anatomy review lota 2015 handout · anatomy, including where anatomical variations lead to clinical...

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Anatomy ReviewWhat makes us move? Anatomy ReviewWhat makes us move?

Rennie Jacobs, PhD, LOTR, CHT

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ObjectivesObjectivesProvide a review of the anatomy pertinent to the field of occupational therapy.

Provide knowledge pertaining to the neuromuscular system and vascular system, as well as osteokinematics and arthrokinematicsassociated with the upper quadrant.

Provide clinical correlations that are rooted in anatomy, including where anatomical variations lead to clinical manifestations.

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THE CADAVER IS THE BEST TOOL FOR LEARNING GROSS ANATOMY

TO LEARN MORE ABOUT CADAVERS, READ4

2 WAYS TO STUDY GROSS ANATOMY

Regional Anatomy: Studying all the structures in an area together; e.g., the lower extremity includes bones, muscles, nerves, and vessels.

Systemic Anatomy: Studying a complete system independent of region.•Skeletal (bones)•Muscular •Neurovascular•Cardiovascular (heart, blood)

Regional AnatomyRegional AnatomyHead/neck

Thorax

Abdomen

Pelvis/perineum

Back

Upper limb

Lower limb

Regions of the Body

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Clinical AnatomyClinical Anatomy

• Relationship of structure and function

• Clinical correlations emphasized throughout presentation

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CC

Anatomical PositionAnatomical Position• Head, eyes, and toes

directed forward (anteriorly).

• Upper limbs by the sides;

palms facing anteriorly.

• Lower limbs together; toes

directed anteriorly.

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The Upper LimbThe Upper Limb

Function: Movement

Parts:• Shoulder• Arm (brachium)• Forearm (antebrachium)• Hand (manus)

Manus

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The Upper LimbThe Upper LimbJoints:

• Pectoral girdle• Sternoclavicular joint• Acromioclavicular joint• Shoulder (glenohumeral) joint

• Elbow joint• Radioulnar joints• Wrist joints• Hand joints

Innervation of the Upper LimbBrachial Plexus

Innervation of the Upper LimbBrachial Plexus

Formed by ventral rami of C5-T1spinal nerves.

Nerves contain somatic motor and sensory fibers and post-synaptic sympathetics from cervical ganglia.

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Roots

C5

C6

C7

C8

T1

BRACHIAL PLEXUSBRACHIAL PLEXUS

Dorsal scapular

Long thoracic12

3

Roots

C5

C6

C7

C8

T1

Trunks

Upper

Middle

Lower

Suprascapular

N. to Subclavius


DS

LT13

Roots

C5

C6

C7

C8

T1

TrunksDivisions

Anterior

Posterior

Anterior


DS

LT

SS

N to SUpper

Middle

Lower

14**No branches come off the divisions

Roots

C5

C6

C7

C8

T1

TrunksDivisionsCords

Lateral

Posterior

Medial

LP

USSLSS TD

MPMAC

LP: Lateral Pectoral

MP: Medial Pectoral

MBC: Medial Brachial Cutaneous n.

MAC: Medial AntebrachialCutaneous n.

USS: Upper Subscapular

TD: Thoracodorsal

LSS: Lower Subscapular


DS

LT

SS

N to S

Anterior

Posterior

Anterior

Upper

Middle

Lower

MBC

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Roots

C5

C6

C7

C8

T1

TrunksDivisionsCords

Lateral

PosteriorAxillary

Musculocutaneous

Median

Terminal BranchesBRACHIAL PLEXUSBRACHIAL PLEXUS

DS

LT

SS

N to S

Anterior

Posterior

Anterior

LP

USSLSS TD

MPMBC

MAC

Medial

Upper

Middle

Lower

Ulnar Radial

In PCTIn Axilla 16

**Median nerve contributions vary from textbook to textbook….

**

ERB-DUCHENNE PALSYThe Erb-Duchenne syndrome results from a lesion of the C5 and C6 ventral rami in the superior trunk of the plexus

Proximal musculature in the upper limb is mainly affected, thus, muscles acting at the shoulder and at the elbow will be weakened.

In patients with this syndrome, the upper limb is held in a “waiter’s tip” position

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CC KLUMPKE’S PARALYSIS

- results from compression or stretching of the C8 and T1 fibers in the inferior trunk of the brachial plexus

Distal muscles in the upper limb that are innervated by the C8 and T1 fibers in the lower trunk will be primarily affected.

Patients experience weakness of the intrinsic muscles of the hand innervated by C8 or T1 fibers in the median and ulnar nerves, resulting in a combination of a full ape hand or a claw hand. 18

CC

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Musculocutaneous Nerve

Musculocutaneous Nerve

(C5,6,7) Innervates anterior arm muscles.

Cutaneous innervation

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Median NerveMedian Nerve(C6,7,8,T1) Innervates anterior forearm muscles (except 1½) and intrinsic thumb muscles.

Cutaneous innervation20

Ulnar NerveUlnar Nerve[(C7) C8,T1] Innervates 1½ anterior forearm muscles, intrinsic finger muscles, and adductor pollicus.


