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Organization of the Upper LimbOrganization of the Upper LimbAudrone Biknevicius, Ph.D.
Dept. Biomedical Sciences, OU HCOM at DublinClinical Anatomy Immersion 2014
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“Anatomical Tool-Kit”
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Week 5
RULE #1Limbs are outgrowths of the ventral body wall that undergo distal growth and differentiation…
Week 7
and rotation
[More detailed limb embryology in MS course]
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The upper limbs are innervated by :
A. Dorsal rami of spinal nn.
B. Ventral rami of spinal nn.
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50% 50%
Dorsal rami of spinal nn. Ventral rami of spinal nn.
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Developmentally-dorsal limb mm.
Developmentally-ventral limb mm.
Primitive Pectoral Limb
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DEVELOPMENTAL/EVOLUTIONARY BASIS
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• 90◦ lateral rotation (forearm mm. undergo incomplete rotation)
• Limb adduction6
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DEVELOPMENTAL/EVOLUTIONARY BASIS
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*
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Developmentally-ventral muscles:• Lie anterior to the long bones in anatomical position
Developmentally-dorsal muscles: • Lie posterior to the long bones in anatomical position (* exceptions)
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RULE #2A: Ventral vs. dorsal limb mm.
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Anterior
Humerus
Posterior
Radius
Anterior
Posterior
5th metacarpal
Anterior
FOREARM
HAND
ARM
Ulnar
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Upper LimbMuscle
Compartments
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Anterior
Humerus
Posterior
Radius
Anterior
Posterior
5th metacarpal
Anterior
FOREARM
HAND
ARM
Ulnar
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No posterior compartment in the hand
Some posterior compartment mm. are found on the anterolateral aspect of the forearm (*brachioradialis, supinator)
*
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Spinal nerveDorsal primary ramusVentral primary ramus (C5-T1)
Anterior division
Posterior division
limb axis
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RULE #2B: Innervation of anterior vs. posterior compartment mm.
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Brachial Plexus(right side; simplified)
Terminal Branches
“Roots of BP” (=ventral rami)
C5
C6
C7
C8
T1
Trunks
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Cord
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PostPost
Med
Divisions
Anterior (ventral) division
Posterior (dorsal) division
“Randy Travis Drinks Cold Beer”
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Brachial Plexus(right side; simplified)
Terminal Branches
“Roots of BP” (=ventral rami)
C5
C6
C7
C8
T1
Trunks
U
M
L
Cord
Lat
PostPost
Med
Divisions
Anterior (ventral) division
Posterior (dorsal) division 12
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Radial n.
Musculocutaneous n.
Median n.
Ulnar n.
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AnteriorMusculocutaneous n.
Humerus
Radial n.
UlnaRadius
Median n. & Ulnar n.
Radial n.
5th metacarpal
Ulnar n. & Median n.
Anterior
Anterior
Posterior
Posterior
Posterior
MOTOR INNERVATION
Muscle Compartments of the Upper Limb
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Musculocutaneous Nerve (arm)
http://emedicine.medscape.com/article/1877731-overview#aw2aab6b3
All mm. in anterior (flexor) compartment of arm
MRI of arm1.Biceps brachii m. 2.Brachialis m. 3.Brachial a. 4.Humerus. 5.Triceps brachii m.
www.med.umich.edu
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Radial Nerve (arm)
All mm. in posterior (extensor) compartment of arm
http://emedicine.medscape.com/article/1877731-overview#aw2aab6b3
Radial nerve
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The brachialis m. is innervated by which division of the brachial plexus: :
A. Anterior division B. Posterior division
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50%50%
Anterior division Posterior division
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The brachialis m. is innervated by:
A. Median n.B. Musculocutaneous n. C. Radial n.D. Ulnar n.
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25%
Median n. Musculocutaneous n. Radial n. Ulnar n.
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The triceps brachii m. is innervated by:A. Musculocutaneous n. B. Radial n.
50%50%
Musculocutaneous n. Radial n.
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Radial Nerve (forearm)
All mm. in posterior (extensor) compartment of forearmAlso * brachioradialis and supinator mm.
http://emedicine.medscape.com/article/1877731-overview#aw2aab6b3
*
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Ulnar Nerve (forearm)
Limited mm. in anterior (flexor) compartment of forearm:-Flexor carpi ulnaris-Flexor digitorum profundus (medial ½)
http://emedicine.medscape.com/article/1877731-overview#aw2aab6b3
Med 1/2
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Median Nerve (forearm)
All anterior (flexor) compartment mm. of forearm except:-Flexor carpi ulnaris m.-Flexor digitorum profundus m. (med ½)
http://emedicine.medscape.com/article/1877731-overview#aw2aab6b3
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RULE #2C
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The extensor digitorum m. lies in the posterior compartment, originates on the lateral epicondyle, and is innervated by:A. Median n.B. Musculocutaneous n. C. Radial n.D. Ulnar n.
25%
25%25%
25%
Median n. Musculocutaneous n. Radial n. Ulnar n.
Lateral epicondyle
Extensor digitorum m.
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“Be specific”
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The flexor carpi radialis m. is in the anterior compartment, attaches to the medial epicondyle, and is innervated by:
A. Median n.B. Radial n.C. Ulnar n.
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33%
33%
Median n. Radial n. Ulnar n.
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The flexor digitorum profundus m. is the anterior compartment, attaches to the medial epicondyle, and is innervated by:A. Median n.B. Median n. & Ulnar n. C. Ulnar n.
