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Upper Limb

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  • 1. Anatomy of the upper limb • Introduction • General considerations • Brachial plexus
  • 2. ANATOMY UPPER LIMB BRACHIAL PLEXUS
  • 3. The spinal nerves from C5 to C8, together with the T1 thoracic spinal nerve, join together to form the brachial plexus. The nerve elements combine, divide and combine again to mix together the various components that lead into the major nerves of the shoulder, arm and hand.
  • 4. A nerve plexus is an area where nerves branch and rejoin. The brachial plexus is a group of nerves in the cervical spine from C5 to C8-T1. This includes the lower half of the cervical nerve roots and the nerve root from the first thoracic vertebra.
  • 5. Brachial Plexus 1 Ventral root of C5 2 Ventral root of C6 3 Ventral root of C7 4 Ventral root of C8 5 Ventral root of T1 6 Ulnar 7 Radial 8 Median 9 Musculocutaneous 10 Cords a Medial b Posterior c Lateral 11 Posterior divisions 12 Anterior divisions a Inferior b Middle c Superior 13 Inferior trunk 14 Middle trunk 15 Superior trunk
  • 6. Erb’s paralysis • C5 - C6 • Birth injury • Arm hangs by the side+Rotate medially • Forearm pronated + extended • Flexed wrist + fingers • deltoid – supraspinatus – infraspinatus – biceps - brachialis
  • 7. Klumpke’s paralysis /kloomp’kz/ • C8 – T1 • Intrinsic muscles of the hand + long flexors of the hand ------ paralysis • Claw hand = extension at MPJ + flexion at IPJ • Cervical rib can cause paralysis similar to Klumpke’s paralysis with post-fixed T2 contribution
  • 8. Winging of the scapula • Injury to the long thoracic nerve • Paralysis of serratus anterior muscle Humeral fracture At the surgical neck ---------- injury to the axillary nerve ---- loss of abduction
  • 9. Arterial blood supply of the upper limb
  • 10. Axillary artery •Continuation of subclavian artery •Runs from lateral border of first rib to lower border of teres major •Pectoralis minor crosses anterior to it and divides it into three parts •First part • Highest thoracic artery (also called supreme or superior) •Second part • Lateral thoracic artery • Thoracoacromial artery •Third part • Subscapular artery • Anterior circumflex humeral artery • Posterior circumflex humeral artery •Collateral circulation around the scapula •Branches of first part of Subclavian artery anastomose with branches of the third part of axillary artery
  • 11. The axillary artery begins at the lateral border of the first rib as a continuation of the subclavian artery. It changes its name to brachial artery at lower (inferior) border of the teres major muscle. For purposes of description, it is broken up into three parts by its relation to the pectoralis minor muscle. The first part is between the lateral border of the first rib and the medial border of the pectoralis minor, the second part is behind the pectoralis minor and the third part is between the lateral border of the pectoralis minor and the inferior border of the teres major
  • 12. Brachial artery Continuation of the axillary artery Runs from lower border of teres major to neck of radius Ends by dividing into radial and ulnar arteries Branches of the brachial artery Profunda brachi which travels in the radial groove of humerus Superior ulnar collateral artery o Inferior ulnar collateral artery Nutrient artery to humerus Terminal branches are radial and ulnar arteries Relations Median nerve crosses anterior to it from lateral to medial side at the level of mid arm
  • 13. 1 superior thoracic a. (supreme thoracic a.) (highest thoracic a.) 2 thoracoacromial a. 3 lateral thoracic a. 4 subscapular a. 5 anterior humeral circumflex a. 6 posterior humeral circumflex a.
  • 14. Ulnar artery Gives rise to common interosseous artery Continues as the superficial palmar arch in the hand Radial artery Continues as the deep palmar arch in the hand Median artery Vestigial in adult life Arises from the anterior interosseous branch of common interosseous artery Provides nutrition to Median nerve Chief source of blood supply to the upper limb in foetal life Passes anterior to carpal tunnel
  • 15. The diagram also shows that the brachial artery terminates just below the elbow joint as the radial and ulnar arteries, to be covered in the forearm
  • 16. 1 brachial 2 radial 3 radial recurrent 4 superficial radial 5 deep radial 6 ulnar 7 anterior ulnar recurrent 7 posterior ulnar recurrent 8 common interosseous 9 posterior interosseous 10 anterior interosseous 11 superficial branch 12 deep branch
  • 17. The superficial arterial arch is formed mainly from the ulnar artery and is completed by the superficial branch of the radial. This completion is not always present or may be extremely small. The deep arterial arch is formed mainly by the deep branch of the radial artery and is finished by the deep branch of the ulnar artery.
  • 18. Upper limb Venous drainage
  • 19. cephalic v. Tributaries lateral side of the dorsal venous arch of the hand; superficial veins of the forearm Drains Into axillary vein Regions Drained superficial parts of the lateral hand and lateral forearm Notes median cubital vein usually shunts some of the blood collected by the cephalic v. to the basilic v. (Latin/Greek, kephale = head)
  • 20. The axillary vein lies along the medial side of the artery and is a continuation of the basilic vein. It begins at the inferior border of the teres major m. and ends at the lateral border of the first rib, where it becomes the subclavian v. It receives tributaries that parallel the branches of the axillary artery.
  • 21. The cephalic v. joins the axillary v. just before it becomes the subclavian. Penetrating wounds in the larger upper part are serious because air might enter into the venous system.
  • 22. The veins that run with their corresponding arteries are frequently multiple (2 or 3 interconnected veins). This interconnected venous network is called the vena commitantes
  • 23. Axilla, Pectoral and scapular regions
  • 24. Anatomically, the boundaries of the axilla are medially: serratus anterior and by the ribcage anteriorly: by the pectoralis major, minor, and subclavius (see also anterior axillary fold) posteriorly: by the subscapularis above, and teres major and latissimus dorsi below(see also posterior axillary fold) laterally: by the intertubercular sulcus (coracobrachialis and the short head of the biceps brachii are in the axilla.) superiorly: by the outer border of first rib, superior border of scapula, and posterior border of clavicle floor/base: by the skin (visible surface of armpit
  • 25. Deep muscles of the chest and front of the arm, with the boundaries of the axilla.
