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Gross Anatomy
Forum
Upper Limb
Upper Limb Forum 1) Define the difference between shoulder separation and shoulder dislocation. A shoulder separation involves injury to the ligaments holding the upper limb to the axial skeleton (or the Acromial-clavicular joint) The ligaments involved are the acromialclavicular ligament and the coracoclavicular ligament A shoulder dislocation is when the head of the humerus dislocates from the glenoid fossa The most common shoulder dislocation occurs anterior/inferiorly because this is the weakest part of the joint (there are not as many muscles or ligaments in this area) James Lamberg 2) What is the clinical significance of the radial groove? The radial nerve runs along the radial groove, the clinical significance is that if you break the shaft of the humerus it can damage the radial nerve causing problems for the forearm and hand 3) List the rotator cuff muscles, their nerve supplies, origins, insertions, and functions. Supraspinatus Proximal – supraspinous fossa Distal – greater tuberosity of the humerus Action – abducts the arm (first 15 degrees), stabilizes shoulder Innervation – suprascapular nerve Infraspinatus Proximal – infraspinous fossa Distal – greater tuberosity of the humerus Action – laterally rotates the arm, stabilizes shoulder Innervation – suprascapular nerve Teres Minor Proximal – Upper 2/3rd lateral border of scapula Distal – greater tuberosity of the humerus Action – medially rotates the arm, stabilizes shoulder Innervation – Axillary nerve (C5, C6) Subscapularis Proximal – Subscapular fossa Distal – lesser tuberosity of the humerus Action – medially rotates the arm, stabilizes shoulder Innervation – subscapular nerve 4) What is the segmental innervation of the following muscles, and the cord of the brachial plexus involved? a. Supraspinatus – suprascapular nerve, levels C5 and C6, off of the lateral cord (roots) b. Infraspinatus – suprascapular never, levels C5 and C6, off the lateral cord (roots) c. Teres minor – Axillary nerve, levels C5 and C6, off of the posterior cord d. Subscapularis – subscapular nerve, levels C5, C6, C7, off of the posterior cord e. Deltoid – Axillary nerve, levels C5 and C6, off of the posterior cord f. Levator scapulae – dorsal scapular nerve, levels C5, off of the lateral cord (trunk) 5) On the figures below, label all muscles that either originate or insert on the scapula. Version: 09Apr2009
Page 1 of 9
Gross Anatomy
Forum
Upper Limb
1 = Long head of biceps brachii- attaches to the supraglenoid tubercle of the glenoid fossa 2 = Trapezius – superior region of scapular spine 3 = Deltoid – lateral region of scapular spine 4 = Long head of triceps brachii – infragelnoid tubercle of the glenoid fossa 5 = Teres Minor – Superior lateral border of scapula 6 = Teres Major- Inferior lateral border of scapula 7 = Latissimus Dorsi – Inferior angle of the scapula 8 = Rhomboid Major – Inferior medial border of the scapula 9 = Infraspinatous – Infraspinous fossa 10 = Rhomboid Minor – Superior medial border of scapula 11 = Levator Scapulae – Superior angle of scapula 12 = Supraspinatous – supraspinous fossa 13 = Omohyoid 14 = Serratus Anterior – Medial border and inferior angle of the scapula 15 = Subscapularis – subscapular fossa 16 = Pectoralis Minor – Inferior section of coracoid process 17/18) Short head of biceps brachii and coracobrachialis – lateral border of coracoids process 1) Define the muscular walls of the axilla. Anterior Wall: Pectoralis Major, Subclavius, and Pectoralis Minor Posterior Wall: Subscapularis, Latissimus Dorsi, Teres Major Medial Wall: Upper 4/5 ribs, serratus anterior Lateral Wall: Coracibrachialis and biceps muscles 2) Define the distribution of the clavipectoral fascia. The clavipectoral fascia extends between the coracoid process, the clavical and the thoracic wall. It includes the muscle fascia that envelops the subclavius and pectoralis minor, the costocoracoid membrane formed in the interval between the two muscles, and the suspensory ligament of the axilla that is continuous downward and blends with the axillary fascia, maintaining the hollow of the armpit. Version: 09Apr2009