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Axillary NerveAxillary Nerve

(C5,6) Innervates deltoid and teres minor muscles.


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Radial NerveRadial Nerve(C5,6,7,8,T1) Innervates posterior arm and forearm muscles.


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Dermatomes of the Upper

Limb

Dermatomes of the Upper

Limb

Anterior

Posterior

Areas used to determine sensation in a particular dermatome:• C4: Skin over acromion.• C5: Skin over lower deltoid m.• C6: Tip of thumb.• C7: Tip of index or middle finger.• C8: Tip of little finger.• T1: Skin over medial side of elbow.• T2: Skin in axilla. 24

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Cutaneous Nerves of the Upper Limb

Cutaneous Nerves of the Upper Limb

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-Can contain more than one dermatome

Blood Supply to the Scapular and Shoulder Regions

Blood Supply to the Scapular and Shoulder Regions

• Arterial supply– Subclavian artery– Axillary artery

• Venous Drainage– Subclavian vein– Axillary vein

Subclavian a.Axillary a.

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132

Anterior scalenus m.

Part 1:• Vertebral a.• Internal thoracic a.• Thyrocervical trunk

– Inferior thyroid a.» Ascend. cervical a.

– Transverse cervical a.– Suprascapular a.

SUBCLAVIAN ARTERYSUBCLAVIAN ARTERYPart 2:

• Costocervical trunk

Part 3:• Dorsal scapular a.

**Named according to relationship to Anterior Scalene muscle, extends to first rib

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Axillary ArteryAxillary ArteryContinuation of subclavian artery from lateral border of rib 1 to inferior border of teres major m. Divided into 3 parts relative to the pectoralis minor m.

Part 2: (posterior)

1. Thoracoacromial a.

2. Lateral thoracic a.

Part 3: (lateral)

1. Subscapular a.

2. Ant. circumflex humeral a.

3. Post. circumflex humeral a.

Part 1: (medial)1. Superior thoracic a.

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** Extends out to the lateral border of the teres major muscle

Arteries of the ArmArteries of the Arm

Brachial artery– Profunda brachii a. (deep

brachial a.)To posterior arm, and anterior and posterior lateral elbow

– Superior and inferior ulnar collateral aa.

To anterior and posterior medial elbow

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Arteries of the Forearm

Arteries of the Forearm

• Radial artery– Pulse point at the lateral wrist.– Also courses through snuff box.

• Ulnar artery– Common interosseous a.

• Anterior interosseous a. to deep anterior forearm. (accompanies anterior interosseous n. from median n.)

• Posterior interosseous a. to deep posterior forearm. (accompanies posterior interosseous n. from radial n.)

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Arteries of the HandArteries of the Hand

• Ulnar artery– Superficial palmar arch

3 common palmar digital aa.Proper palmar digital aa. (to adjacent sides of digits 2-4).Deep palmar br. (anastomoses with deep palmar arch).

• Radial artery– Deep palmar arch

Radialis indicis a. (to 2nd digit)Princeps pollicis a. (to thumb)Palmar metacarpal aa.Superficial palmar br. (anastomoses with superficial palmar arch).

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Special Test for Peripheral Circulation

Special Test for Peripheral Circulation

Allen’s Test Capillary Nail Blanch Test

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CC

Raynaud’s PhenomenonRaynaud’s Phenomenon

• The pathophysiologic event of loss of arterial inflow to the digits

• Condition associated w/ vasospasm• Usually triggered by cold or stress

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CC Superficial Veins of the UESuperficial Veins of the UE

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THE BACKTHE BACK

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The BackDermatomes & Cutaneous Nerves

The BackDermatomes & Cutaneous Nerves

Medial brs of dorsal rami of spinal nerves

Lateral brs of dorsal rami of spinal nerves

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Dorsal ramus

Ventral ramus

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MUSCLES OF THE BACK

MUSCLES OF THE BACK

• Extrinsic muscles– Superficial muscles

move the upper limb – Intermediate muscles

weak assist in respiration

• Intrinsic muscles:– Move the axial skeleton

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Extrinsic Back MusclesSuperficial Muscles

• Trapezius m.• Latissimus dorsi m.• Levator scapulae m.• Rhomboid minor m.• Rhomboid major m.

Movement of the upper limb

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Superficial Back MusclesTrapezius

• Attachments

• Nerve supplyMotor: Accessory n. (CN XI).

• ActionsElevates and depresses,

retracts & laterally rotates the scapula.

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• Nerve supply Thoracodorsal n. (C6, C7, C8).

• ActionsExtends, adducts, &

medially rotates the humerus at the shoulder. Raises trunk on fixed limbs.

• Attachments

Superficial Back MusclesLatissimus Dorsi

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Floor of intertubercular groove

Spinous process of T7-T12, thoracolumbar fascia, iliac

crest, inferior 3 or 4 ribs

• Nerve supplyDorsal scapular n. (C5) and C3 & C4 nn.

