Transcript PPT

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Organization of the Upper Limb
Audrone Biknevicius, Ph.D.
Dept. Biomedical Sciences, OU HCOM at Dublin
Clinical Anatomy Immersion 2014
“Anatomical Tool-Kit”
www2.warwick.ac.uk
www.medicinenet.com
www.telegraph.co.uk
virtuallaboratory.colorado.edu
www.cedars-sinai.edu
2
Week 5
Week 7
RULE #1
Limbs are outgrowths
of the ventral body wall
that undergo distal
growth and
and rotation
differentiation…
[More detailed limb embryology in MS course]
3
The upper limbs are innervated by :
A. Dorsal rami of spinal nn.
B. Ventral rami of spinal nn.
50%
Dorsal rami of spinal nn.
50%
Ventral rami of spinal nn.
4
DEVELOPMENTAL/EVOLUTIONARY BASIS
Primitive Pectoral Limb
Developmentally-ventral limb mm.
Stern Essential of Gross Anatomy
Developmentally-dorsal limb mm.
DEVELOPMENTAL/EVOLUTIONARY BASIS
Stern Essential of Gross Anatomy
• 90◦ lateral rotation (forearm
mm. undergo incomplete
rotation)
• Limb adduction
6
RULE #2A: Ventral vs.
dorsal limb mm.
Developmentally-dorsal muscles:
• Lie posterior to the long bones in
anatomical position (* exceptions)
Stern Essential of Gross Anatomy
*
Developmentally-ventral muscles:
• Lie anterior to the long bones in
anatomical position
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Anterior
Upper Limb
Muscle
Compartments
Humerus
ARM
Posterior
Anterior
Radius
FOREARM
Ulnar
Stern Essential of Gross Anatomy
Posterior
Anterior
HAND
5th metacarpal
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Anterior
Humerus
ARM
Posterior
Some posterior
compartment mm. are found
on the anterolateral aspect
of the forearm
(*brachioradialis, supinator)
*
Radius
Anterior
FOREARM
Ulnar
Stern Essential of Gross Anatomy
Posterior
No posterior compartment in
the hand
Anterior
HAND
5th metacarpal
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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
Stern Essential of Gross Anatomy
limb axis
10
“Roots of BP”
(=ventral rami)
C5
C6
Brachial Plexus
(right side; simplified)
“Randy Travis Drinks Cold Beer”
Trunks
Divisions
M
Cord
Terminal
Branches
C7
U
Lat
L
C8
T1
Post
Stern Essential of Gross Anatomy
Med
Anterior (ventral) division
Posterior (dorsal) division
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“Roots of BP”
(=ventral rami)
C5
C6
Brachial Plexus
(right side; simplified)
Trunks
Divisions
M
Cord
Terminal
Branches
Musculocutaneous n.
C7
U
Lat
L
C8
T1
Post
Stern Essential of Gross Anatomy
Med
Median n.
Radial n.
Ulnar n.
Anterior (ventral) division
Posterior (dorsal) division
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Anterior
MOTOR INNERVATION
Muscle Compartments
of the Upper Limb
Musculocutaneous n.
Humerus
Radial n.
Posterior
Anterior
Median n. & Ulnar n.
Radius
Ulna
Stern Essential of Gross Anatomy
Radial n.
Posterior
Anterior
Ulnar n. & Median n.
5th metacarpal
Posterior
Musculocutaneous Nerve (arm)
All mm. in anterior (flexor)
compartment of arm
MRI of arm
1.Biceps brachii m.
2.Brachialis m.
3.Brachial a.
4.Humerus.
5.Triceps brachii m.
www.med.umich.edu
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http://emedicine.medscape.com/article/1877731-overview#aw2aab6b3
Radial Nerve (arm)
Radial nerve
All mm. in posterior (extensor)
compartment of arm
BB
B
TLat
TMed
TLong
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http://emedicine.medscape.com/article/1877731-overview#aw2aab6b3
The brachialis m. is innervated by which division of the
brachial plexus: :
A. Anterior division
B. Posterior division
50%
50%
www.aokainc.com
Anterior division
Posterior division
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The brachialis m. is innervated by:
A.
B.
C.
D.
Median n.
Musculocutaneous n.
Radial n.
Ulnar n.
25%
25%
25%
25%
www.aokainc.com
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.
Radial Nerve (forearm)
All mm. in posterior (extensor)
compartment of forearm
Also * brachioradialis and
supinator mm.
*
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http://emedicine.medscape.com/article/1877731-overview#aw2aab6b3
Ulnar Nerve (forearm)
Limited mm. in anterior (flexor)
compartment of forearm:
- Flexor carpi ulnaris
- Flexor digitorum profundus (medial ½)
Med 1/2
20
http://emedicine.medscape.com/article/1877731-overview#aw2aab6b3
Median Nerve (forearm)
All anterior (flexor) compartment mm. of
forearm except:
- Flexor carpi ulnaris m.
- Flexor digitorum profundus m. (med ½)
en.wikipedia.org
21
http://emedicine.medscape.com/article/1877731-overview#aw2aab6b3
RULE #2C
www.acacpt.com
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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.
Lateral epicondyle
B. Musculocutaneous n.
C. Radial n.
Extensor digitorum m.