Page 2 of 9
Gross Anatomy
Forum
Upper Limb
3) Into what large vessel does the cephalic vein drain? Axillary vein 4) What is the principal function and innervation of the pectoral muscles? Pectoralis Major Adduction and medial rotation, Medial and lateral pectoral nerves Pectoralis Minor Depressed the shoulder at the point of the coracoids process, medial pectoral nerve 5) What structure occupies the bicipital groove? Long head of the biceps tendon runs through it to attach to the supraglenoid tubercle (latissimus dorsi runs along the floor of the bicepital groove of the humerus, and pectoralis major and teres major run along the outer ridges 6) What happens to the scapula following complete section of the long thoracic n.? This denervates the entire serratus anterior and therefore this causes winging of the scapula as the serratus anterior holds the scapula to the thoracic wall 7) Explain the anatomical location of each of the three cords of the brachial plexus. The cords are posterior, medial, and lateral. They are in the axilla and named by their position in respect to the axillary artery. The posterior cord is formed from the three posterior divisions of the trunks (C5-T1) The lateral cord is the anterior divisions from the upper and middle trunks (C5-C7) The medial cord is simply a continuation of the lower trunk (C8-T1) 8) Outline the anatomical location of each of the three parts of the axillary artery, and identify the branches of each. From the first rib to the upper border of pectoralis minor Superior Thoracic Artery Deep to the pectoralis minor Thoracoacromial artery Lateral Thoracic artery Lower border of the pectoralis minor to the lower border of the teres minor Subscapular artery Anterior and Posterior circumflex humeral arteries 9) Draw and label a complete brachial plexus
Version: 09Apr2009
Page 3 of 9
Gross Anatomy
Forum
Upper Limb
1) What is the significance of collateral blood supply/circulation? Serves to supply an area where the main blood supply has been cut off 2) The medial, lateral, and posterior cords of the brachial plexus are named due to their position relative to what structure? The axillary artery 3) List at least one motor deficit that would follow section of each of these nerves at the indicated places: a. median nerve, proximal to the elbow The pronator muscles of the forearm and the long flexor muscles of the wrist (except for the flexor carpi ulnarus) b. ulnar nerve, proximal to the elbow Loss of function of the flexor carpi ulnaris and medial half of the flexor digitum profundus (ulnar claw) c. axillary, at the shoulder The shoulder will not be able to abduct pass 15 degrees (due to loss of deltoid function) and the arm would not be able to medially rotate due to loss of function of the teres minor d. radial, proximal to the origin of the triceps
Version: 09Apr2009
Page 4 of 9
Gross Anatomy
Forum
Upper Limb
The triceps, anconeus and long extensors of the wrist are paralyzed; Unable to extend the elbow joint the wrist joint and the fingers (wrist drop occurs) e. lower subscapular, near its origin Loss of function of teres major and subscapularis, therefore the arm would be unable to medially rotate f. musculocutaneous nerve, in the axilla The biceps and coracobrachialis are paralyzed and the brachialis muscle is weakened 4) Draw upper limb with dermatome level map. C5, C6, C7
5) Describe the boundaries of the cubital fossa. The cubital fossa is a triangular depression that lies in front of the elbow. Laterally: Brachioradialis Medially: Pronator teres The base of the triangle is formed by an imaginary line drawn between the two epicondyles of the humerus. The floor is formed by the supinator laterally and the brachialis medially. The roof is formed by skin and fascia and is reinforced by the bicipital aponeurosis. 6) List in order, the mediolateral relationships of the biceps tendon, median nerve, and brachial artery in the cubital fossa. Median Nerve, Brachial artery (bifurcation into ulnar and radial branches), biceps tendon Version: 09Apr2009
Page 5 of 9
Gross Anatomy
Forum
Upper Limb
7) In the figure below, which is a section through the arm at the humeral mid-shaft, label the structures indicated.