• ActionsElevates the scapula.

• Attachments

Superficial Back MusclesLevator Scapulae

Superficial Back MusclesLevator Scapulae

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• Attachments

• Nerve supplyDorsal scapular n. (C4 & C5)

• ActionsRetracts and medially rotates scapula.

Superficial Back MusclesRhomboid Major & Minor

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43http://quizlet.com/13621749/anatomy-head-neck-thoracic-back-and-abdominal-muscles-flash-cards/

Intrinsic Back

Muscles

Intrinsic Back

Muscles• Control movement of

vertebral column.• Maintain posture.• Chief extensors of

the vertebral column with a bilateral contraction.

-All Innervated by dorsal rami of spinal nerves

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SCAPULAR and PECTORAL REGIONS

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The Pectoral RegionDermatomes & Cutaneous Nerves

The Pectoral RegionDermatomes & Cutaneous Nerves

T2T3

T4

T5T6T7T8T9T10T11T12

Dermatomes (C4, T2-T6,7)

Anterior cutaneous branches med. & lat.

Lateral cutaneous branches ant. & post.

Intercostal nerves

(ant. rami)

Cutaneous Nerves

Intercostobrachial

nerve C4

Bones of the Shoulder RegionBones of the Shoulder Region

• Pectoral (shoulder) girdle:For attachment of the upper limb to the trunk. Provides strength, support, and mobility for the upper limb.Clavicle: Articulates with the axial

skeleton (sternum).Articulates with the scapula (acromion).

Scapula: Attached to axial skeleton (ribs) by muscles.Articulates with the clavicle and with the head of the humerus.

Humerus

ClavicleScapula

Humerus (arm bone): Articulates with the glenoid fossa of the scapula. 47

ClavicleClavicle

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No surgery, full range of

motion…

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ScapulaScapula

Anterior

Posterior 49

Movements of the ScapulaMovements of the Scapula

Elevation

Depression

Protraction

Retraction

Medial rotation

Internal/downward

Lateral rotation

External/upward50

Movements of the ScapulaMovements of the Scapula• Elevation

1. Trapezius (upper fibers)2. Levator scapulae3. Rhomboid major & minor

• Depression1. Pectoralis minor2. Serratus anterior (lower

fibers)3. Trapezius (lower fibers)4. Latissimus dorsi

• Protraction1. Pectoralis minor2. Serratus anterior

• Retraction1. Rhomboid major & minor2. Trapezius (middle fibers)3. Latissimus dorsi

• Medial (downward) rotation

1. Levator scapulae2. Rhomboid major & minor3. Latissimus dorsi4. Pectoralis minor

• Lateral (upward) rotation1. Trapezius (upper & lower fibers)2. Serratus anterior

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Muscles That Attach to the ScapulaMuscles That Attach to the Scapula

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HumerusHumerusPosterior surface

Anterior surface

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Movements at the ShoulderMovements at the Shoulder

• Flexion1. Pectoralis major (clavicular head)2. Deltoid (anterior fibers)3. Coracobrachialis4. Biceps brachii (short head)

• Extension1. Latissimus dorsi2. Deltoid (posterior fibers)3. Teres major

• Abduction1. Supraspinatus2. Deltoid (middle fibers)3. Serratus anterior4. Trapezius

• Adduction1. Pectoralis major2. Latissimus dorsi3. Subscapularis 54

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Movements at the ShoulderMovements at the Shoulder• Medial (internal) rotation

1. Pectoralis major2. Latissimus dorsi3. Teres major4. Subscapularis5. Deltoid (anterior fibers)

• Lateral (external) rotation1. Infraspinatus2. Teres minor3. Deltoid (posterior fibers)

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Circumduction is a Combination

Circumduction is a Combination

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Joints of the Pectoral GirdleJoints of the Pectoral Girdle

Acromioclavicular jt.– Plane synovial jt; acromion articulates with

clavicle.– Acromioclavicular lig.– Coracoclavicular lig. (conoid, trapezoid)– Coracoacromial lig.

Sternoclavicular jt.– Saddle synovial jt.; manubrium articulates

with clavicle.– Accessory motion important for UE motion

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Acromioclavicular Joint Dislocation“Shoulder” Separation

Acromioclavicular Joint Dislocation“Shoulder” Separation

1: Acromioclavicular ligament is sprained.

2: Acromioclavicular ligament is torn; coracoclavicularligaments intact.

3: Acromioclavicular, trapezoid, and conoid ligaments are torn.

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CC

Glenohumeral (Shoulder) JointGlenohumeral (Shoulder) JointType of joint: Ball and socket

Articulation: Head of humerus in glenoid fossa of scapula

Movements: Flexion/extension, abduction/adduction, rotation, circumduction

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Glenohumeral (Shoulder) JointLigaments

Glenohumeral (Shoulder) JointLigaments

Ball and socket joint.

Weakest inferiorly.

Strengthened anterior, posterior, and superior by muscles and:

− Glenohumeral ligs.

− Coracohumeral lig.

− Coracoacromial lig.