  • 26. Artery axillary artery Vein axillary vein axillary nerve, medial cord, Nerve posterior cord, lateral cord axillary lymph Lymph nodes
  • 27. Lymphatics Structure Location Afferents from Efferents to Regions drained Notes axillary nodes axilla cubital nodes; efferents vessels upper limb, most axillary nodes lymphatic vessels form the of the mammary number from 20 from the upper subclavian trunk, gland, some of the to 30 and are limb, thoracic wall some drainage to anterolateral chest organized in five and subscapular inferior deep wall, posterior groups based on region cervical nodes thoracic wall and their position scapular region within the axilla: 1) pectoral nodes, along the lateral border of the pectoralis major m.; 2) lateral nodes, located along the distal axillary v.; 3) central nodes, centrally located along axillary v.; 4) subscapular nodes, located along the subscapular v. and its tributaries; 5) apical nodes, located at the apex of axilla
  • 28. There are some 15 to 20 nodes usually arranged into to five groups. The groups consist of: A pectoral (anterior) L lateral P posterior C central Ap apical
  • 29. Muscles of Axilla and the Pectoral region
  • 30. Pectoralis major Origin medial 1/2 of the clavicle, manubrium & body of sternum, costal cartilages of ribs 2-6, sometimes from the rectus sheath of the upper abdominal w Insertion crest of the greater tubercle of the humerus Action flexes and adducts the arm, medially rotates the arm Nerve supply medial and lateral pectoral nerves (C5-T1) Arterial blood supply pectoral branch of the thoracoacromial trunk the deep fascia on its anterior surface should not be fused to the fascia of the mammary gland - if it is, this is an important clinical sign indicating breast disease (Latin, pectus = breast bone)
  • 31. Pectoralis minor origin ribs 3-5 Insertion coracoid process of the scapula Action draws the scapula forward, medialward, and downward Nerve supply medial pectoral nerve (C8, T1) arterial supply pectoral branch of the thoracoacromial trunk Notes; branches of medial pectoral nerve usually pierce pectoralis minor to reach the pectoralis major muscle .
  • 32. serratus anterior Origin ribs 1-8 or 9 Insertion medial border of the scapula on its costal (deep) surface Action it draws the scapula forward; the inferior fibers rotate the scapula superiorly Nerve supply long thoracic nerve (from ventral rami C5-C7) Arterial supply lateral thoracic a. a lesion of long thoracic nerve will cause winging of the scapula (i.e., the medial border of the scapula falls away from the posterior chest wall and looks like an angel's wing) (Latin, serratus = to saw)
  • 33. Topographical Anatomy of the Thorax Structure/Space Description/Boundaries Significance midaxillary line an imaginary vertical line used as a surface landmark passing through the middle for descriptive purposes of the axilla midclavicular line an imaginary vertical line used as a surface landmark passing through the for descriptive purposes midshaft of the clavicle
  • 34. deltopectoral triangle a triangle in the upper chest region that is bounded medially by the clavicle, superiorly by the deltoid m., and inferiorly by the pectoralis major m. the deltopectoral triangle is pierced by the cephalic vein on its course from the upper limb to join the axillary vein in the axilla
  • 35. nipple located superficial to the 4th location of the left nipple may be intercostal space in the male and used to help locate the apex of heart, prepuberal female; areola is dark ring which is approximately 8 cm from surrounding nipple the midline in the left 5th intercostal space; a surface landmark used to place the stethoscope for auscultation of the bicuspid valve suprasternal notch the notch located at the superior also known as: jugular notch border of the manubrium of the sternum, between the sternal ends of the clavicles
  • 36. parasternal nodes lateral border of anterior phrenic nodes, larger lymphatic medial side of the parasternal nodes sternum, along the lymphatic vessels from vessels in the root of mammary gland; constitute an course of the internal the anterior thoracic the neck medial part of the important drainage thoracic vessels wall anterior chest wall and pattern in cases of muscles cancer of the mammary gland; one or two parasternal nodes may be found in the anterior end of intercostal spaces 1-6; also known as: sternal nodes pectoral nodes along the lateral lymphatic vessels from central axillary nodes anterolateral thoracic an important group of border of the the mammary gland wall and muscles; most nodes to examine pectoralis major m. and anterolateral of the mammary gland during a breast along the course of the thoracic wall physical exam; also lateral thoracic vessels known as: anterior axillary nodes
  • 37. SCAPULAR REGION
  • 38. Muscles of the Scapular Region Muscle Origin Insertion Action Innervation Artery Notes deltoid lateral one-third of deltoid tuberosity abducts arm; axillary nerve posterior the deltoid muscle the clavicle, of the humerus anterior fibers flex (C5,6) from the circumflex humeral is the principle acromion, the & medially rotate posterior cord of a. abductor of the lower lip of the the arm; posterior the brachial plexus arm but due to crest of the spine fibers extend & poor mechanical of the scapula laterally rotate the advantage it arm cannot initiate this action; it is assisted by the supraspinatus m. teres major dorsal surface of crest of the lesser adducts the arm, lower subscapular circumflex scapular teres major inserts the inferior angle tubercle of the medially rotates nerve (C5,6) from a. beside the tendon of the scapula humerus the arm, assists in the posterior cord of latissimus dorsi, arm extension of the brachial and assists plexus latissimus in its actions triceps brachii long head: olecranon process extends the radial nerve deep brachial long head of the infraglenoid of the ulna forearm; the long (profunda brachii) triceps separates tubercle of the head extends and a. the triangular and scapula; lateral adducts arm quadrangular head: spaces (teres posterolateral major, teres minor humerus & lateral and the humerus intermuscular are the other septum; medial boundaries); all head: three heads of posteromedial origin insert by a surface of the common tendon inferior 1/2 of the humerus
  • 39. rotator cuff supraspinatus supraspinato greater abducts the suprascapular suprascapular supraspinatus initiates us fossa tubercle of arm (initiates nerve (C5,6) a. abduction of the arm, then the humerus abduction) from the the deltoid muscle (highest superior completes the action; a facet) trunk of the member of the rotator cuff brachial group plexus infraspinatus infraspinatou greater laterally suprascapular suprascapular infraspinatus, supraspinatus, s fossa tubercle of rotates the nerve a. teres minor and the humerus arm subscapularis are the rotator (middle facet) cuff muscles teres minor upper 2/3 of greater laterally axillary nerve circumflex fixes the head of the the lateral tubercle of rotates the (C5,6) from scapular a. humerus in the glenoid fossa border of the the humerus arm the posterior during abduction & flexion of scapula (lowest facet) cord of the the arm; a member of the brachial rotator cuff group plexus subscapularis medial two- lesser medially upper and subscapular subscapularis, supraspinatus, thirds of the tubercle of rotates the lower a. infraspinatus, and teres costal surface the humerus arm; assists subscapular minor are the rotator cuff of the scapula extention of nerves (C5,6) muscles (subscapular the arm fossa)
