from subclavian artery
-SUPRASCAPULAR ARTERY; passes to posterior side of scapula (above SUPRASCAPULAR ligament and SUPRASCAPULAR notch)
-TRANSVERSE/SUPERICIAL cervical artery ; comes directly off subclavian; has a deep branch (DORSAL SCAPULAR ARTERY) at the medial border of scapula that pass deep to trapezius, rhomboids ad LEVATOR scapulae.
2- Branch from the AXILLARY artery
-SUBSCAPULAR ARTERY ; largest branch of the AXILLARY artery, passes along the lateral border of the scapula , has a CIRCUMFLEX SCAPULAR BRANCH, that participates in the anastomoses
136
Name the vessels
- branches of the aorta that supply the thoracic wall
- a few join the transverse cervical artery at the medial border of the scapula
INTERCOSTAL ARTERIES
137
Why is the arterial anastomoses at the shoulder joint important?
- AXILLARY artery can be a created by penetrating wound (e.g knife) to area below clavicle or subject to aneurysm.
* *Patient requires immediate ligation of artery.
- Ligations of the subclavian or AXILLARY arteries can be made anywhere btw the thyrocervical trunk and subscapular artery and still maintain blood flow to upper extremity without blood loss
138
Neurovascular supply to supraspinatus and Infraspinatus muscles passes above or below SUPRASCAPULAR ligament, which bridges over suprascapular notch
Which verses passes superiorly over ligament?
Which go inferiorly under ligament
SUPRASCAPULAR Nerve
- branch of the upper trunk of the brachial plexus
- passes POSTERIORLY and runs through the SUPRASCAPULAR notch INFERIOR to the SUPRASCAPULAR ligament to reach the supraspinatus and Infraspinatus fossa
SUPRASCAPULAR ARTERY
- a branch of the thyrocervical trunk of the subclavian artery
- passes POSTERIORLY and runs SUPERIOR TO THE SUPRASCAPULAR ligament to reach the supraspinatus and infraspinatus fossa
* *ARMY go over bridge (artery)
* *NAVY go under bridge (nerve)
139
Name the artery
- a branch of the thyrocervical trunk of the subclavian artery
- passes POSTERIORLY and runs SUPERIOR TO THE SUPRASCAPULAR ligament to reach the supraspinatus and infraspinatus fossa
SUPRASCAPULAR ARTERY
141
What is the lateral bone of the forearm?
- proximal end (head) is smaller than its distal end
- rounded head articulates with what part of humerus at elbow joint?
- distal end articulates with what carpal bones at wrist joint?
What else is on distal end?
RADIUS
- proximal end/head articulates with CAPITULUM of humerus at elbow joint
- distal end articulates with SCAPHOID and LUNATE of wrist joint
* *
- has a styloid process at distal end
142
What connects radius to ulnar?
TOUGH SHEET OF CONNECTIVE TISSUE - THE INTEROSSEOUS MEMBRANE
**serves as an attachment site for muscles and separates anterior from posterior compartment muscles of forearm
143
What if the medial bone of the forearm?
Is proximal end larger than distal end?
How is this bone connected to the humerus at the proximal end and carpals at distal end?
What is on the distal end (2)
ULNAR
- proximal end is larger than the distal end
- OLECRANON articulates with TROCHLEA of humerus at elbow joint
- Articular disc of cartilage separates distal end of ulna from TRIUETRUM (carpal bone) of wrist joint
**Styloid process and head at distal head
144
The carpal bones are divided into proximal row and distal row. What are all the bones IN PROXIMAL ROW
1- Which one is palpable/has tubercle
2- what is a sesamoid bone in tendon of flexor carpi ulnaris and palpable
```
PROXIMAL ROW (lateral to medial)
1- scaphoid (boat shape/tubercle/palpable)
```
2- lunate (crescent moon shape)
3- Triquetrum (triangular shape)
4- Pisiform (pea shaped)
- SESAMOID BONE (bone with a tendon) in tendon of flexor carpi ulnaris
- located ANTERIOR to triquetrum
- is PALPABLE
145
The carpal bones are divided into proximal row and distal row. What are all the bones IN DISTAL ROW (5-8)
1- which articulates with metacarpal 1 of thumb, has tubercle and is palpable
2-which articulate with metacarpal 4 and 5, has a hook and is palpable
DISTAL ROW (from lateral to medial)
5- Trapezium (4-sided)
- articulates with metacarpal 1 of THUMB
- has a tubercle (palpable)
6- Trapezoid (4-sided)
- articulates with metacarpal II of INDEX finger
7- Capitate (head shaped)
-articulates with metacarpal III of MIDDLE finger
8- Hamate (hook shape)
- articulates with metacarpals IV and V of ring and little fingers
- has a HOOK/PALPABLE
146
What is the most common fracture of the carpal bones that results in AVASCULAR NECROSIS?
Fracture of the middle of SCAPHOID BONE
- most common fracture of carpal bones
- blood supply to scaphoid goes through the DISTAL part of bone to reach the PROXIMAL part of scaphoid in 10% of the population
- Fracture at the middle f the scaphoid could DISRUPT BLOOD SUPPLY t the PROXIMAL PART OF SCAPHOID resulting in AVASCULAR NECROSIS (death of tissue) of proximal part of scaphoid
147
Carpal bones do not lie flat but form an arch. The space btw the arch of the carpal bones and the flexor reticulum is called what?
-what is the flexor reticulum? (How does it attach to lateral and medial ends of of carpal bones)
CARPAL TUNNEL
*Flexor reticulum; very thick ligament that attaches to the medial and lateral ends of the carpal arch by attaching to the pisiform and hook of hamate MEDIALLY and the tubercles of scaphoid and trapezium LATERALLY
148
WHAT are the CONTENTS of carpal tunnel?
what nerve is not a part of carpal tunnel
-Ulnar nerve is NOT in carpal tunnel
CONTENTS
- Median nerve
- Tendon of Flexor digitorum Superficialis (to middle phalanges of digits 2-5)
- Tendon of Flexor digitorum profundus (to distal phalanges of digits 2-5)
- Tendon of Flexor policis longus (to distal phalanx of thumb)
149
Which finger has only 2 phalanges instead of 3 like the others?
THUMB
150
Name the group of muscles
- flexors and pronators of the hand
- can also ABDUCT (radial deviation) and ADDUCT (ulnar deviation) the hand.
- divided into superficial (4), intermediate (1) and deep group (3)
MUSCLES OF ANTERIOR COMPARTMENT OF FOREARM (8)
151
There are 20 total muscles of the forearm. 8 in the anterior and 12 in the posterior. Of the 8 anterior muscles of the forearm, 4 make up the SUPERFICIAL GROUP
**PFPF
```
1- PRONATOR TERES
Origin
Insertion
Action
Nerve
```
PRONATOR TERES
Origin ;
-Medial epicondyle of humerus
-Coronoid process of ulna
Insertion
-Midshaft radius
Action
-Pronates forearm
Nerve
MEDIAN NERVE
**ALL superficial group of anterior forearm muscles originate in part from medial epicondyle of humerus
152
There are 20 total muscles of the forearm. 8 in the anterior and 12 in the posterior. Of the 8 anterior muscles of the forearm, 4 make up the SUPERFICIAL GROUP
**PFPF
```
2- FLEXOR CARPI RADIALIS
Origin
Insertion
Action
Nerve
```
Origin ; Medial epicondyle of humerus
Insertion; Bases of 2nd and 3rd metacarpals
Action ; FLEXES and ABDUCTS (radially deviates) hand at wrist joint
Nerve
MEDIAN NERVE
*ALL PFPF muscles originate form medial epicondyle of humerus
153
There are 20 total muscles of the forearm. 8 in the anterior and 12 in the posterior. Of the 8 anterior muscles of the forearm, 4 make up the SUPERFICIAL GROUP
**PFPF
```
3- PALMARIS LONGUS
Origin
Insertion
Action
Nerve
```
Origin ; Medial epicondyle of humerus
Insertion; Palmar aponeurosis
Action
FLEXES THE WRIST
Nerve
MEDIAN NERVE
**ALL PFPF originate from medial epicondyle of humerus
154
There are 20 total muscles of the forearm. 8 in the anterior and 12 in the posterior. Of the 8 anterior muscles of the forearm, 4 make up the SUPERFICIAL GROUP
**PFPF
4- FLEXOR CARPI ULNARIS
HUMERAL head
ULNAR head
Origin
Humeral head. - medial epicondyle of humerus
Ulnar head - Olecranon of ulna
Insertion
- Pisiform
- hook of hamate
- 5th metacarpal
Action
FLEXES and ADDUCTS (ulnar deviates) hand at wrist
Nerve
ULNAR NERVE
155
ALL 8 anterior muscles of the forearm are innervated by what nerve?
