Sc13 Sheilaʼs Sore Shoulder

Introduction to Upper Limb Anatomy1. Label features A-S1

2. Which artery(ies) run from the subclavian over the 1st rib and ultimately divide into ulnar and radial branches near the cubital fossa? 2

3. Name the main branches off of this artery before it divides into ulnar and radial3

4. Which artery gives rise to the common interosseous artery?4

5. Name the two vascular features formed by the convergence of radial and ulnar arteries in the hand.5

6. Which arteries emerge from this structure?6

1 A = Phylanges, B = metacarpals, C = carpals, D = styloid processes, E = bicipital tuberosity, F = radial tubersosity, G = ulnar tuberosity, F = trochlea, I = capitulum, J = lateral epicondyle (medial epicondyle on other side of humerus next to trochlea), K = deltoid tuberosity, L = bicipital groove, M = lesser tuberosity, N = greater tuberosity, O = corocoid process P = acromion, Q = glenoid, R = inferior angle of the scapula (superior angle is opposite), S = scapula

2 brachial, axillary 3 produnda brachii, superior and medial ulnar collaterals, radial collateral4 superior ulnar collateral, the common interosseous then divides into the posterior and anterior interosseous arteries5 deep (mainly radial) and superficial palmar arches (mainly ulnar)6 digital arteries

7. Which feature of the forearm connects to biceps brachii?7

8. Which artery runs in between the venae commitantes?8

9. Which veins drain directly into the axilliary vein?9

10. The cephalic and basilic veins run down the length of the upper arm and forearm, which vein runs between them at the cubital fossa?10

11.Which vein is formed out of this one and runs down the length of the forearm only?11

The Pectoral Girdle

1. Name the five muscles that attach to the clavicle superiorly (i.e. muscles are below the clavicle) and their nervous innervations12

2. Which two bony features does the clavicle attach to?13

3. Name the main ligament attached to the medial end of the clavicle14

4. Which feature(s) of the clavicle does the coraco-clavicular ligament attach to?15

5. What type/class of joint is the sterno-clavicular joint?16

6. What type/class of joint is the acromio-clavicular joint?17

7. What part of the scapula does the coraco-clavicular ligament attach to?18

7 radial tuberosity8 brachial artery9 basilic, cephalic (through bicep) and venae comitantes10 median cubital11 median vein of the forearm12 pectoralis major (medial and lateral pectoral nerve), sternocleidomastoid (c2-3, 6th spinal accessory nerve) trapezius (c3-4, 6th spinal accessory nerve), deltoid (axillary nerve), subclavius (subclavian nerve)

13 the articular facet of the manubrium of the sternum medially, the articular facet of the scapla laterally

14 costo-clavicular ligament

15 conoid tubercle and trapezoid ridge at the lateral end of the clavicle

16 synovial (joint capsule containing synovial fluid with fibrous cartliage at edge of bones)

17 synovial

18 coracoid process

8. Considering an anterior view of the right humerus in the anatomical position, which tubercle of the humoral head would be most medial and which would be the most lateral?19

9. Which 'neck' of the humerus is the most superior?20

10.Name the groove that runs down the humerus from between the tubercles and the artery it contains21

11.Which part of the humerus does the deltoid (shoulder) muscle attach to?22

12.The trochlea and the capitulum are features at the end of the humerus, which bone insterts into which? 23

13.What are the bony prominences either side of these?24

14.Name the two fossae on the anterior surface of the humerus immediately above the trochlea and the capitulum25

15.Name the fossa on the posterior surface above the trochlea26

16.What are the three attachments of pectoralis major?27

17.What are the four attachments of pectoralis minor and what is its nervous innervation28?

18.What is the name of the smaller of the two muscles (i.e. other than biceps brachii) that attaches the corocoid process of the scapula to the shaft of the humerus?29

19.What is its nervous innervation?30

19 lesser tubercle would be most medial, greater would appear on lateral edge of humoral head

20 anatomical neck is most superior before the tubercles, surgical neck is further down

21 the bicipital or intertubecular groove, contains a branch of the anterior humeral circumflex artery which comes from the axilliary artery

22 deltoid process

23 radius into the capitulum, ulnus into the trochlea

24 medial epichondyle immediately medial to the ulnus/trochlea (inside side), lateral epichondyle immediately lateral to the radius/capitulum (outside side)

25 capitulum = radial fossa, trochlea = coronoid fossa,

26 olecranon fossa

27 bicipital groove, clavicular head, sternal head

28 3rd, 4th, 5th ribs and the coracoid process of the scapula, median pectoral nerve only

29 coracobrachialis

30 musculocutaneous nerve c5-c6

20.What is the nerouvs innervation of biceps brachii?31

21.What are the three fossae on the surface of the scapula?32

22.What is the name of the fossa on the scapula into which the humerus attaches?33