  • 40. Nerves of the Scapular Region Nerve Source Branches Motor Sensory Notes axillary n. posterior cord of superior lateral deltoid, teres skin of the upper axillary n. is the brachial brachial minor lateral arm endangered by plexus cutaneous nerve surgical neck fractures lower posterior cord of unnamed subscapularis m., no cutaneous subscapularis subscapular n. the brachial muscular brs. teres major m. branches and teres major plexus (C5, C6) are synergists (medial rotation of the humerus) middle posterior cord of unnamed latissimus dorsi no cutaneous also called the subscapular n. the brachial muscular brs. m. branches thoracodorsal n. plexus (C7, C8) suprascapular n. superior trunk of no named supraspinatus no cutaneous suprascapular n. the brachial branches m., infraspinatus branches passes through plexus (C5-C6) m. the scapular notch inferior to the superior transverse scapular ligament thoracodorsal n. posterior cord of unnamed latissimus dorsi no cutaneous also called the the brachial muscular brs. m. branches middle plexus (C7, C8) subscapular n. upper posterior cord of unnamed subscapularis m. no cutaneous subscapularis is a subscapular n. the brachial muscular brs. branches strong medial plexus (C5, C6) rotator of the humerus
  • 41. Arteries of the Scapular Region Artery Source Branches Supply to Notes anterior circumflex humeral axillary a., 3rd part unnamed muscular branches deltoid m.; arm muscles near anterior circumflex humeral a. the surgical neck of the anastomoses with the posterior humerus circumflex humeral a. posterior circumflex humeral axillary a., 3rd part unnamed muscular branches deltoid; arm muscles near the posterior circumflex humeral a. surgical neck of the humerus anastomoses with the anterior circumflex humeral a.; it passes through the quadrangular space with the axillary nerve axillary subclavian a. (axillary a. is the 1st part: superior thoracic a.; pectoral region, shoulder pectoralis minor m. crosses continuation of the subclavian 2nd part: thoracoacromial a., region and upper limb anterior to the axillary artery lateral to the 1st rib) lateral thoracic a.; 3rd part: and is used to delineate the 3 anterior humeral circumflex a., parts mentioned at left posterior humeral circumflex a., subscapular a. circumflex scapular subscapular a. unnamed muscular branches teres major m., teres minor m., circumflex scapular a. infraspinatus m. anastomoses with the suprascapular a. and the dorsal scapular a. to form the scapular anastomosis dorsal scapular subclavian a., 3rd part unnamed muscular branches levator scapulae m., dorsal scapular a. anastomoses rhomboideus major m., with the suprascapular a. and rhomboideus minor m. the subscapular a. to form the scapular anastomosis; dorsal scapular a is a branch of the transverse cervical a. in ~30% of cases subscapular axillary a., 3rd part circumflex scapular a., subscapularis m., teres major the circumflex scapular branch thoracodorsal a. m., teres minor m., of the subscapular infraspinatus m. a.anastomoses with the suprascapular a. and the dorsal scapular a. in the scapular anastomosis suprascapular thyrocervical trunk muscular supraspinatus & infraspinatus, anastomoses with the shoulder joint circumflex scapular a. and the dorsal scapular a. to form the scapular anastomosis thoracodorsal subscapular a. unnamed muscular branches latissimus dorsi m. thoracodorsal a. accompanies the thoracodorsal n.
  • 42. Topographic Anatomy of the Scapular Region Structure/Space Description/Boundaries Significance quadrangular space the space bounded by the the axillary n. and the teres minor m. superiorly, posterior circumflex the teres major m. inferiorly, humeral a. pass through this the long head of the triceps space brachii m. medially and the humerus laterally triangular interval the interval between the the radial n. passes through teres major m. superiorly, this interval to get from the long head of the triceps axilla to the posterior brachii m. medially and surface of the humerus humerus laterally triangular space the space bounded by the the circumflex scapular teres minor m. superiorly, vessels are located in this the teres major m. inferiorly space as they pass from the and the long head of the axilla to the dorsum of the triceps brachii m. laterally scapula
  • 43. The scapular and circumflex arteries. (Quadrangular space is visible but not labeled. Posterior humeral circumflex artery is visible entering quadrangular space at center right.)
  • 44. Suprascapular and axillary nerves of right side, seen from behind. Quadrangular space is the lateral space, labeled in green at center right. Axillary nerve is visible entering it.
  • 45. Pectoral region The human breast (Mammary gland )
  • 46. consists of 10–20 simple glands. The presence of more than two nipples is known as polythelia and the presence of more than two complex mammary glands as polymastia.
  • 47. I. Introduction/General Information A. Embryologically: belong to integument B. Functionally: part of reproductive system 1. Respond to sexual stimulation 2. Feed babies C. Modified apocrine sweat glands - apex of cell becomes part of secretion and breaks off D. Present in males and females
  • 48. II. Anatomy A. Position and Attachment 1. Lateral aspect of pectoral region 2. Located between ribs 3 and 6/7 3. Extend form sternum to axilla 4. Surrounded by superficial fascia 5. Rest on deep fascia 6. Fixed to skin & underlying fascia by fibrous C.T. bands a. Cooper’s (Suspensory) Ligaments b. Ligaments may retract when breast tumors are present
  • 49. Breast Anatomy
  • 50. Left breast is usually slightly larger Base is circular, either flattened or concave Separated from pectoralis major muscle by fascia, retromammary space B. Structure 1. Outer surface convex, skin covered 2. Nipple: a. At fourth intercostal space b. Small conical/cylindrical prominence below center
  • 51. Nipple location 4th intercostal space
  • 52. c. Surrounded by areola: pigmented ring of skin d. Thin skinned region lacking hair, sweat glands e. Contains areolar glands 3. Areola: contains dark pigment that intensifies with pregnancy a. Circular and radial smooth muscle fibers b. Cause nipple erection
  • 53. Lobes and Lobules
  • 54. 5. Excretory (lactiferous) ducts converge toward areola a. Form ampullae (collection sites of lactiferous sinuses) b. Ducts become contracted at base of nipple 6. Secretory epithelium a. Changes with hormonal signals b. Onset of menstruation c. Pregnancy (glands begin to enlarge at 2nd month) d. After birth, 1st secretion is colostrom (contain antibodies
  • 55. 7. “Tail of Spence” = axillary tail a. prolongation of upper, outer quadrant in axillary direction b. Passes under axillary fascia c. May be mistaken for axillary lymph nodes 8. Fatty Tissue: surrounds surface, fills spaces between lobes a. Determines form & size of breast b. No fatty deposit under nipple & areola
  • 56. “Tail of Spence” Axillary Tail
  • 57. Breast: Fatty Tissue
  • 58. Vessels & nerves 1. Arteries: derived from thoracic branches of three pairs of arteries a. Axillary arteries continuous with subclavian a. gives rise to external mammary ( = lateral thoracic) artery
  • 59. b. Internal mammary (thoracic) arteries 1) first descending branch of subclavian artery 2) supply intercostal spaces & breast 3) used for coronary bypass surgery c. Intercostal arteries: 1) numerous branches from internal & external mammary arteries 2) supply intercostal spaces & breast Veins: a. form a ring around the base of the nipple (“circulus venosus”) b. Large veins pass from circulus venosus to circumference Of mammary gland, then to c. External mammary v to axillary v or d. Internal mammary v to subclavian v
  • 60. Arterial Supply to the Breast Subclavian a. Axillary a. Internal mammary (thoracic) a. External mammary (thoracic) a.