**What are the 2 exceptions
MEDIAN NERVE
* *EXCEPTIONS - ULNAR NERVE
1) Flexor Carpi ulnaris - superficial group
2) Medial half of the flexor digitorum profundus (to digits 4 and 5)- deep group
156
There are 20 total muscles of the forearm. 8 in the anterior and 12 in the posterior. Of the 8 anterior muscles of the forearm, 4 make up the SUPERFICIAL GROUP and only 1 makes up the INTERMEDIATE GROUP
FLEXOR DIGITORUM SUPERFICIALIS
Humeroulnar head
Radial head
```
Origin
HUMEROULNAR HEAD
-Medial epicondyle of humerus
-coronoid process
RADIAL HEAD
-Radius
```
Insertion
Sides of the middle phalanx of 2nd, 3rd, 4th, 5th digits by tendon that splits into two slips
Action
-FLEXES hand at wrist and digits at MP-metacarpophalangeal and PIP (proximal interphalangeal joints)
Nerve
MEDIAN NERVE
157
There are 20 total muscles of the forearm. 8 in the anterior and 12 in the posterior. Of the 8 anterior muscles of the forearm, 4 make up the SUPERFICIAL GROUP, 1 in INTERMEDIATE GROUP and 3 in DEEP GROUP
1- FLEXOR POLLICIS LONGUS
Origin
Radius and interosseous membrane
Insertion ; Distal phalanx of thumb
Action
FLEXES metacarpophalangeal joint and interphalangeal joint of the thumb
Nerve
MEDIAN NERVE
158
There are 20 total muscles of the forearm. 8 in the anterior and 12 in the posterior. Of the 8 anterior muscles of the forearm, 4 make up the SUPERFICIAL GROUP, 1 in INTERMEDIATE GROUP and 3 in DEEP GROUP
2- FLEXOR DIGITORUM PROFUNDUS
(4 tendons)
Origin
Ulnar and interosseous membrane
Insertion
- Distal phalanx of 2,3,4,5 digits.
- Each tendon passes through bifurcation of tendon of flexor digitorum Superficialis
Action
FLEXES hand at wrist and all phalanges of digits 2-5
Nerve
Lateral half - MEDIAN NERVE
Media half - ULNAR NERVE
159
There are 20 total muscles of the forearm. 8 in the anterior and 12 in the posterior. Of the 8 anterior muscles of the forearm, 4 make up the SUPERFICIAL GROUP, 1 in INTERMEDIATE GROUP and 3 in DEEP GROUP
3- PRONATOR QUADRATUS
Origin
Distal ulna
Insertion
Distal radius
Action
Pronation
Nerve
MEDIAN NERVE
160
What is the connective tissue that surrounds long flexor tendons to fingers
- produces a thin lubricating film of fluid
- reduces wear of tendon against adjacent bones or tendons
SYNOVIAL SHEATH
161
What is the orientation of the median nerve to the medial epicondyle of humerus
Median nerve is ANTERIOR to medial epicondyle of humerus
162
Name the nerve
- leaves the cubital fossa by passing btw 2 heads of PRONATOR Teres
- descends btw intermediate and deep muscle layers in MEDIAN ANTERIOR forearm
- located LATERAL to flexor digitorum Superficialis tendons and MEDIAL to flexor Carpi radialis tendon proximal to the wrist
- continues deep into the palm of hand in the carpal tunnel
- has 2 branches
MEDIAN NERVE
163
Name the 2 nerves.
They are both branches of what nerve?
1- MOTOR nerve that innervated the DEEP muscle group of the ANTERIOR compartment (flexor pollicis longus, lateral half of flexor digitorum profundus, PRONATOR quadratus)
- medial half of flexor digitorum profundus is not innervated by this nerve
- courses with the anterior interosseous artery anterior to the interosseous membrane
2-SENSORY branch
-innervated the skin of the proximal medial 2/3rds of the palm of the hand
1- ANTERIOR INTEROSSEOUS NERVE
2- PALMAR CUTANEOUS BRANCH OF MEDIAN NERVE
-sensory branch that comes off the median nerve in the distal forearm
**The 2 branches of the MEDIAN NERVE
164
Name the nerve
- passes POSTERIOR to the medial epicondyle of the humerus and enters forearm by passing btw. Heads of flexor carpi ulnaris
- DOES NOT GO UNDER RETICULUM /TUNNEL
- descends along medial aspect of forearm to innervate adjacent flexor carpi ulnaris and medial half of flexor digitorum profundus
- becomes superficial at wrist (lateral to pisiform bone) to enter palm of hand
- gives off2 sensory branches in distal forearm prior to entering palm of hand
ULNAR NERVE
165
Name the 2 sensory nerves and what are they branches of?
1-innervate the dorsal side of the medial 1/3rd of the hand and the medial 1.5 digits
2- innervates the proximal palmar side of the medial 1/4 of the hand
1- DORSAL CUTANEOUS BRANCH OF ULNAR NERVE
2- PALMAR CUTANEOUS BRANCH OF ULNAR NERVE
2 sensory branches of the ULNAR NERVE
166
- AXILLARY artery becomes brachial artery (right after Teres major)
- Brachial artery travels down arm and becomes radial and ulnar artery (at elbow joint)
**TELL me about ULNAR artery
ULNAR ARTERY
- MEDIAL and LARGER terminal branch of the brachial artery
- Leaves the cubital fossa by passing deep to the PRONATOR Teres
- descends along the medial aspect of the forearm btw flexor carpi ulnaris and flexor digitorum produces; courses with ulnar nerve
- becomes superficial at wrist (lateral to pisiform bone) to enter palm of hand with ulnar nerve
167
What are the branches of the ulnar artery
1- Anterior ulnar recurrent (arterial anastomosis with inferior ulnar collateral a.)
2- Posterior ulnar recurrent (arterial anastomosis with superior ulnar collateral a.)
3- Common interosseous artery
- gives off the interosseous recurrent branch (arterial anastomosis with middle collateral a.)
- courses POSTERIORLY above interosseous interosseous membrane to enter posterior compartment of forearm
- descends with the DEEP branch of RADIAL NERVE (posterior to interosseous membrane) in the posterior compartment of forearm)
168
- AXILLARY artery becomes brachial artery (right after Teres major)
- Brachial artery travels down arm and becomes radial and ulnar artery (at elbow joint)
**TELL me about RADIAL artery
What is the branch?
Where is the side of radial pulse?
- LATERAL and SMALLER terminal branch of the brachial artery
- has a RADIAL RECURRENT branch (arterial anastomosis with radial collateral artery) in cubital fossa
- leaves cubital fossa by passing deep to brachioradialis muscle
- located LATERAL to tendon of flexor carpi radialis in distal forearm (SITE OF RADIAL PULSE)
- passes around the lateral side of the wrist to the dorsum of the hand
- enters the anatomical snuff box on the dorsum of the hand
169
Name the group of muscles
- divided into superficial and deep groups of EXTENSORS-SUPINATOR
- can extend, ADDUCT, an ADDUCT hand at the wrist, supinate hand and extend thee digits
What nerve innervates this group?
MUSCLES OF POSTERIOR COMPARTMENT OF FOREARM
-ALL innervated by the RADIAL NERVE
170
There are 20 total muscles of the forearm. 8 in the anterior compartment and 12 in the posterior compartment. Of the 12 are 7 muscles in the SUPERFICIAL GROUP of posterior forearm
1- BRACHIORADIALIS
Origin ; lateral supracondylar ridge of humerus
Insertion; Distal radius
Action
-FLEXES forearm when forearm in mid-prone position (beer drinking)
Nerve
RADIAL NERVE
171
There are 20 total muscles of the forearm. 8 in the anterior compartment and 12 in the posterior compartment. Of the 12 are 7 muscles in the SUPERFICIAL GROUP of posterior forearm
2- EXTENSOR CARPI RADIALIS LONGUS
Origin
Lateral Supracondylar ridge of humerus
Insertion
Base of 2nd metacarpal
Action
EXTENDS and radially deviates (ABDUCTS) the wrist
Nerve
RADIAL NERVE
172
There are 20 total muscles of the forearm. 8 in the anterior compartment and 12 in the posterior compartment. Of the 12 are 7 muscles in the SUPERFICIAL GROUP of posterior forearm
3- EXTENSOR CARPI RADIALIS BREVIS
Origin
Lateral epicondyle of humerus
Insertion
Base of 2nd and 4rd metacarpal
Action
EXTENDS and ABDUCTS (radially deviates) the wrist
Nerve
RADIAL NERVE
173
There are 20 total muscles of the forearm. 8 in the anterior compartment and 12 in the posterior compartment. Of the 12 are 7 muscles in the SUPERFICIAL GROUP of posterior forearm
4- EXTENSOR DIGITORUM
Origin
lateral humeral epicondyle of humerus
Insertion
MIDDLE and DISTAL phalanges of 2nd - 5th digits via the extensor expansion
Action
EXTENDS digits 2-5 at MP, PIP and DIP joints and extends hand at wrist
Nerve
RADIAL NERVE
174
There are 20 total muscles of the forearm. 8 in the anterior compartment and 12 in the posterior compartment. Of the 12 are 7 muscles in the SUPERFICIAL GROUP of posterior forearm
5- EXTENSOR DIGITI MINIMI
Origin
Lateral humeral epicondyle of humerus
Insertion
Extensor hood of 5th digit
Action
EXTENDS 5th digit
NERVE
RADIAL NERVE
175
There are 20 total muscles of the forearm. 8 in the anterior compartment and 12 in the posterior compartment. Of the 12 are 7 muscles in the SUPERFICIAL GROUP of posterior forearm
6- EXTENSOR CARPI ULNARIS
Origin
Lateral humeral epicondyle
Insertion
Base of 5th metacarpal
Action
EXTENDS and ADDUCTS (ulnar deviates) wrist
Nerve
RADIAL NERVE
176
There are 20 total muscles of the forearm. 8 in the anterior compartment and 12 in the posterior compartment. Of the 12 are 7 muscles in the SUPERFICIAL GROUP of posterior forearm
7- ANCONEUS
Origin
lateral humeral epicondyle
Insertion
Olecranon of ulna
Action
- EXTENDS forearm (assists triceps)
- ABDUCTS ulna during pronation
Nerve
RADIAL NERVE
177
There are 20 total muscles of the forearm. 8 in the anterior compartment and 12 in the posterior compartment. Of the 12 are 7 muscles in the SUPERFICIAL GROUP of posterior forearm and the remaining 5 are the DEEP GROUP.
