Upper Limb

Question 1

Clavipectoral fascia borders

Answer 1

Superior = clavicle (continue superior to clavicle to become the investing layer of deep cervical fascia)

Inferior = axillary fascia

Medial = membrane of 1st / 2nd ext IC

Lateral = coracoid process / coracoclavicular lig

Question 2

Structures enclosed by clavipectoral fascia

Answer 2

1. Subclavius

2. Pec minor

Question 3

Structures perforating clavipectoral fascia

Answer 3

1. Thoraco-acromial A
2. Cephalic V
3. Lateral pectoral N
4. Lymphatics from anterior breast (to apical node)

Question 4

Costocoracoid lig

Answer 4

@ lower border of subclavius x2 layers of clavipectoral fascia fuse to form a well-developed band

Stretches from the coracoid process to the 1st rib (costochondral junction)

Question 5

Main stabilising factor of the SCJ

Answer 5

Costoclavicular lig

Binds the clavicle to the 1st CC + the adjacent end of the 1st rib just lateral to the joint

Question 6

Main stabilising factor of the ACJ

Answer 6

Coracoclavicular lig

x2 parts - trapezoid, conoid
~4cm from the ACJ + give it vertical stability

Question 7

Coracoid-clavicular distance

Answer 7

Otherwise known as CC distance

<12mm

Question 8

Borders of axilla

Answer 8

Medial - serratus ant (slips 1-4)

Lateral - bicipital groove / LH of biceps tendon

Anterior - CP fascia / pec minor / pec major

Posterior - subscap / teres major / lat dorsi tendon

Roof - bound by:

1. Scapula (posterior)
2. Outer border of 1st rib (medial)
3. Clavicle (anterior)

Floor - axillary fascia (supported by suspensory lig)

Question 9

Contents of axilla

Answer 9

1. Cords of brachial plexus
2. Long thoracic N
3. Axillary A + V
4. LNs
5. LH of biceps
6. Tendon of lat dorsi
7. Teres major
8. Pec minor / CP fascia
9. Coracobrachialis
10. Short head of biceps

Question 10

Br of axillary A

Answer 10

“Screw The Lawyer Save A Patient”

1st part x1 / 2nd part x2 / 3rd part x3

1. Superior thoracic A - 1st part
2. Thoracoacromial A - 2nd part
3. Lateral thoracic A - 2nd part
4. Subscapular A - 3rd part
5. Ant humeral Cx A - 3rd part
6. Post humeral Cx A - 3rd part

Question 11

Axillary sheath

Answer 11

Covers the axillary A NOT the axillary V

Continuation of prevertebral fascia from the neck

Question 12

Subscap A

Answer 12

4th br of axillary A (arises from 3rd part)

Runs along posterior wall of the axilla giving off Cx scapular A

Cx scapular A passes between subscap / TM (medial to LH of triceps + thus, medial to quad space)

After br CSA the subscap A becomes the thoracodorsal A + supplies lat dorsi

Question 13

Cx Humeral A

Answer 13

Post:

• Larger br
• Passes through quad space w/ axillary N
• Anastomoses w/ ant br + profunda brachii A

Ant: 
- Smaller br
- Passes deep to coracobrachialis + x2 heads of biceps 
  around the surgical NOH
- Anastomoses w/ post br

Question 14

Comparison of scapula winging

Answer 14

Lateral scapula winging

• Trapezius weakness
• Spinal accessory N (CN XI)

Medial scapula winging

• Serratus ant
• Long thoracic N (C5 / C6 / C7)

Question 15

Dangers of lat approach to shoulder J

Answer 15

Lateral incision w/ splitting of deltoid

Incision should be no longer than 5cm from the acromion to avoid inj to the axillary N

Axillary N circles the humeral head ~7cm inferior to the acromion

Question 16

Path of Axillary N

Answer 16

Passes through quadrangular space + circumflexes the head of the humerus ~7cm below the acromion

Question 17

Scapular anastomosis

Answer 17

1. Dorsal scapular A (via transverse cervical A)
2. Suprascapular A
3. Subscapular A, which gives off:
   
   4. Cx humeral A
   5. Thoracodorsal A

Question 18

Spaces assoc. w/ Teres major

Answer 18

1. Quadrangular space - axillary N + post Cx humeral A
2. Triangular interval - radial N + profunda brachii A
3. Triangular space - Cx scapular A