− Transverse humeral lig.

Also protected superiorly by coracoacromial arch in addition to the ligaments.

Glenohumeral ligs.

Coracohumeral lig.

Coracoacromial lig.

Tendon of long head of biceps brachii

Subscapular bursa

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The rotator cuff muscles lie on the anterior, superior, and posterior aspects of the joint

The rotator cuff is deficient inferiorly and anteriorly - site of potential weakness

Glenohumeral Joint (Opened)Lateral View

ANT.POST.

SUP.

INF.61

Shoulder DislocationShoulder Dislocation-Occur inferiorly.

-Designated as ‘anterior’ or ‘posterior’ depending on relation to the glenoid fossa. Anterior most common.

-Axillary nerve vulnerable – What muscles would be affected????

Axillary n.Axillary n.

Radial n.Radial n.

Axillary n.Axillary n.

Radial n.Radial n.

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CC

Bursae of the ShoulderBursae of the ShoulderBursa: Sac-like structure containing a film of synovial fluid, located between tendons and bone, ligaments, or other tendons, or where skin moves over a bony prominence.

Subscapular bursa

Between subscapularis tendon and neck of scapula.

Subacromial-subdeltoid bursa

Between acromion-deltoid m. and supraspinatus tendon.

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Subacromial BursitisSubacromial BursitisIrritation and inflammation of the subacromial bursa. Can be due to bone spurs on the inferior surface of acromion, calcification of the supraspinatus tendon, or general irritation from overuse.

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CC

Scapular RegionScapular Region

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• Deltoid m.• Supraspinatus m.• Infraspinatus m.• Teres minor m.• Teres major m.• Subscapularis m.

Scapulohumeral Muscles(Scapular Region)

Scapulohumeral Muscles(Scapular Region)

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DeltoidNerve: Axillary n.

Actions: Abducts, flexes, extends, medially and laterally rotates the humerusat the shoulder.

Scapular Region MusclesScapular Region MusclesClavicle

Acromion

Spine of scapula

67Deltoid tuberosity

Scapular Region MusclesScapular Region Muscles• Supraspinatus

Nerve: Suprascapular n.

Actions: Stabilizes shoulder joint; initiates and assists with abduction of the humerus.

• InfraspinatusNerve: Suprascapular n.

Actions: Laterally rotates humerus.

Supraspinous fossa

Superior facet of greater tubercle of humerus

Supraspinatus

Infraspinous fossa

Middle facet of greater tubercle of humerus

Infraspinatus

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Scapular Region MusclesScapular Region Muscles• Teres minor

Nerve: Axillary n.Actions: Stabilizes shoulder joint; laterally rotates humerus.

Inferior facet of greater tubercle of humerus

Lateral border of scapula

• Teres majorNerve: Lower subscapular n.Actions: Adducts, extends, and medially rotates humerus.

Inferior-lateral border of scapula Medial lip of bicipital

groove of humerus

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Scapular Region MusclesScapular Region Muscles

SubscapularisNerve: Upper & lower

subscapular nn.

Actions: Stabilizes shoulder joint; medially rotates the humerus.

Lesser tubercle of humerus

Subscapular fossa of scapula

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Rotator Cuff MusclesRotator Cuff MusclesBlend with articular capsule; stabilize shoulder joint.

Teres minor

SupraspinatusInfraspinatus

Subscapularis

“S I T S”muscles

Anterior

Posterior

S

SI

T

Supraspinatus

Infraspinatus

Teres minor

Subscapularis

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Rotator Cuff Tear

Rotator Cuff Tear

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-In addition to trauma, both cumulative and acute, either from internal or external sources, RTC tears can be due to calcification of supraspinatus tendon > tendinitis > tear

CC

Subacromialbursa

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Pectoral Region Pectoral Region

• Pectoralis major m.• Pectoralis minor m.• Serratus anterior m.

Pectoral Region MusclesPectoral Region Muscles

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• Pectoralis major m. (clavicular and sternocostal heads)Nerve: Medial and lateral pectoral nn.Actions: Flexes, adducts, and

medially rotates the humerus at the shoulder.

Clavicle (med. ½)

Sternocostal head

Bicipital groove

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Pectoralis minor

Coracoid process


• Pectoralis minorNerve: Medial (and lateral) pectoral nn.Actions: Protracts the scapula and

depresses shoulder.3

4

5

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• Serratus anterior m.Nerve: Long thoracic n.Actions: Protracts scapula; laterally

rotates scapula.

Paralysis of the long thoracic nerve results in “winging of the scapula”

Medial border

Inferior angle

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3

4

5

6

7

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9 CC

Axilla (Armpit)Axilla (Armpit)Pyramid-shaped space that provides a passageway for vessels and nerves (brachial plexus) going to and from the upper limb.

Note narrow opening!

