Anatomy for Health Care ProfessionalsNUR469: Lecture 2

September 14, 2009

Curtis L. Whitehair, MD

Georgetown UniversitySchool of Nursing & Health Studies

Graduate Program

Upper Arterial Supply LAB

Veins

Brachial Plexus

Robert Taylor Drinks Cold Beer

Brachial Plexus

Brachial Plexus Injuries Injuries to the brachial plexus affects movement and cutaneous sensations in

the upper limb. Erb-Duchenne Palsy: Upper Trunk or C5,6 Roots – results in waiters tip.

Shoulder Adducted

Medially rotated arm

Extend Elbow

Brachial Plexus Injuries Compression of cords of the brachial plexus from prolonged hyperabduction of

the arm. Results in pain radiating down the arm with hand weakness.

Brachial Plexus Injuries Klumpke Palsy: Less common, inferior brachial plexus injury(C8-T1), may be

from trying to break a fall. Intrinsic muscle of the hand affected, develops claw hand.

Brachial Plexus Injuries

Injuries to the brachial plexus affects movement and cutaneous sensations in the upper limb.

Erb-Duchenne Palsy: Upper Trunk or C5,6 Roots – results in waiters tip. Compression of cords of the brachial plexus from prolonged hyperabduction of

the arm. Results in pain radiating down the arm with hand weakness. Klumpke Palsy: Less common, inferior brachial plexus injury(C8-T1), may be

from trying to break a fall. Intrinsic muscle of the hand affected, develops claw hand.

Acute Brachial Plexus Neuritis (Parsonage Turner Syndrome): sudden on set of severe shoulder pain then is followed by weakness. Inflammation is often preceded by some event (URI, Vaccination or Non-specific Trauma)

Anterior muscles of the Arm

Biceps Brachii Musculocutaneous (C5,C6) (bi, two + L. caput, head) – 2 heads

Short head Tip of coracoid process

Long head Supraglenoid tubercle of scapula

Single distal tendon attached to Radius with biceps tendon

Bicipital aponeurosis runs from biceps tendon across the cubital fossa Protects structures of cubital fossa

No attachment to Humerus “Three joint muscle”

Glenohumeral joint Elbow joint Radioulnar joint

When elbow is extended – flexor of elbow Elbow 90o :

Supinated – flexor Pronated – primary supinator of the arm Semiprone – active with resistance only

Bicipital Myotatic Reflex

Deep Tendon Reflex / Muscle Stretch Reflex – C5

Biceps Tendonitis

Wear and tear, usually long head of the biceps

Speed’s test – flexion pain at insertion

Yergason test – elbow 90o resisted supination

Rupture of the Tendon usually long head, rare distally.

Brachialis LAB

Musculocutaneous C5, C6

Flexes forearm all positions – not effected by position

MAIN flexor of the forearm

Coracobrachialis LAB

Musculocutaneous C5, C6, C7 Flexes arm Helps arm adduction

Stabilizes glenohumeral joint from inferior dislocation Carrying suitcase

Posterior muscles of the Arm

Triceps brachii LAB Radial nerve (C6,C7, C8) 3 heads Long head Crosses glenohumeral joint Helps Adduct and extend

Arm Stabilizes inferior

dislocation Medial head

Workhorse of forearm extension

Lateral head Strongest but is recruited

against resistance

Anconeus

Radial C7, C8, T1

Tenses the capsule of the elbow joint preventing its being pinched during extension.