1- SUPINATOR
Origin
Lateral humeral epicondyle and supinator crest of ulnar
Insertion
Lateral upper radius
Action
SUPINATES forearm and hand
Nerve
RADIAL NERVE
178
There are 20 total muscles of the forearm. 8 in the anterior compartment and 12 in the posterior compartment. Of the 12 are 7 muscles in the SUPERFICIAL GROUP of posterior forearm and the remaining 5 are the DEEP GROUP.
2- ABDUCTOR POLLICIS LONGUS
(2 tendons)
Origin
Radius, interosseous membrane and ulna
Insertion
Base of 1st metacarpal
Action
ABDUCTS thumb
Nerve
RADIAL NERVE
179
There are 20 total muscles of the forearm. 8 in the anterior compartment and 12 in the posterior compartment. Of the 12 are 7 muscles in the SUPERFICIAL GROUP of posterior forearm and the remaining 5 are the DEEP GROUP.
3- EXTENSOR POLLICIS BREVIS
(Brevis sandwich)
Origin
Radius and interosseous membrane
Insertion
Proximal phalanx of thumb
Action
EXTENDS proximal phalanx of thumb
Nerve
RADIAL NERVE
180
There are 20 total muscles of the forearm. 8 in the anterior compartment and 12 in the posterior compartment. Of the 12 are 7 muscles in the SUPERFICIAL GROUP of posterior forearm and the remaining 5 are the DEEP GROUP.
4- EXTENSOR POLLICIS LONGUS
Origin
Ulna and interosseous membrane
Insertion ; distal phalanx of thumb
Action
EXTENDS distal phalanx of thumb
Nerve
RADIAL NERVE
181
There are 20 total muscles of the forearm. 8 in the anterior compartment and 12 in the posterior compartment. Of the 12 are 7 muscles in the SUPERFICIAL GROUP of posterior forearm and the remaining 5 are the DEEP GROUP.
5- EXTENSOR INDICIS
Origin
Ulna and interosseous membrane
Insertion
Extensor hood of index finger
Action
EXTENDS 2nd digit
Nerve
RADIAL NERVE
182
In the superficial group (7) of the posterior forearm muscles:
- What is the common tendon of ORIGIN?
- What does the group usually insert to?
- What is the clinal condition where there is an INFLAMMATION of the common tendon
- common tendon of ORIGIN is ; LATERAL epicondyle of humerus or lateral supracondylar ridge of humerus.
- Insertion; Mostly On METACARPALS or on dorsum of digits
- TENNIS ELBOW ; is the inflammation of the common tendon from the lateral epicondyle due to repeated extension of the wrist joint
183
What are the muscles that originated from the lateral supracondylar ridge of the humerus ?
2 muscles in the superficial group of posterior forearm
1- BRACHIORADIALIS
2- EXTENSOR CARPI RADIALIS LONGUS
184
What are the muscles that originate from lateral epicondyle of humerus?
```
6 total
5 in Superficial group of posterior forearm
1- EXTENSOR CARPI RADIALIS BREVIS
2- ENTENSOR DIGITORUM
3- EXTENSOR DIGITI MINIMI
4- EXTENSOR CARPI ULNARIS
5- ANCONEUS
```
1 IN Deep group
1- SUPINATOR
Origins; lateral humeral epicondyle and supinator crest of ulna
185
What is the only muscle in the POSTERIOR forearm that acts to FLEX forearm ?
When does it perform this action?
BRACHIORADIALIS
(Beer drinking arm)
**When forearm is in Mid-prone position
(Most of the FLEXORS/PRONATORS of the hand are found in the ANTERIOR compartment of the forearm)
186
What tendons form extensor expansions?
What does extensor expansions form?
What does it divide into ?
1- the 4 tendons of EXTENSOR DIGITORUM form extensor expansions on the dorsum of proximal phalanges of digits 2-5
2- Extensor expansions form A HOOD over the dorsum and sides of proximal phalanges
3- Extensor expansions divides into
- CENTRAL SLIP; inserts on middle phalanx
- 2 SIDE SLIPS; insert on distal phalanx
187
Name the clinical condition;
-RUPTURE of the SIDE SLIPS of the extensor expansion that insert into the distal phalanx
What is the cause?
MALLET or BASEBALL FINGER
**Due to a HYPERFLEXION of the DIP joint
188
Name the clinical condition
-RUPTURE of the CENTRAL SLIP of the extensor expansion that inserts into the MIDDLE phalanx
What is the cause?
BOUTENNIERE DEFORMITY
**Results from a FLEXION of the PIP joint and EXTENSION of the DIP joint from TRAUMA to the end of the dorsum of the finger
189
Name the group of muscles
- associated with thumb or index finger (with the exception of 1 muscle)
- Most originate from the ULNA and INTEROSSEOUS MEMBRANE (with the exception of same 1 muscle)
DEEP GROUP of POSTERIOR FOREARM
- Abductor pollicis longus
- Extensor pollicis brevis
- Extensor pollicis longus
- Extensor indicis
Exception
* SUPINATOR
- Origin; lateral humeral epicondyle and supinator crest of ulna
- Insertion; lateral upper RADIUS
190
Name this
- THICKENING of the deep fascia forming a transverse band at the dorsum of the wrist
- holds the extensor tendons in place during EXTENSION at wrist joint
- PREVENTS BOWSTRINGING of tendons upon hyperextension of the hand at the wrist joint
EXTENSOR RETICULUM
191
Name this
- CONNECTIVE TISSUE SHEATH that surrounds long extensor tendons
- produces a thin lubricating film of fluid
- REDUCES WEAR of tendon against adjacent bones, tendons and extensor reticulum
SYNOVIAL SHEATH
192
Name the nerve
- leaves radial groove of humerus to pass anteriorly into the distal anterior arm
- innervates the brachioradialis and extensors carpi radialis longus and brevis proximal to cubital fossa
- divides into 2 branches
RADIAL NERVE of posterior compartment
2 branches
1- DEEP BRANCH
-innervates the muscles of the posterior compartment
-KEY LANDMARK; passes POSTERIORLY through the 2 heads of the supinator to enter the posterior compartment of the forearm and descends with posterior interosseous artery posterior to the interosseus membrane
2-SUPERFICIAL BRANCH
- SENSORY NERVE ONLY
- descends in the anterior forearm underneath the brachioradialis
- in distal part of anterior forearm, the nerve courses deep to the brachioradialis tendon to pass into the superficial fascia of the skin of the dorsolateral hand
193
What is the arterial supply to posterior forearm compartment muscles
1- Branches from radial artery
2- Posterior interosseous branch of ulnar artery
194
what is the triangular depression located on the dorsolateral wrist and hand called?
Border
Contents
ANATOMICAL SNUFFBOX
BORDERS
LATERAL; Abductor pollicis longus and extensor pollicis brevis tendons
MEDIAL; Extensor pollicis longus tendon
CONTENTS
1- RADIAL ARTERY (Can feel PULSE)
2- SCAPHOID and TRAPEZIUM
(Can palpate scaphoid to assess for SCAPHOID FRACTURE) **when you FOOSH
FOOSH- fall on outstretched hands
195
SUMMARY OF THICK VERSUS THIN SKIN
Which has stratum lucidum?
