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Dr / Ahmed Salah Ashour(Ph.D.)
Associate professor of human anatomy
Dr.Ahmedashour@gmu.ac.ae
USMLE Clinical Anatomy
NERVES
Injuries to the nerves of the upper limb can result from trauma, compression,
lacerations, or certain medical conditions. Nerve injuries may lead to various
symptoms, including pain, weakness, numbness, or loss of function in specific areas
of the upper limb. Nerve injuries may range from mild to severe, and appropriate
medical evaluation and treatment are essential. Physical therapy, splinting,
medications, or in some cases, surgical intervention may be recommended based on
the type and severity of the nerve injury. Early intervention is crucial for optimal
recovery.
ā€¢ Roots
C.5,6,7, 8 and Th1
ā€¢ Trunks
Upper trunk
Middle trunk
Lower trunk
BRACHIAL PLEXUS
NERVE ROOT
AXILLARY C 5,6
MUSCULSKELETAL C 5,6,7
RADIAL C 5,6,7,8 T1
MEDIAN C 5,6,7,8 T1
ULNAR C 7,8 T1
ā€¢ Divisions & cords
Each trunk divides into anterior or ventral division and posterior or dorsal division
ā€¢ Cords:
A- The lateral cord
is formed by union of the anterior divisions of the upper and middle trunks.
B- The medial cord
is formed by the anterior division of the lower trunk only.
C- The posterior cord
is formed by union of the posterior divisions of the 3 trunks.
ā€¢ Branches of Roots:
- n. to seRRatus anterior (long thoracic)
C5, 6, 7
- n. to Rhomboids (Dorsal Scapular
Nerve)
C5
N. to serratus anterior (long thoracic)
c5, 6, 7
serratus anterior
Scapula winging
Damage to the long thoracic [C5-7]
nerve may lead to ā€œwingingā€ of the
scapula, most evident when a patient
pushes forward with the upper limb
against resistance.
This type of nerve injury may occur from
ā€¢ Trauma to the lateral thoracic wall
ā€¢ Lateral flexion of the neck to the
opposite side
ā€¢ Radical mastectomy .
Clinical Insight
Complicated right Radical mastectomy
Clinical Insight
N. to Rhomboids (Dorsal Scapular Nerve)
C5
Clinical Insight
DSN damage
Damage to the dorsal scapular nerve can weaken
the rhomboid muscles, resulting in an ipsilateral
lateral shift of the scapula.
ā€¢ Branches of upper trunk :
SUPRA-scapular nerve.
Nerve to SUB-clavius.
Supra-scapular nerve.
ā€¢ Branches of Lateral cord:
Lateral pectoral nerve.
Lateral root of median nerve,
MuscuLo-cutaneous nerve.
lateral cord
lateral pectoral nerve
musculo-cutaneous nerve
lateral root of median nerve
median nerve
ā€¢ Branches of Medial cord:
Medial pectoral nerve.
Medial root of median nerve.
Medial cutaneous nerve of arm
Medial cutaneous nerve of forearm.
Ulnar nerve
Medial cord
Medial pectoral nerve
Medial root of median nerve
Medial cutaneous nerve of forearm
Ulnar nerve
Medial cutaneous nerve of arm
ā€¢ Branches of Posterior cord
Upper subscapulra
Lower subscapular nerves
N. to latissimus dorsi [Thoraco-dorsal
nerve ]
Axillary nerve
Radial n
Posterior cord
Upper subscapular
Radial
Axillary
Lower subscapular
N. to latissimus dorsi
(Thoraco-dorsal)
Obstetric Brachial Plexus Palsy
(OBPP)
is defined as brachial plexus nerve injury
that occurs during early delivery.
OBBP commonly happen during delivery
process and resulting in overstretch of
the neck.
Erbā€™s Palsy which involved the upper
brachial plexus (C5, C6 & C7)
Klumpkeā€™s Palsy involves forearm and
hand . (C8 & T1)
Clinical Insight
Erbā€™s palsy
Extended elbow
Flexed wrist
Klumpkeā€™s palsy
Claw hand
ā€¢ Course
In the arm:
The nerve descends lateral to the upper part of
the brachial artery then crosses in front of it to
run along its medial side to reach the cubital
fossa.
MEDIAN NERVE C 5,6,7,8 T1
median nerve
brachial artery
cubital fossa
median nerve
brachial artery
cubital fossa
It then runs exactly in the midline of
forearm deep to the flexor digitorum
superficialis
median nerve
brachial artery
cubital fossa
flexor digitorum superficialis
Median nerve + palmaris longus
By having the patient make a tight fist,
one can determine if the patient
possesses the palmaris longus muscle, as
its tendon will appear in the mid wrist.
The median nerve lies just lateral to the
tendon of this muscle before entering the
carpal tunnel.
Clinical Insight
Median nerve
Lateral division
Medial division
In the hand:
divides into lateral and medial divisions
ā€¢ Branches
It supplies all flexor muscles of the front of forearm
except
1- Flexor polices + lateral Ā½ FDP
2- FCU+ medial Ā½ of FDP
Flexor polices
FDP
median n.
FCU
Ulnar n.
N.B: FCU+ medial Ā½ of FDP supplied by ulnar
Flexor polices
FDP
median n.
FCU
Ulnar n.
median n.
ant interosseous of median
Flexor polices
FDP
N.B: Flexor polices + lateral Ā½ FDP supplied by ant interosseous
of median
N.B: anterior interosseous nerve supplies 3 muscles
1. - Flexor pollicis longus
2. - Lateral 1/2 of the flexor digitorum profundus
3. - Pronator quadratus median n.
ant interosseous of median
Flexor polices
FDP
Pronator quadratus
In hand
a) Lateral division
ā€¢ 3 muscles of the thenar eminence by
recurrent motor branch
ā€¢ 1st lumbrical muscle
ā€¢ 3 digital branches: To thumb and index
Recurrent motor branch to thenar eminence
3 digital branches
Branch to 1st lumbrical muscle
Lateral division
Medial division
Carpal Tunnel Syndrome
Entrapment of the median nerve and
other structures in the carpal tunnel due
to any condition that reduces the space
results in carpal tunnel syndrome.
Clinical Insight
Carpal Tunnel Syndrome
The median nerve is the only nerve affected in
Carpal Tunnel Syndrome
and the patient will present with:
ā€¢ Atrophy and weakness of the thenar
compartment muscles (opposition of the
thumb-ape hand) .
