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Organization of the Upper Limb
d-etre.blogspot.com Organization of the Upper Limb Audrone Biknevicius, Ph.D. Dept. Biomedical Sciences, OU HCOM at Dublin Clinical Anatomy Immersion 2014
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“Anatomical Tool-Kit”
virtuallaboratory.colorado.edu www2.warwick.ac.uk
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Week 7 and rotation [More detailed limb embryology in MS course] Week 5 RULE #1 Limbs are outgrowths of the ventral body wall that undergo distal growth and differentiation…
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The upper limbs are innervated by :
Dorsal rami of spinal nn. Ventral rami of spinal nn.
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Primitive Pectoral Limb
DEVELOPMENTAL/EVOLUTIONARY BASIS Developmentally-dorsal limb mm. Developmentally-ventral limb mm. Primitive Pectoral Limb Stern Essential of Gross Anatomy
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DEVELOPMENTAL/EVOLUTIONARY BASIS
90◦ lateral rotation (forearm mm. undergo incomplete rotation) Limb adduction Stern Essential of Gross Anatomy
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* RULE #2A: Ventral vs. dorsal limb mm.
Developmentally-dorsal muscles: Lie posterior to the long bones in anatomical position (* exceptions) Developmentally-ventral muscles: Lie anterior to the long bones in anatomical position Stern Essential of Gross Anatomy
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Upper Limb Muscle Compartments
Anterior Humerus Posterior Radius 5th metacarpal FOREARM HAND ARM Ulnar Upper Limb Muscle Compartments Stern Essential of Gross Anatomy
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* ARM FOREARM HAND Anterior Humerus Posterior
Radius 5th metacarpal FOREARM HAND ARM Ulnar Some posterior compartment mm. are found on the anterolateral aspect of the forearm (*brachioradialis, supinator) * Stern Essential of Gross Anatomy No posterior compartment in the hand
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RULE #2B: Innervation of anterior vs. posterior compartment mm.
Spinal nerve Dorsal primary ramus Ventral primary ramus (C5-T1) Anterior division Posterior division limb axis Stern Essential of Gross Anatomy
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(right side; simplified)
“Roots of BP” (=ventral rami) C5 C6 C7 C8 T1 Brachial Plexus (right side; simplified) Trunks U M L “Randy Travis Drinks Cold Beer” Divisions Anterior (ventral) division Posterior (dorsal) division Cord Lat Post Med Terminal Branches Stern Essential of Gross Anatomy
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(right side; simplified)
“Roots of BP” (=ventral rami) C5 C6 C7 C8 T1 Brachial Plexus (right side; simplified) Trunks U M L Divisions Anterior (ventral) division Posterior (dorsal) division Cord Lat Post Med Terminal Branches Musculocutaneous n. Median n. Ulnar n. Radial n. Stern Essential of Gross Anatomy
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Muscle Compartments of the Upper Limb
Anterior Musculocutaneous n. Humerus Radial n. Ulna Radius Median n. & Ulnar n. 5th metacarpal Ulnar n. & Median n. Posterior MOTOR INNERVATION Muscle Compartments of the Upper Limb Stern Essential of Gross Anatomy
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Musculocutaneous Nerve (arm)
All mm. in anterior (flexor) compartment of arm MRI of arm Biceps brachii m. Brachialis m. Brachial a. Humerus. Triceps brachii m.
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Radial Nerve (arm) All mm. in posterior (extensor) compartment of arm
BB B TLong TLat TMed
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The brachialis m. is innervated by which division of the brachial plexus: :
Anterior division Posterior division
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The brachialis m. is innervated by:
Median n. Musculocutaneous n. Radial n. Ulnar n.
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The triceps brachii m. is innervated by:
Musculocutaneous n. Radial n.
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Radial Nerve (forearm)
All mm. in posterior (extensor) compartment of forearm Also * brachioradialis and supinator mm. *
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Ulnar Nerve (forearm) Limited mm. in anterior (flexor) compartment of forearm: Flexor carpi ulnaris Flexor digitorum profundus (medial ½) 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) en.wikipedia.org
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RULE #2C
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The extensor digitorum m
The extensor digitorum m. lies in the posterior compartment, originates on the lateral epicondyle, and is innervated by: Median n. Musculocutaneous n. Radial n. Ulnar n. Lateral epicondyle Extensor digitorum m.
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“Be specific” thepainsource.com
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The flexor carpi radialis m
The flexor carpi radialis m. is in the anterior compartment, attaches to the medial epicondyle, and is innervated by: Median n. Radial n. Ulnar n.
