Upper Limb

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  • 1. Anatomy of the upper limb Introduction General considerations Brachial plexus

2. ANATOMY UPPER LIMB BRACHIAL PLEXUS 3. The spinal nerves from C5 to C8, together with the T1 thoracic spinal nerve,join together to formthe brachial plexus.The nerve elements combine,divideand combine again tomix together the variouscomponents that lead into the major nerves of theshoulder, arm and hand. 4. A nerve plexus is an area where nerves branchand rejoin.The brachial plexus is a group of nerves in the cervical spine from C5 to C8-T1.This includes the lower half of the cervical nerve roots and the nerve root from the first thoracic vertebra. 5. Brachial Plexus1 Ventral root of C52 Ventral root of C63 Ventral root of C74 Ventral root of C85 Ventral root of T1 6 Ulnar7 Radial8 Median 9 Musculocutaneous10 Cordsa Medialb Posteriorc Lateral 11 Posterior divisions 12 Anterior divisionsa Inferiorb Middle c Superior13 Inferior trunk14 Middle trunk 15 Superior trunk 6. Erbs paralysis C5 - C6 Birth injury Arm hangs by the side+Rotate medially Forearm pronated + extended Flexed wrist + fingers deltoid supraspinatus infraspinatus biceps - brachialis 7. Klumpkes paralysis /kloompkz/ C8 T1 Intrinsic muscles of the hand + long flexors of the hand ------ paralysis Claw hand = extension at MPJ + flexion at IPJ Cervical rib can cause paralysis similar to Klumpkes paralysis with post-fixed T2 contribution 8. Winging of the scapula Injury to the long thoracic nerve Paralysis of serratus anterior muscleHumeral fracture At the surgical neck ---------- injury to the axillary nerve ---- loss of abduction 9. Arterial blood supplyof the upper limb 10. Axillary artery Continuation of subclavian artery Runs from lateral border of first rib to lower border of teres major Pectoralis minor crosses anterior to it and divides it into three parts First part Highest thoracic artery (also called supreme or superior) Second part Lateral thoracic artery Thoracoacromial artery Third part Subscapular artery Anterior circumflex humeral artery Posterior circumflex humeral artery Collateral circulation around the scapula Branches of first part of Subclavian artery anastomose with branches of the third part of axillary artery 11. The axillary artery begins at the lateral border of the first rib as a continuation of the subclavian artery.It changes its name to brachial artery at lower (inferior) border of the teres major muscle.For purposes of description, it is broken up into three parts by its relation to the pectoralis minor muscle. The first part is between the lateral border of the first rib and the medial border of the pectoralis minor,the second part is behind the pectoralis minor and the third part is between the lateral border of the pectoralis minor and the inferior border of the teres major 12. Brachial artery Continuation of the axillary artery Runs from lower border of teres major to neck of radius Ends by dividing into radial and ulnar arteriesBranches of the brachial artery Profunda brachi which travels in the radial groove of humerus Superior ulnar collateral artery o Inferior ulnar collateral artery Nutrient artery to humerus Terminal branches are radial and ulnar arteriesRelations Median nerve crosses anterior to it from lateral to medial side at the level of mid arm 13. 1 superior thoracic a.(supreme thoracic a.) (highest thoracic a.)2 thoracoacromial a. 3 lateral thoracic a.4 subscapular a. 5 anterior humeral circumflex a. 6 posterior humeral circumflex a. 14. Ulnar artery Gives rise to common interosseous artery Continues as the superficial palmar arch in the handRadial artery Continues as the deep palmar arch in the handMedian artery Vestigial in adult life Arises from the anterior interosseous branch of common interosseous artery Provides nutrition to Median nerve Chief source of blood supply to the upper limb in foetal life Passes anterior to carpal tunnel 15. The diagram also shows that the brachial artery terminates just below the elbow joint as the radial and ulnar arteries, to be covered in the forearm 16. 1 brachial 2 radial 3 radial recurrent 4 superficial radial 5 deep radial 6 ulnar 7 anterior ulnar recurrent 7 posterior ulnar recurrent 8 common interosseous 9 posterior interosseous 10 anterior interosseous 11 superficial branch 12 deep branch 17. The superficial arterial arch is formed mainly from the ulnar artery and is completed by the superficial branch of the radial. This completion is not always present or may be extremely small. The deep arterial arch is formed mainly by the deep branch of the radial artery and is finished by the deep branch of the ulnar artery. 