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Upper Limb Introduction
Dr.Rikki Deogade
Department of Anatomy
DMMC
Nagpur
Anatomical Planes
- Sagittal
- Coronal
- Axial
(= Transverse or Horizontal)
Anterior - Posterior
Medial - Lateral
Superior - Inferior
Proximal - Distal
Cranial - Caudal
Rostral
Superficial - Deep
Ipsilateral - Contralateral
Note
Proximal - Distal used
differently in limbs vs.
nerves, blood vessels,
airways, urinary tract and
reproductive organs
Overview
• Shoulder
• Arm
• Forearm
• Hand
Overview
• Bones
• Bones
• Areas of transition
Overview
Upper limb movements
Upper limb
movements
Upper limb movements
Upper limb movements
Upper limb movements
Innervation of the Upper Limb
Limbs Develop on the
Hypaxial = Ventral = Anterior
Side of the Trunk
• Most of the muscles that
attach to the girdle and
limb are hypaxial
muscles
• Thus, they are
innervated by branches
of anterior rami of spinal
nerves
• The only exceptions are the
trapezius and SCM that are
not hypaxial muscles and are
innervated by cranial nerve XI
Posterior rami to epaxial muscles
Including erector spinae et al.
Anterior rami to
hypaxial muscles
including the upper and
lower limb muscles
Epaxial
Hypaxial
The Trapezius and Sternocleidomastoid
Only muscles acting directly on the upper limb
that are not innervated by branches of anterior
primary rami of spinal nn.
Trapezius
Trapezius
Trapezius
Innervated by spinal
accessory n. (CN XI)
SCM
SCM
Limbs have posterior and anterior
“halves”relative to their internal axis
• Limb girdle with
posterior and
anterior elements
• Limb skeleton in
plane of separation
• Nerves with dorsal
and ventral divisions
• Muscles in posterior
(extensor) and
anterior (flexor)
groups
Posterior limb
muscles and nerve
branches
Anterior limb muscles
and nerve branches
Bones in central
plane of the limb
Overview
Anterior Compartment of Arm
Biceps (short
head)
Biceps (long
head)
Triceps (long
head)
Triceps brachii = “three-headed
arm muscle”
• Origin –
– infraglenoid tubercle of the
scapula (long head)
– posterior surface of
humerus, superior (lateral
head)
– inferior to the radial groove
(medial head)
• Insertion – olecranon of ulna
• Innervation – axillary (LH) and
radial nerve
• Action – extension of arm and
forearm
Triceps (medial
head)
Triceps (lateral head) -
CUT
Muscles in the posterior
compartments of arm AND forearm
are innervated by radial n.
Posterior Compartment of Arm
Asyou look down atyour left
elbow in anatomicalposition: a
clockwise rotation
Ulna
L Radius
Posterior
M
Radial n
Median n
Ulnar n
Anterior
L M
Radial n
Median n Ulnar n
Radius Ulna
Brachioradialis
& supinator
Idealized LeftArm
Actual LeftArm
Asyou look down atyour left
elbow in anatomical position
Compartments of the forelimb
L M
Anterior right limb Posterior left limb
L M
Radius Ulna
Posterior
Anterior
L M
L M
Compartments of the forelimb
Part ulnar
Ulnar
Radial
Radial
Anterior Compartment of the Arm – Mostly Median
Intrinsic Muscles of Hand – Mostly Ulnar
Median
Limb innervation
• Limbs are multi-segmental
• They are supplied by multiple nerve
segments
Randy Travis Drinks Cold (Root) Beer
Randy Travis
The Brachial Plexus
Musculocutaneous n.
Muscles of anterior
compartment of arm
Ulnar n.
Most Muscles of anterior
hand; fl.carp.ul. and medial
½ fl.dig.prof in anterior
forearm
Radial n.
Median n.
Most Muscles of anterior
compartment of forearm;
thenar muscles in hand
All Muscles of posterior
compartment of arm
(except LHT) and forearm.
There are no posterior
muscles in hand.
Upper Limb: Major motor nerves
Axillary n.
Deltoid, Teres minor and
Long head of triceps
Suprascapular n.
