Cross Sectional Anatomy: Upper Limb ___________________________________________________________________________________ Section 1: a. cephalic vein b. deltoid c. humerus d.

lateral head of triceps brachii e. long head of triceps brachii f. medial head of triceps brachii g. basilic vein h. coracobrachialis i. musculocutaneous nerve j. biceps brachii Section 2: a. brachialis b. radial nerve c. brachial artery d. ulnar nerve e. median nerve Section 3: a. brachioradialis b. radial nerve c. lateral supracondylar ridge d. ulnar nerve e. median nerve Section 4: a. extensor carpi radialis longus b. extensor carpi radialis brevis c. capitulum d. anconeus e. olecranon process of ulna f. tendon of the triceps muscle g. trochlea h. pronator teres (humeral head) i. flexor carpi radialis j. brachialis k. bicipital aponeurosis of biceps brachii l. tendon of biceps brachii m. brachioradialis Section 5: a. radial artery b. cephalic vein c. radius d. ulna e. brachialis f. tendon of biceps brachii g. basilic vein Section 6: a. superficial branch of radial nerve b. brachioradialis c. extensor carpi radialis longus

d. e. f. g. h. i. j. k. l. m. n. o. p. q.

extensor carpi radialis brevis extensor digitorum supinator extensor digiti minimi extensor carpi ulnaris anconeus flexor digitorum profundus flexor carpi ulnaris ulnar nerve common interosseous artery flexor digitorum superficialis median nerve flexor carpi radialis pronator teres

Section 7: a. brachioradialis b. extensor carpi radialis longus tendon c. extensor carpi radialis brevis muscle and tendon d. deep branch of radial nerve e. extensor digitorum f. abductor pollicis longus g. extensor digiti minimi h. extensor pollicis longus i. extensor carpi ulnaris j. flexor digitorum profundus k. flexor carpi ulnaris l. ulnar nerve m. interosseous membrane n. palmaris longus tendon o. flexor digitorum superficialis p. median nerve q. flexor pollicis longus Section 8: a. flexor carpi radialis b. radial artery c. brachioradialis tendon d. abductor pollicis longus tendon e. extensor carpi radialis brevis tendon f. extensor carpi radialis longus tendon g. extensor pollicis brevis muscle and tendon h. extensor digitorum tendons (digits 2-5) i. extensor pollicis longus j. extensor indicis muscle and tendon k. dorsal branch of ulnar nerve l. flexor carpi ulnaris muscle and tendon m. ulnar nerve and artery n. flexor digitorum profundus muscle and tendon o. palmaris longus tendon p. flexor digitorum superficialis muscle and tendon q. pronator quadratus Section 9: a. trapezium b. 1st metacarpal bone c. trapezoid d. scaphoid

e. f. g. h. i. j. k.

lunate extensor tendons of posterior forearm triquetrum hypothenar compartment muscles flexor tendons of anterior forearm capitate thenar compartment muscles

Section 10: a. abductor digiti minimi b. tendons of flexor digitorum superficialis and profundus c. palmar aponeurosis and digital branch of median nerve d. tendon of flexor pollicis longus and radial bursa e. flexor pollicis brevis f. abductor pollicis brevis g. tendon of extensor pollicis longus and first metacarpal h. princeps pollicis artery i. first dorsal interosseous j. adductor pollicis k. lumbrical and tendon of flexor digitorum profundus l. tendons of extensor digitorum m. tendons of extensor digitorum n. third palmar interosseous and fifth metacarpal Section 11: a. tendons of flexor digitorum superficialis and profundus b. third and fourth lumbricals c. common palmar digital artery d. tendon of flexor digitorum superficialis e. tendon of flexor digitorum profundus f. second dorsal interosseous and first palmar interosseous g. second palmar interosseous muscle Section 12: a. proper palmar digital nerve and artery. b. tendon of flexor digitorum profundus c. tendon of extensor digitorum Terminal Branches of the brachial plexus Musculocutaneous From lateral cord of brachial plexus (C5-C7) Enters deep surface of coracobrachialis (innervates coracobrachialis) Descends between biceps brachii and brachialis (innvervates them) Enters cubital fossa from between the biceps brachii and brachialis muscles, exits cubital fossa by piercing the roof lateral to the biceps tendon where it becomes the lateral LATERAL ANTEBRACHIAL CUTANEOUS NERVE. Provides motor innervation in the arm and sensory innerrvation in the forearm. Descends along lateral border of forearm to wrist. Axillary From posterior cord of brachial plexus (C5-C6) Passes to posterior aspect of arm through quandrangular space (w/ posterior circumflex humeral artery) innvervates teres minor and deltoid Winds around surgical neck of humerus; innvervates shoulder joint Gives rise to LATERAL BRACHIAL CUTANEOUS NERVE. Innervates skin over inferior deltoid Radial From posterior cord of brachial plexus (C5-T1)