ā€¢ There is also sensory loss and numbness on
the palmar surfaces of the lateral 3 Ā½ digits.
Clinical Insight
Ape hand
Carpal Tunnel Syndrome
Note that the skin on the lateral side of
the palm (thenar eminence) is healthy in
Carpal Tunnel Syndrome because the
palmar cutaneous branch of the median
nerve which supplies the lateral palm
enters the hand superficial to the flexor
retinaculum and does not course through
the carpal tunnel.
Clinical Insight
Lacerations of thenar eminence
The recurrent branch of the median nerve lies
somewhat superficial in the palm.
Lacerations across the palm and thenar eminence
may cut.
Therefore, clinically, physician must carefully test
the integrity of these muscles in case of hand
lacerations.
Clinical Insight
Clinical Insight
Ape hand deformity
is a condition in which the thumb is
permanently rotated and adducted,
resulting in a loss of its opposable
function.
This deformity is caused by damage to
the median nerve, which supplies the
muscles that control the thumb
b) Medial division:
ā€¢ 2nd lumbrical muscle
ā€¢ 4 digital branches: to adjacent sides of
the index and middle fingers and to
adjacent sides of the middle and ring
fingers.
Lateral division
Branch to 2nd lumbrical muscle
4 digital branches
Medial division
Median nerve entrapment
The median nerve is liable for entrapment at the carpal tunnel as part of carpal
tunnel syndrome.
Clinical Insight
carpal tunnel
In the axilla and arm:
It descends medial to the brachial artery and contiues
back of the medial epicondyle.
In the forearm
descends deep to flexor carpi ulnaris
ULNAR NERVE C 5,6,7,8 T1
brachial artery
ulnar nerve
flexor carpi ulnaris
Cubital tunnel syndrome
As the ulnar nerve passes between the 2 heads
of the flexor carpi ulnaris, the nerve can
become compressed, leading to a cubital tunnel
syndrome.
Compression may be especially acute as the
elbow is flexed because this narrows the space
between the 2 muscle heads.
Clinical Insight
Elbow ulnar neuropathy
Ulnar neuropathy at the elbow presents with
ā€¢ Paresthesia over digits 4 and 5
ā€¢ Weakness of the flexor muscles of the forearm (wrist
and finger flexion)
ā€¢ Weakness of the intrinsic muscles of the hand (hand
grip).
Clinical Insight
In the hand:
divides into superficial and deep terminal branches
Ulnar nerve
Superficial terminal branches
Deep terminal branches
ā€¢ Branches
1- Branch to flexor carpi ulnaris.
2- Branch to medial 1/2 of the flexor
digitorum profundus.
Ulnar nerve
flexor carpi ulnaris.
flexor digitorum profundus.
Medial 1/2 of the flexor digitorum profundus
Lateral 1/2 of the flexor digitorum profundus
Ulnar nerve
Ant. Interosseous nerve
Of
Median nerve
3- Palmar cutaneous branch:
supply the medial 1/3 of the palm
4- Dorsal cutaneous branch:
supply the medial 1/3 of the back of the
hand
Ulnar nerve
Dorsal cutaneous branch
Palmar cutaneous branch
Dorsal cutaneous branch
5- Superficial terminal branch
ā€¢ Two palmar digital branches:
medial 1.5 fingers.
ā€¢ Branch to the palmaris brevis
muscle
6- Deep terminal branch;
ā€¢ All muscles of the hand except
Ć¼ Thenar muscles
Ć¼ Lateral two lumbricals
Ulnar nerve
Deep terminal branch
Superficial terminal branch
2 palmar digital branches
palmaris brevis muscle
Ulnar nerve + bone fracture
The ulnar nerve is vulnerable with a fracture of the medial epicondyle of the
humerus (at the elbow) or a wrist fracture on the hamate bone.
Clinical Insight
Claw hand
Ulnar nerve injury can present as a claw
hand and an inability to effectively use
the ring and little fingers, as well as a
loss of abduction and adduction of the
2nd to 5th digits.
Clinical Insight
claw hand
It enters the spiral groove at back of arm.
RADIAL NERVE C 5,6,7,8 T1
radial nerve in spiral groove
After leaving the spiral groove the nerve is divided into
Ƙ superficial division ( loop to back of forearm deep to
brachioradialis )
Ƙ deep division ( loop in mass of supinator and continue
in back of forearm) radial nerve
deep division
supinator
superficial division
brachioradialis
Fracture shaft humerus
As the radial nerve passes around the
shaft of the humerus, fractures of the
shaft of the humerus can place the radial
nerve in jeopardy of being stretched or
torn as it wraps around the humerus,
affecting wrist and finger extensors.
Clinical Insight
About 5 cm above the wrist, the superficial
division of the nerve winds round the lateral side
of the radius to reach the back of the hand
About 5 cm above the wrist, the superficial division of the nerve
winds round the lateral side of the radius to reach the back of
the hand
ā€¢ Branches
Before spiral groove:
1- Long head of triceps
2- Medial head of triceps
radial nerve
Long head of triceps
Medial head of triceps
In the spiral groove:
3- Lateral head of triceps
4- Medial head of triceps
radial nerve
Lateral head of triceps
Medial head of triceps
On the lateral side of arm;
5- A branch to lateral part of brachialis.
6- A branch to brachioradialis.
7- A branch to extensor carpi radialis
longus.
8- A branch to anconeus
radial nerve
brachialis.
brachioradialis.
extensor carpi
radialis longus.
In the forearm and hand:
9- Posterior Interosseous Nerve (continuation of radial deep
division.
ā€¢ PIN, supplies all extensor compartment, except:
ā€¢
radial main trunk
ā€¢
radial superficial division
ā€¢
radial deep division
ā€¢
Posterior interosseous nerve
ā€¢
radial superficial division
Anconeus Radial nerve (main trunk)
Brachioradialis Radial nerve (main trunk)
ECRL Radial nerve (main trunk)
10- Dorsal digital branches: skin of the lateral
2/3 of dorsum of the hand
Dorsal digital branches
Posterior compartment neuropathy
The deep branch of the radial nerve (continues as PIN) can become
compressed as it passes through the supinator, leading to a
posterior compartment neuropathy, resulting in weakened
extension of the wrist and fingers.
Clinical Insight
supinator
PIN
weakened extension of the
wrist and fingers
Supinator compression
Spiral groove
As the radial nerve runs in the spiral groove in direct contact with bone, it is
vulnerable with a fracture of the shaft of the humerus.
