Upper Extremity 1

Question 0

describe the 4 regions of the UE

Answer 0

1. shoulder girdle: bony ring (scapula and clavicle), posterior (attaches to axial skeleton via scapthoracic joint which is NOT a true joint), Anterior (attaches to axial skeleton via SC joint which IS a true synovial joing)
2. arm: the region btwn the shoulder and elbow; humerous bone
3. forearm: the region between the elbow and wrist; radius and ulna bone
4. hand: contains carpals, metacarpals, phalanges

Question 1

list 4 regions of the UE

Answer 1

shoulder (pectoral) girdle
arm
forearm
hand

Question 2

list the bony landmarks of the shoulder girdle and arm

Answer 2

clavicle
scapula
humerus

Question 3

list the articulations and bony landmarks of the clavicle & extra info

Answer 3

medial: manubrium, forms sternoclavicular joint
lateral: scapula, forms acromioclavicular joint

1. sternal end-medial
2. acromial end- lateral
3. deltoid tubercle (superior; attachment of deltoid)
4. impression for costoclavicular ligament (inferior; attachment of costoclavicular ligament)
5. subclavian groove (inferior; attachment for subcalvius)
6. trapezoid line (inferior; attachment for trapazoid ligament)
7. Conoid tubercle (inferior; attachment for conoid ligament)

“S” shaped for optimal shoulder elevation
superior view is smooth
this is the ONLY connection of axial skeleton to UE!!!!

clinical:
fractures-Most common at junction btwn middle and lateral third
severe osteoarthritis of SC or AC joints limits functional movement of shoulder

Question 4

describe the articulations, landmarks and extra info about the scapula

Answer 4

articulation:
scapulothoracic articulation
glenohumeral joint (glenoid fossa of scapula and head of humerus)
AC joint (acromion process of scapular with lateral en of clavicle)

1. acromion (AC joint, deltoid and trapezius attachment)
2. coracoid process (short head biceps brachii, coracobrachialis, pec minor attachment)
3. spine of scapula (deltoid and trapezius attachment
4. supraspinous fossa (posterior; supraspinatous attachment)
5. infraspinous fossa (posterior; infraspinatous attachment)
6. subscapular fossa (anterior; subscapularis attachment)
7. suprascapular notch
8. head
9. neck
10. glenoid cavity/fossa
11. supraglenoid tubercle (long head biceps brachii attachment)
12. infraglenoid tubercle (long head triceps attachment)
13. medial border, lateral border, superior border
14. superior angle (junction of medial and superior borders), inferior angle (junction of medial and lateral borders), lateral angle (junction of lateral and superior borders and less distinct)

shoulder blade = triangular flat bone
critical role in shoulder function

Question 5

describe the articulations, land marks and extra info of the humerus

Answer 5

articulation: 
glenohumeral joint (head of humerus and glenoid fossa of scapula)
elbow: 1. humeroradial joint (capitulum of humerus and radial head), 2. humeroulnar joint (trochlea of humerus and trochlear notch of ulna)

1. anatomical neck (medial to tubercles , indentation distal to head of humerus is attachment for articular capsule)
2. surgical neck (distal to tubercles, COMMON fracture site)
3. head
4. greater tubercle (attachment for external rotators of rotator cuff muscles supraspinatus, infraspinatus, teres minor)
5. lesser tubercle (attachment for internal rotator of rotator cuff muscle subscapularis)
6. bicipital groove (btwn lesser and greater tubercles, attachment for long head of biceps brachii, pec major lateral lip, latissimus dorsi floor, and teres major medial lip)
7. deltoid tuberosity (lateral part of humerus near mid shaft for deltoid muscle)
8. radial spiral groove (groove for radial nerve as it travels posterior to humerus)
9. trochlea
10. capitulum
11. olecranon fossa (posterior)
12. coronoid fossa (anterior)
13. radial fossa (anterior)
14. medial epicondyle (attachment for flexor muscles of forearm)
15. lateral epicondyle (attachment for extensor muscles of forearm)

Question 6

list muscles of the anterior thoracoappendicular region and the landmark within it

Answer 6

pectoralis major clavicular head and sternocostal head
pectoralis minor
subclavius
serratus anterior

deltopectoral triangle

Question 7

describe the deltopectoral triangle

Answer 7

landmark in the anterior thoracoappendicular region
deltoid, pec major (inferior), clavicle
cephalic vein passes superficial to deep and joins with axillary vein