A) Biceps brachii B) Brachialis C) Cephalic vein D) Musculocutaneous nerve E) Medial cutaneous nerve of forearm F) Brachial artery G) Basilic vein H) Median nerve I) Long head of triceps J) Medial head of triceps K) Lateral head of triceps L) Radial nerve M) Radial collateral artery
Version: 09Apr2009
Page 6 of 9
Gross Anatomy
Forum
Upper Limb
1) List the muscles associated with the common flexor tendon of the forearm. Flexor carpi ulnarus, flexor carpi radialis, and Palmaris longus 2) Describe the course of the median nerve in relation to the pronator teres and flexor digitorum superficialis. The median nerve pierces the pronator teres and runs with the flexor digitorum superficialis 3) In the figure below, which is a cross-section of the wrist through the distal carpal row, identify the tendons, nerves, arteries, and bones.
A
Trapezium
K
B C
Trapezoid Capitate
L M
D
Hamate
N
E
Palmaris Longus Tendon
O
F
Ulnar artery
P
G H I
Ulnar nerve Median Nerve Flexor digitorum superficialis tendons Flexor digitorum profundus tendons
Q R S
J
T
Flexor pollicis longus tendon in tendon sheath Flexor carpi radialis tendon Tendon m. extensor carpi radialis longus Tendon m. extensor carpi radialis brevis Tendon m. extensor pollicis longus Tendon m. extensor digiti minimi Not labeled in atlas Not labeled in atlas Radial artery Tendon m. extensor carpi ulnaris
4) What is carpal tunnel syndrome? What are the physical symptoms of a patient with it? Produced by compression of the medial nerve within the tunnel (formed by the bones of the hand and the flexor retinaculum) The median nerve lies within a restricted space and gets compressd (exact mechanism unknown – thickening of synovial sheath) causing pins and needles feelings (burning pain) along the distribution of the median nerve, the lateral 3.5 fingers and the thenar muscles James Lamberg
Page 7 of 9
Gross Anatomy
Forum
Upper Limb
5) If a patient suffers a fracture at the medial epicondyle of the humerus, what nerve is most likely to be injured? The ulnar nerve 6) What is a Colles' fracture? Besides an x-ray, what is an obvious indication that a patient has a Colles' fracture? Fracture of the distal end of the radius usually due to a fall on the hand The posterior displacement sticks out getting 1) What are the principal digital movements mediated by the: a) palmar interossei; b) dorsal interossei? Palmer adduction; Dorsal abduction 2) What is the extensor expansion and what muscles insert into it? It’s a sheet-like tendon that holds the flexor digitorum to the surface of the fingers 3) Define the boundaries of the "anatomical snuff box" and list its key contents. Extensor pollicis longus (medially), center = extensor pollicis brevus, abductor pollicis longus (lateral) 4) What are the osseous attachments of the extensor retinaculum? The extensor retinaculum extends on the posterior wrist from the lateral margin of the radius to the styloid process of the ulna, the pisiform, and the triquetrum. 5) In the following diagram identify the cutaneous distribution of the median, ulnar and radial nerves.
