CLINICAL ANATOMY OF THE UPPER LIMB

Dermatomes & Cutaneous Nerves of the Upper LimbDermatomes for C3-6

lateral margin of the upper limb

Dermatome for C7 on the middle finger

Dermatomes for C8, T1, T2 medial margin of the limb

Tendon Reflexes & Segmental Innervation of Muscles of the Upper Limb

Biceps brachii tendon reflex C5 and 6

flexion of the elbow joint by tapping the biceps tendon

Tendon Reflexes & Segmental Innervation of Muscles of the Upper Limb

Triceps tendon reflex C6, 7, and 8

extension of the elbow joint by tapping the triceps tendon

Tendon Reflexes & Segmental Innervation of Muscles of the Upper Limb

Brachioradialis tendon reflex C5, 6, and 7

supination of the radioulnar joints by tapping the insertion of the brachioradialis tendon

Brachial Plexus InjuriesBrachial Plexus Injuries

Upper Lesions of the Brachial Plexus (Erb-Duchenne Palsy)

C5 and C6 roots

Lower Lesions of the Brachial Plexus (Klumpke Palsy)

C8 and T1 roots

Upper Lesions of the Brachial Plexus (Erb-Duchenne Palsy)

excessive displacement of the head to the opposite side

depression of the shoulder on the same side

in infants during a difficult delivery in adults after a blow to or fall on the shoulder

Upper Lesions of the Brachial Plexus (Erb-Duchenne Palsy)

C5 and C6 rootssuprascapular nerve the nerve to the subclaviusmusculocutaneous nerveaxillary nerve

1.supraspinatus abductor of the shoulder2.infraspinatus lateral rotator of the shoulder3.subclavius depresses the clavicle4.biceps brachii supinator of the forearm, flexor of the elbow, weak flexor of the shoulder5.greater part of the brachialis flexor of the elbow6.coracobrachialis flexor of the shoulder7.deltoid abductor of the shoulder8.teres minor lateral rotator of the shoulder

Upper Lesions of the Brachial Plexus (Erb-Duchenne Palsy)

WWaiter’s tip positionaiter’s tip positionUpper limb hanging by the sideMedially rotatedForearm pronated+loss of sensation down the lateral side of the arm

Lower Lesions of the Brachial Plexus

(Klumpke Palsy)usually traction injuries person falling from a height grasping smthg to

break a fallbaby's upper limb pulled excessively during delivery

ulnar and median nerves

C8 and T1 roots

Lower Lesions of the Brachial Plexus

(Klumpke Palsy)ulnar and median nerves

all the small muscles of the handall the small muscles of the hand

Claw(ed) hand hyperextension of metacarpophalangeal joints

flexion of the interphalangeal joints

Lower Lesions of the Brachial Plexus

(Klumpke Palsy)C8 and T1 rootsloss of sensation

along the medial side of the arm8th cervical nerve damaged

+ medial side of the forearm, hand, and medial two fingers

Foerster (1933)

Long Thoracic Nerve Injuries

Difficulty in raising the arm above the headInferior border of scapula not closely applied to the chest wall

Protrude posteriorly

Winged scapula

C5, C6, C7

serratus anterior

blows to or pressure on the posterior triangle of the neck

during the surgical procedure of radical mastectomy

Axillary Nerve Injuriesposterior cord of the brachial plexus (C5 and 6)

pressure of a badly adjusted crutch pressing upward into the armpit

shoulder dislocations Quadrangular space fracttures of the surgical neck of humerus

deltoid and teres minor deltoid and teres minor Loss of skin sensation over the lower half of deltoid region (lateral part of the arm)

Upper lateral cutaneous nerve of the armImpaired abduction of the shoulder (the other one: Supraspinatus only)Shoulder weaknessDifficulty lifting the arm above the head

Axillary Nerve Injuriesposterior cord of the brachial plexus (C5 and 6)

I.M. injectionsOperations around the shoulder

runs transversely under cover of the deltoidruns transversely under cover of the deltoid at the level of the surgical neck of the humerusat the level of the surgical neck of the humerus

commonly damaged in the axilla & in the spiral (radial) groove

Radial Nerve Injuries

Radial Nerve Injuries @ Axillapressure of the upper end of a badly fitting crutch

drunk falling asleep with one arm over the back of a fractures and dislocations of the proximal end of the humerus