23.Which two muscles attach to opposite sides of the acromion process of the scapula?34

24.Name muscles A and B and their nervous innervation35

25. Name muscles A-F and their nervous innervation36

The Shoulder Joint and Axilla

1. What are the attachments of subscapularis? 37

2. What are the actions of subscapularis?38

31 musculocutaneous nerve c5-c6

32 supra spinous, infra spinous and sub scapular

33 glenoid fossa

34 trapezius (back) and deltoid (shoulder)

35 A = Subscaoularis (upper and lower subscapular nerves), B = Serratus anterior (long thoracic nerve)

36 A = levator scapulae (dorsal scapular nerve) B = supraspinatus (supra scapular nerve), C = Rhomboid minor (dorsal scapular nerve), D = rhomboid major (dorsal scapular nerve), E = teres major (lower subscapular nerve) (latissiumus dorsi would be behind this), F = Infraspinatus (suprascapular nerve), G = teres minor (axilliary nerve)

37 subscapular fossa on thhe posterior side of the scapula with the lesser tubercle of the humoral head

38 adduction (away from median plane) of limb and medial rotation of shoulder

3. Which two muscles rotate the scapula in order to increase the joint angle between the humerus and the scapula?39

4. How would you identify winging of the scapula?40

5. Winging of the scapula signifies damage to which muscles and/or nerve?41

6. Which muscle has sternal and clavicular heads as well as an attachment to the lateral ridge of the bicipital groove?42

7. Name the three muscles that attach to the corocoid process43

8. What is the glenoid labrum?44

9. Why does the glenohumoral joint capsule hang down into the axilla?45

10.What are the attachments on the scapula for the long tendons of biceps and triceps?46

11.Which muscle attached to the greater tubercle initiates abduction of the arm?47

12.What feature prevents rubbing of the supraspinatus muscle against the acromion process?48

13.Describe the course of the axillary nerve from the axilla to the deltoid muscle which it supplies49

14.How do you test for a trapped axillary nerve in a dislocated shoulder?50

15.What is the clinical sign for a broken clavicle or dislocated shoulder?51

39 trapezius and serratus anterior

40 get the patient to push against a wall/object

41 serratus anterior and/or the long thoracic nerve to serratus anterior

42 pectoralis major

43 pec minor, coracobrachialis, biceps brachii

44 ring of fibrocartilage around the edges of the glenohumoral joint, aims to deepen the joint capsule

45 to allow adduction of the glenophumoral joint

46 infra and supraglenoid tubercles respectively

47 supraspinatus

48 sub-acromial bursa

49 goes from anterior to posterior along the medial (inside side) of the surgical neck

50 after innervating the deltoid muscle, the axilliary nerve innervates the skin above it, so if nerve is trapped the skin will be hypersensitive or desensitised

51 spasm of the powerful supraspinatous muscle causes the arm to collapse medially onto the chest

16.Name muscles a-d52

Arm and Elbow Joint1.Label trunks A-C and nerves i-xiv on the diagram of the brachial plexus53

2.Which parts of the spinal vertebrae/surrounding nerves does the brachial plexus originate from?54

3.Which nerve of the brachial plexus supplies most of the structures in the posterior compartments of the arm and forearm?55

4. What structures are contained within the axilliary sheath?56

5. What is the only muscle attached to the lesser tubercle?57

6. What is the nerve in red on the diagram above?58

7. What is the nervous innervation and attachments of biceps brachii?59

8. Which nerve runs through the spiral grove of the humerus?60

52 A- subscapularis, B- supraspinatus, C - infraspinatus, D - teres major

53 A - lateral cord, B - posterior cord, C - medial cord, i - dorsal scapula nerve, ii - subclavian nerve, iii - suprascapular nerve, iv - musculocutaneous (C5-7), v - median nerve (C5-T1), vi - axilliary nerve (C5-6), vii- radial nerve (C5-T1), viii - ulnar nerve C8-T1, ix - lower subscapular, x - thoraco-dorsal, xi - upper subscapular, xii -median pectoral, xiii - median cutaneous,xiv- median cutaneous nerve of the forearm

54 anterior rami

55 radial nerve C5-T1

56 axilliary artery and vein, 3x cords of brachial plexus

57 subscapularis

58 C5-7 long thoracic nerve to serratus anterior

59 Nervous innervation = musculocutaneous, attachments = SH tendon in coracoid process, LH tendon to scapula via intertubercular groove, insterion = bicipital aponeurosis across ulna and radius, radial tuberoisity

60 radial nerve (posterior cord of brachial plexus)

9. Which is medial to it?61

10.Which flexor of the arm lies over the distal half of the humerus only?62

11.Which nerve enters this muscle posterior to anterior and which anterior to posterior?63