James Lamberg
Page 8 of 9
Gross Anatomy
Forum
Upper Limb
6) The muscles of the hand receive motor input from the median and ulnar nerves. List the motor deficits that will result from nerve injury at the indicated locations: Median nerve, proximal to flexor retinaculum (as in wrist slashing): Loss of ability to oppose the thumb (loss of ability to lateral 3.5 fingers) an thenar muscles Ulnar nerve, at the wrist (ulnar nerve entrapment): Ulnar claw (pinkie and ring finger)
James Lamberg
Page 9 of 9
Forum
Upper Limb
Upper Limb Forum 1) Define the difference between shoulder separation and shoulder dislocation. A shoulder separation involves injury to the ligaments holding the upper limb to the axial skeleton (or the Acromial-clavicular joint) The ligaments involved are the acromialclavicular ligament and the coracoclavicular ligament A shoulder dislocation is when the head of the humerus dislocates from the glenoid fossa The most common shoulder dislocation occurs anterior/inferiorly because this is the weakest part of the joint (there are not as many muscles or ligaments in this area) James Lamberg 2) What is the clinical significance of the radial groove? The radial nerve runs along the radial groove, the clinical significance is that if you break the shaft of the humerus it can damage the radial nerve causing problems for the forearm and hand 3) List the rotator cuff muscles, their nerve supplies, origins, insertions, and functions. Supraspinatus Proximal – supraspinous fossa Distal – greater tuberosity of the humerus Action – abducts the arm (first 15 degrees), stabilizes shoulder Innervation – suprascapular nerve Infraspinatus Proximal – infraspinous fossa Distal – greater tuberosity of the humerus Action – laterally rotates the arm, stabilizes shoulder Innervation – suprascapular nerve Teres Minor Proximal – Upper 2/3rd lateral border of scapula Distal – greater tuberosity of the humerus Action – medially rotates the arm, stabilizes shoulder Innervation – Axillary nerve (C5, C6) Subscapularis Proximal – Subscapular fossa Distal – lesser tuberosity of the humerus Action – medially rotates the arm, stabilizes shoulder Innervation – subscapular nerve 4) What is the segmental innervation of the following muscles, and the cord of the brachial plexus involved? a. Supraspinatus – suprascapular nerve, levels C5 and C6, off of the lateral cord (roots) b. Infraspinatus – suprascapular never, levels C5 and C6, off the lateral cord (roots) c. Teres minor – Axillary nerve, levels C5 and C6, off of the posterior cord d. Subscapularis – subscapular nerve, levels C5, C6, C7, off of the posterior cord e. Deltoid – Axillary nerve, levels C5 and C6, off of the posterior cord f. Levator scapulae – dorsal scapular nerve, levels C5, off of the lateral cord (trunk) 5) On the figures below, label all muscles that either originate or insert on the scapula. Version: 09Apr2009
Page 1 of 9
Gross Anatomy
Forum
Upper Limb
1 = Long head of biceps brachii- attaches to the supraglenoid tubercle of the glenoid fossa 2 = Trapezius – superior region of scapular spine 3 = Deltoid – lateral region of scapular spine 4 = Long head of triceps brachii – infragelnoid tubercle of the glenoid fossa 5 = Teres Minor – Superior lateral border of scapula 6 = Teres Major- Inferior lateral border of scapula 7 = Latissimus Dorsi – Inferior angle of the scapula 8 = Rhomboid Major – Inferior medial border of the scapula 9 = Infraspinatous – Infraspinous fossa 10 = Rhomboid Minor – Superior medial border of scapula 11 = Levator Scapulae – Superior angle of scapula 12 = Supraspinatous – supraspinous fossa 13 = Omohyoid 14 = Serratus Anterior – Medial border and inferior angle of the scapula 15 = Subscapularis – subscapular fossa 16 = Pectoralis Minor – Inferior section of coracoid process 17/18) Short head of biceps brachii and coracobrachialis – lateral border of coracoids process 1) Define the muscular walls of the axilla. Anterior Wall: Pectoralis Major, Subclavius, and Pectoralis Minor Posterior Wall: Subscapularis, Latissimus Dorsi, Teres Major Medial Wall: Upper 4/5 ribs, serratus anterior Lateral Wall: Coracibrachialis and biceps muscles 2) Define the distribution of the clavipectoral fascia. The clavipectoral fascia extends between the coracoid process, the clavical and the thoracic wall. It includes the muscle fascia that envelops the subclavius and pectoralis minor, the costocoracoid membrane formed in the interval between the two muscles, and the suspensory ligament of the axilla that is continuous downward and blends with the axillary fascia, maintaining the hollow of the armpit. Version: 09Apr2009