Clinical Insight
Saturday night palsy
The term Saturday night palsy
has become synonymous with
radial nerve compression in the
arm resulting from direct
pressure against a firm object.
It typically follows deep sleep
on the arm, often after alcohol
intoxication.
Clinical Insight
Saturday night palsy
The radial nerve is vulnerable to stretching or
tearing in fractures of the shaft of the humerus
and can be compressed by tourniquets that are too
tight or by direct compression (Saturday night
palsy) leading to weakened elbow, wrist and
finger extension, and supination.
Wristdrop is a common clinical sign if the
forearm extensor muscles are affected.
Clinical Insight
Porter (Policeman) tip hand
The posterior cord of the brachial
plexus gives rise to the axillary and radial
nerves.
An injury to this structure will manifest as:
ā€¢ Inability to perform shoulder abduction
[axillary n.]
ā€¢ Wrist extension [radial n.]
Clinical Insight
MUSCULOCUTANEOUS NERVE C 5,6,7
ā€¢ Course:
It pierce the corachobrachialis muscle from the
back , Lie between biceps and brachialis
Continue in forearm as lateral cutaneous n. of
forearm
musculocutaneous n.
corachobrachialis
brachialis
biceps
lat cut n of forearm
ā€¢ Branches
Ć¼ Muscular: to all the ant compartment of arm
Ć¼ Cutaneous: lat cut n of forearm
musculocutaneous n.
corachobrachialis
brachialis
biceps
lat cut n of forearm
Musculocutaneous compression
Since the musculocutaneous nerve runs
through the coracobrachialis muscle, it is
vulnerable to nerve compression within the
muscle and this can lead to weakness of elbow
flexion (loss of some brachialis and biceps
function) and hypesthesia of the lateral
forearm.
Clinical Insight
ā€¢ Course
It curves backwards to enter the quadrangular
space and come in contact with the surgical
neck of the humerus where it divides into
anterior and posterior divisions
AXILLARY NERVE C 5,6
ā€¢
axillary nerve posterior division
ā€¢
quadrangular space
ā€¢
surgical neck of the humerus
ā€¢ Branches
1. Articular branch to supply the shoulder joint.
2. Posterior division:
- Branches to the deltoid and teres minor.
- Upper lateral cutaneous nerve of the arm
3. Anterior division: ends in the deltoid.
ā€¢
axillary nerve posterior division
ā€¢
quadrangular space
ā€¢
surgical neck of the humerus
ā€¢
Upper lateral cutaneous nerve of the arm
TER. MIN.
D
E
LT
D
.
Hand sensation
Testing of radial sensation can only be
done reliably over the dorsal web space
between the thumb and index finger.
Median sensation is tested reliably on the
palmar (volar) aspect of the tip of the
index finger.
Ulnar sensation is tested reliably on the
palmar aspect of the tip of the little
finger.
Clinical Insight
Clinical Insight
SUMMARY NERVE SUPPLY
Clinical Insight
SUMMARY NERVE SUPPLY
Clinical Insight
SUMMARY NERVE INJURY
Formative Quiz
Q1 A 45-year-old woman presents to the clinic with discomfort in her left shoulder.
She recently underwent a left mastectomy and axillary dissection for breast cancer.
Physical examination shows a notable protrusion of the posterior left shoulder blade
when she is asked to push up against the wall. Which of the following spinal nerve
roots give rise to the most likely affected nerve branch?
ā€¢ C3-C5
ā€¢ C5-C6
ā€¢ C5-C7
ā€¢ C8-T1
Q2 A 27-year-old man is brought to the emergency department
after falling off a ladder from the height of the roof. An x-ray
of the patientā€™s right arm is shown.
Which of the following neurologic deficits is most likely to
occur as a result of his fracture?
A protruding scapula
Inability to abduct the arm fully
Inability to hold a piece of paper between the fingers
Pain over the palmar aspects of the first three and a half digits
Weakness in wrist extension
Q3 A 16-year-old boy is brought to the emergency department for severe arm pain
after he fell out of a tree. Physical examination reveals tenderness to palpation over
the left shoulder. There is limited range of motion at the shoulder including loss of
abduction and decreased flexion. His arm dangles at his side, with the forearm
pronated and extended. Sensation is absent along his left lateral forearm.
Which of the following structures is most likely injured in this patient?
Axillary nerve
C5-C6 nerve roots
C8-T1 roots
Long thoracic nerve
Lower trunk
Radial nerve
Q4. A patient presents with weakness in wrist extension and finger abduction,
commonly known as "wrist drop." This condition is most likely due to damage to
which nerve?
a) Median nerve
b) Ulnar nerve
c) Radial nerve
d) Axillary nerve
Q5. The musculocutaneous nerve innervates muscles in the anterior compartment of
the arm. Which muscle primarily relies on the musculocutaneous nerve for motor
innervation?
a) Biceps brachii
b) Brachialis
c) Coracobrachialis
d) Pronator teres
Q6. Damage to the median nerve can result in a characteristic "ape hand" deformity,
with weakness in thumb opposition and flexion of the wrist. Which anatomical
landmark is a common site for compression of the median nerve, leading to
conditions like carpal tunnel syndrome?
a) Guyon's canal
b) Cubital fossa
c) Carpal tunnel
d) Supracondylar ridge
Q7. The ulnar nerve innervates several intrinsic muscles of the hand and plays a
crucial role in fine motor control. Damage to the ulnar nerve can lead to weakness
in intrinsic muscles and the development of which hand deformity?
a) Claw hand
b) Pope's blessing
c) Ape hand
d) Wrist drop
Q8. The axillary nerve, a branch of the brachial plexus, innervates the deltoid
muscle and the teres minor muscle. Damage to the axillary nerve can lead to
weakness in shoulder abduction and is often associated with traumatic injuries or
surgical procedures in which region of the body?
a) Axilla
b) Elbow
c) Wrist
d) Forearm
Q9 A 74-year-old man is brought to the emergency department with left shoulder
pain after being involved in a motor vehicle accident. Physical examination reveals
difficulty abducting the left shoulder. Passive movement of the shoulder elicits
severe pain. There are mild sensory deficits over the inferior aspect of the deltoid
muscle. The patient has good hand grip with active motion. X-ray of the left
shoulder discloses a fracture of the surgical neck of the humerus.
An injury to which of the labeled locations in the image would most likely explain
this patientā€™s physical findings?