12.Name the carpal bones (SLTPTTCH)64

13.Which bones of the palm are not connected to adjacent bones by interosseus ligaments?65

14.What is the styloid process?66

15. Between which two veins does the median cubital vein run?67

16. Which two arteries does the brachial artery split into when it goes through the cubital fossa?68

17.Which nerve runs through the cubital fossa and is therefore in potential danger during cannulation?69

18.Where is the quadrate ligament?70

19.Where is the annular ligament?71

20.What is the nervous innervation and attachments of the triceps?72

61 Ulnar nerve (medial cord of brachial plexus)62 Brachialis63 radial is post-ant having run through the spiral grove at the back of the humerus, ulnar is ant-post64 Scaphoid, lunate, triquetral, pisiform, trapezium, trapezoid, capitate, hamate65 The 1st and 2nd layers or carpals are not connected to each other by interosseus ligaments (mid-carpal joint), metacarpal 1 (thumb) is also not connected to the carpals by an interosseus ligament66 End of radius and ulna at carpal junction, lined with hyaline cartilage and serving as an attachment site for muscles67 Basilic and cephalic68 Ulnar and radial69 Median nerve70 Down the length of the forearm between radius and ulna71 A band of fibres encircling the head of the radius72 Radial nerve, olecranon process of ulna, infraglenoid tubercle if scapula, lateral head above the radial sulcus, and medial head below

Calcium Homeostasis

1. Under what citcumstances could dietary calcium absorbtion increase and when would it decrease?73

2. Which three dietary components increase calcium absorbtion and which decreases it?74

3. What is the normal range for plasma calcium concentration?75

4. In what forms is calcium found in the blood? 76

5. What is the distribution of calcium in body compartments? Give rough values in g77

6. What is the typical amount absorbed out of 1200mg in dietary calcium per day?78

7. How much calcium is lost in the urine and sweat?79

8. What are the symptoms associated with hypercalcemia and hypocalcemia?80

9. What are the effects of PTH, cholecalciferol (vitamin D) and calcitonin on blood calcium and potassium?81

10. What is the stimulus for release of PTH?82

11.What are the second messengers and enzymes involved in stimulation and inhibition of PTH secretion?83

12.What are the only bone related cell which present PTH receptors?84

73 Increase during childhood, pregnancy, and lactation, decrease with age and raised calcium intake.

74 Lactose, basic amino acids and vitamin D increase, Phytic acid (inositol hexaphosphate) decreases

75 2.2-2.6mM

76 1.2mM free ionic form (biologically active), 1mM bound to plasma proteins, 0.3mM in complexes e.g. with citrate

77 Plasma 350g, ECF 1g, soft tissues 3.6g, bone 1000g

78 1200mg eaten in a day, 450mg absorbed, but 150mg back into gut, 900mg in faeces. Net gain of 300mg/d

79 250mg/d in urine, 50mg/d in sweat

80 Hyper - sluggish nervous responses, ectopic calcification. Hypo - Hyperexcitable nervous system, tetany

81 PTH increases Ca in blood (by increasing reabsorbtion in the distal tubule) and decreases Pi (by decreasing reabsorbtion in the kidney, although additional Pi is released from bone), Vit D increases both, Calcitonin decreases both (calci-ʻtone-downʼ)

82 Low blood calcium, sensed by Ca receptor on PTH cell, it increases blood Ca but decreases Pi

83 Stimulation = acetylcholine and cAMP, Inhibition = phospholipase C and IP3

84 Osteoblasts, these effect osteoclasts which release calcium and phosphate contents.

13.What effect does PTH have on vitamin D and how?85

14.What are the effects of hyperparathyroidism and hypoparathyroidism?86

15.Which cells in the thyroid produce calcitonin?87

16.What demographic groups may be most at risk of vitamin D deficiency?88

17.How does vitamin D increase calcium absorbtion in the gut?89

18. What is the effect of vitamin D on the kidney?90

19. What is the effect of glucocorticoids on calcium homeostasis?91

20. What is the basic difference between osteomalacia and osteoporosis?92

21. Aside from ethnicity, family history, age and gender, what are the main osteoporosis risk factors?93

22. List the main treatments for osteoporosis94

Forearm 1: Pronators and Supinators

1. List the muscles and tendons with origins at the common flexor origin?95

2. What is their nervous innervation?96

3. Which flexor of the hand does not originate here and what is its nervous innervation?97

85 Activated 1-alpha hydroxylase which is needed to activate vitamin D

86 Hyper- hypercalcaemia through excessive bone reabsorbtion and ectopic calcification.Hypo- hypocalcemia

87 C cells or parafollicular cells

88 Vegans - vitamin D not present in plants, elderly and asian women and children

89 Up-regulates production of calbindin proteins, also has a direct effect on cell membranes to increase calcium absorbtion.