  • 61. Veins draining the Breast Subclavian vein External mammary vein
  • 62. Innervation: derived from: a. anterior & lateral cutaneous nerves of thorax b. spinal segments T3 – T6 Lymphatics: clinically significant! a. Glandular lymphatics drain into anterior axillary (pectoral) nodes  central axillary nodes  apical nodes  deep cervical nodes subclavicular (subclavian) nodes b. Medial quadrants drain into parasternal nodes c. Superficial regions of skin, areola, nipples: -form large channels & drain into pectoral nodes d. NOTE: axillary nodes also drain lymph from arm
  • 63. Lymph Nodes of the Breast Subclavian nodes Axillary nodes Parasternal Lateral nodes pectoral nodes
  • 64. Lymph Nodes and Lymph Drainage Axillary Nodes
  • 65. Routes of Metastasis • From medial lymphatics to parasternal nodes – Then to mediastinal nodes • Across the sternum in lymphatics to opposite side via cross-mammary pathways – Then to contralateral breast • From subdiaphragmatic lymphatics to nodes in abdomen – Then to liver, ovaries, peritoneum
  • 66. Major Routes of Metastasis Channels to Contralateral Breast Axillary Lymph Channels Subdiaphragmatic Lymph Channels
  • 67. The arteries supplying the mammæ are derived from the thoracic branches of the axillary, the intercostals, and the internal mammary. The veins describe anastomotic circle around the base of the papilla, called by Haller the circulus venosus. From this, large branches transmit the blood to the circumference of the gland, and end in the axillary and internal mammary veins. The arteries supplying the mammæ are derived from the thoracic branches of the axillary, the intercostals, and the internal mammary.
  • 68. Muscles of the upper limb
  • 69. ORIGIN CORACOBRACHIALIS Coracoid process of scapula with biceps brachii INSERTION Upper half medial border of humerus ACTION Flexes and weakly adducts arm NERVE Musculocutaneous nerve (C5, 6, 7) (from lateral cord)
  • 70. Latin musculus brachialis Gray's subject #124 444 Origin anterior surface of the humerus, particularly the distal half of this bone Insertion coronoid process and the tuberosity of the ulna Artery radial recurrent artery Nerve musculocutaneous nerve Actions flexion at elbow joint
  • 71. The biceps is tri-articulate, meaning that it works across three joints. The most important of these functions are to supinate the forearm and flex the elbow. These joints and the associated actions are listed as follows in order of importance Proximal radioulnar joint Humeroulnar joint Glenohumeral joint
  • 72. Latin musculus biceps brachii Gray's subject #124 443 Origin short head: coracoid process of the scapula. long head: supraglenoid tubercle Insertion radial tuberosity and bicipittal aponeurosis into deep fascia on medial part of forearm Artery brachial artery Nerve Musculocutaneous nerve (C5–C7) Actions flexes elbow and supinates forearm Antagonist Triceps brachii muscle
  • 73. Anterior compartment Muscle Origin Insertion Artery Nerve Action Antagonist coracobrachialis coracoid process of medial humerus brachial artery musculocutaneous adducts humerus scapula nerve biceps brachii short head: coracoid radial tuberosity brachial artery Musculocutaneous flexes elbow and supinates Triceps brachii process of the scapula. nerve (Lateral cord: forearm muscle long head: supraglenoid C5, C6, C7) tubercle brachialis anterior surface of the coronoid process and the radial recurrent musculocutaneous flexion at elbow joint humerus, particularly the tuberosity of the ulna artery nerve distal half of this bone
  • 74. POSTERIOR COMPARTMENT • TRICEPS MUSCLE
  • 75. Schematic drawing with measurements indicating the relationship of the radial nerve to osseous landmarks. Note the course of the radial nerve along the posterior humerus and its relationship to the distal deltoid tuberosity and lateral epicondyle
  • 76. MUSCLES THAT ACT ON ANTERIOR FOREARM: •BICEPS BRACHII •BRACHIALIS •BRACHIORADIALIS •PRONATOR TERES MUSCLES THAT ACT ON POSTERIOR FOREARM: •TRICEPS BRACHII - LONG HEAD •TRICEPS BRACHII - MEDIAL HEAD •TRICEPS BRACHII - LATERAL HEAD •ANCONEUS
  • 77. Posterior compartment Antagoni Muscle Origin Insertion Artery Nerve Action st triceps long head: olecranon Profunda radial extends Biceps brachii scapula process of brachii nerve forearm, caput brachii lateral head: ulna longum adducts muscle posterior shoulder humerus medial head: posterior humerus anconeu Lateral lateral Profunda radial partly blended s epicondyle surface of brachii, nerve in with the of the the recurrent (C7, C8, triceps, which it humerus olecranon interosse and T1) assists in process and ous extension of the the superior artery forearm. part of the Stabilises the posterior elbow and ulna abducts the ulna during pronation.
  • 78. Cubital Fossa The cubital fossa is the region of the upper limb in front of the elbow joint. It is a triangular area with the following boundaries: laterally, brachioradialis muscle medially, pronator teres muscle superiorly, an imaginary line from the medial and lateral epicondyles.
  • 79. artery-nerve layer aponeurotic layer 1 brachial artery 1 bicipital 2 median nerve aponeurosis 2 biceps tendon venous layer 1 cephalic vein 2 basilic vein 3 median cubital vein bony floor muscular floor 1 humerus 1 supinator 2 radius 2 brachialis 3 ulna 3 biceps tendon
  • 80. Forearm Anterior compartment
  • 81. flexor carpi radialis origin common flexor tendon from the medial epicondyle of the humerus insertion base of the second and third metacarpals action flexes the wrist, abducts the hand Nerve supply median nerve
  • 82. flexor carpi ulnaris Origin common flexor tendon & (ulnar head) from medial border of olecranon & upper 2/3 of the posterior border of the ulna insertion pisiform, hook of hamate, and base of 5thmetacarpal action Flex the wrist, adducts hand Nerve supply ulnar nerve
  • 83. flexor digitorum profundus origin posterior border of the ulna, proximal two-thirds of medial border of ulna, interosseous membrane insertion base of the distal phalanx of digits 2-5 action flexes the metacarpophalangeal, proximal interphalangeal and distal interphalangeal joints Nerve supply median nerve via anterior interosseous branch (radial one- half); ulnar nerve (ulnar one-half)
  • 84. flexor digitorum superficialis origin humeroulnar head: common flexor tendon; radial head: middle 1/3 of radius insertion shafts of the middle phalanges of digits 2-5 action flexes the metacarpophalangeal and proximal interphalangeal joints Nerve supply median nerve
  • 85. flexor pollicis longus origin anterior surface of radius and interosseous membrane insertion base of the distal phalanx of the thumb action flexes the metacarpophalangeal and interphalangeal joints of the thumb Nerve supply median nerve via anterior interosseous branch
  • 86. pronator quadratus origin medial side of the anterior surface of the distal one-fourth of the ulna insertion anterior surface of the distal one-fourth of the radius action pronates the forearm Nerve supply median nerve via anterior interosseous branch
  • 87. palmaris longus origin medial epicondyle of humerus insertion distal half of flexor retinaculum and palmaris aponeurosis action flexes hand (at wrist) and tightens palmar aponeurosis Nerve supply median n. (C7 and C8) ulnar a.