A
B
C
D
E
Q10 A 10-year-old boy is brought to the pediatrician with a 4-day history of fever,
fatigue, and right shoulder pain. His temperature is 38.6Ā°C (101.5Ā°F). On physical
examination, he has right shoulder tenderness, worse at the right axillary region, and
painful and weak abduction. On palpation, a swollen mass in the axillary region is
noted. He also has wrist-extension weakness and triceps hyporeflexia in the same
limb. Sensory examination reveals absent sensation to light touch over the right
shoulder and lateral and posterior arm. Imaging identifies an abscess in the right
axillary region. The most likely diagnosis is an abscess.
Which of the following structures is most likely being compressed by the abscess?
Axillary nerve
Lateral cord of the brachial plexus
Medial cord of the brachial plexus
Posterior cord of brachial plexus
Radial nerve
Q11 A 34-year-old woman comes to the physician with right hand weakness for the
last 3 months. She has had progressive difficulty opening jars with her right hand.
She does not recall any trauma. She has no significant medical history and is not on
medication. On physical examination there is diminished sensation to light touch
over digits 4 and 5 on the right hand. Strength is 3/5 in the right hand involving the
following muscle groups: attempted abduction of the index finger, wrist flexion, and
flexion of the fourth and fifth digits.
Damage or compression of which of the following nerves is most likely in this
patient?
Axillary
Median
Musculocutaneous
Radial
Ulnar
Q12 A 17-year-old boy is brought to the clinic with shooting pain in his right hand
following a snowboarding accident, in which he directly struck a tree with his arms
raised. On physical examination, the right fingers are held in flexion at the proximal
and distal interphalangeal joints. The patient also has decreased sensation over the
medial aspect of his right palm, atrophy of the hypothenar eminence, and inability
to maintain finger abduction against resistance.
Which of the following parts of the brachial plexus is most likely injured in this
patient?
Lateral cord
Lower trunk
Middle trunk
Posterior cord
Upper trunk
Q13 A 24-year-old man comes to the emergency department because of a laceration
over the palmar surface of the middle section of his left index finger. A
subcutaneous local block is used to numb the area with lidocaine so that it can be
sutured.
The nerve that the physician is most likely targeting also provides cutaneous
innervation to which of the following areas?
2/3 of the outer palmar side of the hand, including 3 and one-half fingers
The lateral aspect of the forearm
The medial surface of the forearm
The radial aspect of the wrist
The ulnar aspect of the wrist
Q14 A 39-year-old man has suffered for many years from pains in his right arm.
Recently, after moving to a new job that requires carrying heavy parcels, the pain
has worsened, and occasional tingling and numbness is felt in the little finger and
ring finger of the right hand. The area of pain in the limb is localized to the medial
side of the arm and forearm and the ulnar side of the hand. General muscle strength
in the right extremity is less than in the left, and there is particular weakness of
opposition and adduction of the right thumb. Wasting of the right hypothenar and
thenar eminence is evident, and the patient cannot hold a piece of paper between his
index and middle fingers. The most likely site of the injury is
(A) lower trunk of the brachial plexus
(B) upper trunk of the brachial plexus
(C) posterior cord of the brachial plexus
(D) ulnar nerve
(E) median nerve
Q15 A 20-year-old man stated that he was unable to raise his right arm. Questioning
revealed that he had been involved in a motorcycle accident, at which time he had
been thrown from the motorcycle and had hit his shoulder against a tree. The patient
held his upper limb limply at his side, with the arm medially rotated and the hand
pronated. Muscles covering the shoulder joint showed significant wasting. The most
likely site of the injury is the
(A) lower trunk of the brachial plexus
(B) upper trunk of the brachial plexus
(C) posterior cord of the brachial plexus
(D) axillarynerve
(E) radial nerve
Q16 Your patient has fallen on his outstretched hand and has dislocated a carpal
bone. The patient does not seek treatment, and several weeks later he begins to
exhibit signs of nerve compression. The patient is most likely to present with which
of the following conditions?
(A) Wrist drop
(B) Clawing of ring and index fingers
(C) Inability to spread and oppose the fingers
(D) Weakness in the ability to oppose the thumb
(E) Pain on the palmar aspects of the ring and little fingers
Q17 A 7-year-old boy is brought to the emergency department after falling off his
grandparentsā€™ deck; an x-ray film shows that he has a mid- shaft fracture of the
humerus. Which of the following defects is most likely to occur with this type of
fracture?
(A) A protruding scapula
(B) Inability to fully abduct the arm
(C) Inability to hold a piece of paper between fingers
(D) Pain over the palmar aspects of the first three and a half digits
(E) Weakness in wrist extension
Q1 C5-C7
Q2 Weakness in wrist extension
Q3 C5-C6 nerve roots
Q4 Radial nerve
Q5 Coracobrachialis
Q6 Carpal tunnel
Q7 Claw hand
Q8 Axilla
Q9 A
Q10 Posterior cord of brachial plexus
Q11 Ulnar
Q12 Lower trunk
Q13 2/3 of the outer palmar side of the hand, including 3 and one-half fingers
Q14 lower trunk of the brachial plexus
Q15 upper trunk of the brachial plexus
Q16 Weakness in the ability to oppose the thumb
Q17 Weakness in wrist extension
List of Texts and Recommended Readings
ā€¢ Last's Anatomy, Regional and Applied. Chummy S. Sinnatamby. 12th edition 2011, ISBN:13 - 978 0 7020 3394 0
(Available in ClinicalKey: https://www.clinicalkey.com/#!/browse/book/3-s2.0- C2009060533X)
ā€¢ Estomih Mtui, Gregory Gruener and Peter Dockery. Fitzgerald's Clinical Neuroanatomy and Neuroscience. 7th
edition; 2016, ISBN: 13 - 978-0-7020- 6727-3 (Available in ClinicalKey:
https://www.clinicalkey.com/#!/browse/book/3-s2.0- C20130134113
ā€¢ Drake, Richard L. Gray's Anatomy for Students, Third Edition, Elsevier Saunders 2015. ISBN-13: 978-0702051319
(Available in ClinicalKey: https://www.clinicalkey.com/#!/browse/book/3- s2.0-C20110061707).