18. Upper limbVenous drainage 19. cephalic v.Tributaries lateral side of the dorsal venous arch of the hand; superficial veins of the forearmDrains Intoaxillary vein Regions Drainedsuperficial parts of the lateral hand and lateralforearmNotes median cubital vein usually shunts some of the blood collected by the cephalic v. to the basilic v. (Latin/Greek, kephale = head) 20. The axillary vein lies along the medial side of the artery and is a continuation of the basilic vein.It begins at the inferior border of the teres major m. and ends at the lateral border of the first rib, where it becomes the subclavian v. It receives tributaries that parallel the branches of the axillary artery. 21. The cephalic v. joins the axillary v. just before it becomes the subclavian. Penetrating wounds in the larger upper part are serious because air might enter into the venous system. 22. The veins that run with their corresponding arteries are frequently multiple (2 or 3 interconnected veins).This interconnected venous network is called the vena commitantes 23. Axilla, Pectoral andscapular regions 24. Anatomically,the boundaries of the axilla aremedially: serratus anterior and by the ribcageanteriorly: by the pectoralis major, minor, and subclavius (see also anterior axillary fold)posteriorly: by the subscapularis above, and teres major and latissimus dorsi below(see also posterior axillary fold) laterally: by the intertubercular sulcus (coracobrachialis and the short head of the biceps brachii are in the axilla.) superiorly: by the outer border of first rib, superior border of scapula, and posterior border of claviclefloor/base: by the skin (visible surface of armpit 25. Deep muscles of the chest and front of the arm, with the boundaries of the axilla. 26. Artery axillary artery Vein axillary vein axillary nerve,medial cord, Nerveposteriorcord, lateralcordaxillary lymph Lymphnodes 27. Lymphatics StructureLocation Afferents fromEfferents toRegions drained Notes axillary nodes axilla cubital nodes;efferents vessels upper limb, most axillary nodes lymphatic vessels form theof the mammary number from 20 from the uppersubclavian trunk, gland, some of the to 30 and are limb, thoracic wall some drainage toanterolateral chest organized in five and subscapular inferior deep wall, posterior groups based on regioncervical nodesthoracic wall and their position scapular region within the axilla: 1) pectoral nodes, along the lateral border of the pectoralis major m.; 2) lateral nodes, located along the distal axillary v.; 3) central nodes, centrally located along axillary v.; 4) subscapular nodes, located along the subscapular v. and its tributaries; 5) apical nodes, located at the apex of axilla 28. There are some 15 to 20 nodes usually arranged into to five groups. The groups consist of: A pectoral (anterior) L lateral P posterior C central Ap apical 29. Muscles of Axilla and the Pectoral region 30. Pectoralis major Origin medial 1/2 of the clavicle, manubrium & body of sternum, costal cartilages of ribs 2-6, sometimes from the rectus sheath of the upper abdominal wInsertion crest of the greater tubercle of the humerus Action flexes and adducts the arm, medially rotates the arm Nerve supply medial and lateral pectoral nerves (C5-T1)Arterial blood supply pectoral branch of the thoracoacromial trunkthe deep fascia on its anterior surface should not be fused to the fascia of the mammary gland - if it is, this is an important clinical sign indicating breast disease (Latin, pectus = breast bone) 31. Pectoralis minor origin ribs 3-5 Insertion coracoid process of the scapula Action draws the scapula forward, medialward, and downward Nerve supply medial pectoral nerve (C8, T1) arterial supply pectoral branch of the thoracoacromial trunkNotes; branches of medial pectoral nerve usually pierce pectoralis minor to reach the pectoralis major muscle . 32. serratus anterior Origin ribs 1-8 or 9 Insertion medial border of the scapula on its costal (deep) surface Action it draws the scapula forward; the inferior fibers rotate the scapula superiorlyNerve supply long thoracic nerve (from ventral rami C5-C7) Arterial supply lateral thoracic a. a lesion of long thoracic nerve will cause winging of the scapula (i.e., the medial border of the scapula falls away from the posterior chest wall and looks like an angel's wing) (Latin, serratus = to saw) 33. Topographical Anatomy of the ThoraxStructure/SpaceDescription/Boundaries Significancemidaxillary line an imaginary vertical line used as a surface landmarkpassing through the middle for descriptive purposesof the axillamidclavicular line an imaginary vertical line used as a surface landmarkpassing through thefor descriptive purposesmidshaft of the clavicle 34. deltopectoral triangle a triangle in the upper chest region that is bounded medially by the clavicle,superiorly by the deltoid m.,and inferiorly by the pectoralis major m. the deltopectoral triangle is pierced by the cephalic vein on its course from the upper limb to join the axillary vein in the axilla 35. nipple located superficial to the 4th location of the left nipple may beintercostal space in the male andused to help locate the apex of heart,prepuberal female; a