Question 8

pectoralis major
O
I
N
A

Answer 8

clavicular and sternocostal heads
this is the inferior border of deltopectorial triangle
this is the lateral border of the anterior wall of the axilla

o:clavicular head = anterior surface of medial half of clavicle; sternocostal head: anterior sternum costal cartilages 1-6 and extended oblique aponeurosis

I: lateral lip of bicipital groove “intertubercular humerus”

N: Lateral and medial pectoral nerves: clavical c5-c5, sternocostal c7-t1

A: draw scapula anterior and inferior –adduction and medial rotation of humerus, clavicular = flexion, sternocostal = extension of humerus

Question 9

pectoralis minor
O
I
N
A

Answer 9

deep to pectoralis major
part of anterior wall of axilla
BVs and Nerve plexuses go under this
clinical:depress scap for crutches, gym -bench press up, seated press up, stretch to improve rounded shoulder posture syndrome

O: ribs 3-5 near costal cartilage

I: medial border and superior coracoid process

N: Medial pectoral nerve c8-t1

A: inferior and anterior movement of scapula, stabilizes scapula, protraction and depression of scapula

Question 10

subclavius
O:
I:
N:
A:

Answer 10

inferior to clavicle

O: junction of rib 1 and costocartilage

I: inferior surface of mid third of clavicle

N: nerve to subclavius c5-6

A: anchor and depress clavicle and stabilize clavicle and SC joint

Question 11

serratus anterior
O
I
N
A

Answer 11

forms medial wall of axilla
clinical: damage to long thoracic nerve = parlaysis/ weakness of serratus anterior = winging of scapula, dysfunction of shoulder abduction

O: external surfaces of lateral ribs 1-8

I: Anterior surfaces of medial border of scapula

N:long thoracic nerve c5-7

A: upward rotation, protraction and stabilization of scapula

Question 12

3 muscles causing up rotation of scapula

Answer 12

serratus anterior, upper trap, lower trap

Question 13

3 muscles medially rotate humerus

Answer 13

PLT pec major, latissimus dorsi, teres major

Question 14

list muscles of posterior thoracoappendicular region

Answer 14

superficial: trapezius, latissimus dorsi
deep: levator scapulae, rhomboid major minor

Question 15

trapezius O I N A

Answer 15

O: axial skeleton
I: shoulder girdle
N: accessory nerve and C2 C3 C4
A: retract scapula

upper - elevate and up rotation, retract scapula
middle- retract scapula
lower- depress and up rotation, retract scapula

referred pain goes up neck and into head

Question 16

latissimus dorsi OINA

Answer 16

“widest back”
acts DIRECTLY on GH joint
acts INdirectly on scapulothoracic joint of shoulder girdle

O:thoracolumbar fascia
I:floor of bicipital groove
N:thoracodorsal nerve
A: hand cuffs, extend, adduct, medially rotate humerus

Question 17

levator scapulae OINA

Answer 17

O:
I:
N: dorsal scapular nerve C3 C4
A: neck- lateral flex and ipsilateral rotation; scapula - elevate and downward rotate scapula

Question 18

rhomboid major minor OINA

Answer 18

O:
I:
N:dorsal scapular nerve
A: retract and downward rotation of scapula, and stabilize it

clinical: damage to dorsal scapular nerve = deviates from midline spine

**DEEP to trapezius

Question 19

3 muscles that attach to the greater tuberocity

Answer 19

supraspinatus infraspinatus teres major

Question 20

list scapulohumereral muscles (6 muscles with attachments on the scapula and humerus

Answer 20

deltoid
teres major
rotator cuff muscles (sits): supraspinatus, infraspinatus, teres major, subscapularis

Question 21

list rotator cuff muscles and their action as a whole

Answer 21

supraspinatus, infraspinatus, teres minor, subscapularis

dynamic stability during elevation (stabilize GH joint)

Question 22

deltoid OINA

Answer 22

clavicle to deltoid tuberosity
anterior, middle, posterior head

N: axillary nerve
A: abduct the arm; when arm is adducted it assists in resisting distraction of GH joint
posterior and anterior - stabilize humerus during abduction
anterior- flex and internal rotate humerus
middle -abduct humerus
posterior-extend and externally rotate humerus

Question 23

teres major OINA

Answer 23

O:scapula
I: distal bicipital groove
N: lower subscapular nerve
A: Hand cuff - medially/internal rotate and adduct humerus

Question 24

supraspinatus OINA

Answer 24

O: supraspinous fossa I: SUperior facet of greater tuberosity N: suprascapular nerve A: "isolated" adbuct humerus as a group these all dynamically stabilize gh joint during elevation