  • 88. pronator teres origin common flexor tendon and (deep or ulnar head) from medial side of coronoid process of the ulna inserion midpoint of the lateral side of the shaft of the radius Actio pronates the forearm Nerve supply median nerve
  • 89. supinator origin lateral epicondyle of the humerus, supinator crest & fossa of the ulna, radial collateral ligament, annular ligament insertion lateral side of proximal one-third of the radius action supinates the forearm Nerve supply deep radial nerve
  • 90. Muscle Origin Insertion Artery Nerve Action Antagonist pronator humeral head: radius ulnar median pronation of Supinator teres medial artery and nerve forearm, flexes muscle epicondyle of radial elbow humerus artery (common flexor tendon) ulnar head: coronoid process of the ulna palmaris medial palmar ulnar median wrist flexor Extensor longus epicondyle of aponeurosis artery nerve carpi humerus radialis (common brevis, flexor tendon) Extensor carpi radialis longus, Extensor carpi ulnaris
  • 91. flexor carpi medial Bases of ulnar artery Median Flexion and Extensor radialis epicondyle of second and nerve abduction at carpi radialis humerus third wrist brevis (common metacarpal muscle, flexor bones Extensor tendon) carpi radialis longus muscle flexor carpi medial pisiform ulnar artery muscular flexion of Extensor ulnaris epicondyle of branches of wrist carpi ulnaris the humerus ulnar nerve muscle (common flexor tendon) flexor medial phalanges ulnar artery median nerve flexor of Extensor digitorum epicondyle of fingers digitorum superficialis the humerus (primarily at muscle (common proximal flexor interphalang tendon), as eal joints) well as parts of the radius and ulna.
  • 92. Deep Muscle Origin Insertion Artery Nerve Action Antagonist pronator medial, anterior lateral, anterior anterior median pronates the forearm Supinator quadratus surface of the surface of the interosseous nerve muscle ulna radius artery (anterior interosseous nerve) flexor ulna distal phalanges anterior median flex hand, Extensor digitorum interosseous (anterior interphalangeal joints digitorum profundus artery interosseous muscle ), muscular branches of ulnar flexor pollicis The middle 2/4 of The base of the Anterior Anterior Flexion of the thumb Extensor longus the distal phalanx of interosseous interosseous pollicis volar [disambiguation the thumb artery nerve longus needed] surface of (branch of muscle, the radius and median Extensor the adjacent nerve) (C8, pollicis interosseus T1) brevis membrane. (Also muscle occasionally a small origin slightly on the medial epicondyle of the ulna.)
  • 93. The muscles are largely involved with flexion and pronation. The superficial muscles have their origin on the common flexor tendon. The Ulna nerve and artery are also contained within this compartment @@@@@@@@@@@@@@@@
  • 94. Forearm posterior compartment
  • 95. abductor pollicis longus origin middle one-third of the posterior surface of the radius, interosseous membrane, mid-portion of posterolateral ulna Insertion radial side of the base of the first metacarpal Action abducts the thumb at carpometacarpal joint Nerve supply radial nerve, deep branch
  • 96. Brachioradialis origin upper two-thirds of the lateral supracondylar ridge of the humerus Insertion lateral side of the base of the styloid process of the radius Action flexes the elbow, assists in pronation & supination Nerve supply radial nerve
  • 97. The Brachioradialis, flexor of the forearm, is unusual in that it is located in the posterior compartment, but it is actually in the anterior portion of the forearm.
  • 98. extensor carpi radialis longus Origin lower one-third of the lateral supracondylar ridge of the humerus Insertion dorsum of the second metacarpal bone (base) Action extends the wrist; abducts the hand Nerve supply radial nerve
  • 99. extensor carpi radialis brevis origin common extensor tendon (lateral epicondyle of humerus) insertion dorsum of the third metacarpal bone (base) Action extends the wrist; abducts the hand Nerve supply deep radial nerve
  • 100. extensor carpi ulnaris origin common extensor tendon & the middle one-half of the posterior border of the ulna insertion medial side of the base of the 5th metacarpal action extends the wrist; adducts the hand Nerve supply deep radial nerve
  • 101. extensor digiti minimi origin common extensor tendon (lateral epicondyle of the humerus) insertion joins the extensor digitorum tendon to the 5th digit and inserts into the extensor expansion action extends the metacarpophalangeal, proximal interphalangeal and distal interphalangeal joints of the 5th digit Nerve supply deep radial nerve
  • 102. extensor digitorum origin common extensor tendon (lateral epicondyle of the humerus) insertion extensor expansion of digits 2-5 action extends the metacarpophalangeal, proximal interphalangeal and distal interphalangeal joints of the 2nd-5th digits; extends wrist deep Nerve supply radial nerve
  • 103. extensor indicis origin interosseous membrane and the posterolateral surface of the distal ulna Insertion its tendon joins the tendon of the extensor digitorum to the second digit; both tendons insert into the extensor expansion action extends the index finger at the metacarpophalangeal, proximal interphalangeal and distal interphalangeal joints Nerve supply deep radial nerve
  • 104. extensor pollicis brevis origin interosseous membrane and the posterior surface of the distal radius insertion base of the proximal phalanx of the thumb action extends the thumb at the metacarpophalangeal joint Nerve supply deep radial
  • 105. extensor pollicis longus Origin interosseous membrane and middle part of the posterolateral surface of the ulna insertion base of the distal phalanx of the thumb action extends the thumb at the interphalangeal joint Nerve supply deep radial nerve
  • 106. Nerves of the upper limbs Radial nerve Median nerve Ulnar nerve
  • 107. RADIAL NERVE The radial nerve originates as a terminal branch of the posterior cord of the brachial plexus. It goes through the arm, first in the posterior compartment of the arm, and later in the anterior compartment of the arm, and continues in the posterior compartment of the forearm.