THICK SKIN
-has 5 layers
**(thin skin only has 4 layers, no lucidum)
196
SUMMARY OF THICK VERSUS THIN SKIN
Which doesn’t have a pronounced dermal papilla
THIN SKIN
**Dermal papillae is pronounced in thick skin
197
SUMMARY OF THICK VERSUS THIN SKIN
Which has sweat glands
Both
THICK SKIN
THIN SKIN
198
SUMMARY OF THICK VERSUS THIN SKIN
WHICH has sebaceous glands
THIN SKIN
199
SUMMARY OF THICK VERSUS THIN SKIN
WHICH HAS hair
THIN SKIN
200
- What clinical conditions most commonly occurs in the RADIAL GROOVE of the humerus from a FRACTURE of the MID-SHAFT of the humerus
- What results in loss of innervation to posterior forearm compartment extensors of hand and gingers
1- WRIST DROP
- loss of extension of hand and fingers (flexors of hand and fingers are unopposed)
2- SENSORY LOSS over dorsolateral hand and proximal part of lateral 3.5 fingers (thumb to lateral half of ring finger) via superficial branch of radial nerve
201
There are 11 total muscles of the hand. 3 of the muscles are THENAR muscles/eminence (form a mound at base of THUMB and insert on the THUMB).
1- ABDUCTOR POLLICIS BREVIS
Action
Nerve
Action
ABDUCTS thumb
Nerve
Recurrent branch of the MEDIAN NERVE
202
There are 11 total muscles of the hand. 3 of the muscles are THENAR muscles/eminence (form a mound at base of THUMB and insert on the THUMB).
2- FLEXOR POLLICIS BREVIS
Action
Nerve
Action
FLEXES thumb
Nerve
Recurrent branch of MEDIAN NERVE
203
There are 11 total muscles of the hand. 3 of the muscles are THENAR muscles/eminence (form a mound at base of THUMB and insert on the THUMB).
3- OPPONENS POLLICIS
Action
Nerve
Action
OPPOSITION of thumb
Nerve
Recurrent branch of MEDIAN NERVE
204
There are 11 total muscles of the hand. 3 of the muscles are THENAR muscles/eminence (form a mound at base of THUMB and insert on the THUMB).
This is not a thenar muscle
ADDUCTOR POLLICIS
Oblique head
Transverse head
Action
Nerve
Action
ADDUCTS thumb
Nerve
ULNAR nerve
205
There are 11 total muscles of the hand. 3 of the muscles are THENAR muscles/eminence (form a mound at base of THUMB and insert on the THUMB).
4 are hypothenar eminence (produce the bulge at the base of the little finger). Hypothenar are mirror images of thenar muscles
1- PALMARIS BREVIS (superficial muscle)
Action
Nerve
Action
Tightens skin over hypothenar eminence
Nerve
ULNAR NERVE
**Palmaris brevis is a small quadrate shaped muscle that is superficial to the hypothenar muscles in the medial hand. It INSERTS INTO THE SKIN
206
There are 11 total muscles of the hand. 3 of the muscles are THENAR muscles/eminence (form a mound at base of THUMB and insert on the THUMB).
4 are hypothenar eminence (produce the bulge at the base of the little finger). Hypothenar are mirror images of thenar muscles
2- ABDUCTOR DIGITI MINIMI
Action
Nerve
Action
ABDUCTS 5th digit
Nerve
ULNAR NERVE
207
There are 11 total muscles of the hand. 3 of the muscles are THENAR muscles/eminence (form a mound at base of THUMB and insert on the THUMB).
4 are hypothenar eminence (produce the bulge at the base of the little finger). Hypothenar are mirror images of thenar muscles
3- FLEXOR DIGITI MINIMI BREVIS
Action
Nerve
Action
FLEXES 5th digit
Nerve
ULNAR NERVE
208
There are 11 total muscles of the hand. 3 of the muscles are THENAR muscles/eminence (form a mound at base of THUMB and insert on the THUMB).
4 are hypothenar eminence (produce the bulge at the base of the little finger). Hypothenar are mirror images of thenar muscles
4- OPPONENS DIGITI MINIMI
Action
Nerve
Action
LATERALLY ROTATES metacarpal 5 to oppose 5th digit
Nerve
ULNAR NERVE
**Oppponens digiti minimi is located deep the short flexor and abductor of the little finger
209
There are 11 total muscles of the hand. 3 of the muscles are THENAR muscles/eminence (originate form the THUMB). 4 are hypothenar eminence, 3 other extra muscles
1- DORSAL INTEROSSEI (4)
Action
Nerve
Action
- ABduct 2nd, 3rd, 4th digits
- FLEX MP (metacarpophalangeal) and EXTEND interphalangeal joints (PIP and DIP)
Nerve
ULNAR NERVE
**DAB
210
There are 11 total muscles of the hand. 3 of the muscles are THENAR muscles/eminence (originate form the THUMB). 4 are hypothenar eminence, 3 other extra muscles
2- PALMAR INTEROSSEI (4)
Action
Nerve
Action
- ADduct digits 1,2,4, 5th digit (except digit 3)
- FLEX MP AND EXTEND interphalangeal joint (DIP and PIP) of 1,2,4 and 5th digits
Nerve
ULNAR NERVES
**PAD
211
There are 11 total muscles of the hand. 3 of the muscles are THENAR muscles/eminence (originate form the THUMB). 4 are hypothenar eminence, 3 other extra muscles
3- LUMBRICALS (4)
Action
Nerve
Action
- FLEX MP (metacarpophalangeal joints)
- EXTEND interphalangeal joints (PIP and DIP)
```
Nerve
2 LATERAL (1 and 2); MEDIAN NERVE
```
2 MEDIAL (3 and 4); ULNAR NERVE
212
On the palm of the hand, there are 2 fascia. what is;
- triangular-shaped thickening of deep fascia that protects the underlying long flexor tendons from forearm muscles and neurovascular bundles
- attached PROXIMALLY to the palmaris longus tendon
- attached DISTALLY by its four longitudinal bands to the fibrous digital sheaths, which cover each digit
PALMAR APONEUROSIS
213
On the palm of the hand, there are 2 fascia of the hand. What;
- cover the palmar side of each digit with arching and cross-shaped fibers
- form a tunnel through with pass the tendons of flexor digitorum Superficialis and profundus to their insertions. Tendons are covered by SYNOVIAL SHEATHS for LUBRICATION (prevent wear and tear against phalanges)
- PREVENT BOW STRINGING of these long flexor tendons (function similar to flexor and extensor retinacula)
FIBROUS DIGITAL SHEATHS (have crossed fibers, keep tendons in line, also for protection)
214
The movements of the digits can be divided into 2 movements; movements of digits 2-5 and movements of the thumb. Identify each of the 2 movements of digits 2-5
1-Decrease/FLEXION and increase/EXTENSION angle of metacarpal to phalanx MP joint or angle to phalanx at interphalangeal IP joint
2- Movement occurs with respect to axis through third metacarpal.
- ABDUCTION is movement away
- ADDUCTION is movement toward this axis
1- FLEXION-EXTENSION of digits 2-5
2- ABDUCTION-ADDUCTION of digits 2-5
215
The movements of the digits can be divided into 2 movements; movements of digits 2-5 and movements of the thumb. The thumb is oriented perpendicular to the other digits. Identify each of the 3 movements of the thumb.
1- FELXION-EXTENSION of thumb
2- ABDUCTION-ADDUCTION of thumb
3- OPPOSITION of thumb
1- FLEXION brings thumb across palm; EXTENSION brings thumb back across palm
2- ABDUCTION moves thumb AWAY FROM PLANE of other fingers at 90 degrees from palm (i.e thumb moves anteriorly from anatomical position);
-ADDUCTION draws thumb towards palm
3- Pad of thumb is brought into position against pad of other digits
216
Name the group of muscles;
- provide for PRECISION MOVEMENTS (precision grip) of the hand unlike the forceful movements (power grip) provided by another group of muscles
- Innervated by DEEP BRANCH OF ULNAR NERVE
- What is the exception
INTRINSIC MUSCLES OF THE HAND (precision movements/precision grip)
*Forceful movements (power grip) is provided by the EXTRINSIC forearm muscles that insert onto the hand
**The exception to the innervation of INTRINSIC MUSCLES OF HAND is MEDIAN NERVE to thenar muscles and lateral 2 lumbricals
217
What are the arteries of the hand?
What forms superficial palmar arch?
What forms deep palmar arch?
- branches of the ULNAR (form SUPERFICIAL palmar arch) and RADIAL (form DEEP palmar arch) arteries
- branches from arches and main arteries supply the hand
218
Name the artery of the hand
- enters the medial side of wrist LATERAL to the PISIFORM bone, courses ANTERIOR to flexor retinaculum and passes MEDIAL to the hook of the hamate to enter the palm
- courses laterally in palm btw the palmar aponeurosis and the long flexor tendons to digits to form the SUPERFICIAL PALMAR ARCH
What fingers does it supply?
ULNAR ARTERY
**mostly supplies the MEDIAL 3.5 FINGERS (little finger to medial side of index finger)
219
What are the branches of the ulnar artery?
-What are the further branches?
