244221 shoulder-and-pectoral

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Shoulder and Pectoral Shoulder and Pectoral regionregion

THE SCAPULATHE SCAPULA

► Supraspinatus Fossa: Supraspinatus Fossa: Depression in the Depression in the scapula, above the scapular spine. scapula, above the scapular spine.

► Infraspinatus Fossa: Infraspinatus Fossa: Depression in the Depression in the scapula, below the scapular spine. scapula, below the scapular spine.

► TRAPEZIUS MUSCLE: It is innervated by the TRAPEZIUS MUSCLE: It is innervated by the spinal accessory nerve. Hence with a spinal accessory nerve. Hence with a cervical neck fracture, some people can still cervical neck fracture, some people can still shrug their shoulders, even though they've shrug their shoulders, even though they've lost upper-limb innervation, due to residual lost upper-limb innervation, due to residual innervation from this nerve. innervation from this nerve.

TRIANGLE OF AUSCULTATIONTRIANGLE OF AUSCULTATION

►On the medial back, it is an area of On the medial back, it is an area of little muscle and hence a good place little muscle and hence a good place to listen to the lungs. to listen to the lungs.

►Medial Border: Trapezius muscle Medial Border: Trapezius muscle ►Lateral Border: Teres Major, laterally Lateral Border: Teres Major, laterally

and deep. and deep. ► Inferior Border (base): Latissimus Dorsi Inferior Border (base): Latissimus Dorsi

TRIANGLE OF AUSCULTATIONTRIANGLE OF AUSCULTATION

►On the medial back, it is an area of On the medial back, it is an area of little muscle and hence a good place little muscle and hence a good place to listen to the lungs. to listen to the lungs.

►Medial Border: Trapezius muscle Medial Border: Trapezius muscle ►Lateral Border: Teres Major, laterally Lateral Border: Teres Major, laterally

and deep. and deep. ► Inferior Border (base): Latissimus Dorsi Inferior Border (base): Latissimus Dorsi

QUADRANGULAR SPACEQUADRANGULAR SPACE

► Just medial to the surgical neck of the Just medial to the surgical neck of the humerus on the posterior side. humerus on the posterior side.

► Superior border: Teres Minor (posteriorly) Superior border: Teres Minor (posteriorly) ► Inferior border: Teres Major (anteriorly) Inferior border: Teres Major (anteriorly) ► Lateral border: Lateral head of the Triceps Lateral border: Lateral head of the Triceps ►Medial border: Long head of the Triceps Medial border: Long head of the Triceps ► CONTENTS: These guys can be damaged CONTENTS: These guys can be damaged

with a fracture of the neck of the humerus. with a fracture of the neck of the humerus. Axillary NerveAxillary Nerve Posterior Circumflex Humeral ArteryPosterior Circumflex Humeral Artery

TRIANGULAR SPACETRIANGULAR SPACE

►Anterior aspect, medial to the neck of Anterior aspect, medial to the neck of the humerus. the humerus.

►Lateral border: Long head of the Lateral border: Long head of the triceps. triceps.

►Upper border: Teres Minor Upper border: Teres Minor ►Lower border: Teres Major Lower border: Teres Major ►CONTENTS: CONTENTS: Circumflex Scapular Circumflex Scapular

BranchBranch of the subscapular artery. of the subscapular artery.

TRIANGULAR INTERVALTRIANGULAR INTERVAL

►Between the two heads of the triceps Between the two heads of the triceps muscle, inferior to the teres major. muscle, inferior to the teres major.

►CONTENTS: CONTENTS: Deep Brachial ArteryDeep Brachial Artery and and Radial NerveRadial Nerve, both of which , both of which continue along the radial groove of the continue along the radial groove of the humerus. humerus.

SCAPULASCAPULA: The shoulder : The shoulder blade. blade.

► From top to bottom, order of the Scapular From top to bottom, order of the Scapular Muscles: Muscles: Supraspinatus Supraspinatus Infraspinatus Infraspinatus Teres Minor Teres Minor Teres Major Teres Major

►WINGED SCAPULAWINGED SCAPULA: Both the Serratus : Both the Serratus Anterior and Rhomboids insert on the medial Anterior and Rhomboids insert on the medial aspect of the scapula. If you lose this aspect of the scapula. If you lose this insertion, you can get winged scapula, where insertion, you can get winged scapula, where the scapula does not stay in place and is the scapula does not stay in place and is raised a bit from the posterior wall. raised a bit from the posterior wall.

Deltoid MuscleDeltoid Muscle

► It inserts on the Deltoid Tuberosity of It inserts on the Deltoid Tuberosity of the humerus and has multiple actions the humerus and has multiple actions

►Anterior part flexes and medially Anterior part flexes and medially rotates the arm. rotates the arm.

►Posterior part extends and laterally Posterior part extends and laterally rotates the arm. rotates the arm.

►Lateral fibers abduct the arm. Lateral fibers abduct the arm.

Abduction of the ArmAbduction of the Arm

►STEP I: Movement of supraspinatus STEP I: Movement of supraspinatus and deltoid muscles, until the angle is and deltoid muscles, until the angle is about 80 at which point the acromion about 80 at which point the acromion and greater tubercle hit each other. and greater tubercle hit each other.

►STEP II: STEP II: Rotation of the ScapulaRotation of the Scapula, to get , to get the acromion process out of the way. the acromion process out of the way. The Serratus Anterior and Trapezius The Serratus Anterior and Trapezius move the inferior border of the scapula move the inferior border of the scapula laterally. laterally.

PECTORALIS MAJORPECTORALIS MAJOR

►Aids in both flexing and extending the Aids in both flexing and extending the arm, depending on part of muscle. arm, depending on part of muscle.

►Clavicular HeadClavicular Head: It flexes the arm. : It flexes the arm. ►Sternocostal Head:Sternocostal Head: It extends the It extends the

arm. arm.

CLAVIPECTORAL FASCIACLAVIPECTORAL FASCIA

► Fascia separating the pectoralis major from Fascia separating the pectoralis major from pectoralis minor, and overlying the pecs, the pectoralis minor, and overlying the pecs, the serratus anterior, and latissimus dorsi muscles. It serratus anterior, and latissimus dorsi muscles. It goes from the pec-minor to the clavicle. goes from the pec-minor to the clavicle.

► Perforations: Perforations: The The Cephalic VeinCephalic Vein goes through the membrane to goes through the membrane to

become the axillary vein. become the axillary vein. The The Thoracoacromial ArteryThoracoacromial Artery comes from axillary artery comes from axillary artery

and perfuses the deltoid and pec-minor muscles. and perfuses the deltoid and pec-minor muscles. ► The subclavius muscle is completely invested by The subclavius muscle is completely invested by

the fascia, both anteriorly and posteriorly. the fascia, both anteriorly and posteriorly. ► Costocoracoid Ligament Costocoracoid Ligament is the strongest part of is the strongest part of

the fascia, going from the 1st rib to the coracoid the fascia, going from the 1st rib to the coracoid process. It travels along the lower border of the process. It travels along the lower border of the subclavius. subclavius.

CEPHALIC VEIN (CEPHALIC VEIN (CLINICAL)CLINICAL)

►A surgeon may pass a fine tube A surgeon may pass a fine tube through the Cephalic Vein ------> through the Cephalic Vein ------> Axillary Vein ------> Subclavvian ------> Axillary Vein ------> Subclavvian ------> SVC ------> Heart to withdraw blood. SVC ------> Heart to withdraw blood.

THE AXILLATHE AXILLA

► Borders of the Axilla: Borders of the Axilla: Anterior Border: The pectoralis major and minor, Anterior Border: The pectoralis major and minor,

and the subclavius, plus investing fascia and the subclavius, plus investing fascia (Clavipectoral fascia). (Clavipectoral fascia).

Base of the Axilla: The skin of the armpit, Base of the Axilla: The skin of the armpit, superficial fascia. superficial fascia.

Apex of the Axilla: The root of the neck, through Apex of the Axilla: The root of the neck, through which the brachial plexus of nerves and vessels which the brachial plexus of nerves and vessels travels. travels.

Medial Border: Serratus Anterior and intercostal Medial Border: Serratus Anterior and intercostal muscles. muscles.

Posterior Border: Subscapularis, Latissimus Dorsi, Posterior Border: Subscapularis, Latissimus Dorsi, and Teres Minor. and Teres Minor.

THE AXILLATHE AXILLA

►CONTENTS: CONTENTS: The axillary artery The axillary artery The axillary vein The axillary vein The Brachial Plexus The Brachial Plexus The Axillary group of lymph nodes The Axillary group of lymph nodes

AXILLARY ARTERYAXILLARY ARTERY

► Branches of the Axillary Artery. Branches of the Axillary Artery. ► 1st Part of Axillary Artery:1st Part of Axillary Artery: Above the Above the

pectoralis minor. Has 1 branch. pectoralis minor. Has 1 branch. Superior Thoracic ArterySuperior Thoracic Artery

► 2nd Part of Axillary Artery:2nd Part of Axillary Artery: Directly deep to Directly deep to the Pectoralis Minor. Has 2 branches. the Pectoralis Minor. Has 2 branches. Thoracoacromial ArteryThoracoacromial Artery (pierces clavipectoral (pierces clavipectoral

fascia) fascia) ►Deltoid Branch of ThoracoacromialDeltoid Branch of Thoracoacromial ►Pectoralis Branch of ThoracoacromialPectoralis Branch of Thoracoacromial. .

Lateral Thoracic ArteryLateral Thoracic Artery (aka External (aka External Mammary Artery) -- important source of blood for Mammary Artery) -- important source of blood for mammary glands. mammary glands.