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Thoracic Outlet SyndromeThoracic Outlet Syndrome

Cervical Rib or Rudimentary First Thoracic Rib

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CC

ARM(Brachium)

ARM(Brachium)

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HumerusHumerusPosteriorAnterior

Bone of the Arm

Greater tubercle

Lesser tubercle

Greater tubercle

Head Head

Intertubercular groove

Capitulum Trochlea Trochlea

Olecranon fossa

Coronoid fossa

Radial fossa

Deltoid tuberosity Spiral (radial)

groove

Lateral supracondylar ridge

Lateral lip

Medial lip

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Movements at the Elbow JointMovements at the Elbow Joint

• Flexion1. Brachialis2. Biceps brachii3. Brachioradialis

(a lateral forearm muscle)

4. Pronator teres (an anterior forearm muscle)

• Extension1. Triceps brachii2. Anconeus

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Muscles of the ArmMuscles of the Arm

• Anterior Arm Compartment1. Biceps brachii m.2. Coracobrachialis m.3. Brachialis m.

Posterior Arm Compartment1. Triceps brachii m.2. Anconeus m.

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Anterior Arm MusclesAnterior Arm Muscles

• Biceps brachii (short and long heads)Nerve: Musculocutaneous n.Actions: Short head: Weak flexor of the humerus at the shoulder; Long and short heads: Strong flexor of the elbow and supinator of the forearm.

Long head

Short head

Biceps brachii

Supraglenoid tubercle

Coracoid process

Radial tuberosity

Bicipital aponeurosis

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Biceps Tendon RuptureBiceps Tendon Rupture• Commonly caused by degenerative changes

within the tendon– Long head of bicep– Distal tendon

• Non-operative treatment for long head of bicep gives good results (loss of power only ~10-20%)

• Distal tendon rupture can cause up to 40% loss of flexion and supination. Surgery more important. 85

CC Anterior Arm MusclesAnterior Arm Muscles

• CoracobrachialisNerve: Musculocutaneous n.

Actions: Flexes and adducts the humerus at the

shoulder.

• BrachialisNerve: Musculocutaneous n.

Actions: Primary flexor of the elbow.

Coracobrachialis

Brachialis

Coracoid process

Shaft of humerus

Coronoid process and ulnar tuberosity

86

Arm StrengtheningArm Strengthening

Brachioradialis – “hammer curl”Biceps – “bicep curls”

Brachialis – “reverse curl” 87

CC Posterior Arm MusclesPosterior Arm Muscles• Triceps brachii (long, lateral,

and medial heads)Nerve: Radial n.Actions: Long head: Weak

extensor and adductor of the shoulder; Long, lateral, and medial heads: Strong extensor of the elbow.

• AnconeusNerve: Radial n.

Actions: Helps extend and stabilize the elbow.

Long head

Lateral head

Medial head

Triceps brachii

Anconeus

Infraglenoid tubercle

Olecranon

Lateral epicondyle

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Elbow AnatomyElbow AnatomyCubital fossa, cubital tunnel, vessels, nerves, and muscles

89

Brachial artery

Ulnar artery

Radial artery

Bones of Elbow and ForearmBones of Elbow and ForearmRadius

Ulna

Interosseous membrane

90

16

ELBOW JOINTELBOW JOINT

Trochlea of humeruswith trochlear notchof the ulna

Capitulum of humerus with headof the radius

Lateral

CapitulumHead of radius

Humerus

Medial

TrochleaTrochlear notch of ulna

Humerus

• Hinge synovial joint

• Articulations: Capitulum of humerus

Trochlea of humerus

Head of radius

Humerus

Radius

Ulna Coronoid process

Coronoid process of ulna important to prevent posterior dislocation 91

Elbow JointLigaments

Elbow JointLigaments

Radial (lateral) collateral lig.Blends with anular ligament

Ulnar (medial) collateral lig.• Anterior cord-like band

• Posterior fan-like band

• Oblique (transverse) band

Subcutaneous olecranon bursa:

Between skin and olecranon.

Lateral Medial

92

BursitisBursitis“Student’s elbow”– Olecranon bursa (most common of the several bursae

around the elbow)– Cause

• Chronic pressure/resting on bursa• Gout• RA• Infection (staph)

93

CC BursitisBursitis

• Clinical presentation:– Swollen, prominent bursa– Little pain or LOM

• Aseptic cases– Parabursal swelling

• Septic cases

94

CC

“Cubital Tunnel Syndrome”“Cubital Tunnel Syndrome”

Compression of ulnar nerve as it passes between olecranon and medial epicondyle

95

CC FOREARM (Antebrachium)FOREARM (Antebrachium)

Anterior Posterior

96

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Movements at Radioulnar JointsMovements at Radioulnar JointsSupination and Pronation

97

RADIOULNAR JOINTS

Pivot Joints

RADIOULNAR JOINTS

Pivot Joints• Proximal radioulnar joint

Articulation: Head of the radius with the radial notch of the ulna.

Ligaments: Annular ligament forms a collar around the head of the radius. Radius rotates under ring.

Head of ulna

Ulnar notch of radius

Radius

• Distal radioulnar jointArticulation: Head of the ulna

with the ulnar notch of the radius.Ligaments: Weak anterior and

posterior ligaments; Triangular fibrocartilage articular disc (triangular “ligament”) binds the radius and ulna together.