  • 108. In arm From the brachial plexus, it travels posteriorly through what is often called the triangular interval (US) or the triangular space of the axilla (UK). The radial nerve enters the arm behind the axillary artery/brachial artery, and it then travels posteriorly on the medial side of the arm. After giving off branches to the long and medial heads of the triceps brachii, it enters a groove on the humerus, the radial sulcus. Along with the deep brachial artery, the radial nerve winds around in the groove (between the medial and lateral heads of the triceps) towards the forearm, running laterally on the posterior aspect of the humerus. While in the groove, it gives off a branch to the lateral head of the triceps brachii. The radial nerve emerges from the groove on the lateral aspect of the humerus. At this point, it pierces the lateral intermuscular septum and enters the anterior compartment of the arm. It continues its journey inferiorly between the brachialis and brachioradialis muscles. When the radial nerve reaches the distal part of the humerus, it passes anterior to the lateral epicondyle and continues in the forearm
  • 109. Branches/Innervations The following are branches/innervations of the radial nerve (including the superficial branch of the radial nerve and the deep branch of the radial nerve/posterior interosseous nerve). Cutaneous Cutaneous innervation is provided by the following nerves: Posterior cutaneous nerve of arm (originates in axilla) Inferior lateral cutaneous nerve of arm (originates in arm) Posterior cutaneous nerve of forearm (originates in arm) The superficial branch of the radial nerve provides sensory innervation to much of the back of the hand, including the web of skin between the thumb and index finger
  • 110. Transverse section across distal ends of radius and ulna.
  • 111. In forearm In the forearm, it branches into a superficial branch (primarily sensory) and a deep branch (primarily motor). The superficial branch of the radial nerve descends in the forearm under the brachioradialis. It eventually pierces the deep fascia near the back of the wrist. The deep branch of the radial nerve pierces the supinator muscle, after which it is known as the posterior interosseous nerve.
  • 112. Motor Muscular branches of the radial nerve: Triceps brachii Anconeus Brachioradialis Extensor carpi radialis longus Deep branch of the radial nerve: Extensor carpi radialis brevis Supinator Posterior interosseous nerve (a continuation of the deep branch after the supinator): Extensor digitorum Extensor digiti minimi Extensor carpi ulnaris Abductor pollicis longus Extensor pollicis brevis Extensor pollicis longus Extensor indicis
  • 113. The Median nerve is derived from the lateral and medial cords of the Brachial plexus. Disk herniations in the Cervical spine (at the level of C5-C8 and T1) can cause numbness and/or decreased grip-strength in the hand
  • 114. the median nerve courses with brachial artery on medial side of arm between biceps brachii and brachialis. At first lateral to the artery, it then crosses anteriorly to run medial to the artery in the distal arm and into the cubital fossa.
  • 115. The median nerves arises from the cubital fossa and passes between the two heads of pronator teres. It then travels between flexor digitorum superficialis and flexor digitorum profundus before emerging between flexor digitorum superficialis and flexor carpi radialis
  • 116. The unbranched portion of the median nerve innervates muscles of superficial and intermediate groups of the anterior compartment except flexor carpi ulnaris
  • 117. The median nerve does give off two branches as it courses through the forearm: The anterior interosseous branch courses with the anterior interosseous artery and innervates all the muscles of the anterior compartment of the forearm except the flexor carpi ulnaris and the medial (ulnar) half of flexor digitorum profundus. Its ends with its innervation of pronator quadratus. The palmar cutaneous branch of the median nerve arises at the distal part of the forearm. It supplies sensory innervation to the lateral aspect of the skin of the palm (but not the digits).
  • 118. Distribution Arm The median nerve has no voluntary motor or cutaneous function in the (upper) arm. It gives vascular branches to the wall of the brachial artery. These vascular branches carry sympathetic fibers. Forearm It innervates all of the flexors in the forearm except flexor carpi ulnaris and that part of flexor digitorum profundus that supplies the medial two digits. The latter two muscles are supplied by the ulnar nerve (specifically the Muscular branches of ulnar nerve). The main portion of the median nerve supplies the following muscles: Superficial group: Pronator teres Flexor carpi radialis Palmaris longus Intermediate group: Flexor digitorum superficialis muscle The anterior interosseus branch of the median nerve supplies the following muscles: Deep group: Flexor digitorum profundus (only the lateral half) Flexor pollicis longus Pronator quadratus
  • 119. MEDIAN NERVE Branches in the hand The median nerve enters the hand through the carpal tunnel, deep to the flexor retinaculum along with the tendons of flexor digitorum superficialis, flexor digitorum profundus, and flexor pollicis longus. From there it sends off several branches: 1. Recurrent branch to muscles of the thenar compartment (the recurrent branch is also called "the million dollar nerve")[1] 2. Digital cutaneous branches to common palmar digital branch and proper palmar digital branch of the median nerve which supply the: a) lateral (radial) three and a half digits on the palmar side b) index, middle and ring finger on dorsum of the hand The median nerve supplies motor innervation to the first and second lumbrical muscles.
  • 120. Hand In the hand, the median nerve supplies motor innervation to the 1st and 2nd lumbrical muscles. It also supplies the muscles of the thenar eminence by a recurrent thenar branch. The rest of the intrinsic muscles of the hand are supplied by the ulnar nerve.
  • 121. The muscles of the hand supplied by the median nerve can be remembered using the mnemonic, "LOAF" for Lumbricals 1 & 2, Opponens pollicis, Abductor pollicis brevis and Flexor pollicis brevis.
  • 122. The median nerve innervates the skin of the palmar side of the thumb, the index and middle finger, half the ring finger, and the nail bed of these fingers The Opponens pollicis muscle is innervated exclusively by the Median nerve . The inability to firmly hold an object between the index finger and thumb is a classic sign of Median nerve pathology.
  • 123. The lateral part of the palm is supplied by the palmar cutaneous branch of the median nerve, which leaves the nerve proximal to the wrist creases. This palmar cutaneous branch travels in a separate fascial groove adjacent to the flexor carpi radialis and then superficial to the flexor retinaculum. It is therefore spared in carpal tunnel syndrome.