90 Increases reabsorbtion of calcium and phosphate ions (opposite to calcitonin)

91 Decrease uptake and increase excretion

92 Osteomalacia - normal amount of bone but reduced mineral matrix ratio, Osteoporosis - reduced amount of bone but normal matrix

93 Nutrition (calcium, sodium, protein, caffeine), Corticosteroids (inhibit osteoblasts)

94 Oestrogen replacement therapy, oestrogen receptor modulators, strontium, biphosphonates (inhibit osteoclast activity), synthetic PTH preparations.

95 Palmiris longus, flexor carpi radialis96 Median nerve97 Flexor carpi ulnaris (ulnar nerve)

4. How many phylanges do the fingers and thumbs have?98

5.What is the distal attachment (insertion) for the flexor digitorum superficialis?99

6.What exists to prevent bowstringing of the tendons over the carpal bones?100

7.Name muscles A-C and their nervous innervation101

8.Is the anterior interosseus branch medial or lateral to the median nerve?102

9.Which muscle (not shown in the diagram), has two heads (one on the lateral epichondyle and one on the ulnar head)?103

10.Which nerve does the posterior interosseus nerve branch from?104

11.What is the other branch of this nerve called once the posterior interosseus has left it?105

Forearm 2: Flexors and Extensors

1. Name muscles A and B?106

2. Which part of the fingers are flexor digitalis superficialis and flexor digitorum profundis attached to?107

98 fingers have proximal, medial and distal thumb just has proximal and distal99 median phalanges of the fingers100 Flexor retinaculum101 A = pronator teres (median), B = brachioradialis (radial), C = pronator quadratus (anterior interosseus and median nerve)102 lateral (interosseus), whereas the medial runs down the ulna103 Supinator104 radial105 deep radial106 A = flexor digitorum profundis, B = flexor pollicis longus107 Profundis = distal phylanges, Superficialis = proximal phylanges

3. What is 'bowstringing'?108

4. What is the origin of the flexor pollicis longus?109

5. What are the attachments for the flexor digitorum profundis? 110

6. What is the main nerve supplying the posterior (extensor) compartment of the forearm? 111

7. And the main nerve supplying the anterior (flexor) compartment?112

8. What type of movement is bringing the thumb towards and away from the palm?113

9. And towards or away from the fingers?114

10.And incontact with the tips of the fingers?115

11.What is the nerve supply for the flexor pollicis longus? 116

12.Which extensor muscle has attachments to the common extensor origin, ulnar and the 5th metacarpal?117

13.Whereabouts on the humerus is the common extensor origin located?118

14. What are the main differences between extensor carpi radialis longus and brevis?119

108 when tendon comes away from its anchorage point or normal course because of damage to the flexor retinaculum which normally holds it in109 Radius and interosseus membrane110 ulna and interosseus membrane111 radial nerve and branches112 ulnar nerve113 flexion and extension114 adduction and abduction115 opposition116 median nerve and the anterior interosseus nerve ( branch of median nerve)117 extensir carpi ulnaris118 lateral epichondyle (closest to the radius)119 brevis is shorter because it is attached to the 3rd and 2nd metacarpals and the lateral epichondyle whereas longus is between the 2nd metacarpal of the index finger and the lateral supraepichondylar ridge

15.What are the nervous innervations of these two muscles?120

16.Why is there no separate muscle for abduction and adduction only for flexion/extension?121

17.Which muscle/tendon/area of the arm becomes inflammed in tennis elbow? 122

18.What are the attachments and nervous innervation of extensor digitorum?123

19.What are the two muscles that split from the same origin in the distal ulna and end up on the auricular and index fingers respectively?124

20. Identify muscles A and B125

21.Which artery runs along the floor of the anatomical snuff box between abductor and extensor pollicis tendons?126

# # # # # 22.What is the clinical sign of fracture of the scaphoid and/or damage to the scaphoid vein?127

120 like all the muscles in the posterior (extensor) compartment, its the radial nerve. Brevis is supplied by the posterior interosseous branch of the radial, as is the extensor carpi ulnaris. With the exception of brachioradialis, which is radial, the flexor muscles are supplied by the median121 Contracting both flexor and extensor muscles but only on lateral or medial side can adduct or abduct122 lateral epichondyle particularly the tendon for extensor carpi radialis brevis123 lateral epichondyle/common extensor origin, attached into the middle and distal phylanges of the four fingers124 extensor digiti minimi and extensor indices (both posterior interosseus nerve) 125 A = abductor pollicis longus, B = abductor pollicis longus126 radial artery127 tenderness in the anatomical snuff box as the scaphoid vein runs through it