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Radial notch of ulnaAnular lig.

Head of radius Ulna

Anterior Forearm MusclesAnterior Forearm Muscles• Superficial layer

1. Pronator teres2. Flexor carpi radialis3. Palmaris longus4. Flexor carpi ulnaris

• Intermediate layer1. Flexor digitorum superficialis

• Deep layer1. Flexor digitorum profundus2. Flexor pollicis longus3. Pronator quadratus 99

Anterior ForearmSuperficial Layer

Anterior ForearmSuperficial Layer

• Pronator teres (humeral & ulnar heads)– To lateral shaft of radius.– Pronates forearm, flexes elbow.

• Flexor carpi radialis– To base of 2nd metacarpal.– Flexes and assists with radial deviation

• Palmaris longus– To apex of palmar aponeurosis.– Tenses palmar skin, flexes wrist.

• Flexor carpi ulnaris (humeral & ulnarheads)

– To pisiform, hook of hamate, 5th MC.– Flexes and assists with wrist UD.

All attached proximally to a common flexor origin on the medial epicondyle of the humerus. All median nerve.

100

Anterior ForearmSuperficial LayerAnterior ForearmSuperficial Layer

101

Pronator SyndromeMedian Nerve Compression at Elbow

Pronator SyndromeMedian Nerve Compression at Elbow

• Pain, numbness, weakness• No increased pain at night!• Provocative testing:

– Resisted pronation– Resisted maximum elbow flexion in full

supination– Resistance of long finger FDS– Pain upon palpation

102

CC

18

Anterior ForearmIntermediate Layer

Anterior ForearmIntermediate Layer

• Flexor digitorum superficialis(humero-ulnar & radial heads)

– From common flexor origin, coronoid process of ulna, and radial shaft

– 4 tendons to middle phalanges of digits 2-5.– Flexes wrist; flexes digits 2-5 at

metacarpophalangeal (MP) and proximal interphalangeal (PIP) joints.

– Median nerve innervation

103

Partial Digital AmputationsFunction depends on the levelPartial Digital AmputationsFunction depends on the level

• Distal to the FDS insertion – Middle phalanx can participate in grasping activities

• Proximal to the FDS insertion – No active flexion of middle

phalanx– only intrinsics working, so

MP flexion often limited to 45 degrees.

Flexor digitorium Profundus

Flexor Digitorum Superficialis

104

CC

Anterior ForearmDeep Layer

Anterior ForearmDeep Layer

• Flexor digitorum profundus– From ulna and interosseous membrane (IM); 4

tendons to distal phalanges of digits 2-5.– Flexes wrist; flexes digits 2-5 at MP, PIP, and

distal interphalangeal (DIP) joints.– Dual innervation b/w Median and Ulnar nn.

• Flexor pollicis longus– From radius and IM to distal phalanx of thumb.– Flexes thumb at MP and interphalangeal (IP)

joints.– Innervated by AIN

• Pronator quadratus– From distal ulna to distal radius.– Prime mover for forearm pronation– Innervated by AIN 105

Anterior ForearmInnervation

Anterior ForearmInnervation

• Ulnar nerve (C8,T1)• To FCU and medial

½ of FDP.

• Median nerve (C6-8,T1)•To all anterior forearm muscles EXCEPT flexor carpiulnaris and medial ½ of flexor digitorum profundus.

•Ant. interosseous n.•Pronator quatratus

•Flex. pollicus long.

•FDP (lat. ½)

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Test for Anterior Interosseous Nerve

Test for Anterior Interosseous Nerve

Common causes:

• tendinous origin of deep head of pronator teres (most common)

• enlarged bicipital tendon bursa 107

CC

• Brachioradialis− To radial styloid.− Flexes elbow in midpronated

position.

• Extensor carpi radialis longus− To base of 2nd metacarpal.− Extends and assists in RD.

Anterior view

Posterior view

Both from lateral supracondylar ridge of the humerus and innervated by Radial nerve.

Lateral ForearmMuscles

Lateral ForearmMuscles

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19

Posterior Forearm MusclesPosterior Forearm Muscles• Superficial layer

1. Extensor carpi radialis brevis 2. Extensor digitorum3. Extensor digiti minimi4. Extensor carpi ulnaris

• Deep layer1. Supinator 2. Abductor pollicis longus3. Extensor pollicis brevis4. Extensor pollicis longus5. Extensor indicis

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Posterior ForearmSuperficial layer

Posterior ForearmSuperficial layer

• Extensor carpi radialis brevis− To base of 3rd metacarpal− Extends and assists in wrist RD

• Extensor digitorum− 4 tendons to extensor expansions of

digits 2-5− Extends wrist and digits 2-5 at MP (PIP and

DIP joints?)• Extensor digiti minimi

− To extensor expansion of 5th digit− Extends 5th digit at MP (PIP and DIP joints?)