ā€¢ Sobotta Atlas of Human Anatomy. F. Paulsen. Vol.1, 15th Edition; 2013, ISBN: 9780702052514 (Available in
ClinicalKey: https://www.clinicalkey.com/#!/content/book/3- s2.0-B9780702052514500067)
ā€¢ Sobotta Atlas of Human Anatomy. F. Paulsen. Vol.2, 15th Edition; 2013, ISBN:13 - 978-0-7020-5252-1 (Available in
ClinicalKey: https://www.clinicalkey.com/#!/browse/book/3- s2.0-C20130046919)
Recap
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  • 1. Dr / Ahmed Salah Ashour(Ph.D.) Associate professor of human anatomy Dr.Ahmedashour@gmu.ac.ae USMLE Clinical Anatomy
  • 3. Injuries to the nerves of the upper limb can result from trauma, compression, lacerations, or certain medical conditions. Nerve injuries may lead to various symptoms, including pain, weakness, numbness, or loss of function in specific areas of the upper limb. Nerve injuries may range from mild to severe, and appropriate medical evaluation and treatment are essential. Physical therapy, splinting, medications, or in some cases, surgical intervention may be recommended based on the type and severity of the nerve injury. Early intervention is crucial for optimal recovery.
  • 4.
  • 5. ā€¢ Roots C.5,6,7, 8 and Th1 ā€¢ Trunks Upper trunk Middle trunk Lower trunk BRACHIAL PLEXUS
  • 6.
  • 7. NERVE ROOT AXILLARY C 5,6 MUSCULSKELETAL C 5,6,7 RADIAL C 5,6,7,8 T1 MEDIAN C 5,6,7,8 T1 ULNAR C 7,8 T1
  • 8.
  • 9. ā€¢ Divisions & cords Each trunk divides into anterior or ventral division and posterior or dorsal division ā€¢ Cords: A- The lateral cord is formed by union of the anterior divisions of the upper and middle trunks. B- The medial cord is formed by the anterior division of the lower trunk only. C- The posterior cord is formed by union of the posterior divisions of the 3 trunks.
  • 10. ā€¢ Branches of Roots: - n. to seRRatus anterior (long thoracic) C5, 6, 7 - n. to Rhomboids (Dorsal Scapular Nerve) C5
  • 11. N. to serratus anterior (long thoracic) c5, 6, 7 serratus anterior
  • 12. Scapula winging Damage to the long thoracic [C5-7] nerve may lead to ā€œwingingā€ of the scapula, most evident when a patient pushes forward with the upper limb against resistance. This type of nerve injury may occur from ā€¢ Trauma to the lateral thoracic wall ā€¢ Lateral flexion of the neck to the opposite side ā€¢ Radical mastectomy . Clinical Insight
  • 13. Complicated right Radical mastectomy Clinical Insight
  • 14. N. to Rhomboids (Dorsal Scapular Nerve) C5
  • 15. Clinical Insight DSN damage Damage to the dorsal scapular nerve can weaken the rhomboid muscles, resulting in an ipsilateral lateral shift of the scapula.
  • 16. ā€¢ Branches of upper trunk : SUPRA-scapular nerve. Nerve to SUB-clavius.
  • 18. ā€¢ Branches of Lateral cord: Lateral pectoral nerve. Lateral root of median nerve, MuscuLo-cutaneous nerve.
  • 19. lateral cord lateral pectoral nerve musculo-cutaneous nerve lateral root of median nerve median nerve
  • 20. ā€¢ Branches of Medial cord: Medial pectoral nerve. Medial root of median nerve. Medial cutaneous nerve of arm Medial cutaneous nerve of forearm. Ulnar nerve
  • 21. Medial cord Medial pectoral nerve Medial root of median nerve Medial cutaneous nerve of forearm Ulnar nerve Medial cutaneous nerve of arm
  • 22. ā€¢ Branches of Posterior cord Upper subscapulra Lower subscapular nerves N. to latissimus dorsi [Thoraco-dorsal nerve ] Axillary nerve Radial n
  • 23. Posterior cord Upper subscapular Radial Axillary Lower subscapular N. to latissimus dorsi (Thoraco-dorsal)
  • 24. Obstetric Brachial Plexus Palsy (OBPP) is defined as brachial plexus nerve injury that occurs during early delivery. OBBP commonly happen during delivery process and resulting in overstretch of the neck. Erbā€™s Palsy which involved the upper brachial plexus (C5, C6 & C7) Klumpkeā€™s Palsy involves forearm and hand . (C8 & T1) Clinical Insight
  • 27. ā€¢ Course In the arm: The nerve descends lateral to the upper part of the brachial artery then crosses in front of it to run along its medial side to reach the cubital fossa. MEDIAN NERVE C 5,6,7,8 T1 median nerve brachial artery cubital fossa
  • 29. It then runs exactly in the midline of forearm deep to the flexor digitorum superficialis median nerve brachial artery cubital fossa flexor digitorum superficialis
  • 30. Median nerve + palmaris longus By having the patient make a tight fist, one can determine if the patient possesses the palmaris longus muscle, as its tendon will appear in the mid wrist. The median nerve lies just lateral to the tendon of this muscle before entering the carpal tunnel. Clinical Insight
  • 31. Median nerve Lateral division Medial division In the hand: divides into lateral and medial divisions
  • 32. ā€¢ Branches It supplies all flexor muscles of the front of forearm except 1- Flexor polices + lateral Ā½ FDP 2- FCU+ medial Ā½ of FDP Flexor polices FDP median n. FCU Ulnar n.
  • 33. N.B: FCU+ medial Ā½ of FDP supplied by ulnar Flexor polices FDP median n. FCU Ulnar n.