AXILLARY ARTERY……AXILLARY ARTERY……

► 3rd Part of Axillary Artery:3rd Part of Axillary Artery: Below the pectoralis Below the pectoralis minor. Has 3 branches. minor. Has 3 branches. Anterior Circumflex Humeral ArteryAnterior Circumflex Humeral Artery Posterior Circumflex Humeral ArteryPosterior Circumflex Humeral Artery -- passes through -- passes through

Quadrangular space along with the axillary nerve. Quadrangular space along with the axillary nerve. ► And anterior and posterior circumflex humerals anastomose And anterior and posterior circumflex humerals anastomose

with each other around the lateral neck of the humerus. with each other around the lateral neck of the humerus. ► The posterior circumflex also anastomoses with the deep The posterior circumflex also anastomoses with the deep

brachial artery. brachial artery. Subscapular ArterySubscapular Artery -- largest branch which supplies -- largest branch which supplies

muscles of posterior wall (scapula) muscles of posterior wall (scapula) ► Circumflex Scapular ArteryCircumflex Scapular Artery branches off and proceeds branches off and proceeds

posteriorly through the posteriorly through the triangular spacetriangular space. . ► Thoracodorsal ArteryThoracodorsal Artery travels along with thoracodorsal travels along with thoracodorsal

nerve. nerve.

AXILLARY VEINAXILLARY VEIN

►The union of the basilic and deep The union of the basilic and deep brachial veins. It then joins with the brachial veins. It then joins with the Cephalic Vein to become the Subclavian Cephalic Vein to become the Subclavian Vein. Vein.

► It travels along the It travels along the medial sidemedial side of the of the axillary artery. axillary artery.

►Commonly receives tributaries from the Commonly receives tributaries from the Thoraco-Epigastric VeinsThoraco-Epigastric Veins, an , an important collateral route for venous important collateral route for venous return, if the IVC becomes obstructed. return, if the IVC becomes obstructed.

THYROCERVICAL TRUNKTHYROCERVICAL TRUNK

► An arterial branch that comes off the subclavian An arterial branch that comes off the subclavian artery, before it turns into the Axillary Artery. It has artery, before it turns into the Axillary Artery. It has the following branches: the following branches:

► Transverse Cervical Artery: Transverse Cervical Artery: Turns into the Dorsal Turns into the Dorsal Scapular Artery. Scapular Artery. Dorsal Scapular Artery: Dorsal Scapular Artery: Branch on the posterior side, Branch on the posterior side,

where it supplies the Levator Scapulae and Rhomboids, where it supplies the Levator Scapulae and Rhomboids, along with the Dorsal Scapular N. along with the Dorsal Scapular N.

► The Suprascapular Artery: The Suprascapular Artery: Heads around the Heads around the scapular notch and anastomoses with the scapular notch and anastomoses with the circumflex circumflex arteryartery to form one of the main collateral channels to form one of the main collateral channels around the scapula. around the scapula. Suprascapular N. follows the suprascapular artery to supply Suprascapular N. follows the suprascapular artery to supply

to the supraspinatus and infraspinatus. to the supraspinatus and infraspinatus.

AXILLARY LYMPH NODESAXILLARY LYMPH NODES

► The apical group is the most crucial for The apical group is the most crucial for spreading of breast cancer. If it has gotten spreading of breast cancer. If it has gotten to the axillary group, you is in trouble. to the axillary group, you is in trouble.

► Lateral Group: Lateral Group: Drains the upper limb. Drains the upper limb. Located near brachial artery. Located near brachial artery.

► Subscapular Group: Subscapular Group: Drains the scapular Drains the scapular region and posterior thoracic wall. region and posterior thoracic wall.

► Pectoral Group: Pectoral Group: Drains the anterior thorax Drains the anterior thorax and some of mammary glands. Assoc. with and some of mammary glands. Assoc. with lateral thoracic artery. lateral thoracic artery.

AXILLARY LYMPH NODES….AXILLARY LYMPH NODES….

►CENTRAL GROUP: CENTRAL GROUP: It receives the It receives the lymph from the previous three groups. lymph from the previous three groups. It forms the largest group and is often It forms the largest group and is often palpable upon examination. palpable upon examination.

►APICAL GROUP: APICAL GROUP: The only one above The only one above the pectoralis minor. It receives lymph the pectoralis minor. It receives lymph from the central group as well as other from the central group as well as other locales, and dumps into the subclavian locales, and dumps into the subclavian trunk. trunk.

THE BRACHIAL PLEXUS OF THE BRACHIAL PLEXUS OF NERVES NERVES

►CERVICAL ROOTS of the Plexus: CERVICAL ROOTS of the Plexus: Dorsal Scapular (C5)Dorsal Scapular (C5) Long Thoracic Nerve (C5,C6,C7)Long Thoracic Nerve (C5,C6,C7). .

►Runs along the Serratus Anterior superficially. Runs along the Serratus Anterior superficially. You gotta watch it during a mastectomy -- it You gotta watch it during a mastectomy -- it could be cut accidentally. could be cut accidentally.

►CLINICAL -- if the Long Thoracic is accidentally CLINICAL -- if the Long Thoracic is accidentally cut, You will get cut, You will get Winged ScapulaWinged Scapula. The long . The long Thoracic will no longer hold the Scapula in Thoracic will no longer hold the Scapula in place, via Rhomboids and Serratus Anterior. place, via Rhomboids and Serratus Anterior.

THE BRACHIAL PLEXUS OF THE BRACHIAL PLEXUS OF NERVESNERVES

►SUPERIOR TRUNK -- C5, C6, part of C4 SUPERIOR TRUNK -- C5, C6, part of C4 Direct Branches Direct Branches

►Suprascapular Nerve (C5,C6)Suprascapular Nerve (C5,C6) ►Subclavius Nerve (C5,C6)Subclavius Nerve (C5,C6)

ANTERIOR DIVISION ------> LATERAL CORD ANTERIOR DIVISION ------> LATERAL CORD POSTERIOR DIVISION ------> POSTERIOR POSTERIOR DIVISION ------> POSTERIOR

CORD CORD


►MIDDLE TRUNK -- C7 MIDDLE TRUNK -- C7 ANTERIOR DIVISION ------> LATERAL CORD ANTERIOR DIVISION ------> LATERAL CORD POSTERIOR DIVISION ------> POSTERIOR POSTERIOR DIVISION ------> POSTERIOR

CORD CORD


► INFERIOR TRUNK -- C8, L1 INFERIOR TRUNK -- C8, L1 ANTERIOR DIVISION ------> MEDIAL CORD ANTERIOR DIVISION ------> MEDIAL CORD POSTERIOR DIVISION ------> POSTERIOR POSTERIOR DIVISION ------> POSTERIOR

CORD CORD


►LATERAL CORD LATERAL CORD Gives off the Gives off the Lateral Pectoral Nerve.Lateral Pectoral Nerve.

(mammary glands) (mammary glands) Becomes the Becomes the MUSCULOCUTANEOUS MUSCULOCUTANEOUS

NERVE (C5,C6,C7).NERVE (C5,C6,C7). Forms a branch with the medial cord, to Forms a branch with the medial cord, to

form the Median Nerve. form the Median Nerve.


►MEDIAL CORD MEDIAL CORD Gives off the Medial Pectoral, Gives off the Medial Pectoral, Medial Medial

BrachiocutaneousBrachiocutaneous, and , and Medial Medial Antebrachial CutaneousAntebrachial Cutaneous Nerves. Nerves. (medial aspect of arm) (medial aspect of arm)

Forms a branch with the Lateral Cord, to Forms a branch with the Lateral Cord, to form the Median Nerve. form the Median Nerve.

Becomes the Becomes the ULNAR NERVE (C8,T1, ULNAR NERVE (C8,T1, some C7).some C7).


►POSTERIOR CORD POSTERIOR CORD Gives off the Upper and Lower Gives off the Upper and Lower

Subscapular Nerves, and the Subscapular Nerves, and the Thoracodorsal NerveThoracodorsal Nerve. .

Forms the Forms the AXILLARY NERVE (C5,C6)AXILLARY NERVE (C5,C6). . Becomes the Becomes the RADIAL NERVE RADIAL NERVE

(C5,C6,C7,C8)(C5,C6,C7,C8)


►MEDIAN NERVE:MEDIAN NERVE: Formed by the union Formed by the union of the anterior divisions of the lateral of the anterior divisions of the lateral and medial cords. It is the bottom-and medial cords. It is the bottom-middle part of the "M" middle part of the "M"

THE BRACHIAL PLEXUS OF THE BRACHIAL PLEXUS OF NERVES (clinical)NERVES (clinical)

► DUCHENNE-ERB PARALYSIS: DUCHENNE-ERB PARALYSIS: Damage to the Damage to the Upper Trunk of the Brachial Plexus Upper Trunk of the Brachial Plexus

► Excessive downward traction of the arm during Excessive downward traction of the arm during birth, which can tear the upper trunk at its root. birth, which can tear the upper trunk at its root.

► This cuts off the suprascapular and subclavius This cuts off the suprascapular and subclavius completely, as well as most of axillary nerve. You completely, as well as most of axillary nerve. You lose shoulder movement. lose shoulder movement.

► Symptom: The arm just droops there, medially Symptom: The arm just droops there, medially rotated, elbow extended, shoulder adducted, rotated, elbow extended, shoulder adducted, forearm pronated. forearm pronated. Waiter's Tip Position.Waiter's Tip Position.

► Erb's Point: Erb's Point: The location of the superior trunk, The location of the superior trunk, where C5 and C6 unite, and where the where C5 and C6 unite, and where the Suprascapular and Subclavius are given off. Suprascapular and Subclavius are given off.