Question 25

infraspinatus OINA

Answer 25

O: infrapsinous fossa I: inferior to supraspinatus attachment, middle facet of the Greater tuberosity N: suprascapular nerve A: external rotation of humerus (working with teres minor synergistically) as a group these all dynamically stabilize gh joint during elevation

Question 26

teres minor OINA

Answer 26

O:superior portion of lateral border of scapula I: inferior to infraspinatus attachment, inferior facet of greater tuberosity N: axillary nerve A: external rotation of humerus (works synergistically with infraspinatus) as a group these all dynamically stabilize gh joint during elevation

Question 27

subscapularis OINA

Answer 27

O: subscapular foss I:Lesser tuberosity of humerus N: upper and lower subscapular nerve A: internal rotation of humerus as a group these all dynamically stabilize gh joint during elevation

Question 28

list and describe the anatomical landmarks of posterior thoracoappendicular region

Answer 28

1. triangular spaces: A. upper triangle (superior/teres minor; inferior/teres major; lateral/long head of triceps; contains circumflex scapular artery) B. lower triangle (superior/teres major; medial/ long head of triceps; lateral/lateral head of triceps; contains radial nerve and deep artery of arm aka profunda brachii artery) 2. Quadrangular space (superior/teres minor and subscapularis; inferior/teres major; medial/long head of triceps; lateral/surgical neck of humerus; contains axillary nerve and posterior humeral circumflex artery) 3. triangle of auscultation (trapezius, latissimus dorsi, medial border of scapula; breath sounds heard most clearly here)

Question 29

describe upper triangle

Answer 29

superior - teres minor inferior- teres major lateral- long head triceps circumflex scapular artery

Question 30

describe lower triangle

Answer 30

superior-teres major medial-long head of triceps lateral - lateral head of triceps radial nerve deep artery of arm (profunda brachii artery)

Question 31

quadrangular space

Answer 31

superior-teres minor and subscapularis inferior- teres major medial - long head of triceps lateral-surgical neck of humerus axillary nerve posterior humeral circumflex artery

Question 32

triangle of auscultation

Answer 32

trapezius latissimus dorsi medial border of scapula most clear breath sounds

Question 33

8 major arteries shoulder girdle and arm

Answer 33

``` aorta subclavian artery axillary artery brachial artery ulna artert radial artery superficial palmer arch deep palmer arch ```

Question 34

describe the diff between R/L subclavian artery

Answer 34

R: brachiocephalic trunk to subclavian artery L: subclavian artery

Question 35

describe axillary artery

Answer 35

starts as subclavian artery begins at the outer border of rib 1 ends inferior border of teres major parts 1 2 3

Question 36

describe brachial artery

Answer 36

starts as axillary artery begins inferior border of teres major ends as it divides into radial and ulna arteries at the elbow

Question 37

major blood vessels that supply the scapula region

Answer 37

``` suprascapular artery subscapular artery transverse cervical artery circumflex scapular artery dorsal scapular artery ```

Question 38

arteries that supply the shoulder and proximal humerus

Answer 38

anterior and posterior circumflex humeral arteries that branch off the 3rd part of axillary artery

Question 39

arteries that supply elbow and distal humerus

Answer 39

deep artery of arm (posteriorly wraps around humerus) radial collaterals (continuous of deep artery) ulnar collaterals (branches off brachial artery) recurrent radial artery (form anatomoses with collaterals) recurrent ulnar artery (form anatomoses with collaterals)

Question 40

describe the axilla and what it contains

Answer 40

pyramidal shaped region at the humction of arm and upper thoax clinical: palpate to ID large lymphnodes.. lymph drainage of breast into nodes in axilla cervicoaxillary canal: axillary lymphnodes AND neurovascular bundle is within the axillary sheath includes: axillary artery and branches, axillary vein, brachial plexus

Question 41

describe the boundaries of the axilla

Answer 41

1. medial wall (thoracic wall ribs 1-4 and intercostals; serratus anterior) 2. lateral wall (narrow wall formed by humerus bicipital groove) 3. anterior wall (pec major and minor and fascia) 4. posterior wall (subscapularis, teres major, latissimus dorsi, scapula) 5. base (axillary fascia, concave skin, subcutaneous tissue) 6. apex (connection btwn neck and axilla, space btwn clavicle, rib 1, and scapula) = cervicoaxillary canal contains bvs lymphatics nerves etc that pass to get to the arm

Question 42

describe brachial plexus

Answer 42

nerves that supply the thoacoappendicular region and UE originate C3-T1 brachial plexus = C5-T1 the network of ventral rami off these spinal nerves: ventral rami merge and divide to form peripheral nerves *major*: 1. axillary nerve 2. musculocutaneous nerve 3. radial nerve 4. median nerve 5. ulnar nerve