  • 34. median n. ant interosseous of median Flexor polices FDP N.B: Flexor polices + lateral Ā½ FDP supplied by ant interosseous of median
  • 35. N.B: anterior interosseous nerve supplies 3 muscles 1. - Flexor pollicis longus 2. - Lateral 1/2 of the flexor digitorum profundus 3. - Pronator quadratus median n. ant interosseous of median Flexor polices FDP Pronator quadratus
  • 36. In hand a) Lateral division ā€¢ 3 muscles of the thenar eminence by recurrent motor branch ā€¢ 1st lumbrical muscle ā€¢ 3 digital branches: To thumb and index Recurrent motor branch to thenar eminence 3 digital branches Branch to 1st lumbrical muscle Lateral division Medial division
  • 37. Carpal Tunnel Syndrome Entrapment of the median nerve and other structures in the carpal tunnel due to any condition that reduces the space results in carpal tunnel syndrome. Clinical Insight
  • 38. Carpal Tunnel Syndrome The median nerve is the only nerve affected in Carpal Tunnel Syndrome and the patient will present with: ā€¢ Atrophy and weakness of the thenar compartment muscles (opposition of the thumb-ape hand) . ā€¢ There is also sensory loss and numbness on the palmar surfaces of the lateral 3 Ā½ digits. Clinical Insight Ape hand
  • 39. Carpal Tunnel Syndrome Note that the skin on the lateral side of the palm (thenar eminence) is healthy in Carpal Tunnel Syndrome because the palmar cutaneous branch of the median nerve which supplies the lateral palm enters the hand superficial to the flexor retinaculum and does not course through the carpal tunnel. Clinical Insight
  • 40. Lacerations of thenar eminence The recurrent branch of the median nerve lies somewhat superficial in the palm. Lacerations across the palm and thenar eminence may cut. Therefore, clinically, physician must carefully test the integrity of these muscles in case of hand lacerations. Clinical Insight
  • 41. Clinical Insight Ape hand deformity is a condition in which the thumb is permanently rotated and adducted, resulting in a loss of its opposable function. This deformity is caused by damage to the median nerve, which supplies the muscles that control the thumb
  • 42. b) Medial division: ā€¢ 2nd lumbrical muscle ā€¢ 4 digital branches: to adjacent sides of the index and middle fingers and to adjacent sides of the middle and ring fingers. Lateral division Branch to 2nd lumbrical muscle 4 digital branches Medial division
  • 43.
  • 44. Median nerve entrapment The median nerve is liable for entrapment at the carpal tunnel as part of carpal tunnel syndrome. Clinical Insight carpal tunnel
  • 45. In the axilla and arm: It descends medial to the brachial artery and contiues back of the medial epicondyle. In the forearm descends deep to flexor carpi ulnaris ULNAR NERVE C 5,6,7,8 T1 brachial artery ulnar nerve flexor carpi ulnaris
  • 46.
  • 47. Cubital tunnel syndrome As the ulnar nerve passes between the 2 heads of the flexor carpi ulnaris, the nerve can become compressed, leading to a cubital tunnel syndrome. Compression may be especially acute as the elbow is flexed because this narrows the space between the 2 muscle heads. Clinical Insight
  • 48.
  • 49. Elbow ulnar neuropathy Ulnar neuropathy at the elbow presents with ā€¢ Paresthesia over digits 4 and 5 ā€¢ Weakness of the flexor muscles of the forearm (wrist and finger flexion) ā€¢ Weakness of the intrinsic muscles of the hand (hand grip). Clinical Insight
  • 50. In the hand: divides into superficial and deep terminal branches Ulnar nerve Superficial terminal branches Deep terminal branches
  • 51. ā€¢ Branches 1- Branch to flexor carpi ulnaris. 2- Branch to medial 1/2 of the flexor digitorum profundus. Ulnar nerve flexor carpi ulnaris. flexor digitorum profundus.
  • 52. Medial 1/2 of the flexor digitorum profundus Lateral 1/2 of the flexor digitorum profundus Ulnar nerve Ant. Interosseous nerve Of Median nerve
  • 53. 3- Palmar cutaneous branch: supply the medial 1/3 of the palm 4- Dorsal cutaneous branch: supply the medial 1/3 of the back of the hand Ulnar nerve Dorsal cutaneous branch Palmar cutaneous branch
  • 55. 5- Superficial terminal branch ā€¢ Two palmar digital branches: medial 1.5 fingers. ā€¢ Branch to the palmaris brevis muscle 6- Deep terminal branch; ā€¢ All muscles of the hand except Ć¼ Thenar muscles Ć¼ Lateral two lumbricals Ulnar nerve Deep terminal branch Superficial terminal branch 2 palmar digital branches palmaris brevis muscle
  • 56.
  • 57. Ulnar nerve + bone fracture The ulnar nerve is vulnerable with a fracture of the medial epicondyle of the humerus (at the elbow) or a wrist fracture on the hamate bone. Clinical Insight
  • 58. Claw hand Ulnar nerve injury can present as a claw hand and an inability to effectively use the ring and little fingers, as well as a loss of abduction and adduction of the 2nd to 5th digits. Clinical Insight claw hand
  • 59. It enters the spiral groove at back of arm. RADIAL NERVE C 5,6,7,8 T1 radial nerve in spiral groove
  • 60. After leaving the spiral groove the nerve is divided into Ƙ superficial division ( loop to back of forearm deep to brachioradialis ) Ƙ deep division ( loop in mass of supinator and continue in back of forearm) radial nerve deep division supinator superficial division brachioradialis
  • 61. Fracture shaft humerus As the radial nerve passes around the shaft of the humerus, fractures of the shaft of the humerus can place the radial nerve in jeopardy of being stretched or torn as it wraps around the humerus, affecting wrist and finger extensors. Clinical Insight
  • 62. About 5 cm above the wrist, the superficial division of the nerve winds round the lateral side of the radius to reach the back of the hand About 5 cm above the wrist, the superficial division of the nerve winds round the lateral side of the radius to reach the back of the hand
  • 63. ā€¢ Branches Before spiral groove: 1- Long head of triceps 2- Medial head of triceps radial nerve Long head of triceps Medial head of triceps
  • 64. In the spiral groove: 3- Lateral head of triceps 4- Medial head of triceps radial nerve Lateral head of triceps Medial head of triceps
  • 65. On the lateral side of arm; 5- A branch to lateral part of brachialis. 6- A branch to brachioradialis. 7- A branch to extensor carpi radialis longus. 8- A branch to anconeus radial nerve brachialis. brachioradialis. extensor carpi radialis longus.
  • 66. In the forearm and hand: 9- Posterior Interosseous Nerve (continuation of radial deep division. ā€¢ PIN, supplies all extensor compartment, except: ā€¢ radial main trunk ā€¢ radial superficial division ā€¢ radial deep division ā€¢ Posterior interosseous nerve ā€¢ radial superficial division Anconeus Radial nerve (main trunk) Brachioradialis Radial nerve (main trunk) ECRL Radial nerve (main trunk)
  • 67. 10- Dorsal digital branches: skin of the lateral 2/3 of dorsum of the hand Dorsal digital branches
  • 68.