1- SUPERFICIAL palmar arch
A. Palmar digital artery to little finger
B. Common palmar digital arteries
2- DEEP branch of ulnar artery
220
Name the branch of ulnar artery
- continuation of the ulnar artery into the palm
- located btw the palmar aponeurosis and the long flexor tendons to digits
- anastomoses with the PALMAR branch of radial artery
How many branches does this branch have?
SUPERFICIAL PALMAR ARCH
* *2 branches
1. Palmar digital artery to little finger
2. Common palmar digital arteries
221
Name the branch of ulnar artery
- three arteries that supply fingers 2-5
- receive palmar metacarpal arteries from DEEP PALMAR ARCH
- bifurcate into PROPER PALMAR digital arteries that enters fingers
COMMON PALMAR DIGITAL ARTERIES
**This is a branch of the superficial palmar arch which is a branch of the ulnar artery
222
Name the branch of ulnar artery
- originates from the ulnar artery at the wrist
- pierces the origin of the hypothenar muscles
- anastomoses with the DEEP PALMAR ARCH, which is located on the bases of the metacarpals
DEEP BRANCH OF ULNAR ARTERY
223
Name the artery of the hand
- leaves the anterior forearm by coursing POSTERIORLY around the lateral side of the wrist
- enters the ANATOMICAL SNUFFBOX on the dorsum of the hand
- passes ANTERIORLY into the palm through the dorsal interosseous muscle in the first interosseous space and btw the 2 heads of the adductor pollicis
- FORMS the DEEP PALMAR ARCH
What parts of the fingers does this artery supply?
RADIAL ARTERY
**Mostly supplies the LATERAL 1.5 fingers (thumb and lateral side of index finger)
224
What are the branches of the radial artery in the hand?
What are the further branches
1- Branches of radial artery in dorsum of hand
A. First dorsal metacarpal artery
B. Dorsal carpal arch
2- Branches of radial artery in palm (lateral to medial)
A. Princeps pollicis artery
B- RADIALIS indicis artery
C. Deep palmar arch
225
Name the branches of the radial artery in the DORSUM OF HAND
1- bifurcated into dorsal digital artery to adjacent sides of thumb and index finger
2- gives rise to DORSAL METACARPAL ARTERIES, which bifurcate into DORSAL DIGITAL ARTERIES to supply adjacent sides of fingers
1- FIRST DORSAL METACARPAL ARTERY
2- DORSAL CARPAL ARCH
226
Name the branches of the radial artery in PALM (lateral to medial)
1- gives off 2 branches that supply the thumb
2- supplies lateral side of index finger
3**IMPORTANT
- located on the PALMAR surface of the bases of the metacarpals
- completed medially by anastomosing with the deep branch of the ulnar artery
- gives off 2 PALMAR METACARPAL ARTERIES, which anastomose with the COMMON palmar digital arteries from the superficial palmar arch
1- PRINCEPS POLLICIS ARTERY
2- RADIALIS INDICIS ARTERY
3- DEEP PALMAR ARCH
227
How do you differentiate btw the superficial landmarks for SUPERFICIAL palmar arch (from ulnar artery) and DEEP palmar arch (from radial artery).
1- SUPERFICIAL palmar arch
-PROXIMAL transverse skin crease in palm or distal border of extended thumb
2- DEEP palmar arch
-HALFWAY btw distal wrist crease and proximal transverse crease in palm or proximal border of extended thumb
228
1- What nerves provide sensory fibers to the skin?
2- What nerves innervate intrinsic muscles of hand
1- MEDIAN, ULNAR and RADIAL
2- MEDIAN and ULNAR
229
Name the nerve and what are the branches
-enters wrist (with the ulnar artery) lateral to pisiform bone and passes anterior to flexor reticulum
ULNAR NERVE
Branches
1- SUPERFICIAL/digital branch (mostly sensory)
2- DEEP (motor)
230
Name the branch of ulnar nerve
- innervates skin of medial 1.5 digits (little finger and medial side of ring finger) and medial 1/3rd of palm of hand
- innervates PALMARIS BREVIS muscle and medial 2 LUMBRICALS (digits 4 and 5)
SUPERFICIAL/DIGITAL branch of ulnar nerve
231
Name the branch of ulnar nerve
- courses with the deep branch of ulnar artery and deep arterial arch
- innervates the hypothenar muscles, interosseous muscles, medial 2 lumbricals and adductor pollicis
DEEP branch of ulnar nerve
232
Name the nerve and what are the branches
- enters the palm of the hand by coursing through the carpal tunnel
- divides into RECURRENT branch of median nerve (motor) and palmar digital nerves (sensory and motor)
MEDIAN NERVE
Branches
1- RECURRENT branch of median nerve
2- Palmar digital nerves
233
Name the branches of Median nerve
1- emerges just DISTAL to the flexor reticulum and passes LATERALLY to innervate the 3 thenar muscles
2
- provides sensory innervation to skin of the palmar side of lateral 3.5 digits (thumb to lateral side of ring finger) and skin over the distal phalanges (nail beds)
- also innervates the lateral 2 lumbrical muscles (to index and middle fingers)
PALMAR DIGITAL NERVES
234
Name the nerve
- is ONLY A CUTANEOUS SENSORY NERVE
- innervates the skin of the dorsolateral hand and the dorsal side of the proximal part of the lateral 3.5 digits (thumb to lateral half of ring finger)
SUPERFICIAL branch of RADIAL NERVE
235
Name the events from this nerve injury to brachial plexus.
```
ERB-DUCHENNE PALSY
1- Where
2- How/Cause
3- What happens/ Results
4- Muscles affected
5- Motor deficits
6- Sensory deficits
```
WHERE; upper trunk of brachial plexus
HOW/CAUSE; wide separation btw the head and shoulder from FALLING ON SHOULDER or in NEWBORN during a difficult delivery with excessive traction on the neck
WHAT HAPPENS/RESULT; tearing of C5 and C6 spinal nerves
MUSCLES AFFECTED; muscles innervated by C5 and C6
- Infraspinatus (via suprascapular nerve); lateral rotator of arm
- Biceps brachii (via Musculocutaneous nerve); supinator of forearm
MOTOR deficits;
A- Loss of lateral rotation (arm is MEDIALLY ROTATED); due to intact subscapularis muscle
B- Loss of supination (forearm is PRONATED); due to relatively intact pronators of forearm
C- WAITER’S TIP; medial rotation of arm and pronation of forearm positions the upper limb as if a waiter is asking for a tip.
SENSORY deficit; of C5 and C6
-Loss of sensations on the lateral side of the arm, forearm and thumb (C5 and C6)
236
Name the events from this nerve injury to brachial plexus.
```
KLUMPKE PALSY
1- Where
2- How/Cause
3- What happens/ Results
4- Muscles affected
5- Motor deficits
6- Sensory deficits
```
1- WHERE; lower trunk of brachial plexus
2- HOW/CAUSE; results from HYPERABDUCTION of arm when you grab something to prevent a fall or when NEWBORN arm is pulled out during delivery
-ALSO results from the presence of a cervical rib placing traction on the lower trunk
3- WHAT HAPPENS; results in mostly tear of T1 (and C8 to a limited extent) spinal nerves
4- MUSCLES AFFECTED; muscles innervated by mostly T1
- course within median and ulnar nerve
- all INTRINSIC muscles of the hand
- Interosseous muscles and lumbricals FLEX MP joint and EXTEND PIP and DIP joints
5- MOTOR DEFICITS
A; LOSS OF FLEXION at MP; fingers hyperextended at MP joints due to intact forearm extensors
B; LOSS OF EXTENSION at PIP and DIP; fingers FLEXED at PIP and DIP due to intact long flexors from anterior forearm (innervated mostly by C8)
C; CLAW HAND - HYPEREXTENSION of MP joints and FLEXION of PIP and DIP joints in digits 2-5 results in all fingers appearing as claws
6- SENSORY DEFICITS
-Loss of sensations on the medial side of the arm and forearm
237
Name the events from this nerve injury
```
LONG THORACIC NERVE INJURY
1- Where
2- How/Cause
3- What happens/ Results
4- Muscles affected
5- Motor deficits
6- Sensory deficits
```
1- Long thoracic nerve is the nerve to Serratus anterior
2- Results from surgery during a RADICAL MASTECTOMY or KNIFE wound to upper-lateral chest
3- What happens ; Loss of Serratus anterior
A. INABILITY to ROTATE SCAPULA for abduction of the arm above the horizontal plane (pt can’t raise arm over head)
B. WINGED SCAPULA - medial border of scapula protruded POSTERIORLY due to inability to hold medial border against chest wall
4- Muscles affected; Serratus anterior
5- motor deficits; winged scapula, loss of abduction above horizontal plane
6- NO SENSORY DEFICITS
238
Name the events from this nerve injury
```
AXILLARY NERVE INJURY
1- Where
2- How/Cause
3- What happens/ Results
4- Muscles affected
5- Motor deficits
6- Sensory deficits
```
1- can occur in the quadrangular space from inferior displacement of the head of the humerus in shoulder dislocation or from fracture of surgical neck of humerus
2- Cause; Surgical neck fracture of humerus, anterior dislocation of shoulder)
3-loss of function of deltoid muscle, loss of sensory innervation to upper lateral arm
4- Muscles affected; Deltoid and Teres major
5- Motor deficit
- Loss of arm abduction past 15 degrees (deltoid paralysis and atrophy)
6- Sensory deficit
Loss of lateral side of upper arm (“police badge” location) via upper lateral cutaneous nerve of arm
239
Name the events from this nerve injury
```
RADIAL NERVE IN AXILLA
1- Where
2- How/Cause
3- What happens/ Results
4- Muscles affected
5- Motor deficits
6- Sensory deficits
```
1- Axilla/ Armpit.