MMotorotorTTriceps, anconeus, and long extensors of the wrist riceps, anconeus, and long extensors of the wrist No extension of the elbow joint, wrist joint, and the fingersWristdrop (flexion of the wrist)

Supination good brachioradialis, supinator down, but biceps brachii

Radial Nerve Injuries @ Axilla

SensorySensoryA small loss of skin sensation down the posterior surface of the lower part of the arm down a narrow strip on the back of the forearm

A variable area of sensory loss on the lateral part of the dorsum of the hand on the dorsal surface of the roots of the lateral 3 ½ fingers

Trophic ChangesSlight

Radial Nerve Injuries @ Spiral Groove of Humerus

At the time of fracture of the shaft of the humerus Following the formation of the callus

Pressure of the back of the arm on the edge of the operating table

Prolonged application of a tourniquet to the arm in a person with a slender triceps temporary radial palsy

Radial Nerve Injuries @ Spiral Groove of Humerus

most commonly @ distal part of the groove

MotorMotorInability to extend the wrist &fingersWrist drop

SensorySensoryA variable small area of anesthesia dorsal surface of the hand dorsal surface of the hand ddorsal surface of roots of lateral orsal surface of roots of lateral 3 ½ 3 ½ fingersfingers

Trophic changesTrophic changesVery slight or absent

potential space located anterior to the proximal radius posterior interosseus nerve

passesstarting from the level of the humeroradial joint extending past the proximal edge of the supinator

The radial nerve bifurcates into deep and superficial branches anterior to the lateral epicondyle of the humerus, between the brachialis and the brachioradialis, in the lateral border of the cubital fossa.

After passing through the two heads of the supinator muscle, the deep branch becomes the posterior interosseous nerve.

DIAGNOSISDIAGNOSIS

Radial nerveLateral part of the elbow, radial tunnel below the supinatorTenderness and pain @ lateral side of the elbow

sudden and often repeated use of the forearm extensor musclespreviously been much used

extensor carpi radialis brevis

Tenderness and pain @ lateral side of the elbow

Pain on wrist extension, pain when shaking hands, and frequently a weakened grip.

In tennis elbow, the tenderness is mostly right where the tendon attaches to the lateral epicondyle of the elbow.

In radial tunnel syndrome, the place that is most tender is about two inches further down the arm, right over where the radial nerve goes into the supinator muscle.

Deep branch of the Radial Nerve InjuriesMotor nerve

Extensor muscles @ posterior compartment of the forearm

fractures of the proximal end of the radius dislocation of the radial head

SSupinator upinator IntactIntactEExtensor carpi radialis longusxtensor carpi radialis longusNo wrist dropNo wrist dropNo sensory lossNo sensory loss

Superficial Radial Nerve Injuries

a variable small area of anesthesia

over the dorsum of the hand over the dorsum of the hand

dorsal surface of the roots of the lateral dorsal surface of the roots of the lateral 3 ½ 3 ½ fingers fingers

Musculocutaneous Nerve InjuriesMusculocutaneous Nerve Injuries

Weak flexion @ shoulder jointFlexion of the forearm @ elbow by remainder of brachialis + flexors of

forearm

Weak supination supinator radial nerve

Sensory loss along the lateral side of the forearm lateral cutaneous nerve of the forearm

Rarely injured (protected position)

Median Nerve Injuriesoccasionally in the elbow region supracondylar fractures of the humerussupracondylar fractures of the humerus

most commonly by stab wounds or broken glass just proximal to the flexor retinaculumjust proximal to the flexor retinaculum

Injuries to the Median Nerve @ the ElbowMotor

pronator & flexor muscles of forearm (EXCEPT?)thenar musclesForearm in supine position- Weak wrist flexion-accompanied by adductionNo flexion @ interphalangeal joints of index & middle fingersWeak flexion @ metacarpophalangeal joints –interossei-

Middle & index fingers remain straight(extended)

POPE’S BLESSINGPOPE’S BLESSING

Injuries to the Median Nerve @ the ElbowMotor

No Flexion of the terminal phalanx of the thumb Thenar eminence flattenedThumb laterally rotated & adducted

APE HAND DEFORMITY APE HAND DEFORMITY

Injuries to the Median Nerve @ the ElbowSensory

Lost skin sensation @lateral half or less of the palm of the hand

palmar aspect of lateral 3 ½ fingers distal part of dorsal surfaces of lateral 3

½ fingers

Injuries to the Median Nerve @ the ElbowVasomotor changes

Skin area affected warmer & drier Arteriolar dilatation and absence of sweating / loss of sympathetic control