  • 69. Posterior compartment neuropathy The deep branch of the radial nerve (continues as PIN) can become compressed as it passes through the supinator, leading to a posterior compartment neuropathy, resulting in weakened extension of the wrist and fingers. Clinical Insight supinator PIN weakened extension of the wrist and fingers Supinator compression
  • 70. Spiral groove As the radial nerve runs in the spiral groove in direct contact with bone, it is vulnerable with a fracture of the shaft of the humerus. Clinical Insight
  • 71. Saturday night palsy The term Saturday night palsy has become synonymous with radial nerve compression in the arm resulting from direct pressure against a firm object. It typically follows deep sleep on the arm, often after alcohol intoxication. Clinical Insight
  • 72. Saturday night palsy The radial nerve is vulnerable to stretching or tearing in fractures of the shaft of the humerus and can be compressed by tourniquets that are too tight or by direct compression (Saturday night palsy) leading to weakened elbow, wrist and finger extension, and supination. Wristdrop is a common clinical sign if the forearm extensor muscles are affected. Clinical Insight
  • 73. Porter (Policeman) tip hand The posterior cord of the brachial plexus gives rise to the axillary and radial nerves. An injury to this structure will manifest as: ā€¢ Inability to perform shoulder abduction [axillary n.] ā€¢ Wrist extension [radial n.] Clinical Insight
  • 74. MUSCULOCUTANEOUS NERVE C 5,6,7 ā€¢ Course: It pierce the corachobrachialis muscle from the back , Lie between biceps and brachialis Continue in forearm as lateral cutaneous n. of forearm musculocutaneous n. corachobrachialis brachialis biceps lat cut n of forearm
  • 75. ā€¢ Branches Ć¼ Muscular: to all the ant compartment of arm Ć¼ Cutaneous: lat cut n of forearm musculocutaneous n. corachobrachialis brachialis biceps lat cut n of forearm
  • 76.
  • 77. Musculocutaneous compression Since the musculocutaneous nerve runs through the coracobrachialis muscle, it is vulnerable to nerve compression within the muscle and this can lead to weakness of elbow flexion (loss of some brachialis and biceps function) and hypesthesia of the lateral forearm. Clinical Insight
  • 78. ā€¢ Course It curves backwards to enter the quadrangular space and come in contact with the surgical neck of the humerus where it divides into anterior and posterior divisions AXILLARY NERVE C 5,6 ā€¢ axillary nerve posterior division ā€¢ quadrangular space ā€¢ surgical neck of the humerus
  • 79.
  • 80. ā€¢ Branches 1. Articular branch to supply the shoulder joint. 2. Posterior division: - Branches to the deltoid and teres minor. - Upper lateral cutaneous nerve of the arm 3. Anterior division: ends in the deltoid. ā€¢ axillary nerve posterior division ā€¢ quadrangular space ā€¢ surgical neck of the humerus ā€¢ Upper lateral cutaneous nerve of the arm TER. MIN. D E LT D .
  • 81. Hand sensation Testing of radial sensation can only be done reliably over the dorsal web space between the thumb and index finger. Median sensation is tested reliably on the palmar (volar) aspect of the tip of the index finger. Ulnar sensation is tested reliably on the palmar aspect of the tip of the little finger. Clinical Insight
  • 86. Q1 A 45-year-old woman presents to the clinic with discomfort in her left shoulder. She recently underwent a left mastectomy and axillary dissection for breast cancer. Physical examination shows a notable protrusion of the posterior left shoulder blade when she is asked to push up against the wall. Which of the following spinal nerve roots give rise to the most likely affected nerve branch? ā€¢ C3-C5 ā€¢ C5-C6 ā€¢ C5-C7 ā€¢ C8-T1
  • 87. Q2 A 27-year-old man is brought to the emergency department after falling off a ladder from the height of the roof. An x-ray of the patientā€™s right arm is shown. Which of the following neurologic deficits is most likely to occur as a result of his fracture? A protruding scapula Inability to abduct the arm fully Inability to hold a piece of paper between the fingers Pain over the palmar aspects of the first three and a half digits Weakness in wrist extension
  • 88. Q3 A 16-year-old boy is brought to the emergency department for severe arm pain after he fell out of a tree. Physical examination reveals tenderness to palpation over the left shoulder. There is limited range of motion at the shoulder including loss of abduction and decreased flexion. His arm dangles at his side, with the forearm pronated and extended. Sensation is absent along his left lateral forearm. Which of the following structures is most likely injured in this patient? Axillary nerve C5-C6 nerve roots C8-T1 roots Long thoracic nerve Lower trunk Radial nerve
  • 89. Q4. A patient presents with weakness in wrist extension and finger abduction, commonly known as "wrist drop." This condition is most likely due to damage to which nerve? a) Median nerve b) Ulnar nerve c) Radial nerve d) Axillary nerve
  • 90. Q5. The musculocutaneous nerve innervates muscles in the anterior compartment of the arm. Which muscle primarily relies on the musculocutaneous nerve for motor innervation? a) Biceps brachii b) Brachialis c) Coracobrachialis d) Pronator teres
  • 91. Q6. Damage to the median nerve can result in a characteristic "ape hand" deformity, with weakness in thumb opposition and flexion of the wrist. Which anatomical landmark is a common site for compression of the median nerve, leading to conditions like carpal tunnel syndrome? a) Guyon's canal b) Cubital fossa c) Carpal tunnel d) Supracondylar ridge
  • 92. Q7. The ulnar nerve innervates several intrinsic muscles of the hand and plays a crucial role in fine motor control. Damage to the ulnar nerve can lead to weakness in intrinsic muscles and the development of which hand deformity? a) Claw hand b) Pope's blessing c) Ape hand d) Wrist drop
  • 93. Q8. The axillary nerve, a branch of the brachial plexus, innervates the deltoid muscle and the teres minor muscle. Damage to the axillary nerve can lead to weakness in shoulder abduction and is often associated with traumatic injuries or surgical procedures in which region of the body? a) Axilla b) Elbow c) Wrist d) Forearm
  • 94. Q9 A 74-year-old man is brought to the emergency department with left shoulder pain after being involved in a motor vehicle accident. Physical examination reveals difficulty abducting the left shoulder. Passive movement of the shoulder elicits severe pain. There are mild sensory deficits over the inferior aspect of the deltoid muscle. The patient has good hand grip with active motion. X-ray of the left shoulder discloses a fracture of the surgical neck of the humerus. An injury to which of the labeled locations in the image would most likely explain this patientā€™s physical findings? A B C D E