THE BRACHIAL PLEXUS OF THE BRACHIAL PLEXUS OF NERVES (clinical)NERVES (clinical)

► KLUMPKE'S PARALYSIS: KLUMPKE'S PARALYSIS: Damage to the lower Damage to the lower trunk (C8-T1). trunk (C8-T1).

► Loss of most of median and especially Loss of most of median and especially ulnar ulnar nerves. nerves. ► Symptoms: Symptoms:

Clawed hands due to loss of innervation of intrinsic Clawed hands due to loss of innervation of intrinsic muscles (T1) of the hand. muscles (T1) of the hand.

Loss of sensation on medial aspect of arm, forearm, and Loss of sensation on medial aspect of arm, forearm, and hand (due to loss of ulnar nerve). hand (due to loss of ulnar nerve).

► Horner's Syndrome:Horner's Syndrome: Associated problem; cervical Associated problem; cervical sympathetic paralysis, resulting in: sympathetic paralysis, resulting in: Constriction of pupils. Constriction of pupils.

► Enophthalmos -- apparent recession of eyeballs. Enophthalmos -- apparent recession of eyeballs.

THE ARMTHE ARM► THE HUMERUS THE HUMERUS ► Radial Groove: Radial Groove: The region of the humerus along which the radial The region of the humerus along which the radial

nerve travels, just posteroinferior to the Deltoid Tuberosity. nerve travels, just posteroinferior to the Deltoid Tuberosity. CLINICAL: Thus a fracture in the middle of the radius could easily damage CLINICAL: Thus a fracture in the middle of the radius could easily damage

the radial nerve. the radial nerve. CONTENTS of Radial Groove: CONTENTS of Radial Groove:

► Radial NerveRadial Nerve ► Deep Brachial ArteryDeep Brachial Artery

► Surgical Neck of the Humerus:Surgical Neck of the Humerus: The The Axillary NerveAxillary Nerve wraps around wraps around the surgical neck of the humerus. Thus injuries to the neck can the surgical neck of the humerus. Thus injuries to the neck can damage that nerve. damage that nerve.

► Cutaneous Innervation of the Arm Cutaneous Innervation of the Arm ► Axillary Nerve: Axillary Nerve: Supplies the skin over the deltoid muscle. Supplies the skin over the deltoid muscle. ► Radial Nerve: Radial Nerve: Posterior of arm and forearm. Posterior of arm and forearm.

The lateral dorsal aspect of the hand (posterior of thumb and index finger The lateral dorsal aspect of the hand (posterior of thumb and index finger up to the DIP joint). up to the DIP joint).

► Medial Antebrachial Cutaneous Nerve: Medial Antebrachial Cutaneous Nerve: Supplies much of the Supplies much of the anterior skin of arm. anterior skin of arm.

THE ARMTHE ARM

►BRACHIAL ARTERY:BRACHIAL ARTERY: Supplies the arm. Supplies the arm. ► The The Deep Brachial ArteryDeep Brachial Artery comes off the comes off the

brachial artery to curl around the back of brachial artery to curl around the back of the humerus, along the radial groove, to the humerus, along the radial groove, to supply to the Triceps. supply to the Triceps. Posterior Circumflex Humeral: Posterior Circumflex Humeral: Deep Brachial Deep Brachial

gives off this branch, which goes back up arm to gives off this branch, which goes back up arm to the Quadrangular space. the Quadrangular space.

Radial CollateralRadial Collateral and and Middle Collateral Middle Collateral ArteriesArteries which join up with Radial Recurrent to which join up with Radial Recurrent to form elbow anastomoses. form elbow anastomoses.

THE ARMTHE ARM

►MUSCULOCUTANEOUS NERVEMUSCULOCUTANEOUS NERVE: The : The major innervator of the arm. major innervator of the arm.

► It goes straight through the It goes straight through the coracobrachialis muscle to innervate coracobrachialis muscle to innervate the anterior aspect of the brachialis. the anterior aspect of the brachialis.

►Lateral Antebrachial Cutaneous Lateral Antebrachial Cutaneous Nerve: Nerve: After innervating the brachialis, After innervating the brachialis, it goes to the anterior arm to innervate it goes to the anterior arm to innervate the skin of the anterior arm. the skin of the anterior arm.

Intermuscular SeptaIntermuscular Septa

►Fibrous sheath that separates the Fibrous sheath that separates the anterior and posterior compartments of anterior and posterior compartments of the forearm. the forearm.

►CONTENTS OF INTERMUSCULAR SEPTUM: CONTENTS OF INTERMUSCULAR SEPTUM: Deep Brachial Artery Deep Brachial Artery Radial Nerve Radial Nerve Basilic Vein Basilic Vein Ulnar Nerve Ulnar Nerve Median Nerve Median Nerve

ARTERIAL ANASTOMOSES ARTERIAL ANASTOMOSES AROUND ELBOW AROUND ELBOW

► Collateral Branches off the Ulnar Artery Collateral Branches off the Ulnar Artery Posterior Ulnar Recurrent Artery:Posterior Ulnar Recurrent Artery: Medial anastomoses with Medial anastomoses with

Inferior Ulnar Collateral. Inferior Ulnar Collateral. Anterior Ulnar Recurrent Artery:Anterior Ulnar Recurrent Artery: Medial anastomoses with Medial anastomoses with

Superior Ulnar Collateral. Superior Ulnar Collateral. ► Collateral Branches off the Radial Artery Collateral Branches off the Radial Artery

Radial Recurrent Artery:Radial Recurrent Artery: Lateral anastomoses with Radial Lateral anastomoses with Radial Collateral Collateral

► Collateral Branches off the Brachial Artery: Collateral Branches off the Brachial Artery: Inferior Ulnar Collateral:Inferior Ulnar Collateral: (Ulnar Recurrent) (Ulnar Recurrent) Superior Ulnar Collateral:Superior Ulnar Collateral: (Ulnar Recurrent) (Ulnar Recurrent)

► Collateral Branches off the Deep Brachial Artery: Collateral Branches off the Deep Brachial Artery: Radial Collateral Artery: Radial Collateral Artery: (Radial Recurrent) (Radial Recurrent) Middle Collateral Artery:Middle Collateral Artery: Anastomoses with Interosseus Anastomoses with Interosseus

Recurrent, but there is variety. Recurrent, but there is variety.

ULNAR ARTERY ULNAR ARTERY

►One of the terminal branches of the One of the terminal branches of the Brachial Artery. Brachial Artery.

►Gives off the Gives off the Common Interosseus Common Interosseus ArteryArtery, a short stub which divides into , a short stub which divides into two parts: two parts: Anterior Interosseus Artery: Anterior Interosseus Artery: Supplies Supplies

the deep muscles of the flexor forearm. the deep muscles of the flexor forearm. Posterior Interosseus Artery: Posterior Interosseus Artery: Supplies Supplies

the entire extensor forearm. the entire extensor forearm.

BREAK TIMEBREAK TIME

THE EXTENSOR FOREARMTHE EXTENSOR FOREARM

► BRACHIORADIALIS: CLINICAL -- it may become BRACHIORADIALIS: CLINICAL -- it may become damaged during a distal radial fracture, because it damaged during a distal radial fracture, because it inserts on the styloid process of the radius. inserts on the styloid process of the radius.

► COMMON EXTENSOR TENDON: COMMON EXTENSOR TENDON: The origin of the The origin of the superficial superficial extensor forearm muscles. It hooks onto extensor forearm muscles. It hooks onto the the lateral epicondylelateral epicondyle and and supracondylar ridgesupracondylar ridge of of the humerus. the humerus.

► POSTERIOR INTEROSSEUS NERVE:POSTERIOR INTEROSSEUS NERVE: The Deep The Deep Branch of the Radial Nerve. It innervates most Branch of the Radial Nerve. It innervates most muscles of the extensor forearm. muscles of the extensor forearm.

► It pierces the supinator muscle to come into the It pierces the supinator muscle to come into the posterior forearm. posterior forearm.

► It travels between the superficial and deep groups It travels between the superficial and deep groups of muscles in the posterior forearm. of muscles in the posterior forearm.

THE EXTENSOR FOREARMTHE EXTENSOR FOREARM

►POSTERIOR INTEROSSEUS ARTERY: POSTERIOR INTEROSSEUS ARTERY: Supplies the extensor forearm muscles Supplies the extensor forearm muscles and travels with the Posterior and travels with the Posterior Interosseus Nerve. It is a branch of the Interosseus Nerve. It is a branch of the Common Interosseus Artery, which Common Interosseus Artery, which comes from the Ulnar Artery. comes from the Ulnar Artery.

EXTENSOR RETINACULUM EXTENSOR RETINACULUM

► The sheath that covers all of the extensor The sheath that covers all of the extensor tendons going into the wrist. tendons going into the wrist.

►ORDER OF EXTENSOR TENDONS GOING ORDER OF EXTENSOR TENDONS GOING INTO THE WRIST INTO THE WRIST Extensor Pollicis Brevis Extensor Pollicis Brevis Extensor Pollicis Longus Extensor Pollicis Longus Extensor Carpi Radialis Longus Extensor Carpi Radialis Longus Extensor Carpi Radialis Brevis Extensor Carpi Radialis Brevis (Extensor Indices, concurrent with and deep to (Extensor Indices, concurrent with and deep to

Extensor Digitorum) Extensor Digitorum) Extensor Digitorum Extensor Digitorum

► Extensor Digiti Minimi Extensor Digiti Minimi

ANATOMICAL SNUFFBOXANATOMICAL SNUFFBOX: :

► In between the In between the Extensor Pollicis LongusExtensor Pollicis Longus and and Extensor Pollicis BrevisExtensor Pollicis Brevis. The . The Abductor Pollicis Abductor Pollicis LongusLongus is directly lateral to it. is directly lateral to it.