Question 43

regions of brachial plexus

Answer 43

roots - trunks- divisions - cords - branches

Question 44

describe the roots

Answer 44

formed by ventral rami of c5-t1 pas thru anterior and posterior scalene muscles merge to form 3 trunks *dorsal scapular nerve (supply levator scapulae and rhomboids) *long thoracic nerve (serratus anterior)

Question 45

describe trunks

Answer 45

``` superior trunk = c5-c6 middle trunk = c7 inferior trunk = c8-t1 each trunk divides into anterior and posterior to form divisions *nerve to subclavius (subclavius) ```

Question 46

describe divisions

Answer 46

anterior and posterior divisions these merge to form cords *suprascapular nerve (supraspinatous and infraspinatous)

Question 47

describe cords

Answer 47

lateral cord - anterior division of superior and middle trunk medial cord - anterior division of inferior trunk posterior cord- posterior division of all three trunks named according to relationship with axillary artery!! cords divide and merge to form branches (peripheral nerves)

Question 48

describe branches

Answer 48

1. lateral cord divides into: musculocutaneous (bicep brachii, brachialis, coracobrachialis) lateral pectoral (pec major) 1/2 median cord (muscles in forearm and hand) 2. medial cord divides into: 1/2 median cord (muscles of forearm and hand) medial pectoral (pec major and pec minor) medial brachial cutaneous (skin of medial arm) medial antebrachial cutaneous (skin of medial forearm) ulnar nerve (hand and forearm) ``` 3. posterior cord divides into: axillary (deltoid and teres major) radial (triceps, anconeus, brachioradialis, muscles of forearm) thoracodorsal (latissimus dorsi) upper subscapular (superior subscapularis) lower subscapular (inferior subscapularis and teres major) ```

Question 49

roots

Answer 49

dorsal scapular - pierces thru medial scalene rhombouids and levator scapulae occasionally long thoracic nerve serratus anterior

Question 50

trunks

Answer 50

nerve to subclavius | supplies subclavius

Question 51

division

Answer 51

suprascapular nerve - passes thru scapular notch | supplies supraspinatus and infraspinatus

Question 52

lateral cord

Answer 52

musculocutneous - pierces coracobrachialis - supplies coracobrachialis, brachialis, biceps brachii - continues on as lateral cutaneous nerve of forearm (lateral antebrachial cutaneous nerve) lateral pectoral -supplies pec major median nerve - lateral and medial cords merge to form this - supplies wrist, hand flexor muscles of forearm and muscles of thenar region of hand

Question 53

medial cord

Answer 53

median nerve medial pectoral nerve -supplies pec minor and pec major medial brachial cutaneous -supplies skin of medial arm DOES NOT SUPPLY ANY MUSCLES*** medial antebrachial cutaneous - supplies skin of medial forearm - DOES NOT SUPPLY ANY MUSCLES** ulnar nerve -supplies muscles of hand and 1 1/2 flexor muscles of the forearm

Question 54

posterior cord

Answer 54

axillary nerve: - exits thru quad space - supplies deltoid and teres minor - continues on as superior lateral brachial cutaneous nerve supplying skin over deltoid region radial n - travels posterior around humerus in radial spiral groove - supplies triceps brachii, anconeus, brachioradialis, wrist hand extensor muscles of forearm thoracodorsal -supplies latissimus dorsi upper subscapular -supplies superior portion of subscapularis lower subscapular -supplies superior portion of inferior portion of subscapularis and teres major ....?

Question 55

describe anterior and posterior compartments of the arm

Answer 55

medial and lateral intermuscular septum divides the anterior and posterior compartments musculocutaneous nerve supplies the anterior radial nerve supplies the posterior

Question 56

list the muscles of the arm

Answer 56

``` coracobrachilais (ant) biceps brachii (ant) brachialis (ant) triceps brachii (post) anconeus (post) ```

Question 57

coracobrachialis OINA

Answer 57

O: coracoid process I: middle third of medial humerus N: musculocutaneous (passes thru) A: flex and adduct arm

Question 58

biceps brachii OINA

Answer 58

O: long head - supraglenoid tubercle of scapula short head - coracoid process of scapula I: radial tuberosity of radius and bicipital anponeruosis N: musculocutaneous nerve A: flexes arm and forearm, supinates forearm clinical: transverse humeral ligament "contains" tendon of long head in bicipital groove- potential for dislocation of tendon biceps tendonitis - irritation of long head tendon as it passes thru bicipital groove rupture of long head tendon rehab strengthening - optimal supinated position

