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Dr. S. Nishan Silva (MBBS)
Arm, Forearm, Elbow Dr. S. Nishan Silva (MBBS)
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Surface Anatomy of Upper Limb
Biceps + Triceps brachii Olecranon Process Medial Epicondyle Cubital Fossa Anterior surface elbow Contents Brachial Artery Median Nerve Boundaries Medial = Pronator teres Lateral = Brachioradialis Superior = Line between epicondyles Frolich, Human Anatomy,UpprLimb
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Elbow (post)
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Elbow Anatomy Elbow joint is made of 3 bones 2 joints One capsule
Hinge joint Flexion(145) and extension
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Elbow Anatomy Elbow joint- where the radius and ulna articulate with the humerus. Flexion and extension-hinge joint
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Elbow (AP)
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Elbow (ant)
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Elbow (lat)
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Elbow (med)
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Elbow Joint Synovial – hinge Diarthrosis Articulations Humerus & Ulna Humerus & Radius Many Ligaments
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Elbow Anatomy Radioulnar joint is a pivot joint.
It allows supination and pronation.
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Elbow (lat)
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Olecranon Bursa
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Elbow Anatomy The ulna does not move.
The radius moves around the ulna. The ulna is locked in place by the proximal end at the olecranon process.
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Elbow Anatomy Medial epicondyle- medial side of humerus at distal end just above trochlea. Pronator teres attachment.
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Elbow Ligaments Medial Collateral Ligament- runs from medial epicondyle of humerus to the medial side of coranoid process and olecranon process.
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Elbow Ligaments Lateral collateral ligament- attaches proximally to the lateral epicondyle and distally to the lateral ulna and annular ligament.
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Elbow Ligaments Annular Ligament- encompasses radial head at the radial notch and hold it against the ulna. (red)
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Ligamentous Support Annular Ligament
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Elbow Anatomy Olecranon fossa- posterior surface of the humerus between the medial and lateral epicondyles.
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Elbow Anatomy Olecranon process- proximal end of ulna, on posterior surface. The point of elbow where triceps attaches.
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Elbow Anatomy Trochlea- located on the medial side of the distal end of the humerus. Articulates with ulna.
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Elbow Anatomy Coronoid Process- just below the trochlear notch and next to the radial notch. Attachment for brachilis.
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anterior
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Distal anterior humerus
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Posterior humeras
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Ulna close up proximal lateral end
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Prox radius
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Radius l and right anterior view
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Anterior elbow
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Bones of Forearm (AP)
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Bones of Forearm (lat)
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Joints of Upper Extremity
Proximal Radioulnar joint Synovial - pivot Diarthrosis Distal Radioulnar joint Synovial – pivot Allows pronation and supination of forearm
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Muscles and nerves by compartment
Frolich, Human Anatomy,UpprLimb
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Muscles of Arm: Cross elbow, Move forearm
2 Compartments Anterior: Flexors of forearm Posterior: Extensors of forearm Anterior Compartment Biceps brachii = MC nerve Brachialis = MC nerve Brachioradialis = Radial nerve Coracobrachialis = MC nerve O = coracoid process of scapula I = medial side humeral shaft A = flex, adduct arm Posterior Compartment Triceps brachii = Radial nerve Anconeus = Radial nerve MC = musculocutaneous nerve
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Muscles of forearm: Cross Wrist = flex, extend, abduct, adduct hand
Cross Fingers = flex, extend fingers Most muscles fleshy proximally, long tendons distally Flexor + Extensor Retinacula wristbands keep tendons from bowing thick, deep fascia Anterior Flexor Compartment (Superficial + Deep layers) Most flexors have common tendon on medial epicondyle Contains 2 pronators Innervated by *Median, Ulna nerves Posterior Extensor Compartment (Superficial + Deep layers) Innervated by Radial nerve (or branches of)
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POSTERIOR AND ANTERIOR COMPARTMENTS
Frolich, Human Anatomy,UpprLimb
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Biceps—anterior compartment, flexion (M-C n.)
Triceps—posterior compartment, extension (radial n.) Frolich, Human Anatomy,UpprLimb
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Elbow/Arm Muscles Brachialis- attaches distal half of the humerus to the coronoid process and ulnar tuberosity of ulna.