► The The Radial NerveRadial Nerve runs over the superficial part runs over the superficial part of the anatomical snuffbox, to innervate the of the anatomical snuffbox, to innervate the lateral cutaneous hand. lateral cutaneous hand.

► The The Radial ArteryRadial Artery is the "floor" of the snuffbox, is the "floor" of the snuffbox, snugged right on top of the Scaphoid bone. snugged right on top of the Scaphoid bone. You can take a pulse in anatomical snuffbox, by You can take a pulse in anatomical snuffbox, by

palpating the radial artery against the Scaphoid bone. palpating the radial artery against the Scaphoid bone.

THE FLEXOR FOREARMTHE FLEXOR FOREARM

► THE FLEXOR FOREARMTHE FLEXOR FOREARM► MEDIAN NERVE: MEDIAN NERVE: Lies in between the Lies in between the flexor digitorum flexor digitorum

superficialissuperficialis and and flexor digitorum profundusflexor digitorum profundus in the forearm. in the forearm. ► Travels into the hand deep to the Travels into the hand deep to the palmaris longuspalmaris longus (right in the (right in the

middle, anterior surface), traveling through the carpal tunnel. middle, anterior surface), traveling through the carpal tunnel. ► Supplies all of flexor forearm EXCEPT the Supplies all of flexor forearm EXCEPT the Flexor Carpi UlnarisFlexor Carpi Ulnaris and and

the medial half of the the medial half of the Flexor Digitorum ProfundusFlexor Digitorum Profundus. . ► INJURY: Can be injured in wrist slashing and carpal tunnel INJURY: Can be injured in wrist slashing and carpal tunnel

syndrome. syndrome. Lost sensation to area supplied by median nerve in hand. Lost sensation to area supplied by median nerve in hand. Paralysis of long flexors of wrist (except the two ulnar flexors) Paralysis of long flexors of wrist (except the two ulnar flexors) Thenar muscles atrophy, with the result that opposition of thumb is Thenar muscles atrophy, with the result that opposition of thumb is

lost. lost. Loss of pronation, depending on where the severance occurs (wrist or Loss of pronation, depending on where the severance occurs (wrist or

elbow) elbow) ► SUMMARY OF INJURY: Very crippling: loss of action of thumb and SUMMARY OF INJURY: Very crippling: loss of action of thumb and

cutaneous sensation on palm of hand. cutaneous sensation on palm of hand.

ULNAR NERVEULNAR NERVE

► In the forearm, it supplies the In the forearm, it supplies the Flexor Carpi Flexor Carpi UlnarisUlnaris and the medial half of the and the medial half of the Flexor Flexor Digitorum ProfundusDigitorum Profundus. .

► It passes It passes superficialsuperficial to the flexor retinaculum. to the flexor retinaculum. ► INJURY: Commonly injured around the INJURY: Commonly injured around the

posterior of the medial epicondyle -- right posterior of the medial epicondyle -- right where the funny bone is. where the funny bone is. Claw-Hand: Claw-Hand: Paralysis of small muscles of hand Paralysis of small muscles of hand

supplied by Ulnar Nerve. This is the result of loss supplied by Ulnar Nerve. This is the result of loss of control over intrinsic hand muscles, which of control over intrinsic hand muscles, which supply the "balance" between the long flexor and supply the "balance" between the long flexor and extensor tendons. Result is over-flexion of distal extensor tendons. Result is over-flexion of distal phalanges and extension of proximal phalanges. phalanges and extension of proximal phalanges.

RADIAL NERVE RADIAL NERVE

► Enters the forearm by traveling over the lateral Enters the forearm by traveling over the lateral epicondyle. Splits into two branches. epicondyle. Splits into two branches.

► Superficial Branch of the Radial Nerve: Superficial Branch of the Radial Nerve: Travels Travels deep to the brachioradialisdeep to the brachioradialis to go to the hand. to go to the hand.

► Deep Branch of the Radial Nerve -- Deep Branch of the Radial Nerve -- Goes deep Goes deep back to posterior compartment, where it is back to posterior compartment, where it is Posterior Interosseus Nerve.Posterior Interosseus Nerve. the the

► INJURY: INJURY: Wrist-DropWrist-Drop is the sign of radial nerve is the sign of radial nerve injury. injury. It is the most frequently injured, due to breaks in the It is the most frequently injured, due to breaks in the

middle of the humerus. middle of the humerus. Paralysis of the long extensors of the fingers. Paralysis of the long extensors of the fingers. Lateral (radial deviation) of hand is difficult. Lateral (radial deviation) of hand is difficult. Movement (extension and abduction) of thumb is difficult. Movement (extension and abduction) of thumb is difficult.

Intrinsic hand musclesIntrinsic hand muscles

► T1: INTRINSIC MUSCLEST1: INTRINSIC MUSCLES -- All intrinsic -- All intrinsic muscles of the hand are supplied by T1 fibers, muscles of the hand are supplied by T1 fibers, whether from the Ulnar or Radial nerves. whether from the Ulnar or Radial nerves.

► LATERAL ANTEBRACHIAL CUTANEOUS LATERAL ANTEBRACHIAL CUTANEOUS NERVE: NERVE: From the Musculocutaneous Nerve, it From the Musculocutaneous Nerve, it innervates the lateral part of the anterior innervates the lateral part of the anterior forearm. forearm.

►MEDIAL ANTEBRACHIAL CUTANEOUS MEDIAL ANTEBRACHIAL CUTANEOUS NERVE: NERVE: From the medial cord of the brachial From the medial cord of the brachial plexus, it innervates the medial part of the plexus, it innervates the medial part of the cutaneous flexor forearm. cutaneous flexor forearm.

Arterial supplyArterial supply

► RADIAL ARTERY: RADIAL ARTERY: One of the terminal branches of the One of the terminal branches of the Brachial Artery. Brachial Artery.

► Gives off the Deep Palmar Arch. Gives off the Deep Palmar Arch. ► Gives off the Dorsalis Pollicis and Dorsalis Indices Arteries. Gives off the Dorsalis Pollicis and Dorsalis Indices Arteries. ► CLINICAL -- CLINICAL -- RADIAL PULSERADIAL PULSE: On the palmar lateral wrist, : On the palmar lateral wrist,

at the location of the at the location of the Radial TrioRadial Trio, you can feel the pulse. , you can feel the pulse. The Radial Artery is found lateral to the The Radial Artery is found lateral to the Flexor Carpi RadialisFlexor Carpi Radialis

and and Flexor Pollicis LongusFlexor Pollicis Longus tendons at this location in the wrist. tendons at this location in the wrist. Those are the components of the radial trio. Those are the components of the radial trio.

► PATH: Then the radial artery goes to the floor of the PATH: Then the radial artery goes to the floor of the anatomical snuffbox ------> through the adductor pollicis anatomical snuffbox ------> through the adductor pollicis and dorsal interosseus muscles ------> deep palmar arch. and dorsal interosseus muscles ------> deep palmar arch.

Arterial supplyArterial supply

►ULNAR ARTERY: ULNAR ARTERY: One of the terminal One of the terminal branches of the Brachial Artery. branches of the Brachial Artery.

►Does notDoes not pass through the Flexor pass through the Flexor Retinaculum. Retinaculum.

►Gives off the Superficial Palmar Arch. Gives off the Superficial Palmar Arch.

FLEXOR RETINACULUMFLEXOR RETINACULUM

► The sheath that contains the flexor tendons The sheath that contains the flexor tendons on the anterior wrist. on the anterior wrist.

► Goes from the Trapezium to the Scaphoid. Goes from the Trapezium to the Scaphoid. ► CARPAL TUNNEL SYNDROME: CARPAL TUNNEL SYNDROME: The The Median Median

NerveNerve passes deep to the flexor retinaculum. passes deep to the flexor retinaculum. If it is entrapped, carpal tunnel syndrome If it is entrapped, carpal tunnel syndrome results. results. Causes numbness and tingling in the lateral part Causes numbness and tingling in the lateral part

of the hand supplied by the median nerve, and of the hand supplied by the median nerve, and some motor dysfunction. some motor dysfunction.

Treatment: Cut the flexor retinaculum and relieve Treatment: Cut the flexor retinaculum and relieve the pressure. the pressure.

Flexor ……..Flexor ……..

►MOBILE WAD: MOBILE WAD: The lateral compartment of The lateral compartment of the flexor forearm, which is more loosely the flexor forearm, which is more loosely connected than the other compartments. It connected than the other compartments. It contains two muscles: contains two muscles:

►BrachioradialisBrachioradialis ► Extensor Carpi Radialis LongusExtensor Carpi Radialis Longus ► PALMARIS LONGUS MUSCLE: Absent in about PALMARIS LONGUS MUSCLE: Absent in about

30% of people, and a good candidate for 30% of people, and a good candidate for surgical surgical tendon transfers tendon transfers when it is when it is present. present.

Flexors ……Flexors ……► FLEXOR DIGITORUM: FLEXOR DIGITORUM: Acts differently than the extensor Acts differently than the extensor

digitorum. digitorum. ► Superficial Flexor Digitorum: Superficial Flexor Digitorum: Inserts on the distal phalanx Inserts on the distal phalanx

and crosses over the DIP joint. and crosses over the DIP joint. ► Profunda Flexor Digitorum: Profunda Flexor Digitorum: Inserts on the proximal Inserts on the proximal

phalanx and crosses over the PIP joint. phalanx and crosses over the PIP joint. ► SPACE OF PARONA: SPACE OF PARONA: The potential space between the The potential space between the

superficial and deep groups of anterior muscles -- essentially superficial and deep groups of anterior muscles -- essentially between the Flexor Digitorum Superficialis and Flexor between the Flexor Digitorum Superficialis and Flexor Digitorum Profundus. Digitorum Profundus.