Supraspinatus; Infraspinatus
Inf. Subscapular n.
Subscapularis, Teres Major
AXILLARY
Thoracodorsal n.
Latissimus Dorsi
Sup. Subscapular n.
Subscapularis
Med. Pectoral n.
Pectorales Maj. et Min.
Nerve to Subclavius
Subclavius
Dorsal Scapular n.
Rhomboids,
Levator scapulae
Long Thoracicn.
Serratus Anterior
Lat. Pectoral n.
Pectoralis Major
C5
C6
C7
C8
T1
C7
ULNAR
MEDIAN
2nd Part Ax. A.
The Brachial Plexus
Med. Cutaneous n. of arm
Med. Cutaneous n. of forearm
RADIAL
MUSCULOCUTANEOUS
It can be helpful to
organize the smaller
motor branches of the
brachial plexus into
posterior and anterior
groups
The Brachial Plexus
Limb innervation
• Dermatomes make sense
from a developmental
perspective
• Arranged superior to inferior
in sequence in an arc
following the central axis of
the limb
Dermatome Maps vs Peripheral Nerve Maps
It is important to understand that peripheral nerves contain fibers from multiple
spinal cord levels and nerve maps are not the same as dermatomes
Avulsion - spinal nerve torn from spinal cord
Rupture - spinal nerve torn beyond CNS
Neuroma - spinal nerve torn and partially healed
Neuropraxia - spinal nerve stretched and damaged
(most common)
Testing Nerves of the Upper Limb
Testing Nerve Function
Symptoms
Anesthesia - Loss of Sensation
Paresthesia – Abnormal sensations e.g., “Pins and Needles”
Paralysis - Loss of Motor Control & Abnormal Limb Postures
If damage is at level of spinal nerve
- both anesthesia and paralysis
- effects entire dermatome and myotome
If damage is more peripheral
- effects more localized region
- may only include anesthesia or paralysis
- can include parts of dermatomes and myotomes
of multiple spinal nerves
Testing myotomes
Testing Nerves of the Upper Limb
Testing spinal level deficits
Dermatomes– Spinal nerves
• Dermatomes overlap
• Minimal areas of overlap (used
for testing):
– C5 – upper lateral arm
– C6 – Pad of thumb (I)
– C7 – Pad of middle finger (III)
– C8 – Pad of little finger (V)
– T1 – Medial elbow
Evaluation of derma- and myotomes may provide important information about
potential breathing problems that may develop (C3-5 is phrenic nerve!)
C3
C4
C5
C6
C7
C8
T1
T2
C8
T1
T2
C3
Brachial plexus injuries
- Upper brachial plexus injuries (Erb-Duchenne palsy)
- Damage to root of C5 and C6
- Traumatic lateral neck bending
- during childbirth
- from fall on shoulder
- Paralysis or weakness of shoulder and arm
- Deltoid, biceps, brachialis and brachioradialis
- “Waiter’stip”position
- adducted and medially rotated arm
- extended elbow
Testing Nerves of the Upper Limb
Waiter’sTip Position
Brachial plexus injuries
Upper brachial plexus injuries (Erb-Duchenne palsy)
Testing Nerves of the Upper Limb
Brachial plexus injuries
- Lower brachial plexus injuries (Klumpke Palsy)
- Damage to roots of C8 and T1
- From traumatic hyper-abduction of arm
- childbirth
- Spiderman (?)
- Paralysis or weakness of most intrinsic muscles of hand
- results in “Claw hand”
Testing Nerves of the Upper Limb
Testing Nerves of the Upper Limb
Accessory n.
Test trapezius function
- elevate scapula (shrug) against resistance while
palpating superior border of muscle
(Trapezius)
(Trapezius)
Axillary Nerve
Common Causes
- Fracture of surgical neck of humerus
- Dislocation of glenohumeral joint
- Improper use of crutches
- Intramuscular injections
Testing Nerves of the Upper Limb
Axillary Nerve
Motor
- paralysis of deltoid
- atrophy of deltoid
Testing Nerves of the Upper Limb
Axillary Nerve
Sensory
- loss of sensation on lateral shoulder
- superior lateral cutaneous n. of arm
Testing Nerves of the Upper Limb
Thoracodorsal n.