Question 59

define bicipital aponeurosis

Answer 59

fascia that extends from distal biceps tendon and blends with fascia of the flexor muscles of the forearm provides protection for structures in the cubital fossa

Question 60

brachialis OINA

Answer 60

O: distal half of anterior surface of humerus I: coronoid tuberosity of ulna N: musculocutaneous nerve A: primary flexor of forearm, flexes forarm in all postions (supinated, neutral, pronated) clinical - rehab strengthening -active in all positions

Question 61

triceps brachii OINA

Answer 61

O: long head- infraglenoid tubercle lateral head - post humerus superior to radial groove medial head -post humerus inferior to radial groove I: olecranon process of ulna N: radial nerve A: primary extensor of forearm clinical- lower cervical SCI - important for therapist to ID if triceps functions .. makes significant difference in ADLs (note tricep supplied by c7-8)

Question 62

Anconeus OINA

Answer 62

O: lateral epicondyle I: olecranon process of ulna N: radial nerve A: assists in forearm extension, stabilizes elbow joint

Question 63

axillary nerve

Answer 63

branches off posterior cord and travels posteriorly | exits thru quad space and supplies teres minor and deltoid

Question 64

musculocutaneous nerve

Answer 64

begins inferior border of pec minor pierces corcobrachialis travels btwn biceps brachii and brachialis after innervation of biceps and brachialis the nerve becomes the lateral cutaneous nerve of forearm

Question 65

radial nerve

Answer 65

travels posterior to brachial artery and medial to humerus descends with deep artery of arm (deep brachial artery) travels posterior to humerus in radial groove wraps anterior and pierces lateral intermuscular septum travels btwn brachialis and brachioradialis to elbow

Question 66

median nerve

Answer 66

follows brachial artery.. runs lateral to brachial artery then crosses to run medial to brachial artery the median nerve does not have any branches in axilla or arm

Question 67

ulnar nerve

Answer 67

travels medial to brachial artery and anterior to triceps mid point of humerus it pierces medial intermuscular septum and descends poteriorly passes posterior to medial epicondyle enters forearm does not have any branches in axilla or arm

Question 68

review of blood supply to arm: brachial artery

Answer 68

axillary artery becomes brachial artery (inferior border of teres major) brachial artery branches: deep artery of arm (goes posterior to humerus in radial groove with the radial nerve) -[that branches the radial collateral arteries (supply lateral elbow)] AND the brachial artery branches into ulnar collateral (supply medial elbow) -- brachial artery ends in cubital fossa and divides into radial and ulna artieries axillary--brachial--radial/unla arteries at the cubital fossa I I-ulnar collateral branches deep artery of arm I radial collateral artery

Question 69

acromioclavicular joint

Answer 69

acromioclavicular joint (AC)- -AC ligament (superior and inferior) -Coracoclavicular ligament (connect coracoid processes of scapula and inferior surface of clavicle: A. trapezoid ligament [ coracoid process to trapezoid line of clavicle], B. conoid ligament [ coracoid process to conoid tubercle of clavicle] clinical: AC joint separation type 1- partial injury to AC lig, corcoclavicular is intact type 2- disruption of AC lig, coracoclavicular lig is intact type 3-disruption of AC lig and Coracoclavicular ligaments, clavicle is displaced SUPERIORLY

Question 70

Joints of UE

Answer 70

``` acromioclavicular joint AC Glenohumeral joint (GH) (sternoclavicular joint??) ```

Question 71

glenohumeral joint (GH)

Answer 71

``` glenohumeral joint (GH) humeral head and glenoid cavity of humerus glenoid labrum increase congruency of joint ``` -glenohumeral ligament (strengthen anterior aspect of joint) superior GH ligament Middle GH ligament inferior GH ligament -coracohumeral ligament coracoid process to greater tuberosity o fhumerus -coracoacromial ligament forms part of the coracoacromial arch (See another slide) -transverse humeral ligament acts as bridge over the bicipital groove contains long head of biceps tendon -bursa of GH: 1. subacromial bursa 2. subscapularis bursa - lies btwn subscapularis tendon and neck of scapula (kinda under the coracoid process), communicates with GH joint capsule (Really an extension of the joint capsule) 3?? subdeltoid bursa??not on hand out ``` clinical: supraspinatus tendonitis impingement syndrome rotator cuff tears dislocation of GH joint ```

Question 72

coracoacromial arch

Answer 72

coracoacromial ligament and acromion process "subacromial space" - suprasinatus tendon passes thru this space supraspinatus tendon is protected by subacromial bursa (lies btwn arch and tendon )