► FASCIA ANTEBRACHIALIS: FASCIA ANTEBRACHIALIS: Thick fascial plane over the Thick fascial plane over the anterior forearm. anterior forearm.

► INTEROSSEUS MEMBRANE: INTEROSSEUS MEMBRANE: Between the radius and ulna, Between the radius and ulna, the posterior limit to the anterior compartment. The Anterior the posterior limit to the anterior compartment. The Anterior Interosseus Nerve and Artery, and the Flexor Digitorum Interosseus Nerve and Artery, and the Flexor Digitorum Profundus, are directly superficial to it. Profundus, are directly superficial to it.

JOINTS OF THE UPPER JOINTS OF THE UPPER EXTREMITYEXTREMITY

► Types of Joints: Joints are structures that connects bones Types of Joints: Joints are structures that connects bones together. together.

► Fibrous Joints: Fibrous Joints: Collagen joints. Collagen joints. Suture of the skull. Suture of the skull. The The interosseus membraneinterosseus membrane between the radius and ulna. This is a between the radius and ulna. This is a

type of type of syndesmosissyndesmosis -- i.e. a sheet of fibrous tissue. -- i.e. a sheet of fibrous tissue. ► Cartilaginous Joints: Cartilaginous Joints:

Examples: Examples: ► Epiphyseal Plates Epiphyseal Plates ► Costochondral Joints Costochondral Joints ► Intervertebral Disc Intervertebral Disc ► Pubic Symphysis Pubic Symphysis

Primary Cartilaginous Joints: Primary Cartilaginous Joints: SynchondrosesSynchondroses -- hyaline cartilage. -- hyaline cartilage. Secondary Cartilaginous Joints: Secondary Cartilaginous Joints: SymphysisSymphysis -- hyaline cartilage -- hyaline cartilage

along with fibrous tissue or fibrous cartilage. along with fibrous tissue or fibrous cartilage.

Joints of Upper extremityJoints of Upper extremity► Types of Joints: Joints are structures that connects bones Types of Joints: Joints are structures that connects bones

together. together. ► Fibrous Joints: Fibrous Joints: Collagen joints. Collagen joints.

Suture of the skull. Suture of the skull. The The interosseus membraneinterosseus membrane between the radius and ulna. This is a between the radius and ulna. This is a

type of type of syndesmosissyndesmosis -- i.e. a sheet of fibrous tissue. -- i.e. a sheet of fibrous tissue. ► Cartilaginous Joints: Cartilaginous Joints:

Examples: Examples: ► Epiphyseal Plates Epiphyseal Plates ► Costochondral Joints Costochondral Joints ► Intervertebral Disc Intervertebral Disc ► Pubic Symphysis Pubic Symphysis

Primary Cartilaginous Joints: Primary Cartilaginous Joints: SynchondrosesSynchondroses -- hyaline cartilage. -- hyaline cartilage. Secondary Cartilaginous Joints: Secondary Cartilaginous Joints: SymphysisSymphysis -- hyaline cartilage -- hyaline cartilage

along with fibrous tissue or fibrous cartilage. along with fibrous tissue or fibrous cartilage.

Joints of upper extremityJoints of upper extremity► Synovial Joints:Synovial Joints:

Characterized by four things. Characterized by four things. ► A A joint cavityjoint cavity, filled with a viscous lubricant substance -- synovial , filled with a viscous lubricant substance -- synovial

fluid. fluid. ► A A synovial membranesynovial membrane, which produces the synovial fluid to fill the , which produces the synovial fluid to fill the

joint cavity. joint cavity. ► Articular cartilageArticular cartilage ► \Fibrous Capsule\Fibrous Capsule

Types of Synovial Joints Types of Synovial Joints ► Plane JointPlane Joint -- moveable only in one axis, in one plane. -- moveable only in one axis, in one plane. ► Hinge JointHinge Joint -- moveable only in one axis -- i.e. flexion and -- moveable only in one axis -- i.e. flexion and

extension. extension. ► Pivot JointPivot Joint -- moveable only in one axis -- i.e. rotation. -- moveable only in one axis -- i.e. rotation. ► Condyloid JointCondyloid Joint -- moveable in two axes -- i.e. flexion-extension, or -- moveable in two axes -- i.e. flexion-extension, or

abduction-adduction. abduction-adduction. It is usually ellipsoid in shape. It is usually ellipsoid in shape.

► Saddle JointSaddle Joint -- two axes. -- two axes. ► Ball and Socket Joint Ball and Socket Joint -- Multi-axis movement. -- Multi-axis movement.

Movements of jointsMovements of joints► Synovial Joints:Synovial Joints:

Characterized by four things. Characterized by four things. ► A A joint cavityjoint cavity, filled with a viscous lubricant substance -- synovial , filled with a viscous lubricant substance -- synovial

fluid. fluid. ► A A synovial membranesynovial membrane, which produces the synovial fluid to fill the , which produces the synovial fluid to fill the

joint cavity. joint cavity. ► Articular cartilageArticular cartilage ► \Fibrous Capsule\Fibrous Capsule

Types of Synovial Joints Types of Synovial Joints ► Plane JointPlane Joint -- moveable only in one axis, in one plane. -- moveable only in one axis, in one plane. ► Hinge JointHinge Joint -- moveable only in one axis -- i.e. flexion and -- moveable only in one axis -- i.e. flexion and

extension. extension. ► Pivot JointPivot Joint -- moveable only in one axis -- i.e. rotation. -- moveable only in one axis -- i.e. rotation. ► Condyloid JointCondyloid Joint -- moveable in two axes -- i.e. flexion-extension, or -- moveable in two axes -- i.e. flexion-extension, or

abduction-adduction. abduction-adduction. It is usually ellipsoid in shape. It is usually ellipsoid in shape.

► Saddle JointSaddle Joint -- two axes. -- two axes. ► Ball and Socket Joint Ball and Socket Joint -- Multi-axis movement. -- Multi-axis movement.

Clinical….Clinical….

► CLINICAL -- Injuries / Diseases of the Joints: CLINICAL -- Injuries / Diseases of the Joints: ► Dislocation:Dislocation: Complete loss of apposition between Complete loss of apposition between

two articular surfaces. two articular surfaces. ► Subluxation:Subluxation: Partial dislocation; partial loss of Partial dislocation; partial loss of

apposition between two articular surfaces. apposition between two articular surfaces. ► Osteoarthritis:Osteoarthritis: Degeneration of articular cartilage Degeneration of articular cartilage

and/or surfaces in weight-bearing joints, resulting and/or surfaces in weight-bearing joints, resulting from age and/or trauma. from age and/or trauma.

► Rheumatoid Arthritis: Rheumatoid Arthritis: Connective tissue disorder Connective tissue disorder affecting the whole body, mainly affecting the small affecting the whole body, mainly affecting the small joints in terms of joints. joints in terms of joints.

► Gout: Gout: Painful inflammation of the joint from excess Painful inflammation of the joint from excess uric acid, resulting sodium biurate deposits in joints. uric acid, resulting sodium biurate deposits in joints.

Movements of joints….Movements of joints….

► CONJUNCT ROTATION: Instinctive or CONJUNCT ROTATION: Instinctive or automatic rotation of the forearm, as automatic rotation of the forearm, as demonstrated by Codman's paradox, where demonstrated by Codman's paradox, where you hold your palm to your side, abduct it, you hold your palm to your side, abduct it, rotate it anteriorly, and bring it back to your rotate it anteriorly, and bring it back to your body, to discover that it is now facing the body, to discover that it is now facing the other way. other way.

► ADJUNCT ROTATION: Deliberate rotation of ADJUNCT ROTATION: Deliberate rotation of the joint, such as when you point your hands the joint, such as when you point your hands laterally and then try to abduct your arm. laterally and then try to abduct your arm.

GLENOHUMERAL JOINT:GLENOHUMERAL JOINT: ► ROTATOR CUFFROTATOR CUFF: The tendons of the muscles surrounding the : The tendons of the muscles surrounding the

shoulder joint. They rotate the shoulder. shoulder joint. They rotate the shoulder. Anterior Border: Subscapularis Anterior Border: Subscapularis Superolateral Border: Head of the biceps Superolateral Border: Head of the biceps Posterior Border: Infraspinatus and Teres Minor Posterior Border: Infraspinatus and Teres Minor Superior Border: Supraspinatus Superior Border: Supraspinatus

► CLINICAL: The joint is covered on all sides except inferiorly. Hence CLINICAL: The joint is covered on all sides except inferiorly. Hence shoulder dislocations tend to occur inferiorly. shoulder dislocations tend to occur inferiorly. In this case you have to watch for damage to the In this case you have to watch for damage to the axillary nerveaxillary nerve and and

Posterior Circumflex Humeral ArteryPosterior Circumflex Humeral Artery, both of which are directly inferior, , both of which are directly inferior, in the Quadrangular Space, because this is straight below the shoulder joint. in the Quadrangular Space, because this is straight below the shoulder joint.

TEST for Axillary Nerve damage: Cutaneous sensation in the Deltoid region TEST for Axillary Nerve damage: Cutaneous sensation in the Deltoid region ► THREE DEGREES OF FREEDOM: Circumduction + Rotation. Hence it is THREE DEGREES OF FREEDOM: Circumduction + Rotation. Hence it is

a mobile but unstable joint. a mobile but unstable joint. The glenohumeral joint is an The glenohumeral joint is an incongruent incongruent joint -- note that the head of the joint -- note that the head of the

humerus does not fit in perfectly with the Glenoid Cavity of the Scapula. humerus does not fit in perfectly with the Glenoid Cavity of the Scapula. ► STABILIZING MUSCLES: The STABILIZING MUSCLES: The deltoiddeltoid and and bicepsbiceps help stabilize the help stabilize the

shoulder, due to the incongruence of the joint. shoulder, due to the incongruence of the joint.