2- poorly fitted crutch or from inebriated person draping their arm over back of chair and falling asleep (SATURDAY NIGHT PALSY)
MOTOR DEFICITS
A. Triceps brachii - loss of extension of forearm at elbow joint
B. Extensors of the wrist - loss of extension of wrist allows the long flexors of wrist to be unopposed
C. Wrist-drop - due to loss of extension of wrist and the unopposed action of the flexors of the wrist
SENSORY DEFICIT
-Small loss over posterior arm, posterior forearm, dorsolateral hand and proximal part of dorsal side of lateral 3.5 fingers
240
Name the events from this nerve injury
```
RADIAL NERVE (In radial groove of humerus)
1- Where
2- How/Cause
3- What happens/ Results
4- Muscles affected
5- Motor deficits
6- Sensory deficits
```
1- In radial groove of humerus
2- results from a fracture of the mid-shaft of the humerus
MOTOR LOSS
-Loss of extension of wrist resulting in WRIST-DROP
SENSORY LOSS
-over the dorsolateral (via the superficial branch of radial nerve) and dorsum of proximal part of lateral 3.5 fingers. NO POSTERIOR DAMAGE
**DOES NOT AFFECT TRICEPS BRACHII (receives innervation in axilla) more the SESORY INNERVATION TO POSTERIOR arm or forearm (cutaneous branches given off proximal to radial groove)
241
Name the events from this nerve injury
```
INJURY TO MEDIAN NERVE (at elbow)
1- Where
2- How/Cause
3- What happens/ Results
4- Muscles affected
5- Motor deficits
6- Sensory deficits
```
1- ELBOW
2- occasionally occur from a SUPRACONDYLAR FRACTURE of humerus
MOTOR LOSS
A. Loss of most long flexors of wrist, all pronators and one abductor - results in WEAK FLEXION and ADDUCTION OF WRIST (due to unopposed flexor carpi ulnaris)
B. Loss of FLEXION at MP, PIP and DIP joints of index and middle finger
-due to loss of flexor digitorum Superficialis and lateral half of flexor digitorum profundus
-but partial FLEXION of DIP joints to ring and little finger due to intact medial part of flexor digitorum profundus
-results in HAND OF BENEDICTION
C. Loss of thenar muscles
-due to loss of function of recurrent branch of median nerve.
-results in loss of opposition of thumb
-atrophy of thenar muscles results in flattened thenar eminence
SENSORY LOSS
A. Lateral 2/3rd of palm of hand
-due to loss of palmar cutaneous branch and digital branches of median nerve
B. Palmar side and nail beds (dorsal side over distal phalanx) of lateral 3.5 fingers
-due to loss of digital branches of median nerve
242
Name the events from this nerve injury
```
INJURY TO MEDIAN NERVE (at wrist)
1- Where
2- How/Cause
3- What happens/ Results
4- Muscles affected
5- Motor deficits
6- Sensory deficits
```
1- Wrist
2- results from laceration by knife or broken glass (accident or suicide attempt)
-results in a sudden impairment of median nerve function in hand
MOTOR LOSS
- loss of opposition of thumb and flattened thenar eminence due to atrophy of muscle
- NO loss of long flexors of hand from anterior compartment of forearm. These muscles are innervated by median nerve in anterior forearm.
SENSORY LOSS
-same as injury to elbow: loss of sensations over palmar side and nail beds (dorsal side over distal phalanx) of lateral 3.5 digits and lateral 2/3rds of palm.
243
Name the events from this nerve injury
```
SEVERANCE OF recurrent branch of MEDIAN NERVE
1- Where
2- How/Cause
3- What happens/ Results
4- Muscles affected
5- Motor deficits
6- Sensory deficits
```
- Can occur from a superficial laceration at thenar eminence
- result in loss of opposition of thumb and atrophy of thenar muscles
- NO sensory loss
244
Name the events from this nerve injury
```
INJURY WITH CARPAL TUNNEL (injury to median nerve)
1- Where
2- How/Cause
3- What happens/ Results
4- Muscles affected
5- Motor deficits
6- Sensory deficits
```
1- is an entrapment of the median nerve in the carpal tunnel due to PRESSURE ON NERVE
2- PRESSURE due to swelling of the tendons and their sheaths from overuse or inflammation of arthritis. This is not severance of the nerve
-develops SLOWLY THROUGH TIME
MOTOR DEFICITS
-Progressive darkness of thenar muscles (loss of opposition of thumb)
SENSORY DEFICITS
-Anesthesia (lack of sensation), Hypoesthesia (diminished sensation), Parasthesia (pins and needles) of distal part of lateral 2/3rd of palm and palmar side and nail beds of lateral 3.5 fingers
* *Sensations on proximal part of lateral palm intact
- Palmar cutaneous branch of median nerve crosses superficial to flexor retinaculum and DOES NOT ENTER CARPAL TUNNEL
TREATMENT
A. Reduce inflammation and limit repetitive movements
B. CARPAL TUNNEL RELEASE
-is the surgical decompression of the nerve by severing the flexor retinaculum
245
There are 2 places injury to ulnar nerve can occur (at elbow and at wrist). Name the events from this nerve injury
```
INJURY TO ULNAR NERVE (at elbow)
1- Where
2- How/Cause
3- What happens/ Results
4- Muscles affected
5- Motor deficits
6- Sensory deficits
```
1- AT ELBOW
2- due too elbow hitting a hard surface or fracture of medial epicondyle resulting in compression or severance of nerve at medial epicondyle of humerus
MOTOR LOSS
A. Loss of flexor carpi ulnaris: Weak FLEXION of wrist joint with abduction of hand (due to unopposed flexor carpi radialis)
B. Loss of medial half of flexor digitorum profundus to ring and little fingers: Pt CANNOT flex their DIP. FLEXION of middle phalanx intact due to flexor digitorum Superficialis.
C. Loss of interosseous muscles: Pt can not ADDUCT-abduct fingers (unable to grip a piece of paper btw fingers)
D. CLAW HAND - damage to ulnar nerve or lower trunk of brachial plexus
LOSS OF INTEROSSEUS AND MEDIAL 2 LUMBRICALS. Impaired FLEXION at MP joints and impaired extension of PIP and DIP of digits 2-5
SENSORY LOSS
-To palmar and dorsal sides of medial 1/3rd of hand and medial 1.5 fingers
A. Palmar side of proximal part of medial 1/3rd of hand (vis palmar cutaneous branch of ulnar nerve)
B. Palmar side of distal part of medial 1/3rd of palm and medial 1.5 digits (via palmar digital nerves)
C. Dorsal 1/3rd of hand and dorsal side of 1.5 digits (via dorsal branch of ulnar nerve)
246
Name the events from this nerve injury
```
INJURY TO ULNAR NERVE (at wrist)
1- Where
2- How/Cause
3- What happens/ Results
4- Muscles affected
5- Motor deficits
6- Sensory deficits
```
- Is easily damaged due to its superficial location (anterior to flexor retinaculum) by LACERATION BY KNIFE OR BROKEN GLASS ( accident or suicide attempt)
- results in CLAW HAND and sensory loss to palmar side of medial 1.5 digits and medial 1/3rd of palm
MOTOR LOSS
A. Paralysis of most intrinsic muscles of hand
-Exceptons; thenar muscles and lateral 2 lumbricals
-loss of abduction-ADDUCTION of fingers
-loss of FLEXION at MP joints and extension of PIP and DIP joints of digits 2-5
-CLAW HAND
SENSORY LOSS
-to medial palm of hand and medial 1.5 fingers
A. Palmar side of medial 1/3rd of hand (via palmar cutaneous branch of ulnar nerve
B. Palmar side of medial 1.5 digits (via palmar digital nerves)
C. Intact sensations from dorsal 1/3rd of hand and dorsum of medial 1.5 digits
-due to intact dorsal cutaneous branch of ulnar nerve, which branches off ulnar nerve in distal forearm
NOT AFFECTED
MOTOR; flexor carpi ulnaris and flexor digitorum profundus (innervated in forearm) and lateral 2 lumbricals (innervated by median nerve)
SENSORY; Intact sensations to dorsum of medial 1/3rd of hand, dorsal side of medial 1.5 digits (dorsal cutaneous branch of ulnar nerve branches off in FOREARM)
247
Name the condition
-can result from an injury to the lower trunk (mostly T1) involving branches of both ULNAR and MEDIAN nerves (all fingers are clawed)
OR
-ULNAR NERVE at wrist and elbow resulting in the damage to only digit 4 and 5 (1 and 2nd lumbricals are innervated by median nerve and not clawed)
CLAW HAND
248
Joint movements can be tested for intact innervation of myotome. How do you test damage to level of spinal cord, spinal nerve, or terminal named nerve
```
MYOTOME
C5
C6
C7
C8
T1
```
```
C5; ABDuction of arm at glenohumeral joint
C6; FLEXION of forearm at elbow
C7; EXTENSION of forearm at elbow
C8; FLEXION of fingers
T1; ABDuction and ADDUCTION of fingers
```
249
What is the dermatome in the upper lim. Sensory/pin-prick
DERMATOME - sensory spinal nerve
```
C5
C6
C7
C8
T1
```
```
C5; Lateral arm, lateral forearm and shoulder
C6; Thumb
C7; middle finger
C8; little finger
T1; medial arm
```
250
What type of joint is this?
