anatomy for health care professionals nur469: lecture 2 september 14, 2009 curtis l. whitehair, md...
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Anatomy for Health Care ProfessionalsNUR469: Lecture 2
September 14, 2009
Curtis L. Whitehair, MD
Georgetown UniversitySchool of Nursing & Health Studies
Graduate Program
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Upper Arterial Supply LAB
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Veins
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Brachial Plexus
Robert Taylor Drinks Cold Beer
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Brachial Plexus
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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
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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.
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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.
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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)
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Anterior muscles of the Arm
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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
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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
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Rupture of the Tendon usually long head, rare distally.
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Brachialis LAB
Musculocutaneous C5, C6
Flexes forearm all positions – not effected by position
MAIN flexor of the forearm
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Coracobrachialis LAB
Musculocutaneous C5, C6, C7 Flexes arm Helps arm adduction
Stabilizes glenohumeral joint from inferior dislocation Carrying suitcase
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Posterior muscles of the Arm
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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
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Anconeus
Radial C7, C8, T1
Tenses the capsule of the elbow joint preventing its being pinched during extension.
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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
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Superficial Layer – forearm LAB
Pronator Teres Median nerve C6,
C7 pronates forearm medial boarder
cubital fossa
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Superficial Layer – forearm LAB
Flexor carpi radialis Median nerve C6,
C7 Flexes wrist Helps abducts
wrist
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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
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Superficial Layer – forearm LAB
Flexor Carpi Ulnaris Most medial flexor Flexes and adducts
the wrist if acting alone
Ulnar C7, C8
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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
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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
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Deep Layer – forearm LAB
Pronator quadratus Deepest muscle of anterior
forearm Sometimes considered fourth
layer Median (anterior
interosseous) C8, T1
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Posterior muscle of the forearm
Superficial layer
Deep layer and Outcropping muscles of deep layer
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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
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Superficial LAB
Extensor carpi radialis longus
Extensor carpi radialis brevis
Extend and abduct wrist
Radial nerve C6, C7
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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)
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Deep Layer LAB
Supinator Prime supinator with arm
extended Radial (deep branch)
Extensor indicis Independent extensor of 2nd
finger Radial C7, C8 – (PI)
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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
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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
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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
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Intrinsic muscle of the hand
Thenar muscle Opposes thumb
Median nerve C8, T1
Adductor pollicis Ulnar nerve C8, T1
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Intrinsic muscle of the hand
Hypothenar muscle Abductor digiti
minimi Flexor digiti minimi Opponens digiti
minimi
Ulnar nerve C8, T1
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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
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Arteries of forearm and hand
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Nerves of the hand
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Nerves of the hand
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Shoulder Joint
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Rotator Cuff
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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.
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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