Test function of Latissimus dorsi
- arm abducted 90˚
-adducted against resistance while
anterior border of muscle is palpated
Susceptible to injury during surgery in inferior part of axilla
Testing Nerves of the Upper Limb
SERRATUS ANTERIOR and LONG THORACIC
NERVE
Serratus anterior m.
Long thoracic nerve
Lateral thoracic artery
Injury to the Long Thoracic Nerve
(C5, 6, 7)
results in a ‘winged scapula’
Musculocutaneous nerve
Testing Nerves of the Upper Limb
Coracobrachia
lis 1 joint
Biceps long
head 2 joints
Biceps short
head 2 joints
Sensory
- Loss of sensation on lateral
surface of forearm
- Lateral cutaneus n. of forearm
Motor
- biceps,
coracobrachialis and
brachialis
- weak elbow flexion
and forearm
supination
Bicipital Reflex
Tests musculocutaneous n. and C5,C6 spinal nerves
Testing Nerves of the Upper Limb
Radial nerve
Motor
- Triceps, brachioradialis, supinator
and extensors of wrist and fingers
- “Wristdrop”- patient unable to extend wrist
- if lesion is beyond humerus, triceps not effected
Sensory
-Loss of sensation on lateral elbow, posterior
forearm and dorsum of hand
-Inferior lateral cut. n. of arm, post. cut. n. of
forearm, and superficial branch of radial nerve
Testing Nerves of the Upper Limb
Median nerve
Motor
- Finger and wrist flexors (most), thenar muscles
and 1st and 2nd lumbricals
- Can’tflex proximal IP joints of digits 1-3
- Can’tflex distal IP joints on digits 2 and 3
- “Benediction hand”when attempting to make fist
Testing Nerves of the Upper Limb
Median nerve
Sensory
- loss of sensation in
lateral palm and tips of
digits 1-3
Testing Nerves of the Upper Limb
Testing Nerves of the Upper Limb
Ulnar nerve
Motor
- Flexor carpi ulnaris, medial part of FDP, most intrinsic hand muscles
- Wrist adduction impared
- Lateral deviation of wrist flexion
- MP joints become hyperextended
- Cannot flex digits 4 and 5 when making a fist
Sensory
- loss of sensation in medial
palm and tip of digit 5

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Upper limb full intro

  • 1. Upper Limb Introduction Dr.Rikki Deogade Department of Anatomy DMMC Nagpur
  • 2. Anatomical Planes - Sagittal - Coronal - Axial (= Transverse or Horizontal) Anterior - Posterior Medial - Lateral Superior - Inferior Proximal - Distal Cranial - Caudal Rostral Superficial - Deep Ipsilateral - Contralateral Note Proximal - Distal used differently in limbs vs. nerves, blood vessels, airways, urinary tract and reproductive organs
  • 5. • Bones • Areas of transition Overview
  • 11. Innervation of the Upper Limb
  • 12. Limbs Develop on the Hypaxial = Ventral = Anterior Side of the Trunk • Most of the muscles that attach to the girdle and limb are hypaxial muscles • Thus, they are innervated by branches of anterior rami of spinal nerves • The only exceptions are the trapezius and SCM that are not hypaxial muscles and are innervated by cranial nerve XI Posterior rami to epaxial muscles Including erector spinae et al. Anterior rami to hypaxial muscles including the upper and lower limb muscles Epaxial Hypaxial
  • 13. The Trapezius and Sternocleidomastoid Only muscles acting directly on the upper limb that are not innervated by branches of anterior primary rami of spinal nn. Trapezius Trapezius Trapezius Innervated by spinal accessory n. (CN XI) SCM SCM
  • 14. Limbs have posterior and anterior “halves”relative to their internal axis • Limb girdle with posterior and anterior elements • Limb skeleton in plane of separation • Nerves with dorsal and ventral divisions • Muscles in posterior (extensor) and anterior (flexor) groups Posterior limb muscles and nerve branches Anterior limb muscles and nerve branches Bones in central plane of the limb
  • 16. Anterior Compartment of Arm Biceps (short head) Biceps (long head)
  • 17. Triceps (long head) Triceps brachii = “three-headed arm muscle” • Origin – – infraglenoid tubercle of the scapula (long head) – posterior surface of humerus, superior (lateral head) – inferior to the radial groove (medial head) • Insertion – olecranon of ulna • Innervation – axillary (LH) and radial nerve • Action – extension of arm and forearm Triceps (medial head) Triceps (lateral head) - CUT Muscles in the posterior compartments of arm AND forearm are innervated by radial n. Posterior Compartment of Arm
  • 18. Asyou look down atyour left elbow in anatomicalposition: a clockwise rotation Ulna L Radius Posterior M Radial n Median n Ulnar n Anterior L M Radial n Median n Ulnar n Radius Ulna Brachioradialis & supinator Idealized LeftArm Actual LeftArm Asyou look down atyour left elbow in anatomical position Compartments of the forelimb
  • 19. L M Anterior right limb Posterior left limb L M Radius Ulna Posterior Anterior L M L M Compartments of the forelimb
  • 20.