Trophic changesChronic casesdry and scaly skinnails crack easily atrophy of the pulp of the fingers

Injuries to the Median Nerve @ the WristMotor

Thenar muscles & first two lumbricalsThenar eminence flattenedThumb laterally rotated and adducted

Ape-like handNo opposition of the thumb

MAKE A FIST, SLOWLYMAKE A FIST, SLOWLYIndex & middle fingers lag behind the ring & little fingers

Carpal Tunnel SyndromeMOST COMMON PERIPHERAL NERVE

INJURY IN THE UPPER LIMB

Carpal Tunnel SyndromeBurning pain or “pins and needles” along the distribution of the median nerve to the lateral 3 ½ fingers

Weakness of thenar musclesNo paresthesia over the thenar eminencepalmar cutaneous branch of the median nerve

Ulnar Nerve Injuriesmost commonly injured @

@ @ elbowelbow where it lies behind the medial epicondyle usually associated with fracture@ @ wristwristwhere it lies with the ulnar artery in front of the flexor retinaculum.

Injuries to the Ulnar Nerve Injuries to the Ulnar Nerve @ the @ the ElbowElbowCUBITAL TUNNEL SYNDROME (2ND most common)CUBITAL TUNNEL SYNDROME (2ND most common)

MotorMotorFFlexor carpi ulnaris lexor carpi ulnaris & & medial half of flexor digitorum profundusmedial half of flexor digitorum profundus

ring & little fingersring & little fingersNo flexion of the terminal phalanges of the ring & No flexion of the terminal phalanges of the ring & little fingerslittle fingersFlexion of wrist = abduction Flexion of wrist = abduction paralysis of flexor paralysis of flexor carpi ulnaris carpi ulnaris medial border of the front of the forearm flattned/wastedAll the small muscles of the hand paralyzed All the small muscles of the hand paralyzed EXCEPT ?EXCEPT ?

Injuries to the Ulnar Nerve Injuries to the Ulnar Nerve @ the @ the ElbowElbowMotorMotor

Extensor digitorum can abduct the fingers to a small extent when metacarpophalangeal joints are hyperextended

Impossible to adduct the thumb adductor pollicis paralyzedFroment’s signFroment’s signGrip a piece of paper between the thumb and index fingers

Froment sign: The patient is asked to hold the paper between the thumb and index finger. (A) With the intact ulnar nerve, the patient is able to make use of the adductor pollicis. ( B) When the ulnar nerve is deficient, the patient compensates for the denervated adductor by using the flexor pollicis longus (median nerve innervated).

Injuries to the Ulnar Nerve Injuries to the Ulnar Nerve @@ the Elbow the ElbowMotorMotor

2 medial lumbricals & interossei Hyperextended metacarpophalangeal joints

Flexed interphalangeal joints

fourth & fifth fingers““claw” deformity claw” deformity main en griffemain en griffe

Injuries to the Ulnar Nerve Injuries to the Ulnar Nerve @ the @ the ElbowElbowMotorMotor

Flattening of hypothenar eminenceFlattening of hypothenar eminenceLoss of the convex curve to the medial border of the handLoss of the convex curve to the medial border of the hand

Hollowing between metacarpal bones @ dorsum of the handHollowing between metacarpal bones @ dorsum of the handwasting of dorsal interossei

Loss of skin sensation Loss of skin sensation anterior & posterior surfaces of medial 1/3 of the hand medial 1 ½ fingers

Vasomotor Changeswarmer and drier skin area arteriolar dilatation and absence of sweating /loss of sympathetic control

Injuries to the Ulnar Nerve Injuries to the Ulnar Nerve @ the @ the ElbowElbowSensorySensory

Injuries to the Ulnar Nerve Injuries to the Ulnar Nerve @ the Wrist@ the WristMotorMotor

Small hand muscles paralyzed, wasted – EXCEPT 3 thenar @ first 2 lumbricals

Claw handMore obviousFlexor digitorum profundus intactMarked flexion of the terminal phalanges

Ulnar paradoxUlnar paradoxHigher lesionHigher lesionLess obvious claw deformityLess obvious claw deformity

More proximal injury More proximal injury Less claw Less claw

PROXIMAL/ @ ELBOWCUBITAL TUNNEL SYNDROMEBETWEEN MEDIAL EPICONDYLE & FLEXOR CARPI ULNARIS

DISTAL/ @ WRISTGUYON’S CANAL GUYON’S CANAL Roof: Palmaris brevis, hamate,pisiforme bones & FCU

Q: Medial half of Flexor digitorum profundus affected in which one most?

