clinical anatomy of the upper limb
DESCRIPTION
Clinical anatomy of the upper limb. Kaan Yücel M.D., Ph.D . 20.March.2012 Tuesday. CLINICAL ANATOMY OF THE AXILLA. Enlargement of Axillary Lymph Nodes. Lymphangitis ( inflammation of lymphatic vessels ) Cause : An infection in the upper limb - PowerPoint PPT PresentationTRANSCRIPT
CLINICAL ANATOMY OF THEUPPER LIMB
Kaan Yücel M.D., Ph.D. 20.March.2012 Tuesday
CLINICAL ANATOMY OF THEAXILLA
Enlargement of Axillary Lymph NodesLymphangitis (inflammation of lymphatic vessels)Cause: An infection in the upper limbHumeral group – first to be involved
Enlargement of Axillary Lymph Nodes
Metastatic cancer of the apical group
adhere to axillary vein
excision of part of the axillary vein
Enlargement of the apical nodes
obstruction of the cephalic vein
superior to pectoralis minor
Enlargement of Axillary Lymph Nodes
Arterial Innervation and Raynaud’s Diseaseo The arteries of the upper limb are
innervated by sympathetic nerves through the brachial plexus.
o Vasospastic diseases involving digital arterioles, such as Raynaud’s disease, may require a cervicodorsal preganglionic sympathectomy to prevent necrosis of the fingers.
o The operation is followed by arterial vasodilatation, with consequent increased blood flow to the upper limb.
Aneurysm of Axillary ArteryThe first part of the axillary artery may enlarge (aneurysm of the axillary artery) and compress the trunks of the brachial plexus, causing pain and anesthesia (loss of sensation) in the areas of the skin supplied by the affected nerves.
Spontaneous Thrombosis of the Axillary VeinSpontaneous thrombosis of the axillary vein occasionally occurs after excessive and unaccustomed movements of the arm at the shoulder joint.
CLINICAL ANATOMY OF THEBRACHIAL PLEXUS
Dermatomes and Cutaneous Nerves of the Upper Limb
Checking the integrity of the spinal cord segments on the skin
Dermatome: Skin area supplied by a spinal segment
C3-C6 lateral margin of the limbC7 middle fingerC8-T2 medial margin of the limb
Shoulder PainThe skin over the point of the shoulder and halfway down the lateral surface of the deltoid muscle is supplied by the supraclavicular nerves (C3 and 4)
The afferent stimuli reach the spinal cord via the phrenic nerves (C3, 4, and 5).
Differential diagnosis time Inflammatory lesions involving the diaphragmatic
pleura or peritoneum Pleurisy Peritonitis Subphrenic abscess Gallbladder disease
Brachial Plexus InjuriesComplete lesions involving all the roots of the plexus are rare.
Incomplete injuries are common and are usually caused by traction or pressure; individual nerves can be divided by stab wounds.
Upper Lesions of the Brachial Plexus (Erb-Duchenne Palsy)
Excessive displacement of the head to the opposite side & depression of the shoulder on the same side.
Result-Excessive traction or even tearing of C5 and 6 roots
Infants during a difficult delivery In adults after a blow to or fall on the shoulder
The actor Martin Sheen, however, is on record as mentioning a birth accident in which forceps "mangled" his shoulder.
shoulder dystocia
Nerves derived from C5 & C6 roots affected Suprascapular nerve Nerve to the subclaviusMusculocutaneous nerve Axillary nerve
Muscles paralyzed
• Supraspinatus (abductor of the shoulder) • Infraspinatus (lateral rotator of the shoulder)• Subclavius (depresses the clavicle)• Biceps brachii (supinator of the forearm, flexor of the
elbow, weak flexor of the shoulder)• Greater part of the brachialis (flexor of the elbow)• Coracobrachialis (flexor of the shoulder)• Deltoid (abductor of the shoulder) • Teres minor (lateral rotator of the shoulder)
Limb hanging by the side
Medially rotated [unopposed sternocostal part of pectoralis major]
Forearm pronated loss of biceps brachii action
Waiter’s tip position
Loss of sensation down the lateral side of the arm
Lower Lesions of the Brachial Plexus (Klumpke Palsy)Usually traction injuries caused by excessive abduction of the arm
First thoracic nerveMedian & ulnar nerves
Hand- Clawed appearance Hyperextension of metacarpophalangeal joints
Flexion of interphalangeal joints
Loss of sensation medial side of the armC8 nerve damaged, medial side of the forearm, hand, and medial two fingers.
Long Thoracic Nerve Injuries
Serratus anterior muscle
Blows to or pressure on the posterior triangle of the neck
During the surgical procedure of radical mastectomy
Difficulty in raising the arm above the head.
