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Organization of the Upper LimbOrganization of the Upper LimbAudrone Biknevicius, Ph.D.
Dept. Biomedical Sciences, OU HCOM at DublinClinical Anatomy Immersion 2014
2
“Anatomical Tool-Kit”
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Week 5
RULE #1Limbs are outgrowths of the ventral body wall that undergo distal growth and differentiation…
Week 7
and rotation
[More detailed limb embryology in MS course]
The upper limbs are innervated by :
A. Dorsal rami of spinal nn.
B. Ventral rami of spinal nn.
4
50% 50%
Dorsal rami of spinal nn. Ventral rami of spinal nn.
Developmentally-dorsal limb mm.
Developmentally-ventral limb mm.
Primitive Pectoral Limb
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DEVELOPMENTAL/EVOLUTIONARY BASIS
• 90◦ lateral rotation (forearm mm. undergo incomplete rotation)
• Limb adduction6
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DEVELOPMENTAL/EVOLUTIONARY BASIS
*
7
Developmentally-ventral muscles:• Lie anterior to the long bones in anatomical position
Developmentally-dorsal muscles: • Lie posterior to the long bones in anatomical position (* exceptions)
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RULE #2A: Ventral vs. dorsal limb mm.
Anterior
Humerus
Posterior
Radius
Anterior
Posterior
5th metacarpal
Anterior
FOREARM
HAND
ARM
Ulnar
8
Upper LimbMuscle
Compartments
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Anterior
Humerus
Posterior
Radius
Anterior
Posterior
5th metacarpal
Anterior
FOREARM
HAND
ARM
Ulnar
9
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No posterior compartment in the hand
Some posterior compartment mm. are found on the anterolateral aspect of the forearm (*brachioradialis, supinator)
*
10
Spinal nerveDorsal primary ramusVentral primary ramus (C5-T1)
Anterior division
Posterior division
limb axis
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RULE #2B: Innervation of anterior vs. posterior compartment mm.
Brachial Plexus(right side; simplified)
Terminal Branches
“Roots of BP” (=ventral rami)
C5
C6
C7
C8
T1
Trunks
U
M
L
Cord
Lat
PostPost
Med
Divisions
Anterior (ventral) division
Posterior (dorsal) division
“Randy Travis Drinks Cold Beer”
11
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Brachial Plexus(right side; simplified)
Terminal Branches
“Roots of BP” (=ventral rami)
C5
C6
C7
C8
T1
Trunks
U
M
L
Cord
Lat
PostPost
Med
Divisions
Anterior (ventral) division
Posterior (dorsal) division 12
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Radial n.
Musculocutaneous n.
Median n.
Ulnar n.
AnteriorMusculocutaneous n.
Humerus
Radial n.
UlnaRadius
Median n. & Ulnar n.
Radial n.
5th metacarpal
Ulnar n. & Median n.
Anterior
Anterior
Posterior
Posterior
Posterior
MOTOR INNERVATION
Muscle Compartments of the Upper Limb
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Musculocutaneous Nerve (arm)
http://emedicine.medscape.com/article/1877731-overview#aw2aab6b3
All mm. in anterior (flexor) compartment of arm
MRI of arm1.Biceps brachii m. 2.Brachialis m. 3.Brachial a. 4.Humerus. 5.Triceps brachii m.
www.med.umich.edu
15
Radial Nerve (arm)
All mm. in posterior (extensor) compartment of arm
http://emedicine.medscape.com/article/1877731-overview#aw2aab6b3
Radial nerve
BB
B
TLongTLat
TMed
The brachialis m. is innervated by which division of the brachial plexus: :
A. Anterior division B. Posterior division
16
50%50%
Anterior division Posterior division
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The brachialis m. is innervated by:
A. Median n.B. Musculocutaneous n. C. Radial n.D. Ulnar n.
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25%
25%25%
25%
Median n. Musculocutaneous n. Radial n. Ulnar n.
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The triceps brachii m. is innervated by:A. Musculocutaneous n. B. Radial n.
50%50%
Musculocutaneous n. Radial n.
19
Radial Nerve (forearm)
All mm. in posterior (extensor) compartment of forearmAlso * brachioradialis and supinator mm.
http://emedicine.medscape.com/article/1877731-overview#aw2aab6b3
*
20
Ulnar Nerve (forearm)
Limited mm. in anterior (flexor) compartment of forearm:-Flexor carpi ulnaris-Flexor digitorum profundus (medial ½)
http://emedicine.medscape.com/article/1877731-overview#aw2aab6b3
Med 1/2
21
Median Nerve (forearm)
All anterior (flexor) compartment mm. of forearm except:-Flexor carpi ulnaris m.-Flexor digitorum profundus m. (med ½)
http://emedicine.medscape.com/article/1877731-overview#aw2aab6b3
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RULE #2C
The extensor digitorum m. lies in the posterior compartment, originates on the lateral epicondyle, and is innervated by:A. Median n.B. Musculocutaneous n. C. Radial n.D. Ulnar n.
25%
25%25%
25%
Median n. Musculocutaneous n. Radial n. Ulnar n.
Lateral epicondyle
Extensor digitorum m.
24
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“Be specific”
The flexor carpi radialis m. is in the anterior compartment, attaches to the medial epicondyle, and is innervated by:
A. Median n.B. Radial n.C. Ulnar n.
25
33%
33%
33%
Median n. Radial n. Ulnar n.
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The flexor digitorum profundus m. is the anterior compartment, attaches to the medial epicondyle, and is innervated by:A. Median n.B. Median n. & Ulnar n. C. Ulnar n.