ULNOHUMERAL JOINT ULNOHUMERAL JOINT (ELBOW) (ELBOW)

► Has higher stability and lower mobility: only one degree Has higher stability and lower mobility: only one degree of freedom (flexion / extension). of freedom (flexion / extension).

► The Humerus articulates only with the Ulna -- the radius The Humerus articulates only with the Ulna -- the radius has nothing to do with it!has nothing to do with it!

► Radial Collateral LigamentRadial Collateral Ligament -- Lateral ligament -- Lateral ligament support. support.

► Ulnar Collateral LigamentUlnar Collateral Ligament -- Medial ligament support. -- Medial ligament support. ► CONGRUENCE: The Olecranon of the Ulna fits much CONGRUENCE: The Olecranon of the Ulna fits much

better into the Olecranon Fossa of the Humerus, as better into the Olecranon Fossa of the Humerus, as compared to the shoulder joint. compared to the shoulder joint.

► Posterior Elbow: The joint capsule is lax on the Posterior Elbow: The joint capsule is lax on the posterior, so that the elbow can flex and extend. posterior, so that the elbow can flex and extend.

ULNORADIAL JOINT (ELBOW) ULNORADIAL JOINT (ELBOW)

►Proximal Ulnoradial Joint: Proximal Ulnoradial Joint: Annular Annular Ligament Ligament holds the Radial Head in holds the Radial Head in place in the Radial Notch of the Ulna. place in the Radial Notch of the Ulna.

► Intermediate Ulnoradial Joint: Intermediate Ulnoradial Joint: Interosseus MembraneInterosseus Membrane holds them holds them together along the shafts of both bones. together along the shafts of both bones.

►Distal Ulnoradial Joint: Distal Ulnoradial Joint: Anterior Anterior and and Posterior Ulnoradial LigamentsPosterior Ulnoradial Ligaments. .

RADIOCARPAL JOINT (WRIST)RADIOCARPAL JOINT (WRIST)

The Radius articulates with the Carpal Bones -- not the Ulna at all!The Radius articulates with the Carpal Bones -- not the Ulna at all! ► TWO DEGREES OF FREEDOM: We can circumduct the wrist. TWO DEGREES OF FREEDOM: We can circumduct the wrist. ► Much of flexion (especially) and extension actually occurs at the Much of flexion (especially) and extension actually occurs at the

Intercarpal JointsIntercarpal Joints between the two rows of Carpal Bones. between the two rows of Carpal Bones. ► Joint of Knuckles and Fingers: Joint of Knuckles and Fingers: ► Carpometacarpal Joints: Carpometacarpal Joints: Joints between distal row of carpal Joints between distal row of carpal

bones and metacarpals. bones and metacarpals. ► Metacarpophalangeal (MCP) Joints: Metacarpophalangeal (MCP) Joints: The knuckles, between The knuckles, between

the metacarpals and proximal phalanges. the metacarpals and proximal phalanges. ► Proximal Interphalangeal (PIP) Joints: Proximal Interphalangeal (PIP) Joints: Between the Between the

proximal and middle phalanges. proximal and middle phalanges. ► Distal Interphalangeal (DIP) Joints: Distal Interphalangeal (DIP) Joints: Between the middle Between the middle

and distal phalanges (not present in thumb). and distal phalanges (not present in thumb). ► THUMBTHUMB -- NOT A STABLE JOINT compared to the other fingers. -- NOT A STABLE JOINT compared to the other fingers.

The thumb has more mobility, too, to allow opposition. The thumb has more mobility, too, to allow opposition.

THE HANDTHE HAND

► Movements of the Fingers: Movements of the Fingers: ► Flexion and Extension of Fingers: Uses the Flexion and Extension of Fingers: Uses the

fingernails as a fan. fingernails as a fan. ► Abduction and Adduction of Fingers: Uses the Abduction and Adduction of Fingers: Uses the

fingernails to slice through the air, centered around fingernails to slice through the air, centered around the middle finger. the middle finger.

► THUMB: Same goes for thumb -- flexion, extension, THUMB: Same goes for thumb -- flexion, extension, abduction, and adduction are based on the position abduction, and adduction are based on the position of the thumb-nail. of the thumb-nail.

► Circumduction: Circumduction: The combination action of flexion, The combination action of flexion, extension, abduction, and adduction. Moving extension, abduction, and adduction. Moving around in a circle, as you can do with your fingers, around in a circle, as you can do with your fingers, wrist, and shoulder. wrist, and shoulder.

Force Transduction through the Force Transduction through the Hand and Arm: Hand and Arm:

►Weight-bearing on the hand can be Weight-bearing on the hand can be transmitted as follows: transmitted as follows: SCAPHOID ------> RadioCarpal joints ------> SCAPHOID ------> RadioCarpal joints ------>

RADIUS ------> Interosseus Membrane ------> RADIUS ------> Interosseus Membrane ------> ULNA ------> Olecranon ------> HUMERUS ------> ULNA ------> Olecranon ------> HUMERUS ------> Glenohumeral Joint ------> SCAPULA ------> Glenohumeral Joint ------> SCAPULA ------> Coracoclavicular Ligaments ------> CLAVICLE Coracoclavicular Ligaments ------> CLAVICLE

► The clavicle is the only bony The clavicle is the only bony articulation between the upper limb articulation between the upper limb and trunkand trunk. .

►Most common points of fracture in a fall: Most common points of fracture in a fall: The surgical neck of the humerus The surgical neck of the humerus The middle of the clavicle The middle of the clavicle

Common Wrist Fractures: Common Wrist Fractures:

►Colles Fracture: Colles Fracture: Fracture of the distal Fracture of the distal radius. radius.

►Scaphoid FracturesScaphoid Fractures: Fracture of the : Fracture of the scaphoid bone. scaphoid bone.

Hand functions…Hand functions…

►Extrinsic Muscles of the Hands: Mostly Extrinsic Muscles of the Hands: Mostly concerned with grip. concerned with grip.

► Intrinsic Muscles of the Hands: Concerned Intrinsic Muscles of the Hands: Concerned with manipulation of the digits. All of with manipulation of the digits. All of them are basically innervated by T1. them are basically innervated by T1.

►PALMAR APONEUROSIS: PALMAR APONEUROSIS: Deep to the Deep to the skin and fascia. It holds it down, so that skin and fascia. It holds it down, so that the skin on the palm is tight and hairless. the skin on the palm is tight and hairless.

Clinical….Clinical….

►DUPUYTREN'S CONTRACTURE: DUPUYTREN'S CONTRACTURE: Flexion of the 4th and 5th digits, Flexion of the 4th and 5th digits, resulting from progressive shortening resulting from progressive shortening of the palmar aponeuroses, from of the palmar aponeuroses, from hypertrophy and hyperplasia. hypertrophy and hyperplasia. Unknown cause. Unknown cause.

FIBROUS FLEXOR SHEATHS FIBROUS FLEXOR SHEATHS

►Strong sheath covering the long Strong sheath covering the long tendons going into the hand, distal to tendons going into the hand, distal to the flexor retinaculum. the flexor retinaculum.

►The fibrous sheaths of the fingers The fibrous sheaths of the fingers contain two tendons: The tendons of contain two tendons: The tendons of the the Flexor Digitorum SuperficialisFlexor Digitorum Superficialis and and the the Flexor Digitorum ProfundusFlexor Digitorum Profundus. .

►The fibrous sheath of the thumb The fibrous sheath of the thumb contains one tendon: The contains one tendon: The Flexor Pollicis Flexor Pollicis Longus.Longus.

SYNOVIAL FLEXOR SHEATHS SYNOVIAL FLEXOR SHEATHS

►): The fibrous sheaths are enclosed in ): The fibrous sheaths are enclosed in synovial sheaths in areas where there synovial sheaths in areas where there is friction. Primarily: is friction. Primarily:

►Deep to the flexor retinaculum. Deep to the flexor retinaculum. ►Within the digits. Within the digits. ►There are NO SYNOVIAL SHEATHS in There are NO SYNOVIAL SHEATHS in

the central palm of the hand. the central palm of the hand.

Bursae…Bursae…

►RADIAL BURSA:RADIAL BURSA: ► Contains the Pollicis Longus tendon. Contains the Pollicis Longus tendon. ► Communicates with Ulnar Bursa in 50% of Communicates with Ulnar Bursa in 50% of

people. people. ►ULNAR BURSA: ULNAR BURSA: ► Contains the Flexor Digitorum Superficialis Contains the Flexor Digitorum Superficialis

and Profundus tendons. and Profundus tendons. ► Communicates with Radial Bursa in 50% of Communicates with Radial Bursa in 50% of

people. people.

CLINICALCLINICAL

HORSESHOE INFECTION: HORSESHOE INFECTION: Infection spreading Infection spreading from little finger to thumb or vice versa, as a from little finger to thumb or vice versa, as a consequence of the communication between consequence of the communication between the radial and ulnar bursae. the radial and ulnar bursae.

DORSAL SUBCUTANEOUS SPACE will receive DORSAL SUBCUTANEOUS SPACE will receive lymph from the palmar aspect of the hand. lymph from the palmar aspect of the hand. Thus a hand-infection can easily result in Thus a hand-infection can easily result in swelling on posterior aspect of the hand, in swelling on posterior aspect of the hand, in which case it would be lymph -- not pus -- so which case it would be lymph -- not pus -- so don't incise it. don't incise it.

Arterial supply of handArterial supply of hand

►SUPERFICIAL PALMAR ARCH: SUPERFICIAL PALMAR ARCH: Main Main arterial supply to the hand. arterial supply to the hand.