Winged scapulaThe vertebral border & inferior angle of the scapula will no longer be kept closely applied to the chest wall and will protrude posteriorly
Axillary Nerve Injuries
Posterior cord of the brachial plexus (C5 & 6)
Pressure of a badly adjusted crutch pressing upward into the armpit
Vulnerable @ quadrangular space Downward displacement of the humeral head in shoulder dislocations
Fractures of the surgical neck of the humerus
Axillary Nerve InjuriesDeltoid & teres minor paralysis
Loss of skin sensation over the lower half of the deltoid muscle
Radial Nerve Injuries@Axilla• Badly fitting crutch pressing up into
the armpit • Drunkard falling asleep with one arm
over the back of a chair• Fractures and dislocations of the
proximal end of the humerus MotorTriceps,anconeus, extensors of the wrist paralyzyedNo extension of elbow, wrist & fingers Wristdrop- flexion of the wrist
Supination ok intact biceps brachii (musculocutaneous nerve)
Radial Nerve Injuries @ AxillaSensory
A small loss of skin sensationDown posterior surface of lower part of the arm Down a narrow strip on the back of the forearmVariable area of sensory loss on the lateral part of the dorsum of the hand &on the dorsal surface of the roots of the lateral 3 ½ fingers.
Area of total anesthesia relatively small
because of the overlap of sensory innervation by adjacent nerves
Radial Nerve Injuries @ Spiral Groove of Humerus
Fracture of the shaft of the humerus
The pressure of the back of the arm on the edge of the operating table
Most common@ distal part of the groove
MotorWristdrop
SensoryVariable small area of anesthesia over the dorsal surface of the hand & dorsal surface of the roots of 3 ½ fingers
Radial Tunnel Syndromeo Tenderness & pain the forearm just below the elbow
oWatch out for lateral epicondylitis (tennis elbow)
o Differential diagnosis made on history & physical exam
oThe difference between these two conditions: where the elbow is most tender
oLateral to the elbow the radial nerve travels below the supinator muscle
Tennis Elbow (Lateral epicondiylitis)o Small area of chronic pain @ lateral
elbow
o Pain on wrist extension, pain when shaking hands, weakened grip
o More common 30 -50 yrs of age
o Many conditions for the cause; not only tennis
o Repeated use of of the forearm extensor muscles
extensor carpi radialis brevis lateral epicondyle to 2nd metacarpal
Injuries to the Deep Branch of the Radial Nerve
Motor nerve to the extensor muscles in the posterior compartment of the forearm
Fractures of the proximal end of the radius Dislocation of the radial head
Supinator (posterior interosseus nerve continuation of deep branch) & extensor carpi radialis longus (radial nerve) undamaged, and because the latter muscle is powerful, it will keep the wrist joint extended, and wristdrop will not occur.
No sensory loss- Motor nerve
Injuries to the Superficial Radial NerveSensory As in a stab wound;A variable small area of anesthesia over the dorsum of the hand & dorsal surface of the roots of the lateral 3 ½ fingers
Musculocutaneous Nerve Injurieso Rarely injured
o Protected beneath the biceps brachii muscle
o Injured high up in the arm;o Biceps & coracobrachialis paralyzed
brachialis muscle is weakened (also supplied by radial nerve).
o Flexion of the forearm at the elbow produced by the remainder of the brachialis & flexors of the forearm.
Musculocutaneous Nerve InjuriesSensory loss along the lateral side of the forearm
lateral cutaneous nerve of the forearmcontinuation of the musculocutaneous nerve beyond the cubital fossa
Median Nerve Injuries
Occasionally in the elbow in supracondylar fractures of the humerus
Most commonly injured by stab wounds or broken glass proximal to the flexor retinaculum:
Here it lies in the interval between the flexor carpi radialis & flexor digitorum superficialis tendons, overlapped by the palmaris longus.
Median Nerve Injuries @ the ElbowMotoro Pronator muscles of the forearm o Long flexor muscles of the wrist &
fingers paralyzed
Exceptionflexor carpi ulnaris & medial half of flexor digitorum profundus
Forearm in supine position; weak wrist flexion accompanied by adduction
No flexion @ interphalangeal joints of the index & middle fingers
Median nerve innervates:Most of the muscles in the anterior compartment of the forearm (except for the flexor carpi ulnaris muscle and the medial half of the flexor digitorum profundus muscle)
In the handThree thenar muscles associated with the thumbTwo lateral lumbrical muscles associated with movement of the index and middle fingers
Flex metacarpophalangeal joints & extend interphalangeal joints Skin over the palmar surface of the lateral 3 ½ digits and over the lateral side of the palm and middle of the wrist.