 Descends anterior to axillary artery, enters radial groove of humerus w/ deep (profunda) brachial artery. Passes between lateral & medial head of triceps. Passes into cubital fossa by piercing lateral intermuscular septum to lie between the brachialis and brachioradialis muscles. At lateral epicondyle, it divides into a SUPERFICIAL and DEEP BRANCHES. The SUPERFICIAL BRANCH accompanies the radial artery and both run under the brachioradialis to supply sensory innvervation to the dorsum of the hand. - Superficial radial nerve courses through the Snuff Box - Supplies skin of the posterior surface of the thumb, index, and half of middle finger. (except the distal phalanges of these digits which are supplied by the median nerve.) The DEEP BRANCH passes between the 2 heads of the Supinator muscle and comes to lie between superficial and deep extensors; After the deep branch exits from between the two heads of the supinator muscles, it is called the POSTERIOR INTEROSSEOUS NERVE and accompanies the Posterior interosseous artery. - POSTERIOR INTEROSSEOUS NERVE innervates many of the posterior compartment of the forearm distal to the supinator. Ulnar From medial cord (C8,T1 often C7) Passes down medial aspect of arm (pierces IM septum to lie in post compartment).Enters forearm by passing behind medial epicondyle. Goes between the two heads of the flexor carpi ulnaris which it innervates. Runs between flexor carpi ulnaris and flexor digitorum profundus (innv only medial of FDP). Ulnar nerves lies superficially in distal part of forearm: Courses lateral to pisiform and anterior to carpal tunnel. Divides into SUPERFICIAL and DEEP BRANCH in the hand. A DORSAL BRANCH of the ulnar nerve branches off in the lower third of the forearm. SUPERFICIAL BRANCH innervates/supplies: Palmaris brevis Divides into digital nerves which are sensory to the palmar surface and sides of the little finger and medial half of ring finger DEEP BRANCH supplies: All three muscles of hypothenar compartment: palmaris brevis, abductor digiti minimi, flexor digiti minimi and opponens digiti minimi 3rd and 4th lumbricals all interossei adductor pollicis deep head of flexor pollicis brevis DORSAL branch supplies: Gives off dorsal digital nerves that are sensory to the to the dorsal surface of the medial two and a half digits. Median From Lateral Cord of Brachial Plexus (C6,C7) Medial Cord of Brachial Plexus (C8,T1) Forms median n. lateral to axillary artery and runs in arm w/ brachial a. Enters cubital fossa anterior to the brachialis muscle and medial to the brachial artery. Passes between the 2 heads of pronator teres and descends between flexor digitorum superficialis & Flexor digitorum profundus. Innvervates flexor compartment of forearm (1 exceptions = 1 flexor carpi ulnaris +1/2 of flexor digitorum profundus) Gives off ANTERIOR INTEROSSEOUS NERVE which passes inferiorly on interosseous membrane to supply: 1/2 flexor digitorum profundus and the other deep ant forearm muscles. At the wrist, the median nerve is found medial to the tendon of flexor carpi radialis and lateral to palmaris longus. It passes deep to flexor retinaculum to enter through carpal tunnel.