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The flexor digitorum profundus m
The flexor digitorum profundus m. is the anterior compartment, attaches to the medial epicondyle, and is innervated by: Median n. Median n. & Ulnar n. Ulnar n. healthfavo.com
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The brachioradialis and supinator mm
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: Median n. Radial n. Ulnar n.
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Median Nerve (hand) Limited hand mm.: Thenar mm.
Lateral two lumbricals
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Ulnar Nerve (hand) All hand mm. not innervated by median n. cnx.org
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What about the most proximal muscles of the upper limb?
medicine.academic.ru
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RULE #2D * Developmentally-dorsal muscles:
Lie posterior to the long bones in anatomical position (* exception = brachioradialis, supinator) -or- Arise from: scapular blade ossification vertebral column Developmentally-ventral muscles: Lie anterior to the long bones in anatomical position -or- Arise from: coracoid ossification sternum and costal cartilages * Stern Essential of Gross Anatomy
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Given the attachments of the latissimus dorsi muscle, its innervation will be from which of division of the brachial plexus: Anterior division Posterior division blog.corewalking.com
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Brachial Plexus (branches) C5 C6 C7 C8 T1 supraspinatus
suprascapular n. supraspinatus & infraspinatus mm. * ** upper subscapular n. thoracodorsal n. lower subscapular n. subscapularis m. latissimus dorsi m. subscapularis & teres major mm. Stern Essential of Gross Anatomy axillary n. deltoid & teres minor mm.
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Given the attachments of the pectoralis muscles muscle, its innervation will be from which of division of the brachial plexus: Anterior division Posterior division
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Brachial Plexus (branches) C5 C6 C7 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. serratus anterior m. Stern Essential of Gross Anatomy
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RULE #3 Proximal-to-Distal Rule
posterior anterior RULE #3 Proximal-to-Distal Rule 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) Somatic motor nerve (GSE, with GSA) Cutaneous nerves (GSA, GVE, GVA)
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- group of muscles innervated by a single spinal nerve root
MYOTOME - group of muscles innervated by a single spinal nerve root sciartmag.blogspot.com
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Brachial Plexus (all branches) C5 C6 C7 * C8 T1 ** Dorsal scapular n.
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) Stern Essential of Gross Anatomy * Nerve to subclavius ** Medial brachial & antebrachial cutaneous nn.
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RULE #3 “MIXED FUNCTIONAL MODALITIES” posterior anterior
Most terminal branches of the brachial plexus are mixed fiber nerves: Somatic motor and somatic sensory (prioprioception) to skeletal mm. Then, cutaneous innervation with somatic sensory and sympathetics to skin Somatic motor nerve (GSE, with GSA) Cutaneous nerves (GSA, GVE, GVA)
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Musculocutaneous n. Tank et al. Lippincott Williams & Wilkins Atlas of Anatomy
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Some purely cutaneous brs. of brachial plexus
Tank et al. Lippincott Williams & Wilkins Atlas of Anatomy
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RULE #5: Dermatome vs. Cutaneous Nerve Distribution
Segmental innervation (C5-T1) Dermatomes
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Segmental (Dermatome) Innervation of Upper Limb
Foerster (1933) – based on clinical findings (used by neurologists) Keegan and Garrett (1948) – based on limb development Moore et al. Essential Clinical Anatomy
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Segmental (Dermatome) Innervation of Upper Limb
Preaxial: C5-C7 Postaxial: C8-T1 Thumb: C6 3rd Digit: C7 5th Digit: C8 Moore et al. Essential Clinical Anatomy
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Dermatomes vs. Cutaneous Nerve Distribution
Segmental innervation (C5-T1) Dermatomes Terminal branches Cutaneous nn.
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Peripheral (Cutaneous ) Innervation of Upper Limb
Moore et al. Essential Clinical Anatomy Anterior Posterior
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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) U M R
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C7 M U C8 C6 R
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Stretch Reflex Reciprocal inhibition of antagonist muscles
apbrwww5.apsu.edu/
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Stretch Reflex academic.scranton.edu Bicipital reflex (C6 cord level) Triceps reflex (C7 cord level)
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UPPER LIMB RADICULAR SYNDROMES
IVD Root Sensory Loss Motor Weakness C4-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 flexion Medial forearm Intrinsic hand mm. Source: Devinsky et al. Neurologic Pearls Cranial Caudal Proximal Distal
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