- located btw the acromion process of scapula and lateral end of clavicle
- Type of joint; SYNOVIAL PLANE JOINT (joint capsule surrounds joint cavity)
- gliding movements occur when scapula rotates or clavicle is elevated or depressed
- Articular disc of fibrocartilage separates the articular surfaces of bones
ACROMIOCLAVICULAR (AC) JOINT
251
The acromioclavicular joint is a SYNOVIAL PLANE JOINT. It has 2 types of extrinsic ligaments. Name each
1- reinforce joint capsule
2- VERY STRONG bipartitie accessory ligament from coracoid process to clavicle
- SUSPENDS WEIGHT of scapula and upper extremity from clavicle
- NOT PART OF AC JOINT
1- SUPERIOR AND INFERIOR acromioclavicular ligament
2- CORACOCLAVICULAR LIGAMENT (NOT an accessory ligament of AC joint)
252
Name the condition
- is not uncommon in contact sports as a fall forcing acromion POSTERIORLY AND INFERIORLY
- Can be associated with rupture of coracoclavicular and acromioclavicular ligaments
- often referred to as a SEPARATED SHOULDER although the shoulder joint is not dislocated.
- Dislocated AC joint and torn coracoclavicular ligament result in shoulder falling away from clavicle (step off deformity)
DISLOCATION OF ACROMIOCLAVICULAR JOINT
- Clavicle ELEVATED due to upward pull of trapezius
- Shoulder droops from weight of upper limb
253
Name the joint
- located btw the glenoid fossa of scapula and the head of humerus
- most commonly dislocated joint in adults to the shallowness of the glenoid fossa
- SYNOVIAL BALL AND SOCKET JOINT
SHOULDER/GLENOHUMERAL JOINT
**The synovial ball and socket joint - permits wide range of movements (e.g FLEXION-extension, abduction-abduction and rotation)
254
In the shoulder joint, the CAPSULE is thin and loose enclosing joint allowing for wide range of movement. The capsule has 2 openings. What are they/
What is the subscapular bursa used for?
1- Opening for subscapular bursa (Opening anteriorly for communication with SUBSCAPULAR BURSA)
* *The subscapular bursa;
- Outpocketing of synovial membrane lining joint capsule
- Bursa REDUCES FRICTION of overlying subscapularis muscle
2- Opening for tendon of long head of biceps brachii (Opening btw tubercles of humerus for passage of tendon of long head of biceps brachii)
255
WHAT are the types of cartilage found in the glenohumeral/shoulder joint?
1- HYALINE CARTILAGE covers articular surfaces of bones
2- FIBROCARTILAGINOUS RIM, the glenoid labrum deepens shallow glenoid cavity
256
There are 3 ligaments in the glenohumeral joint that help provide static stability to joint. Identify each ligament;
1- THICKENINGS of the anterior part of capsule best observed on the inner surface of the capsule (between glenoid fossa and humerus)
2
- accessory ligament extending from greater to lesser tubercles of humerus
- forms a bridge over bicipital groove (intertubercular sulcus) that holds tendon of long head of biceps against humerus
3
- strong and extends from coracoid process of scapula to greater tuberosity of humerus
- strengthens superior part of joint capsule
1- Superior middle and inferior glenohumeral ligaments
2- Transverse humeral ligament
3- Coracohumeral ligament
257
What group of muscles are more important than ligaments for joint stability. They hold head of humerus in glenoid cavity
ROTATOR CUFF MUSCLES
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-SITS muscles reinforce capsule of shoulder joint on anterior, posterior and superior sides
Supraspinatus
Infraspinatus
Teres minor
Subscapularis
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258
Name the clinical condition
- usually results form a hard blow to fully abducted and extended arm (e.g quarterback tackled while throwing ball) with head of humerus driven inferiorly through joint capsule
- INFERIOR DISLOCATION can damage AXILLARY NERVE resulting in weakening of arm abduction. Strong flexor (e.g pectoralis major) and abductor (e.g deltoid) muscles pull humeral head to site below coracoid process
DISLOCATION OF GLENOHUMERAL/SHOULDER JOINT
**Head of humerus driven INFERIORLY through weakness of joint capsule (lack of rotator cuff): AXILLARY NERVE can be damages
259
Name the joint
- is between trochlea and capitulum of humerus and trochlea notch of ulna and head of radius
- SYNOVIAL HINGE JOINT permitting FLEXION-extension movements
- has capsule that completely encloses joint
- has COLLATERAL LIGAMENTS (radial and ulnar)
-can have POSTERIOR DISLOCATION
ELBOW JOINT
260
Name this
- completely encloses elbow joint
- ANTERIOR and POSTERIOR parts are weak and thin but sides are strengthened by collateral ligaments
- is attached above to upper margins of coronoid and radial fossa of humerus, while below it is attached to margin of coronoid process of ulnar and annular ligament surrounding radius
Elbow joint CAPSULE
261
What are the ligaments of the elbow joint that strengthens the joint at medial and lateral sides of joint?
Which ligament can be replaced/ grafted by palmaris longus
1- RADIAL/LATERAL collateral ligament
-is a STRONG TRIANGULAR shaped ligament extending from lateral epicondyle of humerus to annular ligament
2- ULNAR/MEDIAL collateral ligament
- is triangular shaped
- consists of 3 strong bands extending mostly form medial epicondyle of humerus to ulna
262
Name the condition
- is not uncommon in young children when they fall (FOOSH) - the olecranon process in kids is not yet ossified
- Humerus is driven ANTERIORLY through weak part of joint capsule and radius and ulna are displaced POSTERIORLY
POSTERIOR DISLOCATION OF ELBOW JOINT
**FOOSH or with elbows slightly flexed
1- Humerus driven through weak ANTERIOR capsule of joint
2- Ulna and radius are driven POSTERIORLY
3- POSTERIOR driven ULNA may damage ULNAR NERVE
263
Name the joint type
1- Is between the circumference of head of radius and radial notch of ulna
2- SYNOVIAL PIVOT JOINT for supination-pronation of forearm in conjunction with DISTAL radio-ulnar joint
3- the capsule encloses joint and is continuous with capsule of elbow joint
4- The ANNULAR LIGAMENT; forms a collar around head of radius, is attached to margins of radial notch on ulna
PROXIMAL RADIO-ULNAR JOINT
264
Name the clinical condition
- is not uncommon in pre-school aged children
- sudden pull on hand (dragging child along) tears attachment of annular ligament resulting in distal displacement of head of radius which is called PULLED ELBOW
DISLOCATION OF SUPERIOR/PROXIMAL RADIO-ULNAR JOINT
-subluxation and dislocation
265
Name the joint
- is between the head of ulna and ulnar notch on distal end of radius
- SYNOVIAL PIVOT TYPE JOINT for supination and pronation of forearm
* has ARTICULAR DISC WHICH;
- extends from lower border of ulnar notch of radius to base of styloid process of ulna
- separated distal radio-ulnar joint from wrist joint
- strongly links radius and ulna
DISTAL RADIO-ULNAR JOINT
266
Name the joint type
- is a SYNDESMOSIS
- formed by the INTEROSSEOUS MEMBRANE of forearm
- fibers in membrane run inferiorly and medially from medial border of radius to ulna
- Membrane transmits force from radius to ulna, and from ulna to humerus as occurs in a FOOSH. This prevents the head of radius from being thrust against capitulum of humerus, which could result in fracture of the radial head
MIDDLE RADIO-ULNAR JOINT
267
Name the joint
- is between radius and articular disc of distal radioulnar joint above and scaphoid, lunate and triquetral bones
- ELLIPSOIDAL SYNOVIAL JOINT permits abduction-adduction (ulnar and radial deviation), FLEXION-extension (no rotation) and circumduction
- capsule completely encloses joint
- 2 ligaments
- colles’ fracture
WRIST or RADIOCARPAL JOINT
268
What are the 2 ligament types of the radiocarpal joint?