►Literally it is formed by a continuation Literally it is formed by a continuation of the artery, and it anastomoses with of the artery, and it anastomoses with the Superficial Palmar Branch of the the Superficial Palmar Branch of the Radial Artery. Radial Artery.

► It gives off It gives off Common Palmar Digital Common Palmar Digital Arteries ------> Proper Palmar Arteries ------> Proper Palmar Digital ArteriesDigital Arteries


►DEEP PALMAR ARCH: DEEP PALMAR ARCH: Lies deep to Lies deep to the flexor retinaculum. the flexor retinaculum.

►This is formed by the radial artery, and This is formed by the radial artery, and it anastomoses with the terminal ulnar it anastomoses with the terminal ulnar artery. artery.

► It gives off the It gives off the Palmar Metacarpal Palmar Metacarpal Arteries ------> Proper Palmar Arteries ------> Proper Palmar Digital ArteriesDigital Arteries


►DORSAL CARPAL ARCH: DORSAL CARPAL ARCH: From the From the dorsal carpal branches of the Radial dorsal carpal branches of the Radial and Ulnar arteries. and Ulnar arteries.

► It gives off the It gives off the Dorsal Metacarpal Dorsal Metacarpal Arteries ------> Dorsal Digital Arteries ------> Dorsal Digital ArteriesArteries. .

Other parts …..Other parts …..

►THENAR SPACE: THENAR SPACE: The area deep to The area deep to the 1st lumbrical muscle and the 2st the 1st lumbrical muscle and the 2st flexor tendon, in the palm of the hand. flexor tendon, in the palm of the hand.

►MIDPALMAR SPACE: MIDPALMAR SPACE: The medial part The medial part of the deep palm of the hand, deep to of the deep palm of the hand, deep to the rest of the flexor tendons. It is next the rest of the flexor tendons. It is next to the Thenar Space. to the Thenar Space.

►A SEPTUM separates the Thenar from A SEPTUM separates the Thenar from MidPalmar spaces. MidPalmar spaces.

CUTANEOUS INNERVATION OF CUTANEOUS INNERVATION OF HAND, FOREARM, ARM HAND, FOREARM, ARM

► Axillary N: Axillary N: Shoulder and Deltoid regions Shoulder and Deltoid regions

► Musculocutaneous N / Lateral Antebrachial Cutaneous N: Musculocutaneous N / Lateral Antebrachial Cutaneous N: Lateral forearm (both posterior and anterior) Lateral forearm (both posterior and anterior)

► Medial Antebrachial Cutaneous N: Medial Antebrachial Cutaneous N: Medial Forearm (both posterior and anterior) Medial Forearm (both posterior and anterior)

► Radial N: Radial N: Central posterior arm and forearm Central posterior arm and forearm Lateral 2/3 of posterior hand (up to middle of 4th digit or so) -- EXCEPT the Lateral 2/3 of posterior hand (up to middle of 4th digit or so) -- EXCEPT the

finger tips!! finger tips!! Lateral part of the thumb Lateral part of the thumb

► Median N: Median N: Lateral two thirds of anterior hand Lateral two thirds of anterior hand Fingertips of lateral 2/3 of posterior hand Fingertips of lateral 2/3 of posterior hand

► Ulnar N: Ulnar N: Medial third of the hand, both anterior and posterior.Medial third of the hand, both anterior and posterior.

LUMBRICALS:LUMBRICALS: ► They provide stability to the digits. They provide stability to the digits. ► They are They are anterioranterior to the Metacarpophalangeal (MCP) joints to the Metacarpophalangeal (MCP) joints

(knuckles). (knuckles). So they So they flexflex the knuckles. the knuckles.

► They are They are posteriorposterior to the proximal and distal interphalangeal to the proximal and distal interphalangeal (PIP and DIP) joints. (PIP and DIP) joints. So they So they extendextend the distal phalanges. the distal phalanges.

► They originate from the tendon of the flexor digitorum They originate from the tendon of the flexor digitorum Profundus. Profundus.

► FUNCTION OF LUMBRICALS: They are rich in FUNCTION OF LUMBRICALS: They are rich in neuromuscular neuromuscular spindle organsspindle organs, and they are thought to give you , and they are thought to give you proprioception proprioception (spatial orientation) and (spatial orientation) and kinesthesiakinesthesia (sense (sense of motion) of the digits, due to the tension placed on them by of motion) of the digits, due to the tension placed on them by the digital tendons. the digital tendons.

► In other words, they allow you to know where your finger is In other words, they allow you to know where your finger is and where it is going. and where it is going.

CLINICAL STUFF: FRACTURES CLINICAL STUFF: FRACTURES AND ENTRAPMENT AND ENTRAPMENT

NEUROPATHIESNEUROPATHIES► SPACE OF PARONA COMPRESSION: Veins are SPACE OF PARONA COMPRESSION: Veins are

subject to compression when swelling or subject to compression when swelling or fluid buildup occurs in any potential space. fluid buildup occurs in any potential space. This causes blood to backflow, which causes This causes blood to backflow, which causes the following course of events. the following course of events.

► Ischemia ------> Necrosis ------> FibrosisIschemia ------> Necrosis ------> Fibrosis ► FASCIOTOMY: FASCIOTOMY: Cutting through the fascia Cutting through the fascia

which is causing the compartment which is causing the compartment syndrome, thereby relieving the pressure syndrome, thereby relieving the pressure and hopefully the compartment syndrome. and hopefully the compartment syndrome.


NEUROPATHIESNEUROPATHIES► SATURDAY NIGHT SYNDROME: SATURDAY NIGHT SYNDROME: Drunk person falling Drunk person falling

asleep on elbow and hence on ulnar nerve. Wake up asleep on elbow and hence on ulnar nerve. Wake up the next morning and the ulnar nerve is dead. the next morning and the ulnar nerve is dead.

► CORACOBRACHIALIS SYNDROME (N447): CORACOBRACHIALIS SYNDROME (N447): Loss of Loss of the the Musculocutaneous NerveMusculocutaneous Nerve where it runs through where it runs through the the Coracobrachialis MuscleCoracobrachialis Muscle. If the muscle dies, then . If the muscle dies, then nerve dies with it. nerve dies with it.

► YOU ALSO LOSE: YOU ALSO LOSE: Biceps, Brachialis, and Lateral Biceps, Brachialis, and Lateral Antebrachial Cutaneous NerveAntebrachial Cutaneous Nerve. .

► LOST FUNCTION: LOST FUNCTION: Lost flexion at elbow. Lost flexion at elbow. Weak supination due to supinator muscle. Weak supination due to supinator muscle.

► Lost sensation over lateral aspect of forearm Lost sensation over lateral aspect of forearm (cutaneous innervation of medial antebrachial (cutaneous innervation of medial antebrachial cutaneous N.) cutaneous N.)


NEUROPATHIESNEUROPATHIES► SUPINATOR CHANNEL SYNDROME: SUPINATOR CHANNEL SYNDROME:

Compression of the Compression of the Deep Branch of the Deep Branch of the Radial NerveRadial Nerve between the between the Superficial and Superficial and Deep Heads of the Supinator, and the Lateral Deep Heads of the Supinator, and the Lateral Epicondyle.Epicondyle.

► This occurs right at the This occurs right at the lateral epicondylelateral epicondyle, , where the Radial Nerve gives off two branches where the Radial Nerve gives off two branches (Deep and Superficial) to innervate the forearm. (Deep and Superficial) to innervate the forearm.

►Arcade of Frohn: Arcade of Frohn: Occurs in 20%-30% of Occurs in 20%-30% of population, where one head of the Supinator is population, where one head of the Supinator is actually a sharp tendon inserting on the lateral actually a sharp tendon inserting on the lateral epicondyle. This can also lead to Radial N. epicondyle. This can also lead to Radial N. damage. damage.


NEUROPATHIESNEUROPATHIES► SUPRACONDYLAR SYNDROME: SUPRACONDYLAR SYNDROME: Entrapment Entrapment

of the of the Median N. Median N. beneath the beneath the Ligament of Ligament of StruthersStruthers, , which connects the which connects the Supracondylar Supracondylar ProcessProcess to the to the Medial Epicondyle.Medial Epicondyle.

► The Supracondylar Process is a bit of bone The Supracondylar Process is a bit of bone sticking out the medial aspect of the humerus. It sticking out the medial aspect of the humerus. It is only present in a small fraction of population. is only present in a small fraction of population.

► LOSS OF FUNCTION AND SENSATION: Anywhere LOSS OF FUNCTION AND SENSATION: Anywhere the median N. innervates. the median N. innervates. Lateral 2/3 of palm of hand, lost cutaneous sensation. Lateral 2/3 of palm of hand, lost cutaneous sensation. Lose motor to the palmar thenar muscles. Lose motor to the palmar thenar muscles. Lose motor to the first two lumbricals. Lose motor to the first two lumbricals.


NEUROPATHIESNEUROPATHIES► PRONATOR TERES SYNDROME: PRONATOR TERES SYNDROME:

Entrapment of Entrapment of Median N. Median N. passing between passing between the Deep and Superficial Heads of the the Deep and Superficial Heads of the Pronator Teres. Pronator Teres.

► The Median N. also passes deep to the The Median N. also passes deep to the Flexor Digitorum Superficialis tendon, right Flexor Digitorum Superficialis tendon, right after it gets past the Pronator Teres. This can after it gets past the Pronator Teres. This can also cause trouble. also cause trouble.

► LOSS OF FUNCTION and SENSATION: Again, LOSS OF FUNCTION and SENSATION: Again, whatever would happen if you lose the whatever would happen if you lose the Median N. See above. Median N. See above.