  • 22. Intrinsic Muscles of Hand – Mostly Ulnar Median
  • 23. Limb innervation • Limbs are multi-segmental • They are supplied by multiple nerve segments
  • 24. Randy Travis Drinks Cold (Root) Beer Randy Travis The Brachial Plexus
  • 25. Musculocutaneous n. Muscles of anterior compartment of arm Ulnar n. Most Muscles of anterior hand; fl.carp.ul. and medial ½ fl.dig.prof in anterior forearm Radial n. Median n. Most Muscles of anterior compartment of forearm; thenar muscles in hand All Muscles of posterior compartment of arm (except LHT) and forearm. There are no posterior muscles in hand. Upper Limb: Major motor nerves Axillary n. Deltoid, Teres minor and Long head of triceps
  • 26. Suprascapular n. Supraspinatus; Infraspinatus Inf. Subscapular n. Subscapularis, Teres Major AXILLARY Thoracodorsal n. Latissimus Dorsi Sup. Subscapular n. Subscapularis Med. Pectoral n. Pectorales Maj. et Min. Nerve to Subclavius Subclavius Dorsal Scapular n. Rhomboids, Levator scapulae Long Thoracicn. Serratus Anterior Lat. Pectoral n. Pectoralis Major C5 C6 C7 C8 T1 C7 ULNAR MEDIAN 2nd Part Ax. A. The Brachial Plexus Med. Cutaneous n. of arm Med. Cutaneous n. of forearm RADIAL MUSCULOCUTANEOUS It can be helpful to organize the smaller motor branches of the brachial plexus into posterior and anterior groups
  • 28. Limb innervation • Dermatomes make sense from a developmental perspective • Arranged superior to inferior in sequence in an arc following the central axis of the limb
  • 29.
  • 30.