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Brachialis O I N F Distal 2/3 anterior humerus Ulna tuberosity
Coronoid process N Musculocutaneous F Elbow flexion
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Biceps Brachii
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Biceps Brachii O Short head – coracoid process
Long head – supraglenoid tubercle of scapula I – Radial tuberosity Biceps brachii aponeurosis N – Musculocutaneous F – Shoulder – flexion Elbow – flexion, forearm supination
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Brachioradialis O – Upper 2/3 of lateral humeral supracondylar ridge
Lateral radius just proximal to base of styloid process N – Radial F – Elbow flexion Supination to midposition Pronation to midposition
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Triceps Brachii
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Triceps Brachii O – I – N – Radial F –
Long Head – infraglenoid tubercle Lateral Head – lateral and posterior surface of proximal ½ of body of humerus Medial Head – distal 2/3 of medial and posterior surfaces of humerus below radial groove I – Posterior surface of olecranon proess N – Radial F – Shoulder – long head – Ext and ADD Elbow -- extension
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Anterior Compartment Forearm--flexors
Medial Epicondyle Brachioradialis Pronator Teres Flexor Carpi Radialis Flexor Carpi Ulnaris Flexor Retinaculum Flexor Digitorum Superficialis is deep to other flexors Anterior View Frolich, Human Anatomy,UpprLimb
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Posterior Compartment of Forearm--extensors
Lateral Epicondyle Brachioradialis Extensor digitorum Ext Carpi Radialis Longus Extensor carpi ulnaris Posterior View Frolich, Human Anatomy,UpprLimb
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Muscles - Elbow Flexion Biceps Brachii Brachialis Brachioradialis
**Pronator Teres - weak
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Muscles - Elbow Extension Triceps Brachii Anconeus
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Muscles - Elbow Pronation Pronator Teres Pronator Quadratus
Brachioradialis
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Muscles - Elbow Supination Biceps Brachii Supinator Brachioradialis
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Elbow/Forearm Muscles
Anconeus- helps the triceps with extension and keeps the annular ligament out of the olecranon fossa.
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Elbow/Forearm Muscles
Pronator quadratus- small flat quadrilateral muscle that pronates the wrist. Deep muscle at distal end of forearm.
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Supinator O – Lateral humeral epicondyle LCL Annular ligament I –
Lateral upper 2/3 of radius N – Radial F – Forearm supination
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Extensor Carpi Radialis Longus
Lower 1/3 of lateral supraconsylar ridge I – Dorsal surface of base of 2nd metacarpal N – Radial F – Wrist extension Wrist radial deviation Elbow flexion
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Extensor Carpi Radialis Brevis
Lateral epicondyle of humerus I – Dorsal surface of base of 3rd metacarpal N – Radial F – Wrist extension Wrist radial deviation Elbow flexion
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Extensor Digitorum Communis
Lateral humeral epicondyle I – Extensor expansions of digits 2-5 N – Posterior interosseus nerve (continuation of radial) F – 2-5 MCP extension 2-5 IP extension
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Extensor Carpi Ulnaris
Lateral humeral condyle I – Posterior base of 5th metacarpal N – Posterior interosseus F – Wrist extension Wrist ulnar deviation
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Pronator Teres O – Medial humeral epicondyle Coronoid process I –
Lateral radius near its center N – Median F – Forearm pronation Elbow flexion
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Flexor Carpi Radialis O – I – N – F – Medial humeral epicondyle
Palmar surface at base of 2nd metacarpal Slip to base of 3rd metacarpal N – Median F – Wrist flexion Wrist radial deviation Elbow flexion
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Palmaris Longus O – Medial humeral epicondyle I – Palmar aponeurosis
Wrist flexor retinaculum N – Median F – Wrist flexion Elbow flexion
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Flexor Carpi Ulnaris O – I – N – F –
medial epicondyle of humerus olecranon and posterior border of ulna I – Pisiform bone, hook of hamate bone, and 5th metacarpal bone N – Ulnar F – Wrist flexion Ulnar deviation Elbow flexion
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Pronator Quadratus O – I – N – F – Distal ¼ anterior ulna
Distal ¼ anterior radius N – Anterior interosseus (median) F – Forearm pronation
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Nerves All of the nerves that travel down the arm pass across the elbow Three main nerves begin together at the shoulder: the radial nerve, the ulnar nerve, and the median nerve. These nerves carry signals from the brain to the muscles that move the arm. The nerves also carry signals back to the brain about sensations such as touch, pain, and temperature.
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Nerves Each nerve travels through its own tunnel as it crosses the elbow. Because the elbow must bend a great deal, the nerves must bend as well. Constant bending and straightening can lead to irritation or pressure on the nerves within their tunnels and cause problems such as pain, numbness, and weakness in the arm and hand.
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Blood Vessels The largest artery is the brachial artery that travels across the front crease of the elbow. If you place your hand in the bend of your elbow, you may be able to feel the pulsing of this large artery. The brachial artery splits into two branches just below the elbow: the ulnar artery and the radial artery that continue into the hand. Damage to the brachial artery can be very serious because it is the only blood supply to the hand.
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Blood Vessels basilic vein
it unites with the Median antebrachial vein(s) to form the axillary v. basilic v. communicates with deep veins of the forearm through perforating veins, especially in the cubital region
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Blood Vessels Cephalic Vein It drains into the Axillary/Subclavin Vein
median cubital vein usually pushes some of the blood collected by the cephalic v. to the basilic v.