• Extensor carpi ulnaris− To base of 5th metacarpal− Extends and assists in wrist UD

Posterior view

All attached proximally to a common extensor origin on the lateral epicondyle of the humerus.

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Lateral EpicondylitisLateral Epicondylitis

The lateral epicondyle is the origin of the common extensor tendon and the supinator. Tenderness just ant and distal to condyle

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CC

• Supinator− From lateral epicondyle of humerus, and ulna

to proximal ⅓ of radius− Supinates forearm

• Abductor pollicis longus− From ulna, IM, and radius to base of 1st metacarpal− Abducts thumb

• Extensor pollicis brevis− From radius and IM to proximal phalanx of thumb− Extends thumb at MP joint

• Extensor pollicis longus− From ulna and IM to distal phalanx of thumb− Extends thumb at MP and IP joints

• Extensor indicis− From ulna and IM to ext. expansion of 2nd digit− Extends wrist and index finger at MP (PIP and DIP

joints?)

Posterior ForearmDeep Layer

Posterior ForearmDeep Layer

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Lateral and Posterior Forearm Innervation

Lateral and Posterior Forearm Innervation

• Deep radial n.To superficial posterior mm.

(ECRB, ED, EDM, ECU) and supinator m.

• Radial n. To lateral two muscles

(BR and ECRL)

Anterior

Posterior

• Posterior interosseous n.(continuation of deep radial n.)To deep posterior mm. exceptsupinator m. ( APL, EBP, EPL, EI) 113

Post. Interosseous Nerve Syndrome Radial Tunnel Syndrome

Post. Interosseous Nerve Syndrome Radial Tunnel Syndrome

Compression of the nerve in the radial tunnel as it passes through the supinator

CC

20

Pain centered at

lateral epicondyle:

tennis elbow

Pain distal to

lateral epicondyle:

radial tunnel115

CC

WRIST & HANDWRIST & HAND116

Carpal bones

Bones of the WristBones of the Wrist

8 carpal bones:Proximal row (l>m):

• S = scaphoid• L = lunate• Tq = triquetrum• P = pisiform

Distal row (l>m):• Tm = trapezium• Td = trapezoid• C = capitate• H = hamate (hook)SL

P

Tq

TmTdCH

Hook of hamate

Articulate with radius117

Bones of the HandBones of the Hand

5 metacarpals

3 phalanges for each finger (digits 2-5): proximal, middle, distal

2 phalanges for the thumb (digit 1): proximal, distal

Body

Base

Head

Body

Base

Head

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Anatomical “Snuff Box”Anatomical “Snuff Box”Boundaries:

Base: Distal radiusApex: 1st metacarpalMedial: Extensor pollicis longustendonLateral: Extensor pollicis brevisand abductor pollicis longustendons

Contents:Scaphoid boneRadial artery

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Scaphoid FracturesScaphoid Fractureso Most commonly fractured carpal bone, often from FOOSH

o Painful palpation in snuff box

o Often missed initially, until reduced bone density seen on x-ray

Nutrient artery enters distal part of the bone120

CC

21

Movements at the Wrist Movements at the Wrist FlexionProduced by long flexor muscles

ExtensionProduced by long extensor muscles

Abduction (Radial deviation)Produced by FCR, ECRL, and ECRB

Adduction (Ulnar deviation)Produced by FCU and ECU

**Circumduction121

Movements of the FingersMovements of the Fingers

Flexion Extension

Produced by bothextrinsic and intrinsic hand muscles.

Produced only by intrinsic hand muscles.

Abduction Adduction

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Movements of the ThumbMovements of the Thumb

Produced by both extrinsic and intrinsic hand muscles.

Palmar Abduction Adduction Radial Abduction/ Extension

Flexion Opposition Reposition

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Joints of the Wrist and

Hand

Distal interphalangeal jointsDistal interphalangeal joints

Proximal interphalangeal jointsProximal interphalangeal joints

Interphalangeal jointInterphalangeal joint

Metacarpophalangeal jointsMetacarpophalangeal joints

Carpometacarpal jointsCarpometacarpal joints

Radiocarpal jointRadiocarpal joint

Intercarpal jointsIntercarpal joints

Intermetacarpal jointsIntermetacarpal joints

What type of joint are each of these? 124

volar/palmar/anterior dorsal/posterior

Wrist LigamentsWrist Ligaments Triangular FibrocartilageComplex (TFCC)

Triangular FibrocartilageComplex (TFCC)

126

Helps stabilize DRUJ and absorb compression

22

TFCC TearsTFCC Tears• Central disc

– Relatively avascular (80-85%), so poor healing• Associated with FOOSH injuries, DR fx,

forced UD, positive ulnar variance, degenerative changes.

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CC

Sup. and Deep transverse metacarpal lig.

Palmar ligs. (plates)

Collateral ligs.

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Collateral ligs.

Hand LigamentsHand Ligaments

Fasciae of the WristAnterior

Fasciae of the WristAnterior

Thickened deep fascia holds tendons of long flexors at the wrist.