  • 31. Dermatome Maps vs Peripheral Nerve Maps It is important to understand that peripheral nerves contain fibers from multiple spinal cord levels and nerve maps are not the same as dermatomes
  • 32. Avulsion - spinal nerve torn from spinal cord Rupture - spinal nerve torn beyond CNS Neuroma - spinal nerve torn and partially healed Neuropraxia - spinal nerve stretched and damaged (most common) Testing Nerves of the Upper Limb
  • 33. Testing Nerve Function Symptoms Anesthesia - Loss of Sensation Paresthesia – Abnormal sensations e.g., “Pins and Needles” Paralysis - Loss of Motor Control & Abnormal Limb Postures If damage is at level of spinal nerve - both anesthesia and paralysis - effects entire dermatome and myotome If damage is more peripheral - effects more localized region - may only include anesthesia or paralysis - can include parts of dermatomes and myotomes of multiple spinal nerves
  • 34. Testing myotomes Testing Nerves of the Upper Limb
  • 36. Dermatomes– Spinal nerves • Dermatomes overlap • Minimal areas of overlap (used for testing): – C5 – upper lateral arm – C6 – Pad of thumb (I) – C7 – Pad of middle finger (III) – C8 – Pad of little finger (V) – T1 – Medial elbow Evaluation of derma- and myotomes may provide important information about potential breathing problems that may develop (C3-5 is phrenic nerve!) C3 C4 C5 C6 C7 C8 T1 T2 C8 T1 T2 C3
  • 37. Brachial plexus injuries - Upper brachial plexus injuries (Erb-Duchenne palsy) - Damage to root of C5 and C6 - Traumatic lateral neck bending - during childbirth - from fall on shoulder - Paralysis or weakness of shoulder and arm - Deltoid, biceps, brachialis and brachioradialis - “Waiter’stip”position - adducted and medially rotated arm - extended elbow Testing Nerves of the Upper Limb
  • 38. Waiter’sTip Position Brachial plexus injuries Upper brachial plexus injuries (Erb-Duchenne palsy) Testing Nerves of the Upper Limb
  • 39. Brachial plexus injuries - Lower brachial plexus injuries (Klumpke Palsy) - Damage to roots of C8 and T1 - From traumatic hyper-abduction of arm - childbirth - Spiderman (?) - Paralysis or weakness of most intrinsic muscles of hand - results in “Claw hand” Testing Nerves of the Upper Limb
  • 40. Testing Nerves of the Upper Limb Accessory n. Test trapezius function - elevate scapula (shrug) against resistance while palpating superior border of muscle (Trapezius) (Trapezius)
  • 41. Axillary Nerve Common Causes - Fracture of surgical neck of humerus - Dislocation of glenohumeral joint - Improper use of crutches - Intramuscular injections Testing Nerves of the Upper Limb
  • 42. Axillary Nerve Motor - paralysis of deltoid - atrophy of deltoid Testing Nerves of the Upper Limb
  • 43. Axillary Nerve Sensory - loss of sensation on lateral shoulder - superior lateral cutaneous n. of arm Testing Nerves of the Upper Limb
  • 44. Thoracodorsal n. Test function of Latissimus dorsi - arm abducted 90˚ -adducted against resistance while anterior border of muscle is palpated Susceptible to injury during surgery in inferior part of axilla Testing Nerves of the Upper Limb
  • 45. SERRATUS ANTERIOR and LONG THORACIC NERVE Serratus anterior m. Long thoracic nerve Lateral thoracic artery Injury to the Long Thoracic Nerve (C5, 6, 7) results in a ‘winged scapula’
  • 46. Musculocutaneous nerve Testing Nerves of the Upper Limb Coracobrachia lis 1 joint Biceps long head 2 joints Biceps short head 2 joints Sensory - Loss of sensation on lateral surface of forearm - Lateral cutaneus n. of forearm Motor - biceps, coracobrachialis and brachialis - weak elbow flexion and forearm supination
  • 47. Bicipital Reflex Tests musculocutaneous n. and C5,C6 spinal nerves Testing Nerves of the Upper Limb
  • 48. Radial nerve Motor - Triceps, brachioradialis, supinator and extensors of wrist and fingers - “Wristdrop”- patient unable to extend wrist - if lesion is beyond humerus, triceps not effected Sensory -Loss of sensation on lateral elbow, posterior forearm and dorsum of hand -Inferior lateral cut. n. of arm, post. cut. n. of forearm, and superficial branch of radial nerve Testing Nerves of the Upper Limb
  • 49. Median nerve Motor - Finger and wrist flexors (most), thenar muscles and 1st and 2nd lumbricals - Can’tflex proximal IP joints of digits 1-3 - Can’tflex distal IP joints on digits 2 and 3 - “Benediction hand”when attempting to make fist Testing Nerves of the Upper Limb
  • 50. Median nerve Sensory - loss of sensation in lateral palm and tips of digits 1-3 Testing Nerves of the Upper Limb
  • 51. Testing Nerves of the Upper Limb Ulnar nerve Motor - Flexor carpi ulnaris, medial part of FDP, most intrinsic hand muscles - Wrist adduction impared - Lateral deviation of wrist flexion - MP joints become hyperextended - Cannot flex digits 4 and 5 when making a fist Sensory - loss of sensation in medial palm and tip of digit 5