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Blood Vessels Median Cubital Vein
Some Blood runs from the Cephalic Vein through the median Cubital into Basilic Vein The Most Common Vein for phlebotomists
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Parts of Brachial Plexus
Really Tired? Drink Coffee Buddy! R = ROOTS (ventral rami) T = TRUNKS D = DIVISIONS C = CORDS B = BRANCHES
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Roots join to form Trunks! (in neck)
Ventral Rami Trunks C5 Upper Trunk C6 C Middle Trunk C8 T Lower Trunk
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Trunks Split to form Divisions! (in neck)
Trunks Divisions Upper Anterior Posterior Middle Anterior Posterior Lower Anterior Posterior
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Divisions Join to form Cords! (in axilla)
Trunks Divisions Cords U A P M A P L A P POSTERIOR CORD LATERAL CORD MEDIAL CORD
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Cords Give off Branches!! (in axilla)
Lateral Musculocutaneous Median Medial Ulnar Posterior Radial Axillary (thoracodorsal) (subscapular)
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PUT IT ALL TOGETHER…... pg 416 Learn Figure 14.11c in textbook!
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Muscles (radial nerve)
ANTERIOR MUSCLES M-C nerve Biceps brachialis Median nerve Forearm flexors Thumb intrinsics (1M$ nerve) Ulnar nerve Flexor carpi ulnaris Hand intrinsics POSTERIOR MUSCLES Muscles (radial nerve) Triceps Anconeus Brachioradialis Carpal, digit extensors Frolich, Human Anatomy,UpprLimb
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Innervation of Anterior Compartment-Forearm Muscles
Nerve Superficial Muscles Flexor digitorum superficialis Median Flexor carpi radialis Median Pronator teres Median Palmaris longus Median Flexor carpi ulnaris Ulnar Deep Muscles Pronator quadratus Median Flexor pollicis longus Median Flexor digitorum profundus Ulnar (med 1/2) Median (lat 1/2)
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Innervation of Posterior Compartment-Forearm Muscles
Nerve Superficial Extensor carpi radialis longus Radial Extensor digitorum Radial Extensor carpi ulnaris Radial Deep Supinator Radial Abductor pollicis longus Radial Extensor pollicis longus + brevis Radial Extensor indicus Radial
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Sensory from limb (dermatomes/sensory skin segments from spine)
Dermatomes extend over limbs Twisted orientation reflects twisting of limb during development Named nerves generally innervate skin over muscles that they innervate Frolich, Human Anatomy,UpprLimb
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Sensory territory of nerves
REMEMBER: Brachial plexus re-directs spinal routes into named nerves covering certain territory Cutaneous branches of medial cord/ulnar nerve Frolich, Human Anatomy,UpprLimb
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Routes of nerves (in human)
M-C: between biceps brachii and brachialis Median: medial/posterior to biceps, branches into forearm flexors at elbow then to hand through carpal tunnel Recurrent median (1M$) superficial at wrist to thumb over thenar emminence) deficit - ape’s hand Ulnar: medial in arm, posterior to medial epicondle of humerus down medial forearm medial to carpal tunnel into palm Radial: deep posterior arm around lateral epicondyle of humerus to forearm (deep and superficial branches) Frolich, Human Anatomy,UpprLimb
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Blood Supply: Veins SUPERFICIAL Cephalic (arm-forearm)
Basilic (arm-forearm) Median Cubital (elbow) Median Vein SF. Palmar Venous Arch Digital DEEP Subclavian (neck) Axillary (axilla) Brachial (arm-elbow) Radial (forearm) Ulnar (forearm) Deep Palmous Venous arch pg 547
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Blood Supply: Arteries
Subclavian (neck) Axillary (armpit) Subscapular Brachial (arm) Deep brachial Radial (forearm) Ulnar (forearm) Common Interosseous Superficial & Deep Palmar arches Digital Pg 536
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TENNIS ELBOW
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Elbow Anatomy Lateral epicondyle- located on lateral side of distal end above capitulum. Anconeus and supinator attach.
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Medial Epicondylitis (Golfer’s Elbow)
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Pronation, wrist flexion and elbow flexion.
MEDIAL EPICONDYLITIS Pronation, wrist flexion and elbow flexion.
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Dislocations Elbow is the second most commonly dislocated major joint.
Most often the ulna/radius dislocate posterior to the humerus. MOI- fall of outstretched arm with elbow locked in extension.
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FRACTURED HUMERUS Brachial Artery Median Nerve HYPEREXTENSION
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FRACTURED RADIUS
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Cubital tunnel syndrome
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Nerve Entrapment Problems
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Axillary Nerve Injury Also called circumflex nerve
It is a branch from posterior cord of Brachial plexus It hooks close round neck of humerus from posterior to anterior It pierces the deep surface of deltoid and supply it and the part of skin over it
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Axillary nerve injury
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Volkmann's Ischemic Contracture
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Ruptured biceps tendon
Usually rotator cuff tear also present Get the “popeye” sign Rarely get significant weakness Brachioradialis and short head of biceps provide 80-85% elbow flexor strength Usually proximal end of the long head ruptures.
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COMPARTMENT SYNDROME May occur in crush injury of the hand with or without associated fracture. Involved compartments of the hand includes: Thenar Hypothenar Adductor pollicis Four interossei
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COMPARTMENT SYNDROME Edema of tissues or hemorrhage within any of these compartments may lead to elevated pressures that result in tissue necrosis and subsequent loss of hand function due to contracture. Sign and symptoms: Pain and paresthesias occur early Paralysis and pulselessness occurring later
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Which bone is fractured?
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