Page 2 of 9
Gross Anatomy
Forum
Upper Limb
3) Into what large vessel does the cephalic vein drain? Axillary vein 4) What is the principal function and innervation of the pectoral muscles? Pectoralis Major Adduction and medial rotation, Medial and lateral pectoral nerves Pectoralis Minor Depressed the shoulder at the point of the coracoids process, medial pectoral nerve 5) What structure occupies the bicipital groove? Long head of the biceps tendon runs through it to attach to the supraglenoid tubercle (latissimus dorsi runs along the floor of the bicepital groove of the humerus, and pectoralis major and teres major run along the outer ridges 6) What happens to the scapula following complete section of the long thoracic n.? This denervates the entire serratus anterior and therefore this causes winging of the scapula as the serratus anterior holds the scapula to the thoracic wall 7) Explain the anatomical location of each of the three cords of the brachial plexus. The cords are posterior, medial, and lateral. They are in the axilla and named by their position in respect to the axillary artery. The posterior cord is formed from the three posterior divisions of the trunks (C5-T1) The lateral cord is the anterior divisions from the upper and middle trunks (C5-C7) The medial cord is simply a continuation of the lower trunk (C8-T1) 8) Outline the anatomical location of each of the three parts of the axillary artery, and identify the branches of each. From the first rib to the upper border of pectoralis minor Superior Thoracic Artery Deep to the pectoralis minor Thoracoacromial artery Lateral Thoracic artery Lower border of the pectoralis minor to the lower border of the teres minor Subscapular artery Anterior and Posterior circumflex humeral arteries 9) Draw and label a complete brachial plexus
Version: 09Apr2009
Page 3 of 9
Gross Anatomy
Forum
Upper Limb
1) What is the significance of collateral blood supply/circulation? Serves to supply an area where the main blood supply has been cut off 2) The medial, lateral, and posterior cords of the brachial plexus are named due to their position relative to what structure? The axillary artery 3) List at least one motor deficit that would follow section of each of these nerves at the indicated places: a. median nerve, proximal to the elbow The pronator muscles of the forearm and the long flexor muscles of the wrist (except for the flexor carpi ulnarus) b. ulnar nerve, proximal to the elbow Loss of function of the flexor carpi ulnaris and medial half of the flexor digitum profundus (ulnar claw) c. axillary, at the shoulder The shoulder will not be able to abduct pass 15 degrees (due to loss of deltoid function) and the arm would not be able to medially rotate due to loss of function of the teres minor d. radial, proximal to the origin of the triceps
Version: 09Apr2009
Page 4 of 9
Gross Anatomy
Forum
Upper Limb
The triceps, anconeus and long extensors of the wrist are paralyzed; Unable to extend the elbow joint the wrist joint and the fingers (wrist drop occurs) e. lower subscapular, near its origin Loss of function of teres major and subscapularis, therefore the arm would be unable to medially rotate f. musculocutaneous nerve, in the axilla The biceps and coracobrachialis are paralyzed and the brachialis muscle is weakened 4) Draw upper limb with dermatome level map. C5, C6, C7
5) Describe the boundaries of the cubital fossa. The cubital fossa is a triangular depression that lies in front of the elbow. Laterally: Brachioradialis Medially: Pronator teres The base of the triangle is formed by an imaginary line drawn between the two epicondyles of the humerus. The floor is formed by the supinator laterally and the brachialis medially. The roof is formed by skin and fascia and is reinforced by the bicipital aponeurosis. 6) List in order, the mediolateral relationships of the biceps tendon, median nerve, and brachial artery in the cubital fossa. Median Nerve, Brachial artery (bifurcation into ulnar and radial branches), biceps tendon Version: 09Apr2009
Page 5 of 9
Gross Anatomy
Forum
Upper Limb
7) In the figure below, which is a section through the arm at the humeral mid-shaft, label the structures indicated.