Muscles of the forearm flexor

The flexors are arranged in three layers Superficial layer

4 muscles Crosses elbow

Intermediate layer 1 muscle Crosses elbow

Deep layer 3 muscles Crosses wrist and phalanges

Superficial Layer – forearm LAB

Pronator Teres Median nerve C6,

C7 pronates forearm medial boarder

cubital fossa

Superficial Layer – forearm LAB

Flexor carpi radialis Median nerve C6,

C7 Flexes wrist Helps abducts

wrist

Superficial Layer – forearm LAB Palmaris Longus

Median nerve Absent in 14% of

people (usually left) Tendon passes

superficial to the flexor retinaculum

Attaches to palmar aponeurosis

Median nerve runs lateral to tendon

CTS Injection - medial

Superficial Layer – forearm LAB

Flexor Carpi Ulnaris Most medial flexor Flexes and adducts

the wrist if acting alone

Ulnar C7, C8

Intermediate layer – forearm LAB

Flexor digitorum superficialis

Distal end four tendons go through carpal tunnel to middle phalanges

Flexes four fingers PIP MCP – stronger

Median C7, C8, T1 Test – one finger flexed

PIP, others extended

Deep Layer – forearm LAB

Flexor Digitorum Profundus Only muscle that flex the DIP

Medial part – Ulnar C8, T1 Lateral part - Median (anterior

interosseous) C8, T1

Flexor Pollicis Longus Only muscle to flex the 1st IP, MCP

and CMC joints Median (anterior interosseous) C8,

T1

Deep Layer – forearm LAB

Pronator quadratus Deepest muscle of anterior

forearm Sometimes considered fourth

layer Median (anterior

interosseous) C8, T1

Posterior muscle of the forearm

Superficial layer

Deep layer and Outcropping muscles of deep layer

Extensor muscle of the forearm Divided into 3 functional groups

Extend, abduct, adduct the hand at the wrist Extensor carpi radialis longus Extensor carpi radialis brevis Extensor carpi ulnaris

Extend the medial four fingers Extensor digitorum Extensor indicis Extensor digiti minimi

Extend or abduct the thumb Abductor pollicis longus Extensor pollicis brevis Extensor pollicis longus

Superficial LAB

Extensor carpi radialis longus

Extensor carpi radialis brevis

Extend and abduct wrist

Radial nerve C6, C7

Superficial LAB

Extensor digitorum Four tendons to extensor

hood of 4 fingers Extensor digiti minimi

5th finger Extensor carpi ulnaris

Extend and adducts wrist joint

Radial nerve C7, C8 (posterior interosseous nerve)

Deep Layer LAB

Supinator Prime supinator with arm

extended Radial (deep branch)

Extensor indicis Independent extensor of 2nd

finger Radial C7, C8 – (PI)

Deep Layer - Outcropping LAB

Abductor pollicis longus Base of 1st metacarpal

Extensor pollicis brevis Base of 1st proximal phalanx

De Quervain’s Tenosynovitis

Extensor pollicis longus Base of 1st distal phalanx

Radial nerve C7, C8

Medial & Lateral Epicondylitis Medial – Common Flexor

Tendon Pitcher’s (Little League)

Elbow

Lateral – Common Extensor Tendon Tennis Elbow

Treatment Splint Physical Therapy NSAIDs Steroids Oral Steroid Injection at the

common flex/ext tendon

Intrinsic muscle of the hand

Thenar muscle Abductor pollicis brevis

Median nerve C8, T1 Flexor pollicis brevis

Superficial head – Median C8, T1

Deep head – Ulnar C8, T1

Intrinsic muscle of the hand

Thenar muscle Opposes thumb

Median nerve C8, T1

Adductor pollicis Ulnar nerve C8, T1

Intrinsic muscle of the hand

Hypothenar muscle Abductor digiti

minimi Flexor digiti minimi Opponens digiti

minimi

Ulnar nerve C8, T1

Intrinsic muscle of the hand

Short Muscles Lumbricals – Ulnar

Flex fingers at the MCP joint

Extend fingers at IP joint

Interossei Dorsal – Abduct from

axial line Palmar – Adduct to

axial line

DAB with a PAD

Arteries of forearm and hand

Nerves of the hand

Nerves of the hand

Shoulder Joint

Rotator Cuff

Nursemaid’s Elbow

Preschool children

Particularly girls

Transient subluxation

•Treatment consists of manipulating the child's arm so that the annular ligament and radial head return to their normal anatomic positions.

•Immobilize the elbow and palpate the region of the radial head with one hand.

•The other hand applies axial compression at the wrist while supinating the forearm and flexing the elbow.

•As the arm is manipulated, a click or snap can be felt at the radial head.

Next Week Must know

559 - Bones of the LE Fig 5.6, 5.7, 5.8 and 5.9 Dermatomes Fig 5.13 Fig 5.15 – Tensor fascia lata Sartorius Rectus Femoris Adductor longus Vastus medialis / lateralis Gracilis Fig 5.17 – Neurovascular

structure Fig 2.3 – Gluteal Region Biceps femoris Semi-tendinosus Semi-mebranosus Gluteus Medius / Maximus Piriformis Popliteal fossa

Tibial nerve Popliteal vein Popliteral artery Common fibular (peroneal)

nerve Sural nerve

Should know Fig 5.15 – Pectinues Adductor brevis Superior gemellus Obturator internus Inferior gemellus Obturator externus

Great to know Table 5.1