D. Ulnar n.
25%
25%
25%
25%
Median n.
Musculocutaneous n.
Radial n.
Ulnar n.
“Be specific”
thepainsource.com
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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.
33%
33%
www.rad.washington.edu
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.
33%
healthfavo.com
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.
33%
33%
33%
www.pelhamrehab.com
Median n.
Radial n.
Ulnar n.
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Median Nerve (hand)
Limited hand mm.:
- Thenar mm.
- Lateral two lumbricals
www.studyblue.com
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http://emedicine.medscape.com/article/1877731-overview#aw2aab6b3
Ulnar Nerve (hand)
cnx.org
All hand mm. not innervated
by median n.
29
http://emedicine.medscape.com/article/1877731-overview#aw2aab6b3
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
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Stern Essential of Gross Anatomy
*
Developmentally-ventral muscles:
•Lie anterior to the long bones in
anatomical position
-or•Arise from:
– coracoid ossification
– sternum and costal cartilages
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
50%
50%
Anterior division
Posterior division
blog.corewalking.com
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Brachial Plexus
(branches)
C5
C6
supraspinatus
& infraspinatus
mm.
suprascapular n.
C7
*
C8
T1
Stern Essential of Gross Anatomy
**
axillary n.
upper subscapular n.
thoracodorsal n.
lower subscapular n.
deltoid & teres minor mm.
subscapularis m.
latissimus dorsi m.
subscapularis &
teres major mm.
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
50%
50%
www.bnchiro.com
Anterior division
Posterior division
34
Brachial Plexus rhomboid mm.
(branches)
dorsal
scapular n.
C5
C6
suprascapular n.
C7
*
pectoralis mm.
C8
lateral pectoral n.
T1
musculoskeletal
n.
serratus
anterior m.
medial n.
medial pectoral n.
pectoralis mm.
**
axillary n.
ulnar n.
radial n.
upper subscapular n.
thoracodorsal n.
lower subscapular n.
35
Stern Essential of Gross Anatomy
long
thoracic n.
posterior
anterior
RULE #3
Proximal-toDistal Rule
Upper “roots” of the brachial
plexus (C5-6 ventral rami)
innervate proximal
muscles (shoulder, elbow)
Somatic motor nerve
(GSE, with GSA)
Cutaneous nerves
(GSA, GVE, GVA)
Lower “roots” of the brachial
plexus (C8-T1 ventral
rami) innervate distal
muscles (hand)
MYOTOME
- group of muscles
innervated by a
single spinal nerve
root
sciartmag.blogspot.com
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38
Dorsal
scapular n.
Brachial Plexus
(all branches)
C5
C6
Suprascapular n.
C7
*
C8
Lateral pectoral n.
T1
Musculoskeletal n.
Stern Essential of Gross Anatomy
Long
thoracic n.
Medial n.
**
Medial pectoral n.
Upper & lower subscapular nn.
Thoracodorsal n.
Axillary n.
Ulnar n.
* Nerve to subclavius
Radial n.
** Medial brachial & antebrachial cutaneous nn.
39
posterior
anterior
RULE #3
“MIXED FUNCTIONAL
MODALITIES”
Most terminal branches of the
brachial plexus are mixed
fiber nerves:
1. Somatic motor and
somatic sensory
(prioprioception) to
skeletal mm.
Somatic motor nerve
(GSE, with GSA)
Cutaneous nerves
(GSA, GVE, GVA)
2. Then, cutaneous
innervation with somatic
sensory and sympathetics
to skin
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
Segmental (Dermatome) Innervation of Upper Limb
Foerster (1933)
– based on
clinical findings
(used by
neurologists)
44
Moore et al. Essential Clinical Anatomy
Keegan and
Garrett (1948)
– based on limb
development
Segmental (Dermatome) Innervation of Upper Limb
Preaxial: C5-C7
Postaxial: C8-T1
Thumb: C6
5th Digit: C8
45
Moore et al. Essential Clinical Anatomy
3rd Digit: C7
Dermatomes vs. Cutaneous Nerve Distribution
Segmental
innervation
(C5-T1)
Dermatomes
Terminal
branches
Cutaneous
nn.
Peripheral (Cutaneous ) Innervation of Upper Limb
Anterior
Posterior
Moore et al. Essential Clinical Anatomy
47
Test for Peripheral Nerve
Sensory Function:
M
U
R
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)
C7
M
C8
U
C6
R
49
Stretch Reflex
Reciprocal inhibition of antagonist muscles
apbrwww5.apsu.edu/
academic.scranton.edu
Stretch Reflex
Bicipital reflex (C6 cord level)
Triceps reflex (C7 cord level)
UPPER LIMB RADICULAR SYNDROMES
IVD
C4-C5
Root
C5
Sensory Loss
Shoulder
Motor Weakness
Shoulder weakness
Cranial
Caudal
Proximal
C5-C6
C6
Anterior upper arm,
Lateral forearm, thumb
Forearm flexion
Biceps reflex
C6-C7
C7
3rd digits
Forearm extension
Triceps reflex
Wrist extension
Hand grip
C7-C8
C8
5th digits
Medial forearm
Wrist flexion
Intrinsic hand mm.
Source: Devinsky et al. Neurologic Pearls
Distal