Injuries to the Ulnar Nerve Injuries to the Ulnar Nerve @ the Wrist@ the Wrist SensorySensory

Main ulnar nervePalmar cutaneous branchPosterior cutaneous Posterior cutaneous branch branch 6.25 cm,2 inch above the pisiform bone

palmar surface of the medial palmar surface of the medial 1/3 1/3 hand hand medial medial 1 ½ 1 ½ fingers fingers the dorsal aspects of the middle the dorsal aspects of the middle and distal phalanges ofand distal phalanges of the same the same fingersfingers

Injection of an anesthetic solution into or immediately surrounding the axillary sheath interrupts conduction of impulses of peripheral nerves.

The distal part of the sheath is closed with finger pressure, and a syringe needle is inserted into the proximal part of the sheath.

Sensation blocked in all deep Sensation blocked in all deep structures of the upper limb and structures of the upper limb and the skin distal to the middle of the skin distal to the middle of the armthe arm.

Brachial Plexus Brachial Plexus BlockBlock

Brachial plexus can be anesthetized using a number of approaches:Brachial plexus can be anesthetized using a number of approaches:

Interscalene blockInterscalene blockSupraclavicular blockSupraclavicular blockInfraclavicular blockInfraclavicular blockAxillary blockAxillary block

• Palpate axillary artery within the axillary sheath high up in the axillaPalpate axillary artery within the axillary sheath high up in the axilla• Abduct the arm to an angle greater than 90°Abduct the arm to an angle greater than 90°• Compress the artery thereCompress the artery there• Insert the need prox. to the point of compressionInsert the need prox. to the point of compressionDisadvantageDisadvantage: Leaking of anesthetic into musculocutanoues nerve Anatomy of complicationsVessel puncture Hematoma formation

PROCEDURPROCEDUREE

Anastomosis around the shoulder

1st part of subclavian artery

3rd part of axillary artery

Brachial artery

Quadrangular Space SyndromeQuadrangular Space Syndrome

compression of axillary nerve axillary nerve & posterior posterior circumflex humeral arterycircumflex humeral arterydownward displacement of

humeral headin shoulder dislocations fractures of surgical neck of humerus

Paralysis Paralysis deltoid deltoid teres minorteres minor

loss of skin sensationloss of skin sensation over lower half of the over lower half of the deltoiddeltoid

Rotator Cuff Tendinitis

SubscapularisSubscapularisSupra-infra spinatusSupra-infra spinatusTeres MINORTeres MINORLesions of the cuff common cause of pain in the shoulder region

Subacromial bursitisSupraspinatus tendinitisPericapsulitis

spasm of pain in the middle range of abductionwhen the diseased area impinges on the acromion

stabilizing the shoulder joint

Rupture of the Supraspinatus Tendon

advanced cases of rotator cuff tendinitisadvanced cases of rotator cuff tendinitisnecrotic supraspinatus tendon

calcified or rupture

Hold humeral head @ glenoid fossa at the beginning of abductionNo initation of abduction of the arm, unless passively assited for the first 15°

Pronator Syndromea nerve entrapment syndrome

compression of the median nerve near the elbowCompressed between heads of pronator teres pronator teres as a result of oTraumaoMuscular hypertrophyoFibrous bands

pain and tenderness @ proximal aspect of anterior forearm

hypesthesia of palmar aspects of radial 3 ½ digits & adjacent palm

flexor pollicis longus flexor pollicis longus flexor digitorum profundusflexor digitorum profundus to index, to index, sometimes middle fingerssometimes middle fingerspronator pronator quadratusquadratus

Pinch deformityPinch deformity

Pronation Pronation

Anterior interosseous nerve syndrome

Venipuncture•obtaining blood for laboratory testing•administering fluid and intravenous drugs

Anatomical snuff box

Scaphoid bone palpableHand in ulnar deviation

Assesment of scaphoid fractures

Radial artery Radial artery through anatomical snuff boxDeep to the extensors of the thumbNext to scaphoid & trapezium

Pulse of the radial artery