 Before the tunnel, it gives off PALMAR CUTANEOUS BRANCH that runs anterior to flexor retinaculum and supplies skin of thenar area. At the distal border of the flexor retinaculum, it divides into branches that are Motor and Sensory. After passing through carpal tunnel it gives off MOTOR (RECURRENT) BRANCH BRANCH . It is motor to the 3 thenar muscles and the first and second lumbricals. Innvervates: abductor pollicis brevis, opponens pollicis, superficial head of flexor pollicis brevis LATERAL BRANCH (SENSORY) Innvervates: Lateral palmar surface Palmar surface of digits 1-3 Lateral half of digit 4 (via palmar and proper digital nerves). These nerves are also sensory to the dorsum of the distal halves of digits 2-4. Note: The motor (recurrent) branch to the thenar muscles arises at the distal border of the flexor retinaculum and is superficial in position. It is vunerable to cuts on thenar eminence. Dorsal Scapular From ventral ramus C5/ w freq contribution from C4 Pierces scalenus medius and descends deep to Levator scapulae and enters deep surface of rhomboids. Long Thoracic From ventral rami of C5,C6, C7 Descends posteriorly to C8 + T1 rami and passes distally on external surface of serratus anterior. Nerve To Subclavius From superior trunk (C5,C6, often C4) Descends posterior to clavicle & anterior to brachial plexus & subclavius Innv: subclavius, sternoclavicular joint Suprascapular From superior trunk (C5,C6/ often C4) Passes laterally across posterior triangle of neck THROUGH scapular notch, under superior transverse scapular ligament Innv: suprspinatus Infraspinatus Glenohumeral Joint Lateral Pectoral From lateral cord (C5-C7) Pierces clavipectoral fascia to reach deep surface of pectoral muscles Innv: pectoralis major loop to medial pectoral nerve, therefore also to pectoralis minor Medial Pectoral From medial cord (C8,T1) Passes between axillary artery + vein & enters deep surface pectoralis minor Innv: Pec minor & sternocostal head of pec major Medial Brachial cutaneous nerve From medial cord (C8,T1) Runs along medial side axillary V. & communicates w/ intercostobrachial N.

 Innv. Skin on medial side of arm Medial Antebrachial Cutaneous From medial cord (C8,T1) Runs between axillary A + Vein, then on medial side of brachial artery. Pierces deep fascia in cubital fossa and runs along medial aspect of forearm Innv: skin over medial side of forearm Upper Subscapular From posterior cord (C6-C8) Arises between upper + lower subscapular nerves & runs inferolaterally along posterior axillary wall to latissimus dorsi Thoracodorsal From posterior cord (C6-C8) Arises btw upper + lower subscapular nerves + runs inferolaterally along posterior axillary wall to latissimus dorsi Lower subscapular From posterior cord (C5,C6) Passes inferolaterally, deep to subscapular artery + vein to innv. Subscapularis and Teres major ABDUCTORS OF WRIST/HAND Flexor carpi radialis Extensor carpi radialis longus Extensor carpi radialis brevis Extensor pollicis brevis Extensor pollicis longus ABDUCTORS OF ARM Deltoid Supraspinatus ADDUCTORS OF WRIST/HAND Flexor carpi ulnaris Extensor carpi ulnaris

ADDUCTORS OF ARM Deltoid Teres Major Corocobrachialis Latissimus dorsi Pectoralis Major MEDIAL ROTATORS OF ARM Teres Major Subscapularis Deltoid Latissimus dorsi Pectoralis Major

LATERAL ROTATORS OF ARM Infraspinatus Teres Minor

Nerve Lesions Upper Brachial Plexus 1. C5 / C6 Roots of Superior Trunk = ERB-DUCHENNE PARALYSIS - excessive separation of head and shoulder - fall, motorcycle accident, botched delivery - stab or bullet to neck - results in tearing / stretching of roots / trunk - Waiter's Tip * limb hangs by the side in medial rotation * palm faces posteriorly instead of medially * most severely affected: deltoid, biceps brachii, brachialis, brachioradialis, supraspinatus, infraspinatus, teres minor