NEUROPATHIESNEUROPATHIES►MARTIN-GRUBER ANASTOMOSIS: MARTIN-GRUBER ANASTOMOSIS:

Connection between the Median and Ulnar Connection between the Median and Ulnar nerves in the palm of the hand, in about nerves in the palm of the hand, in about 30% of population. When the connection is 30% of population. When the connection is there, it is mainly a motor connection. there, it is mainly a motor connection.

►Result = people with Ulnar N. damage Result = people with Ulnar N. damage may still have cutaneous anesthesia, but may still have cutaneous anesthesia, but they may keep some motor function in the they may keep some motor function in the hand. hand.


NEUROPATHIESNEUROPATHIES► CARPAL TUNNEL SYNDROME: CARPAL TUNNEL SYNDROME: The The Median NerveMedian Nerve

passes deep to the flexor retinaculum. If it is passes deep to the flexor retinaculum. If it is entrapped, carpal tunnel syndrome results. entrapped, carpal tunnel syndrome results.

► Carpus is actually U-Shaped. Carpus is actually U-Shaped. ► LOSS OF FUNCTION: LOSS OF FUNCTION:

Causes numbness and tingling in the lateral part of the Causes numbness and tingling in the lateral part of the hand supplied by the median nerve. hand supplied by the median nerve.

Weakening and wasting of the Thenar muscles. Weakening and wasting of the Thenar muscles. ► TREATMENT: Cut the flexor retinaculum and relieve TREATMENT: Cut the flexor retinaculum and relieve

the pressure. the pressure. ► Superficial Palmar Branch of Median NSuperficial Palmar Branch of Median N does does

not go through the Carpal Tunnelnot go through the Carpal Tunnel. It results in an . It results in an area of skin in the middle of the palm that is not area of skin in the middle of the palm that is not affected by Carpel Tunnel Syndrome. affected by Carpel Tunnel Syndrome.


NEUROPATHIESNEUROPATHIES► CUBITAL TUNNEL SYNDROME: CUBITAL TUNNEL SYNDROME:

Compression of the Compression of the Ulnar NerveUlnar Nerve between between the two heads of origin of the the two heads of origin of the Flexor Carpi Flexor Carpi UlnarisUlnaris. .

► The The Pisiform bonePisiform bone, distally, acts as a lever , distally, acts as a lever in allow the flexor carpi ulnaris to flex the in allow the flexor carpi ulnaris to flex the fingers more strongly. fingers more strongly.

► LOSS OF FUNCTION: Medial two heads of the LOSS OF FUNCTION: Medial two heads of the flexor digitorum profundus and most of the flexor digitorum profundus and most of the intrinsic muscles of the hand. intrinsic muscles of the hand.


NEUROPATHIESNEUROPATHIES►GUYON'S CANAL SYNDROME : GUYON'S CANAL SYNDROME : Compression Compression

of the of the Ulnar NerveUlnar Nerve in in Guyon's CanalGuyon's Canal, , between the between the Volar Carpal Ligament Volar Carpal Ligament and the and the Flexor RetinaculumFlexor Retinaculum. .

►Volar Carpal Ligament: Volar Carpal Ligament: Is superficial to the Is superficial to the flexor retinaculum. The ulnar artery and nerve flexor retinaculum. The ulnar artery and nerve pass superficial to the flexor retinaculum but pass superficial to the flexor retinaculum but deep to the volar carpal ligament. deep to the volar carpal ligament.

► CUBITAL TUNNEL -VS- GUYON'S CANAL:CUBITAL TUNNEL -VS- GUYON'S CANAL: In In Guyon's Canal, only the intrinsic muscles of Guyon's Canal, only the intrinsic muscles of the hand are lost, whereas in Cubital Tunnel the hand are lost, whereas in Cubital Tunnel Syndrome you also lose the innervation of the Syndrome you also lose the innervation of the medial half of the flexor digitorum profundus. medial half of the flexor digitorum profundus.


NEUROPATHIESNEUROPATHIES► DUPUYTREN'S CONTRACTURE: DUPUYTREN'S CONTRACTURE: Progressive Progressive

shortening of the palmar aponeuroses, from shortening of the palmar aponeuroses, from hypertrophy and hyperplasia. Unknown cause. hypertrophy and hyperplasia. Unknown cause.

► Found esp. in those who have done a lot of manual Found esp. in those who have done a lot of manual labor. labor.

► SYMPTOM: Tends to bring the medial two fingers in SYMPTOM: Tends to bring the medial two fingers in toward the palm and flex them downward a bit. toward the palm and flex them downward a bit.

► LOSS OF FUNCTION: Blood vessels that reach the LOSS OF FUNCTION: Blood vessels that reach the skin through the palmar aponeurosis are skin through the palmar aponeurosis are compromised!!! compromised!!!

► TREATMENT: If caught early enough, incise the TREATMENT: If caught early enough, incise the aponeurosis. aponeurosis.


NEUROPATHIESNEUROPATHIES► TENOSYNOVITIS:TENOSYNOVITIS: Not to be messed with. Not to be messed with.

Inflammation of the tendons in the synovial Inflammation of the tendons in the synovial joints, which can spread proximally all the way joints, which can spread proximally all the way to the elbow. to the elbow.

► INFECTION CAN SPREAD from the INFECTION CAN SPREAD from the Ulnar Ulnar Bursa ------> Carpal Tunnel Bursa ------> Carpal Tunnel (with secondary (with secondary carpal tunnel syndrome) carpal tunnel syndrome) ------> Space of ------> Space of Parona ------> Cubital FossaParona ------> Cubital Fossa. .

► Tenosynovitis in the index finger flexor tendon Tenosynovitis in the index finger flexor tendon can rupture and get into the can rupture and get into the Thenar SpaceThenar Space, , causing a compartment syndrome there as causing a compartment syndrome there as well. well.


NEUROPATHIESNEUROPATHIES►DEQUERVAIN'S DISEASE: DEQUERVAIN'S DISEASE: A specific A specific

tenosynovitis of the first extensor tenosynovitis of the first extensor compartment, which transmits the Extensor compartment, which transmits the Extensor Pollicis Longus and Brevis. Pollicis Longus and Brevis.

► Found in people who use their thumb a lot Found in people who use their thumb a lot and are not used to it. and are not used to it.

► SYMPTOM: Dull pain around wrist and lack of SYMPTOM: Dull pain around wrist and lack of desire to move the fingers. desire to move the fingers.

►Dequervain's test:Dequervain's test: Make a fist like a child Make a fist like a child with the thumb inside, and then ulnar with the thumb inside, and then ulnar deviate (adduct) the wrist. It hurts even deviate (adduct) the wrist. It hurts even without the disease! without the disease!


NEUROPATHIESNEUROPATHIES► SCAPHOID FRACTURE: SCAPHOID FRACTURE: If the scaphoid is If the scaphoid is

fractured, there is potential for avascular fractured, there is potential for avascular necrosis in 1/3 of all people, because blood necrosis in 1/3 of all people, because blood comes from only one place -- the distal end. comes from only one place -- the distal end.

► This will result in demineralization of the This will result in demineralization of the Scaphoid from lack of use, and it will appear Scaphoid from lack of use, and it will appear dark on the X-Ray as a result. dark on the X-Ray as a result.

►When the fracture occurs in the When the fracture occurs in the neck neck of the of the Scaphoid, blood supply is cut off to the Scaphoid, blood supply is cut off to the proximal part. proximal part.


NEUROPATHIESNEUROPATHIES►TRIGGER FINGER: TRIGGER FINGER: Swelling of the Swelling of the

fibrous sheaths going around the fibrous sheaths going around the tendons, such that, when the tendon is tendons, such that, when the tendon is on one side of the swelling, such that the on one side of the swelling, such that the finger is flexed, it will stay that way and finger is flexed, it will stay that way and you can't extend it. Then you can pull real you can't extend it. Then you can pull real hard to get the tendon past the hard to get the tendon past the "bottleneck" to the other side of the "bottleneck" to the other side of the swelling, such that the finger extends, swelling, such that the finger extends, and then you can't flex it again! and then you can't flex it again!


NEUROPATHIESNEUROPATHIES►RAYNAUD'S DISEASE: RAYNAUD'S DISEASE: Vascular Vascular

problem of too high of sympathetic problem of too high of sympathetic tone, which can cause complications in tone, which can cause complications in the hand. the hand.

►Spasmodic vasoconstriction at the wrist Spasmodic vasoconstriction at the wrist will cause one or two fingers to become will cause one or two fingers to become cyanotic and ischemic. cyanotic and ischemic.

►You could cut the sympathetic nerves at You could cut the sympathetic nerves at the neck to try and treat it. the neck to try and treat it.

► It is a very serious disease. It is a very serious disease.


NEUROPATHIESNEUROPATHIES►VARUS: VARUS: A bone-fracture that creates A bone-fracture that creates

angulation angulation toward the midline of the toward the midline of the bodybody. .

►VALGUS: VALGUS: A bone-fracture that creates A bone-fracture that creates angulation angulation away from the midline of away from the midline of the bodythe body. .


NEUROPATHIESNEUROPATHIES► TYPES OF FRACTURES: TYPES OF FRACTURES: ► Transverse Transverse ► Oblique Oblique ► Spiral Spiral ► Longitudinal Longitudinal ► Segmental Fracture: Segmental Fracture: Broken bone in two or more Broken bone in two or more

places, creating pieces of bone between the places, creating pieces of bone between the fractures. fractures.

► Open Fracture Open Fracture -- fracture within an exposed -- fracture within an exposed wound and hence vulnerable to infection. wound and hence vulnerable to infection.

► Close FractureClose Fracture -- not exposed by a wound and -- not exposed by a wound and hence not susceptible to infection. hence not susceptible to infection.

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244221 shoulder-and-pectoral