1- strengthen anterior and posterior surface of capsule
2
- extend from styloid process of radius and ulna to carpal bones, respectively
- somewhat limit abduction-adduction movements
1- DORSAL and PALMAR radiocarpal ligaments
2- RADIAL and ULNAR collateral ligaments
269
Name the clinical condition
- fracture of the distal end of the radius and ulna
- most COMMON fracture in persons OVER 50 YEARS of age
- most frequent in women due to weakened bones from OSTEOPOROSIS
- typically occur when person fall on outstretched hands FOOSH (forced extension of hand)
- Distal fragment of radius is often displaced POSTERIORLY from shaft of radius resulting in a DINNER FORK deformity
COLLES’ FRACTURE
- result from FOOSH
- DINNER FORK deformity
- DISTAL fragment of RADIUS displaced POSTERIORLY
- can also have AVULSED ulnar styloid process
270
Name the following joints
1- SYNOVIAL PLANE JOINTS allowing a small amount of gliding movement
2- permit little movement of metacarpals 2-5
3- btw the trapezium and base of first metacarpal, is a SYNOVIAL SADDLE SHAPED JOINT that permit FLEXION-extension and adduction-abduction
1- INTERCARPAL JOINTS
2- CARPOMETACARPAL joints for metacarpals 2-5
3- CARPOMETACARPAL joint of thumb
271
Name the joint
- are SYNOVIAL CONDYLOID joints between heads of metacarpal bones and base of proximal phalanges
- permit movement of FLEXION-extension and abduction-adduction
-has capsule that surrounds joint
-has 3 ligaments
WHAT ARE the ligaments?
METACARPOPHALANGEAL (MP) Joints
3 LIGAMENTS
1- PALMAR ligaments
-firmly attach phalanx to metacarpals
-are tense when joint is extended
2- DEEP TRANSVERSE METACARPAL LIGAMENT
-holds heads of metacarpal bones together
3- COLLATERAL LIGAMENT
- are present on medial and lateral sides of joints
- are tense when joint is flexed
272
Name the joint
- consist of PIP and DIP joint for digits 2-5 and just PIP for thumb
- have SYNOVIAL HINGE TYPE of articulation
- permits only FLEXION-extension movements
- structure is similar to metacarpal-phalanges joints
INTERPHALANGEAL (IP) JOINTS
273
What are the radiographic views of the hand
PA view
OBLIQUE view
LATERAL view
274
What is the name of the area where patients from arthritis get bone breakdown
DISTAL TUFT
275
What view of the hand is useful for looking for dislocation, avulsion fractures or alignment of carpals
LATERAL VIEW of hand
276
Name the clinical condition
- TRANSVERSE fracture of 5th metacarpal
- most COMMON type of metacarpal fracture
- almost always result as a consequence of a DIRECT BLOW with a clenched fist against a solid surface
- Only a poorly thrown punch results in this type of fracture, actually uncommon in professional boxers who are taught to transfer as much power as possible through the 2 and 3rd metacarpals
BOXER’S FRACTURE
**Bar fight/Amateur boxer
YOUNG MALES
277
What are the views of the wrist
PA
OBLIQUE
LATERAL
278
From the PA view o the wrist, list all the carpal bones from lateral to medial
*What is the space btw ulna and carpal bones 3/4
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1- Scaphoid
2- Lunate
3- Triquetrium
4- Pisiform
5- Trapezium
6- Trapezoid
7- Capitate
8-Hamate
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**Triangular FIBROCARTILAGE complex is the space because you cant see cartilage on x-ray
279
Name the scaphoid fracture
- most commonly fractured carpal
- usual mechanism of injury is FOOSH resulting in hyper-extension of the wrist
- radiographs indicated if there is post-traumatic wrist pain with anatomical snuff box tenderness
- If fracture is missed, AVASCULAR NECROSIS of the proximal pole of the scaphoid may occur due to disruption of the blood supply
SCAPHOID FRACTURE (waist of scaphoid)
280
What is the best view to identify all the 8 carpal bones at the wrist
OBLIQUE VIEW
281
What view of the wrist can you view 3 bones lined up.
What are the 3 bones
LATERAL VIEW OF WRIST
Capitate
Lunate
Radius
- Articular surfaces of radius, lunate and capitate should be in a straight line and be congruent (parallel)
- The “apple” (capitate) should sit in the “cup” (lunate), which should sit in the “saucer” (radius)
282
Name the clinical condition
- MOST SEVERE of carpal instabilities
- caused by high energy trauma resulting in loading of a dorsiflexed wrist (HIGH FALL)
- Involves disruption of most of the major carpal ligaments
- produces VOLAR dislocation and forward rotation of lunate
- capitate drops into space vacated by lunate
- TRIANGULAR APPEARANCE of lunate on frontal projection (PIECE OF PIE SIGN)
- commonly associated with a scaphoid fracture
LUNATE DISLOCATION
**can occur with styloid fracture of ulnar
283
Name the clinical condition
- result of a FOOSH, hyperextended hand
- relatively rare
- occurs when the lunate maintains normal position with respect to the distal radius while all other carpal bones are dislocated POSTERIORLY
- very commonly associated with a SCAPHOID FRACTURE
- Lunate appears TRIANGULAR in shape on frontal view (piece of pie sign)
PERILUNATE DISLOCATION
**This injury involves dislocation of the capitate dorsal to the lunate, WHich remains in normal alignment with the distal radius
284
What are the views of the forearm
AP
| LATERAL
285
Name the clinical condition
- fracture of the PROXIMAL THIRD of the ULNA and an ANTERIOR DISLOCATION of the head of the radius at the elbow
- may result from a direct blow to the posterior ulna or FOOSH INJURY
- most commonly, physical exam reveals radial head displacement into the cubital fossa with elbow pain and tenderness
MONTEGGIA FRACTURE
286
Name the clinical condition
- fracture of the DISTAL THIRD OF THE RADIUS associated with SUBLUXATION (partial dislocation) of the head of the ulnar at the wrist joint
- usually occurs from FOOSH injury
GALEAZZI FRACTURE
* also known as a REVERSE MONTEGGIA FRACTURE
287
What are the views of the elbow
AP
| LATERAL
288
Name the clinical condition
- MOST COMMON elbow fracture in adults
- common cause is by FOOSH
- MAY not be visible on the radiograph
- visible posterior fat pad sign indicating ELBOW EFFUSION (sail sign)
- CT may aid in diagnosis
- In adult with elbow effusion after trauma, suspect RADIAL HEAD FRACTURE
RADIAL HEAD FRACTURE
289
WHAT Separates the fibrous membrane from the fibrous membrane of the joint capsule in regions overlying the coronoid fossa, olecranon fossa and the radial fossa
PADS OF FAT
-accommodate the related bony processes during extension and FLEXION of the elbow
290
What is the posterior fat pad sign or positive sail sign?
- Suggests an occult fracture and indicates the presence of elbow joint effusion
- It is caused by displacement of fat pad around the elbow joint.
- An ANTERIOR FAT PAD IS NORMAL, unless it has the appearance of a sail.
- A posterior fat pad seen on a lateral x-ray of the elbow is always ABNORMAL
291
What are the views of the shoulder
AP
| GRASHEY
292
1 -What is the most common injury to the shoulder? In children and adolescents that do altheltic activity
2-Most common in MIDDLE AGE
3- Most common in ELDERLY
4- What radiograph
1- FRACTURE OF CLAVICLE
2-Shoulder dislocations and AC joint separations
3- FRACTURE OF PROXIMAL HUMERUS
4- Injuries involving soft tissue and cartilage often require use of MRI for diagnosis
293
What view of the shoulder prevents overlap of the humeral head over the glenoid
**Known as the TRUE AP
GRASHEY VIEW
294
What is damaged when AC joint is separated form shoulder (common in middle age with shoulder dislocation)
-AC (acromioclavicular) and coracoclavicular ligaments are TORN
**Clavicle ELEVATED and scapula falls away from weight of upper limb
**CORACOACROMIAL ligament is INTACT
295
What are the specific separations of the AC JOINT injury
1- soft tissue swelling
2- Widening of the AC joint
-normal: 5-8mm
-greater than 2-4mm asymmetry (compared to contralateral side)
3- INCREASED coracoclavicular distance
- normal: 10-13 mm
- greater than 5 mm asymmetry (compared to contralateral side)
4- SUPERIOR DISPLACEMENT of the distal clavicle
296
Name the clinical condition
- ANTERIOR DISLOCATION of the shoulder results in displacement of the humeral head anterior to the glenoid cavity
- more than 95% of all shoulder dislocations are ANTERIOR
- In most cases, the humeral head lies ANTERIOR and INFERIOR to the glenoid. Sometimes this positioning can be extreme and the dislocation is termed an anterior inferior dislocation
ANTERIOR SHOULDER DISLOCATION
- Injury Results from application of INDIRECT FORCE to the arm through a combination of ;
- ABDUCTION
- EXTENSION
- EXTERNAL ROTATION
