1. Anatomy for Health Care Professionals NUR469: Lecture 2 September 14, 2009
Curtis L. Whitehair, MD
Georgetown University
School of Nursing & Health Studies
Graduate Program

2. Upper Arterial Supply LAB

4. Veins

5. Brachial Plexus
Robert Taylor Drinks Cold Beer

6. Brachial Plexus

9. Brachial Plexus Injuries
Shoulder Adducted
Medially rotated arm
Extend Elbow
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.

10. 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.

11. 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.

12. 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)

13. Anterior muscles of the Arm

14. 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

15. 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

16. Rupture of the Tendon usually long head, rare distally.

17. Brachialis LAB Musculocutaneous C5, C6
Flexes forearm all positions – not effected by position
MAIN flexor of the forearm

18. Coracobrachialis LAB Musculocutaneous C5, C6, C7 Flexes arm
Helps arm adduction
Stabilizes glenohumeral joint from inferior dislocation
Carrying suitcase

19. Posterior muscles of the Arm

20. 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

21. Anconeus
Radial C7, C8, T1
Tenses the capsule of the elbow joint preventing its being pinched during extension.

22. Muscles of the forearm flexor
The flexors are arranged in three layers
Superficial layer
4 muscles
Crosses elbow
Intermediate layer
1 muscle
Deep layer
3 muscles
Crosses wrist and phalanges

23. Superficial Layer – forearm LAB
Pronator Teres
Median nerve C6, C7
pronates forearm
medial boarder cubital fossa

24. Superficial Layer – forearm LAB
Flexor carpi radialis
Median nerve C6, C7
Flexes wrist
Helps abducts wrist

25. 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

26. Superficial Layer – forearm LAB
Flexor Carpi Ulnaris
Most medial flexor
Flexes and adducts the wrist if acting alone
Ulnar C7, C8

27. 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

29. 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

30. Deep Layer – forearm LAB
Pronator quadratus
Deepest muscle of anterior forearm
Sometimes considered fourth layer
Median (anterior interosseous) C8, T1

31. Posterior muscle of the forearm
Superficial layer
Deep layer and Outcropping muscles of deep layer

32. 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

33. Superficial LAB Extensor carpi radialis longus
Extensor carpi radialis brevis
Extend and abduct wrist
Radial nerve C6, C7

34. Superficial LAB Extensor digitorum Extensor digiti minimi
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)

35. Deep Layer LAB Supinator Extensor indicis
Prime supinator with arm extended
Radial (deep branch)
Extensor indicis
Independent extensor of 2nd finger
Radial C7, C8 – (PI)

36. 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

37. 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

38. 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

39. Intrinsic muscle of the hand
Thenar muscle
Opposes thumb
Median nerve C8, T1
Adductor pollicis
Ulnar nerve C8, T1

40. Intrinsic muscle of the hand
Hypothenar muscle
Abductor digiti minimi
Flexor digiti minimi
Opponens digiti minimi
Ulnar nerve C8, T1

41. 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

42. Arteries of forearm and hand

43. Nerves of the hand

44. Nerves of the hand

45. Shoulder Joint

46. Rotator Cuff

47. 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.

48. Next Week Should know Great to know Must know Fig 5.15 – Pectinues
Adductor brevis
Superior gemellus
Obturator internus
Inferior gemellus
Obturator externus
Great to know
Table 5.1
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