  • 95. Q10 A 10-year-old boy is brought to the pediatrician with a 4-day history of fever, fatigue, and right shoulder pain. His temperature is 38.6Ā°C (101.5Ā°F). On physical examination, he has right shoulder tenderness, worse at the right axillary region, and painful and weak abduction. On palpation, a swollen mass in the axillary region is noted. He also has wrist-extension weakness and triceps hyporeflexia in the same limb. Sensory examination reveals absent sensation to light touch over the right shoulder and lateral and posterior arm. Imaging identifies an abscess in the right axillary region. The most likely diagnosis is an abscess. Which of the following structures is most likely being compressed by the abscess? Axillary nerve Lateral cord of the brachial plexus Medial cord of the brachial plexus Posterior cord of brachial plexus Radial nerve
  • 96. Q11 A 34-year-old woman comes to the physician with right hand weakness for the last 3 months. She has had progressive difficulty opening jars with her right hand. She does not recall any trauma. She has no significant medical history and is not on medication. On physical examination there is diminished sensation to light touch over digits 4 and 5 on the right hand. Strength is 3/5 in the right hand involving the following muscle groups: attempted abduction of the index finger, wrist flexion, and flexion of the fourth and fifth digits. Damage or compression of which of the following nerves is most likely in this patient? Axillary Median Musculocutaneous Radial Ulnar
  • 97. Q12 A 17-year-old boy is brought to the clinic with shooting pain in his right hand following a snowboarding accident, in which he directly struck a tree with his arms raised. On physical examination, the right fingers are held in flexion at the proximal and distal interphalangeal joints. The patient also has decreased sensation over the medial aspect of his right palm, atrophy of the hypothenar eminence, and inability to maintain finger abduction against resistance. Which of the following parts of the brachial plexus is most likely injured in this patient? Lateral cord Lower trunk Middle trunk Posterior cord Upper trunk
  • 98. Q13 A 24-year-old man comes to the emergency department because of a laceration over the palmar surface of the middle section of his left index finger. A subcutaneous local block is used to numb the area with lidocaine so that it can be sutured. The nerve that the physician is most likely targeting also provides cutaneous innervation to which of the following areas? 2/3 of the outer palmar side of the hand, including 3 and one-half fingers The lateral aspect of the forearm The medial surface of the forearm The radial aspect of the wrist The ulnar aspect of the wrist
  • 99. Q14 A 39-year-old man has suffered for many years from pains in his right arm. Recently, after moving to a new job that requires carrying heavy parcels, the pain has worsened, and occasional tingling and numbness is felt in the little finger and ring finger of the right hand. The area of pain in the limb is localized to the medial side of the arm and forearm and the ulnar side of the hand. General muscle strength in the right extremity is less than in the left, and there is particular weakness of opposition and adduction of the right thumb. Wasting of the right hypothenar and thenar eminence is evident, and the patient cannot hold a piece of paper between his index and middle fingers. The most likely site of the injury is (A) lower trunk of the brachial plexus (B) upper trunk of the brachial plexus (C) posterior cord of the brachial plexus (D) ulnar nerve (E) median nerve
  • 100. Q15 A 20-year-old man stated that he was unable to raise his right arm. Questioning revealed that he had been involved in a motorcycle accident, at which time he had been thrown from the motorcycle and had hit his shoulder against a tree. The patient held his upper limb limply at his side, with the arm medially rotated and the hand pronated. Muscles covering the shoulder joint showed significant wasting. The most likely site of the injury is the (A) lower trunk of the brachial plexus (B) upper trunk of the brachial plexus (C) posterior cord of the brachial plexus (D) axillarynerve (E) radial nerve
  • 101. Q16 Your patient has fallen on his outstretched hand and has dislocated a carpal bone. The patient does not seek treatment, and several weeks later he begins to exhibit signs of nerve compression. The patient is most likely to present with which of the following conditions? (A) Wrist drop (B) Clawing of ring and index fingers (C) Inability to spread and oppose the fingers (D) Weakness in the ability to oppose the thumb (E) Pain on the palmar aspects of the ring and little fingers
  • 102. Q17 A 7-year-old boy is brought to the emergency department after falling off his grandparentsā€™ deck; an x-ray film shows that he has a mid- shaft fracture of the humerus. Which of the following defects is most likely to occur with this type of fracture? (A) A protruding scapula (B) Inability to fully abduct the arm (C) Inability to hold a piece of paper between fingers (D) Pain over the palmar aspects of the first three and a half digits (E) Weakness in wrist extension
  • 103. Q1 C5-C7 Q2 Weakness in wrist extension Q3 C5-C6 nerve roots Q4 Radial nerve Q5 Coracobrachialis Q6 Carpal tunnel Q7 Claw hand Q8 Axilla Q9 A Q10 Posterior cord of brachial plexus Q11 Ulnar Q12 Lower trunk Q13 2/3 of the outer palmar side of the hand, including 3 and one-half fingers Q14 lower trunk of the brachial plexus Q15 upper trunk of the brachial plexus Q16 Weakness in the ability to oppose the thumb Q17 Weakness in wrist extension
  • 104. List of Texts and Recommended Readings ā€¢ Last's Anatomy, Regional and Applied. Chummy S. Sinnatamby. 12th edition 2011, ISBN:13 - 978 0 7020 3394 0 (Available in ClinicalKey: https://www.clinicalkey.com/#!/browse/book/3-s2.0- C2009060533X) ā€¢ Estomih Mtui, Gregory Gruener and Peter Dockery. Fitzgerald's Clinical Neuroanatomy and Neuroscience. 7th edition; 2016, ISBN: 13 - 978-0-7020- 6727-3 (Available in ClinicalKey: https://www.clinicalkey.com/#!/browse/book/3-s2.0- C20130134113 ā€¢ Drake, Richard L. Gray's Anatomy for Students, Third Edition, Elsevier Saunders 2015. ISBN-13: 978-0702051319 (Available in ClinicalKey: https://www.clinicalkey.com/#!/browse/book/3- s2.0-C20110061707). ā€¢ Sobotta Atlas of Human Anatomy. F. Paulsen. Vol.1, 15th Edition; 2013, ISBN: 9780702052514 (Available in ClinicalKey: https://www.clinicalkey.com/#!/content/book/3- s2.0-B9780702052514500067) ā€¢ Sobotta Atlas of Human Anatomy. F. Paulsen. Vol.2, 15th Edition; 2013, ISBN:13 - 978-0-7020-5252-1 (Available in ClinicalKey: https://www.clinicalkey.com/#!/browse/book/3- s2.0-C20130046919)
  • 105. Recap