- results from injury to the upper trunk (C5,6) of the brachial plexus which may occur during the course of a complicated birth. In such a delivery, marked downward traction on the head of the fetus results in a widening of the angle between the head and shoulder. In this paralysis, the hand hangs at the side in medial rotation with the forearm pronated and the fingers and wrist relaxed. This is referred to as the "head waiter's tip hand". The clinical appearance is produced by a paralysis of the abductors and lateral rotators of the shoulder joint which are innervated by the axillary (deltoid, teres minor) and suprascapular (supraspinatus and infraspinatus) nerves (C5,6). Abductors Deltoid Supraspinatus Lateral rotators Teres minor Infraspinatus -There is also a weakness of the flexors of the elbow. Since the biceps is a powerful supinator, this weakness will also result in pronation of the hand. Biceps through musculocutaneous (C5,6,7) Brachialis through musculocutaneous (C5,6,7) Brachioradialis through radial (C5,6,7,8, and T1) - There is a weakness of the adductors and medial rotators of the shoulder: Pectoralis major through lateral pectoral nerve (C5,6,7) Latissimus dorsi through thoracodorsal nerve (C5,6,7) 2. Posterior Cord - poor fitting crutches = pressure on radial n. - saturday night palsy = intoxicated person hangs arm over back of chair for extended time- Wrist Drop * person unable to extend forarm, hand, digits due to affected muscles inner. by radial n. 3. Lower Brachial Plexus - sudden upward pulling of upper limb (break a fall, babies limb pulled excessively) - cervical rib or pulmonary carcinoma - inferior trunk of brachial plexus > Ulnar n. (C8, T1) - see Claw Hand exp. - KLUMPKE PARALYSIS. This results from injury to the lower trunk of the brachial plexus and may result from upward traction on the shoulder. It may be sustained in falling from a high place and seizing something to break the fall, or it may occur in a breech birth when the arms are carried over the head. The first thoracic spinal nerve is the one usually involved, but the whole lower trunk (C8, T1) may be torn. There is weakening of the extensors of the elbow, wrist and fingers due to the C8, T1 contribution to the radial nerve. There is a paralysis of the intrinsic muscles of the hand due to loss of the deep branch of the ulnar nerve (T1). Paralysis of the interosseous muscles and the flexors of the fingers results in a "claw hand." 4. Long Thoracic N = "Winged Scapula" - axillary trauma - patient can't hold scapula against thorax wall when asked to push against wall - cannot fully aBduct upper limb b/c scapula can't be rotated 5. Musculocutaneous N. -injury in axilla - weakness of upper limb flexion - severe weakness of forearm flexion - weakness when supinating forearm from partially flexed position (biceps brachii) 6. Radial N. - fractured Humerous in radial groove - frac. Humerous in radial groove - little loss of forearm extension - wrist drop 7. Radial N. - at neck of radius ( Deep Radial n. )

- wrist drop not as severe - ECR Longus and Brevis are spared - still loss of digital extension of prox. phalages and thumb 8. Median N. - injury in axilla - loss of forearm pronation, diminished hand and digital flexion - wasting of thenar eminence - loss of palmar senation and loss of sweating on lateral palm 9. Median N. - injury at wrist / Carpal Tunnel Syn. - wasting away of thenar eminence - loss of sensation 10. Ulnar N. - injury in axilla, arm or medial epicond. fracture - severe motor and sensory loss to the hand - Claw Hand * imbalance of flex / ext. which occurs at MP and IP joints * unable to aBduct or aDduct digits 2-5 (loss to interossei) * hyperextended MP joints of digits 4 & 5 and somewhat flexed IP joints (loss of lumbricals 4-5) * will not be able to make a fist = b/c FDP to digit 4-5 is affected