  • 124. ULNAR NERVE Arm The ulnar nerve comes from the medial cord of the brachial plexus, and descends on the posteromedial aspect of the humerus. It goes behind the medial epicondyle, through the cubital tunnel, at the elbow Forearm It enters the anterior (flexor) compartment of the forearm through the two heads of flexor carpi ulnaris and runs alongside the ulna. There it supplies one and a half muscles (flexor carpi ulnaris & medial half of flexor digitorum profundus). It soon joins with the ulnar artery, and the two travel inferiorly together, deep to the flexor carpi ulnaris muscle. In the forearm it gives off the following branches:[2] Muscular branches of ulnar nerve Palmar branch of ulnar nerve Dorsal branch of ulnar nerve
  • 125. Hand After it travels down the ulna, the ulnar nerve enters the palm of the hand. The ulnar nerve and artery pass superficial to the flexor retinaculum, via the ulnar canal The course of the ulnar nerve through the wrist contrasts with that of the median nerve, which travels deep to the flexor retinaculum of the hand and therefore through the carpal tunnel In the hand Ulnar nerve gives Superficial branch of ulnar nerve Deep branch of ulnar nerve
  • 126. HAND ANATOMY AND THE WRIST
  • 127. Carpal bones 1. scaphoid Metacarpal bones 2. lunate 9. I 3. triquetrum 10. II 4. pisiform 11. III 5. trapezium 12. IV 6. trapezoid 13. V 7. capitate 8. hamate hook of hamate Phalanges proximal 14 middle 15 distal 16
  • 128. •flexor retinaculum (FR) •1 scaphoid •2 trapezium median nerve •3 pisiform tendons of flexor digitorum superficialis •4 hamate tendons of flexor digitorum profundus tendon of flexor pollicis longus tendon of flexor carpi radialis
  • 129. Muscles of the Hand From Superficial to Deep The intrinsic muscles of the hand can be arranged into three groups according to either to a region or to depth. Regional groups of muscles are the thenar and hypothenar group. The thenar muscles are three in number and act on the thumb. The hypothenar group are three in number and act on the little finger. The ramainder muscles can be arranged from superficial to deep as shown in the diagrams below. Once the palmar aponeurosis is removed, the first layer is made up of the tendons of the flexor digitorum superficialis. This and the other layers are shown below.
  • 130. Palmar aponeurosis Lumbricals Flexor digitorum superficialis
  • 131. Palmar interossei Dorsal interossei
  • 132. The superficial arterial arch is formed mainly from the ulnar artery and is completed by the superficial branch of the radial. This completion is not always present or may be extremely small. The deep arterial arch is formed mainly by the deep branch of the radial artery and is finished by the deep branch of the ulnar artery.
  • 133. The dorsal venous plexus of the hand and the ensuing cephalic (1) and basilic (2) veins drain the superficial aspects of the hand. The cephalic vein ends up in the axillary vein just before it becomes the subclavian and the basilic vein joins the brachial vein to become the axillary vein.
  • 134. Dorsum of Hand posterior antebrachial cutaneous skin of dorsum of wrist skin of dorsum of thumb and radial nerve 2 1/2 digits as far as the distal interphalangeal joint ulnar 1 1/2 digits and ulnar nerve adjacent part of dorsum of hand
  • 135. palm of hand sensory to skin of ulnar 1 1/2 digits motor to muscles of hypothenar eminence ulnar nerve motor to ulnar two lumbricals motor to 7 interossei motor to adductor pollicis muscle sensory to skin of palmar aspect of thumb and 2 1/2 digits including the skin on the dorsal aspect median nerve of the distal phalanges motor to muscles of thenar eminence motor to radial two lumbrical muscles
  • 136. abductor digiti minimi proximal phalanx of little pisiform ulnar abducts little finger (hypothenar muscle) finger flexor digiti minimi flexor retinaculum proximal phalanx of little ulnar flexes little finger (hypothenar muscle) hook of hamate finger opponens digiti minimi flexor retinaculum opposes little finger to 5th metacarpal ulnar (hypothenar muscle) hook of hamate other digits medial side of 2nd adducts index finger palmar interosseus I medial base of index finger ulnar metacarpal towards middle finger lateral side of 4th adducts ring finger interosseous II lateral base of ring finger ulnar metacarpal towards middle finger lateral side of 5th adducts little finger interosseous III medial base of little finger ulnar metacarpal towards middle finger adjacent sides of lateral aspect of extensor abducts ring finger away dorsal interosseous I ulnar metacarpal bones expansion of ring finger from middle finger adjacent sides of medial aspect of extensor abducts the middle finger dorsal interosseous II ulnar metacarpal bones expansion of middle finger away from its long axis adjacent sides of lateral aspect of extensor abducts the middle finger dorsal interosseous III ulnar metacarpal bones expansion of middle finger away from its long axis abducts the index finger adjacent sides of lateral aspect of extensor dorsal interosseous IV ulnar away from the middle metacarpal bones expansion of index finger finger flex the tendons of flexor lateral aspect of extensor metacarpophalangeal joint lumbricals I & II median digitorum superficialis expansion extend the interphalangeal joints flex the tendons of flexor lateral aspect of extensor metacarpophalangeal joint lumbricals III & IV ulnar digitorum superficialis expansion extend the interphalangeal joints
  • 137. superficial nerves of palm of hand deep nerves of palm of hand dorsum of the hand
  • 138. The Interossei dorsales of left hand. The Interossei volares of left hand.
  • 139. Transverse section across the wrist and digits.
  • 140. Anatomical snuff box The anatomical snuffbox, or radial fossa, (in Latin Foveola radialis), is a triangular deepening on the radial, dorsal aspect of the hand – at the level of the carpal bones, specifically, the scaphoid and trapezium bones forming the floor. The name originates from the use of this surface for placing and then sniffing powdered tobacco, or “snuff.”
  • 141. Anatomical snuff box The boundaries The medial border of the snuffbox is the tendon of the extensor pollicis longus. The lateral border tendons, of the extensor pollicis brevis and the abductor pollicis longus. The proximal border is formed by the styloid process of the radius The distal border is formed by the approximate apex of the schematic snuffbox isosceles triangle. The floor of the snuffbox varies depending on the position of the wrist, but both the trapezium and primarily the scaphoid can be palpated.
  • 142. Deep to the tendons which form the borders of the anatomical snuff box lies the radial artery, which passes through the anatomical snuffbox on its course from the normal radial pulse detecting area, to the proximal space in between the first and second metacarpals to contribute to the superficial and deep palmar arches. The cephalic vein arises within the anatomical snuffbox, while the dorsal cutaneous branch of the radial nerve can be palpated by stroking along the extensor pollicis longus with the dorsal aspect of a fingernail
  • 143. Ligaments Of The Upper Limb The acromio-clavicular ligament joins the acromion process to the clavicle. The coraco-clavicular ligament joins the coracoid process to the clavicle. The coraco-acromial ligament joins the coracoid process to the acromion process. The ligaments of the shoulder-joint are : 1. Capsular. 3. Gleno-humeral. 2. Coraco-humeral. 4. Glenoid The ligaments of the elbow are in the form of a capsule which surrounds the joint on all sides. They are the (1) External lateral, (3) Anterior, (2) Internal lateral, (4) Posterior. The ligaments of the wrist are the (1) Anterior, (3) Internal lateral, (2) Posterior, (4) External lateral. Synovial Membrane.—The pisiform, and the upper metacarpal joint of the thumb, have each a separate synovial membrane. The other carpal and metacarpal joints have a single synovial membrane.