A) Biceps brachii B) Brachialis C) Cephalic vein D) Musculocutaneous nerve E) Medial cutaneous nerve of forearm F) Brachial artery G) Basilic vein H) Median nerve I) Long head of triceps J) Medial head of triceps K) Lateral head of triceps L) Radial nerve M) Radial collateral artery
Version: 09Apr2009
Page 6 of 9
Gross Anatomy
Forum
Upper Limb
1) List the muscles associated with the common flexor tendon of the forearm. Flexor carpi ulnarus, flexor carpi radialis, and Palmaris longus 2) Describe the course of the median nerve in relation to the pronator teres and flexor digitorum superficialis. The median nerve pierces the pronator teres and runs with the flexor digitorum superficialis 3) In the figure below, which is a cross-section of the wrist through the distal carpal row, identify the tendons, nerves, arteries, and bones.
A
Trapezium
K
B C
Trapezoid Capitate
L M
D
Hamate
N
E
Palmaris Longus Tendon
O
F
Ulnar artery
P
G H I
Ulnar nerve Median Nerve Flexor digitorum superficialis tendons Flexor digitorum profundus tendons
Q R S
J
T
Flexor pollicis longus tendon in tendon sheath Flexor carpi radialis tendon Tendon m. extensor carpi radialis longus Tendon m. extensor carpi radialis brevis Tendon m. extensor pollicis longus Tendon m. extensor digiti minimi Not labeled in atlas Not labeled in atlas Radial artery Tendon m. extensor carpi ulnaris
4) What is carpal tunnel syndrome? What are the physical symptoms of a patient with it? Produced by compression of the medial nerve within the tunnel (formed by the bones of the hand and the flexor retinaculum) The median nerve lies within a restricted space and gets compressd (exact mechanism unknown – thickening of synovial sheath) causing pins and needles feelings (burning pain) along the distribution of the median nerve, the lateral 3.5 fingers and the thenar muscles James Lamberg
Page 7 of 9
Gross Anatomy
Forum
Upper Limb
5) If a patient suffers a fracture at the medial epicondyle of the humerus, what nerve is most likely to be injured? The ulnar nerve 6) What is a Colles' fracture? Besides an x-ray, what is an obvious indication that a patient has a Colles' fracture? Fracture of the distal end of the radius usually due to a fall on the hand The posterior displacement sticks out getting 1) What are the principal digital movements mediated by the: a) palmar interossei; b) dorsal interossei? Palmer adduction; Dorsal abduction 2) What is the extensor expansion and what muscles insert into it? It’s a sheet-like tendon that holds the flexor digitorum to the surface of the fingers 3) Define the boundaries of the "anatomical snuff box" and list its key contents. Extensor pollicis longus (medially), center = extensor pollicis brevus, abductor pollicis longus (lateral) 4) What are the osseous attachments of the extensor retinaculum? The extensor retinaculum extends on the posterior wrist from the lateral margin of the radius to the styloid process of the ulna, the pisiform, and the triquetrum. 5) In the following diagram identify the cutaneous distribution of the median, ulnar and radial nerves.
James Lamberg
Page 8 of 9
Gross Anatomy
Forum
Upper Limb
6) The muscles of the hand receive motor input from the median and ulnar nerves. List the motor deficits that will result from nerve injury at the indicated locations: Median nerve, proximal to flexor retinaculum (as in wrist slashing): Loss of ability to oppose the thumb (loss of ability to lateral 3.5 fingers) an thenar muscles Ulnar nerve, at the wrist (ulnar nerve entrapment): Ulnar claw (pinkie and ring finger)
James Lamberg
Page 9 of 9
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