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33%
33%
33%
Median n. Median n. & Ulnar n. Ulnar n.
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The brachioradialis and supinator mm. lie in the anterior aspect of the forearm but attach to the lateral epicondyle of the humerus. They are innervated by:A. Median n.B. Radial n. C. Ulnar n.
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33%
33%
33%
Median n. Radial n. Ulnar n.
www.pelhamrehab.com
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Median Nerve (hand)
Limited hand mm.:-Thenar mm.-Lateral two lumbricals
http://emedicine.medscape.com/article/1877731-overview#aw2aab6b3
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Ulnar Nerve (hand)
All hand mm. not innervated by median n.
http://emedicine.medscape.com/article/1877731-overview#aw2aab6b3
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What about the most proximal muscles of the upper limb?
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*
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Developmentally-dorsal muscles: •Lie posterior to the long bones in anatomical position (* exception = brachioradialis, supinator)
Developmentally-ventral muscles:•Lie anterior to the long bones in anatomical position-or-•Arise from:
– coracoid ossification – sternum and costal cartilages
-or-•Arise from:
– scapular blade ossification– vertebral column
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RULE #2D
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Given the attachments of the latissimus dorsi muscle, its innervation will be from which of division of the brachial plexus:
A. Anterior division B. Posterior division
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Anterior division Posterior division
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C5
C7
C6
C8
T1
**
*
suprascapular n.supraspinatus & infraspinatus mm.
axillary n.
deltoid & teres minor mm.
upper subscapular n.thoracodorsal n.lower subscapular n.
subscapularis m.latissimus dorsi m.subscapularis & teres major mm.
Brachial Plexus(branches)
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Given the attachments of the pectoralis muscles muscle, its innervation will be from which of division of the brachial plexus:
A. Anterior division B. Posterior division
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Anterior division Posterior division
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C5
C7
C6
C8
T1
radial n.
axillary n.
medial n.
musculoskeletal n.
suprascapular n.
upper subscapular n.thoracodorsal n.lower subscapular n.
medial pectoral n.
lateral pectoral n.
long thoracic n.
dorsal scapular n.
**
*
ulnar n.
rhomboid mm.
pectoralis mm.
pectoralis mm.
serratus anterior m.
Brachial Plexus(branches)
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posterior anterior
Upper “roots” of the brachial plexus (C5-6 ventral rami) innervate proximal muscles (shoulder, elbow)
Lower “roots” of the brachial plexus (C8-T1 ventral rami) innervate distal muscles (hand)
RULE #3 Proximal-to-Distal Rule
Somatic motor nerve(GSE, with GSA)
Cutaneous nerves(GSA, GVE, GVA)
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MYOTOME- group of muscles innervated by a single spinal nerve root
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C5
C7
C6
C8
T1
Radial n.
Axillary n.
Medial n.
Musculoskeletal n.
Suprascapular n.
Upper & lower subscapular nn.Thoracodorsal n.
Medial pectoral n.
Lateral pectoral n.
Long thoracic n.
Dorsal scapular n.
**
*
Ulnar n.
Brachial Plexus(all branches)
* Nerve to subclavius** Medial brachial & antebrachial cutaneous nn. 39
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“MIXED FUNCTIONAL MODALITIES”
Most terminal branches of the brachial plexus are mixed fiber nerves:
1.Somatic motor and somatic sensory (prioprioception) to skeletal mm.
2.Then, cutaneous innervation with somatic sensory and sympathetics to skin
posterior anterior
RULE #3
Somatic motor nerve(GSE, with GSA)
Cutaneous nerves(GSA, GVE, GVA)
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Some purely cutaneous brs. of brachial plexusTank e
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Segmental innervation(C5-T1)
Dermatomes
RULE #5: Dermatome vs. Cutaneous Nerve Distribution
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Foerster (1933) – based on clinical findings (used by neurologists)
Keegan and Garrett (1948) – based on limb development
Segmental (Dermatome) Innervation of Upper LimbM
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Preaxial: C5-C7
Postaxial: C8-T1
Segmental (Dermatome) Innervation of Upper LimbM
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Thumb: C6
3rd Digit: C7
5th Digit: C8
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Dermatomes vs. Cutaneous Nerve Distribution
Terminalbranches
Cutaneous nn.
Segmental innervation(C5-T1)
Dermatomes
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Anterior Posterior47
Peripheral (Cutaneous ) Innervation of Upper LimbM
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U
M
R
Test for Peripheral Nerve Sensory Function:
Ulnar n. – Tip of 5th digit (little finger)Median n. – Tip of 2nd digit (index finger)
Radial n. – Webbing b/w thumb & index finger (dorsum)
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M
U
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C6
C7
C8
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Stretch Reflex
apbrwww5.apsu.edu/
Reciprocal inhibition of antagonist muscles
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Bicipital reflex (C6 cord level) Triceps reflex (C7 cord level)
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Stretch Reflex
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IVD Root Sensory Loss Motor WeaknessC4-C5 C5 Shoulder Shoulder weakness
C5-C6 C6 Anterior upper arm, Forearm flexion
Lateral forearm, thumb Biceps reflex
C6-C7 C7 3rd digits Forearm extension Triceps reflex
Wrist extension Hand grip
C7-C8 C8 5th digits Wrist flexionMedial forearm Intrinsic
hand mm.
Source: Devinsky et al. Neurologic Pearls
UPPER LIMB RADICULAR SYNDROMES
Proximal
Distal
Cranial
Caudal