  • 144. The 5 flexor tendon zones in the hand are Zone I consists of the profundus tendon only and is bounded proximally by the insertion of the superficialis tendons and distally by the insertion of the FDP tendon into the distal phalanx. Zone II is often referred to as "Bunnell's no man's land," . Proximal to zone II, the flexor digitorum superficialis (FDS) tendons lie superficial to the flexor digitorum profundus (FDP) tendons. Within zone II and at the level of the proximal third of the proximal phalanx, the FDS tendons split into 2 slips, collectively known as Camper chiasma. These slips then divide around the FDP tendon and reunite on the dorsal aspect of the FDP, inserting into the distal end of the middle phalanx Zone III extends from the distal edge of the carpal ligament to the proximal edge of the A1 pulley, Within zone III, the lumbrical muscles originate from the FDP tendons. The distal palmar crease superficially marks the termination of zone III and the beginning of zone II. Zone IV includes the carpal tunnel and its contents (ie, the 9 digital flexors and the median nerve). Zone V extends from the origin of the flexor tendons at their respective muscle bellies to the proximal edge of the carpal tunnel.
  • 145. Flexor tendons with attached vincula. Membranous portion of the flexor tendon Retinacular portion of the flexor tendon sheath sheath (pulley system).
  • 146. Flexor Muscles of the Digits The forearm can be divided anatomically into anterior and posterior compartments. The anterior compartment contains the flexor-pronator group of muscles, most of which arise from a common flexor attachment on the medial epicondyle of the humerus. The 8 muscles of the anterior compartment may be divided further into 3 distinct functional groups, as follows: (1) muscles that rotate the radius on the ulna, (2) (2) muscles that flex the wrist, and (3) (3) muscles that flex the digits. The muscles that flex the digits include the flexor digitorum profundus (FDP), flexor digitorum superficialis (FDS), and the flexor pollicis longus (FPL).
  • 147. Digital Flexor Sheath The digital flexor sheath is a closed synovial system consisting of both membranous and retinacular portions. The membranous portion comprises visceral and parietal layers that invest the flexor digitorum profundus (FDP) and flexor digitorum superficialis (FDS) tendons in the distal aspect of the hand. The retinacular component consists of tissue condensations arranged in cruciform, annular, and transverse patterns that overlie the membranous, or synovial, lining. The digital flexor sheath has been proposed to have a 3-fold function, as follows: (1) it facilitates smooth gliding of the tendons; (2) the retinacular component acts as a fulcrum, adding a mechanical advantage to flexion; (3) it is a contained system, or bursa, with synovial fluid bathing the tendons and aiding in their nutrition.
  • 148. The membranous portion of the sheath appears macroscopically as a number of cul-de-sacs, or plicae, that interdigitate between both the tendons and the retinacular tissue condensations. The first cul-de-sac is located approximately 10-14 mm proximal to the distal metacarpal head and represents the point of transition between the parietal and visceral layers of synovium. This outpouching occurs for each separate tendon, in effect forming 2 separate plicae. (Note that this is true only for the middle 3 rays of the hand. In most instances, both the first- and fifth-digit synovial layers begin much more proximally at the level of the wrist, and are referred to as the radial and ulnar bursa, respectively.)
  • 149. Distally, the parietal layer of synovium forms plicae between each of the retinacular elements of the pulley system. The synovium ends distally, forming a final single cul-de-sac prior to the insertion of the FDP tendon on the distal phalanx.
  • 150. Extensor Tendon Zones of hand. The dorsum of the hand, wrist, and forearm are divided into 8 anatomic zones Zone 1 (distal interphalangeal [DIP] joint) Zone 2 (middle phalanx) Zone 3 (proximal interphalangeal [PIP] joint) Zone 4 (proximal phalanx) Zone 5 (metacarpophalangeal [MCP] joint) Zone 6 (dorsum of hand) Zone 7 (wrist) Zone 8 (dorsal forearm)
  • 151. Thenar eminence The muscles in this location are usually innervated by the recurrent branch of the median nerve. They all control movement of the thumb. The following three muscles are considered part of the thenar eminence: Abductor pollicis brevis abducts the thumb. This muscle is the most proximal of the thenar group. Flexor pollicis brevis, which lies next to the abductor, will flex the thumb, curling it up in the palm. Opponens pollicis lies deep to abductor pollicis brevis. As its name suggests it opposes the thumb, bringing it against the fingers. This is a very important movement, as most of our dexterity comes from this action. The innervation of these muscles by the median nerve is unusual, as most of the intrinsic muscles on the palm of the hand are supplied by the ulnar nerve. The lateral two lumbrical muscles are the other exception. Another muscle that controls movement of the thumb is adductor pollicis. It lies deeper and more distal to flexor pollicis brevis. Despite its name, its main action is mainly rotation and opposition. It is not in the thenar group of muscles, so is supplied by the ulnar nerve.[3] The muscles of hand can be remembered using the mnemonic, "A OF A OF A" for, Abductor pollicis longus, Opponens pollicis, Flexor pollicis brevis, Adductor pollicis (thenar muscles) and Opponens digiti minimi, Flexor digiti minimi, Abductor digiti minimi (hypothenar muscles). [4]
  • 152. Nerve Innervation The Opponens pollicis and Abductor pollicis brevis are normally innervated by the median nerve. The Flexor pollicis brevis can be innervated by the median or ulnar nerve. The adductor pollicis is typically innervated by the ulnar nerve. There are normal variations. In a Cannieu-Riche anastomasis, fibers from the deep palmar branch of the ulnar nerve innervate the opponens pollicis and/or abductor pollicis brevis. Regardless of their final innervation, the nerves that reach the thenar muscles arise from the C8 and T1 roots, pass through the lower trunk of the plexus, and then through the lateral cord of the plexus. The ulnar nerve is exclusively responsible for the innervations of the hypothenar eminence. Both nerves contribute to the innervations of the midpalmar group[5].
  • 153. Mnemonic A good way to remember what muscles are in the thenar eminence is "OAF"; oafs have big thenar eminences. 'O' = opponens, 'A' = abductor, 'F' = flexor. There is only one opponens. The other two muscles each have a long partner and thus are called "brevis." Meat-LOAF: the "M" in the word "Meat" helps you remember that the LOAF muscles of the hand are innervated by the Median Nerve ABOF (pronounced "above") the Law muscles. The law states muscles of the hand are supplied by ulnar nerve. However, ABOF the Law muscles are supplied by MEDIAN nerve. 'AB' = abductor, 'O' = Opponens, 'F' = Flexor, Law 'L' = Lateral Lumbricals (2). MAINTAINER --Main(Median nerve) --Tainer(thenar muscles)

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