Question 19

Borders of quadrangular space

Answer 19

Medial = LH of triceps

Lateral = SNOH

Superior = Teres minor

Inferior = Teres major

Question 20

Borders of triangular interval

Answer 20

Base = Teres minor

Medial = LH of triceps

Lateral = humeral shaft

Question 21

Triangular space

Answer 21

Lateral (base) = LH of triceps

Superior = Teres minor

Inferior = Teres major

Question 22

Stability of the shoulder

Answer 22

1. RC muscles + fusion of tendons w/ capsule
2. Coracoacromial arch (overhanging coracoid / CA lig / acromion process)
3. Glenoid labrum
4. Muscles attached from pec girdle to humerus
   
   • Esp. LH biceps / LH triceps

Question 23

Anatomical relations of biceps aponeurosis

Answer 23

Passes medially from insertion of biceps onto radial tuberosity to insert into deep fascia of the forearm flexors

Brachial A + median N pass deep to bicipital aponeurosis + medial to radial tubersity

Medial cubital V passes superficial to the biceps aponeurosis

Question 24

Musculocutaneous N in the arm

Answer 24

Runs underneath biceps muscle + above brachial

Terminal branch is the lateral cut N of forearm, which runs between the brachialis + biceps to reach its endpoint

Question 25

C4 / C5 disc herniation

Answer 25

Weakness with elbow flexion + supination (i.e. biceps muscle) Reduced sensation in lateral aspect of arm (lateral aspect of forearm is C6) Loss of biceps tendon reflex (C4 / C5, but predominantly C5)

Question 26

Structure @ risk w/ anterior appr to shoulder J

Answer 26

Musculocutaneous N, which pierces the coracobrachialis 3-8cm distal to the coracoid process

Question 27

Only muscle in the anterior arm compartment w/ dual nerve supply?

Answer 27

Brachialis Supplied by: 1. Musculocutaneous N (pre-dominant) 2. Radial N (small area of lateral aspect of muscle)

Question 28

Important relations of brachioradialis

Answer 28

@ distal humerus the radial N lies between brachioradialis (deep) + brachial (superficial) Superficial sensory br of radial N runs distally in the forearm under the cover of brachioradialis, lateral to the radial A

Question 29

Surg appr to humerus

Answer 29

Long anterior curved incision Medialise the biceps w/ retraction Divide the brachialis muscle centrally

Question 30

Surg appr distal humerus

Answer 30

Oblique incision between brachialis + brachioradialis Medialise biceps + brachialis w/ retraction Lateralise brachioradialis w/ retraction Need to identify radial N, which lies immediately deep to brachioradialis

Question 31

Radial N passes through...

Answer 31

Lateral + medial heads of triceps in the radial groove

Question 32

Median N passes through...

Answer 32

x2 heads of pronator teres

Question 33

Ulnar N passes through

Answer 33

x2 heads of FCU

Question 34

Medial IM septum of arm

Answer 34

Arises from medial supracondylar ridge behind CB + fades out above - between CB + LH of triceps Pierced by ulnar N + ulnar collateral A

Question 35

Lateral IM septum of arm

Answer 35

Arises from lateral supracondular ridge Between triceps (posterior) + ECRL / BR (anterior) Pierced by radial N + ant descending br of profunda brachii A

Question 36

Relationship of pronator teres to NV structures

Answer 36

Median N passes between the CFO / ulnar heads of pronator teres Ulnar head separates the median N + ulnar A from each other 1. Median N runs superficial to the ulnar head 2. Ulnar A runs deep to the ulnar head

Question 37

Parona's space

Answer 37

Potential space in volar wrist between PQ + FDP Facilitates communication between the radial + ulnar bursae from the fingers Space can act as a conduit for the spread of a hand infection

Question 38

Borders of Parona's space

Answer 38

Dorsal = PQ Volar = FDP Ulnar = FCU Radial = FPL

Question 39

FCR / PL / Median N relationship

Answer 39

FCR is medial + PL is lateral to the median N Deep lac to FCR may result in median N inj Palm cut br of median N arises between PL + FCR + is @ risk w/ carpal tunnel incision or Henry (volar) appr to DR

Question 40

Lumbrical plus finger

Answer 40

= paradoxical extension of finger when trying to flex the finger Due to disruption of FDP distal to the insertion of the lumbricals into the dorsal expansion