26
33%
33%
33%
Median n. Median n. & Ulnar n. Ulnar n.
health
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The brachioradialis and supinator mm. lie in the anterior aspect of the forearm but attach to the lateral epicondyle of the humerus. They are innervated by:A. Median n.B. Radial n. C. Ulnar n.
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33%
33%
33%
Median n. Radial n. Ulnar n.
www.pelhamrehab.com
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Median Nerve (hand)
Limited hand mm.:-Thenar mm.-Lateral two lumbricals
http://emedicine.medscape.com/article/1877731-overview#aw2aab6b3
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Ulnar Nerve (hand)
All hand mm. not innervated by median n.
http://emedicine.medscape.com/article/1877731-overview#aw2aab6b3
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What about the most proximal muscles of the upper limb?
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*
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Developmentally-dorsal muscles: •Lie posterior to the long bones in anatomical position (* exception = brachioradialis, supinator)
Developmentally-ventral muscles:•Lie anterior to the long bones in anatomical position-or-•Arise from:
– coracoid ossification – sternum and costal cartilages
-or-•Arise from:
– scapular blade ossification– vertebral column
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RULE #2D
Given the attachments of the latissimus dorsi muscle, its innervation will be from which of division of the brachial plexus:
A. Anterior division B. Posterior division
32
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50% 50%
Anterior division Posterior division
C5
C7
C6
C8
T1
**
*
suprascapular n.supraspinatus & infraspinatus mm.
axillary n.
deltoid & teres minor mm.
upper subscapular n.thoracodorsal n.lower subscapular n.
subscapularis m.latissimus dorsi m.subscapularis & teres major mm.
Brachial Plexus(branches)
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Given the attachments of the pectoralis muscles muscle, its innervation will be from which of division of the brachial plexus:
A. Anterior division B. Posterior division
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50% 50%
Anterior division Posterior division
C5
C7
C6
C8
T1
radial n.
axillary n.
medial n.
musculoskeletal n.
suprascapular n.
upper subscapular n.thoracodorsal n.lower subscapular n.
medial pectoral n.
lateral pectoral n.
long thoracic n.
dorsal scapular n.
**
*
ulnar n.
rhomboid mm.
pectoralis mm.
pectoralis mm.
serratus anterior m.
Brachial Plexus(branches)
35
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posterior anterior
Upper “roots” of the brachial plexus (C5-6 ventral rami) innervate proximal muscles (shoulder, elbow)
Lower “roots” of the brachial plexus (C8-T1 ventral rami) innervate distal muscles (hand)
RULE #3 Proximal-to-Distal Rule
Somatic motor nerve(GSE, with GSA)
Cutaneous nerves(GSA, GVE, GVA)
37
MYOTOME- group of muscles innervated by a single spinal nerve root
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C5
C7
C6
C8
T1
Radial n.
Axillary n.
Medial n.
Musculoskeletal n.
Suprascapular n.
Upper & lower subscapular nn.Thoracodorsal n.
Medial pectoral n.
Lateral pectoral n.
Long thoracic n.
Dorsal scapular n.
**
*
Ulnar n.
Brachial Plexus(all branches)
* Nerve to subclavius** Medial brachial & antebrachial cutaneous nn. 39
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“MIXED FUNCTIONAL MODALITIES”
Most terminal branches of the brachial plexus are mixed fiber nerves:
1.Somatic motor and somatic sensory (prioprioception) to skeletal mm.
2.Then, cutaneous innervation with somatic sensory and sympathetics to skin
posterior anterior
RULE #3
Somatic motor nerve(GSE, with GSA)
Cutaneous nerves(GSA, GVE, GVA)
41
Musculocutaneous n.Tank e
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Some purely cutaneous brs. of brachial plexusTank e
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Segmental innervation(C5-T1)
Dermatomes
RULE #5: Dermatome vs. Cutaneous Nerve Distribution
44
Foerster (1933) – based on clinical findings (used by neurologists)
Keegan and Garrett (1948) – based on limb development
Segmental (Dermatome) Innervation of Upper LimbM
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Preaxial: C5-C7
Postaxial: C8-T1
Segmental (Dermatome) Innervation of Upper LimbM
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Thumb: C6
3rd Digit: C7
5th Digit: C8
Dermatomes vs. Cutaneous Nerve Distribution
Terminalbranches
Cutaneous nn.
Segmental innervation(C5-T1)
Dermatomes
Anterior Posterior47
Peripheral (Cutaneous ) Innervation of Upper LimbM
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U
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Test for Peripheral Nerve Sensory Function:
Ulnar n. – Tip of 5th digit (little finger)Median n. – Tip of 2nd digit (index finger)
Radial n. – Webbing b/w thumb & index finger (dorsum)
49
M
U
R
C6
C7
C8
Stretch Reflex
apbrwww5.apsu.edu/
Reciprocal inhibition of antagonist muscles
Bicipital reflex (C6 cord level) Triceps reflex (C7 cord level)
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Stretch Reflex
IVD Root Sensory Loss Motor WeaknessC4-C5 C5 Shoulder Shoulder weakness
C5-C6 C6 Anterior upper arm, Forearm flexion
Lateral forearm, thumb Biceps reflex
C6-C7 C7 3rd digits Forearm extension Triceps reflex
Wrist extension Hand grip
C7-C8 C8 5th digits Wrist flexionMedial forearm Intrinsic
hand mm.
Source: Devinsky et al. Neurologic Pearls
UPPER LIMB RADICULAR SYNDROMES
Proximal
Distal
Cranial
Caudal