L
Median Nerve Injuries @ the ElbowAsk the patient to make a fisto Index finger, lesser extent
middle finger straighto Ring & little fingers flexo No flexion @ thumb’s terminal
phalanx flexor pollicis longus paralysis
Thenar eminence flattened thenar muscles wasted
Thumb laterally rotated & adducted
Hand flattened«ape-like» hand
Orator’s hand posture
Median Nerve Injuries @ the ElbowSensorySkin sensation loss Lateral half or less of the palm of the hand Palmar aspect of lateral 3 ½ fingers Vasomotor ChangesWarmer & drier skin arteriolar dilatation and absence of sweating resulting from loss of sympathetic control
Trophic ChangesDry skin and scalyNails crack easilyAtrophy of the pulp of the fingers
Median Nerve Injuries @ the WristMotor Thenar muscles paralyzedThenar eminence flattenedThumb laterally rotated & adductedNo opposition of the thumb
«ape-like» hand
First two lumbricals paralyzed
When the patient is asked to make a fist slowly, index & middle fingers tend to lag behind the ring & little fingers.
Median Nerve Injuries
Perhaps most serious disability of all in median nerve injuries :
Loss of ability to oppose the thumb to the other fingers Loss of sensation over the lateral fingers
Delicate pincer-like action of the hand is no longer possible.
Ulnar Nerve Injuries
Most commonly injured at the elbow where it lies behind the medial epicondyleusually associated with fractures of the medial epicondyle
Most commonly injured at the wristwhere it lies with ulnar artery in front of flexor retinaculum
Ulnar nerve innervates:Flexor carpi ulnaris muscle & medial half of the flexor digitorum profundus muscle
All intrinsic muscles of the hand (except for the three thenar muscles and the two lateral lumbrical muscles)
Skin over the palmar surface of the little finger, medial half of the ring finger, and associated palm and wrist, and the skin over the dorsal surface of the medial part of the hand
Ulnar Nerve Injuries @ the Elbow
MotorFlexor carpi ulnaris & medial half of the flexor digitorum profundus paralyzed
ASK YOUR PATIENT TO MAKE A FIST
o No observation/thightening of the flexor carpi ulnaris tendon passing to the pisiform bone o No fxn of the profundus tendonsNo flexion of ring & little fingers’ terminal phalanges
Flexion of the wrist joint will result in abduction, owing to paralysis of the
flexor carpi ulnaris.
Ulnar Nerve Injuries @ the ElbowMedial border of the front of the forearm flattens
wasting of underlying ulnaris & profundus muscles
Small muscles of the hand paralyzed except thenar muscles & first 2 lumbricals -median nerve-
Ulnar Nerve Injuries @ the ElbowUnable to grip a piece of paper placed between the fingers
No adduction & abduction of fingers
No adduct the thumbParalyzed adductor pollicis
Extensor digitorum abduct fingers to a small extent, when metacarpophalangeal joints hyperextended
FROMENT’S SIGNAsk your patient to grip a piece of paper between the thumb & index finger:S/he does so by strongly contracting flexor pollicis longus & flexing the terminal phalanx
Ulnar Nerve Injuries @ the Elbow
Metacarpophalangeal joints hyperextended
Interphalangeal joints flexed
Lumbrical & interosseous muscles paralysis4th & 5th fingers
Ulnar Nerve Injuries @ the Elbow In longstanding cases the hand
assumes the characteristic “claw” deformity (Main en griffe).
Flattening of the hypothenar eminence
Loss of the convex curve to the medial border of the hand
Examination of the dorsum of the hand:
Hollowing between the metacarpal bones caused by wasting of the dorsal interosseous muscles.
Ulnar Nerve Injuries @ the ElbowSensoryLoss of skin sensation o Anterior & posterior surfaces of the medial
third of the hand
o Medial 1 ½ fingers
Vasomotor ChangesWarmer and drier skin
arteriolar dilatation & absence of sweating resulting from loss of sympathetic control
Ulnar Nerve Injuries @ the WristMotor Small muscles of the hand-except thenar & first 2 lumbricalsClawhand more obvious
flexor digitorum profundus not paralyzed, marked flexion of terminal phalanges
Ulnar Nerve Injuries @ the WristSensory
Main ulnar nerve & its palmar cutaneous branch usually severed Posterior cutaneous branch, arises from the ulnar nerve trunk about 2.5 in. (6.25 cm) above the pisiform bone usually unaffected
Sensory loss confined to o Palmar surface of medial 1/3 of the hand o Medial 1 ½ fingers o Dorsal aspects of middle & distal phalanges of the same fingers
Ulnar Nerve Injurieso With ulnar nerve injuries, the higher the lesion is the less obvious is the clawing deformity of the hand.
o Unlike median nerve injuries, lesions of the ulnar nerve leave a relatively efficient hand. Sensation over the lateral part of the hand is intact, pincer-like action of the thumb and index finger is reasonably good, although there is some weakness, owing to loss of the adductor pollicis.
CLINICAL ANATOMY OF THESHOULDER
Compression of axillary nerve & posterior circumflex humeral artery @ quadrilateral space o Downward displacement of the humeral head in shoulder
dislocations o Fractures of the surgical neck of the humerus Deltoid & teres minor paralysisLoss of skin sensation lower half of deltoid muscle
Quadrangular Space Syndrome
Excessive overhead activity of the upper limb may be the cause of tendinitis, although many cases appear spontaneously.
Rotator Cuff Tendinitis
Stabilizing the shoulder joint
Common cause of pain in the shoulder
Subacromial bursa-Supraspinatus
Good for the ease of friction during abduction of the shoulder
Subacromial bursitis, supraspinatus tendinitis, or pericapsulitis
Characterized by the presence of a spasm of pain in the middle range of abduction, when the diseased area impinges on the acromion.
Rotator Cuff Tendinitis
Rupture of the Supraspinatus Tendono In advanced cases of rotator cuff tendinitis, the necrotic
supraspinatus tendon can become calcified or rupture.
o Inability to initiate abduction of the arm
o However, if the arm is passively assisted for the first 15° of abduction, the deltoid can then take over and complete the movement to a right angle.
CLINICAL ANATOMY OF THEFOREARM & HAND
o Important clinically
o Even with a complete lesion of the median nerve, some muscles may not be paralyzed.
o Erroneous conclusion that the median nerve has not been damaged.
Communications Between Median & Ulnar Nerves
The common place:o Where radial artery lies on the anterior surface of distal end of the radius, proximal to the wrist, between flexor carpi radialis & brachioradialis tendons. o Here the artery is covered by only fascia and skin.
Measuring Pulse Rate
o Anatomical snuff box between extensor pollicus longus & brevis.
For straightforward blood testsMedian cubital vein
Cephalic vein for short-term intravenous cannula
Venipuncture
Why an important clinical region?
1) Palpating the scaphoid bone to asses a fracture – when hand is in ulnar deviation
2) Pulse of the radial artery
Anatomical snuffbox
Lateral border Abductor pollicis longus &Extensor pollicis brevis tendons
Medial borderExtensor pollicis longus tendon
Floor Scaphoid & trapezium, distal ends of the extensor carpi radialis longus &extensor carpi radialis brevis tendons
Radial artery passes via anatomical snuffbox, deep to extensor tendons of the thumb adjacent to scaphoid & trapezium
Anatomical snuffbox
Peripheral mono-neuropathy of the upper limbCompression of the median nerve as it passes through the carpal tunnel into wrist
Lies immediately beneath palmaris longus tendon and anterior to the flexor tendons
Carpal tunnel syndrome
Conditions Diabetes mellitusRheumatoid arthritisAcromegalyHypothyroidismPregnancy Tenosynovitis
Gradual onset of numbness and tingling in the median nerve
distribution of the hand
CLINICAL ANATOMY OF THEPECTORAL REGION
& MAMMARY GLANDS
Breast Quadrants
For the anatomical location and description of tumors and cysts, the surface of the breast is divided into four quadrants.
Mammography o Radiographic examination of the
breasts, mammography, is one of the techniques used to detect breast masses.
o A carcinoma appears as a large, jagged density in the mammogram.
o Surgeons use mammography as a guide when removing breast tumors, cysts, and abscesses.
Mastectomy –breast excision-
Simple mastectomy
Breast is removed down to the retromammary space.
Radical mastectomyMore extensive surgical procedure
Removal of the breast, pectoral muscles, fat, fascia, and as many lymph nodes as possible in the axilla and pectoral region.
Gynecomastia Breast hypertrophy in males after puberty
Relatively rare (<1%) • Age or drug related • Imbalance between estrogenic and androgenic hormones • A change in the metabolism of sex hormones by the liverRule out important potential causes, e.g. suprarenal or testicular cancers
Polymastia (supernumerary breasts) Only a rudimentary nipple & areola mistaken for a mole (nevus)Polythelia (accessory nipples)
AmastiaNo breast development
@ Axillary fossa or anterior abdominal wall
Extra breasts along a line from axilla to groinembryonic mammary crest milk line
CLINICAL ANATOMY OF THESUPERFICIAL MUSCLES
OF THE BACK
Site on the back where breath sounds may be most easily heard with a stethoscope
Auscultatory Triangle
Boundaries
Latissimus dorsi TrapeziusMedial border of the scapula
Levator scapulae connects the neck and shoulder
Pain when trying to turn the head to the side where it hurts, often turning the body instead of the neck to look behind Common causes• Turning the head to one side while
typing• Long phone calls without a headset• Sleeping without proper pillow
support with the neck tilted or rotated• Activities such as vigorous tennis,
swimming the crawl stroke
Stiff Neck