Flexor retinaculum (transverse carpal ligament)

Antebrachial fascia and palmarcarpal ligament

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Carpal TunnelCarpal Tunnel

Flexor retinaculum is attached laterally to the scaphoid and trapezium, and medially to the pisiform and hamate.

Carpal tunnel is a fibro-osseous passageway under the flexor retinaculum and over a deep arch formed by the carpal bones.

130

S

T

Carpal TunnelContents

Carpal TunnelContents

234

5

Flexor retinaculum

Median n.

Flexor digitorumsuperficialis tendons

Flexor digitorumprofundus tendons

Flexor pollicis longustendon

∗ Flexor carpi radialis tendon (not in carpal tunnel)

∗

131

Median nerve compression

Carpal tunnel

Median n.

Carpal Tunnel SyndromeCarpal Tunnel SyndromeCC

23

Pillar PainPillar Pain

o Temporary tenderness on each side of the palm where the ligament is attached to the bones (trapezial ridge and hook of hamate). Usually tender for at least four to six weeks after a carpal tunnel release.

133

CC Ulnar Tunnel SyndromeUlnar Tunnel Syndrome

• Compression at Guyon’s canal– “hypothenar hammer

syndrome”– “handlebar palsy”

• Tunnel formed by ligament that connects pisiform and hook of hamate

• Causes:– Fractures– Ganglions (space occupying

lesions)– Extended compression/vibration 134

CC

1. Abductor pollicis longusExtensor pollicis brevis

2. Extensor carpi radialis longusExtensor carpi radialis brevis

3. Extensor pollicis longus

4. Extensor digitorum

Extensor indicis

5. Extensor digiti minimi

6. Extensor carpi ulnaris

Extensor retinaculum: From radius to pisiform and hamate. Forms 6 tunnels for long extensor tendons.

1

2

3

4

5

6

Anterior

Posterior

Fasciae of the WristPosterior

Fasciae of the WristPosterior

135

Dequervain’s and Intersection Syndrome

Dequervain’s and Intersection Syndrome

Compartment I Compartment II

136

CC

Fascia of the HandFascia of the HandPalmar fascia: Deep fascia, thin medially and laterally, thick centrally.

Palmar aponeurosis Thick, triangular-shaped; 4 bands attach proximal phalanges of digits 2-5.

Base: Superficial transverse metacarpal lig. between bands

Apex: Attached to flexor retinaculum and plamaris longus tendon.

137

Dupuytren’s DiseaseDupuytren’s Diseaseo Pretendinous bands of palmar

aponeurosis and palmar fascia

o Active fibroblasts w/ occasional mitosis

o Abundant collagen production

o BENIGN process

138

CC

24

Synovial Sheaths and Infections

Synovial Sheaths and Infections

Thumb and small finger tendon sheaths are continuous with the carpal tendon sheath. The remaining fingers usually have separate sheaths.

139

CC Extrinsic Hand MusclesExtrinsic Hand Muscles

Palmar

Long Flexors

*Fibrous digital sheaths (pulleys)-forms osseofibroustunnel around tendons.

*Extensor expansion

Long Extensors

Dorsum*JuncturaeTendinum

140

Trigger FingerTrigger Finger

**occurs most often w/ composite flexion!!

**A2 and A4 are most crucial to function

141

CC Juncturae TendinumJuncturae Tendinumo Can cause a

misdiagnosis of an extensor tendon laceration because they can aid continual extension of a digit whose tendon was cut proximal to the juncturae.

142

CC

Long extensor tendon

Extensor ExpansionExtensor

Expansion

Central bandLong extensor tendon

• Triangular expansion (hood) of the long extensor tendons.

• Wraps around head of metacarpal and base of proximal phalanx.

• Consists of:

• central band attached to the middle phalanx

• 2 lateral bands attached to the distal phalanx

• Terminal slip/tendon attached to distal phalanx

• Intrinsic muscles insert into the extensor expansion. 143

Precision FailedPrecision Failed

• Swan neck deformity

• Boutonniere deformity

Palmar ligs. (plates)

144

CC

25

Precision FailedPrecision Failed

• Swan neck deformity

• Boutonniere deformity

145

CC Precision FailedPrecision Failed• Mallet finger

– Traumatic disruption of the terminal tendon

146

CC

Intrinsic Hand MusclesThenar Compartment

Intrinsic Hand MusclesThenar Compartment

Attachment: All attached proximally to flexor retinaculum, scaphoid, and trapezium.Nerve: Recurrent br. of median n.

Proximal phalanx of thumb – lateral side

1st metacarpal –lateral side

Flexor pollicisbrevis m.Flexes thumb at CMC and MP jts

Abductor pollicisbrevis m.Abducts thumb

Opponenspollicis m.Medially rotates 1st metacarpal at CMC jt. to oppose thumb

PB

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Intrinsic Hand MusclesHypothenar CompartmentIntrinsic Hand MusclesHypothenar Compartment

Nerve: Deep ulnar n.

Pisiform/hammate

Flexor retinaculum

Proximal phalanx of 5th digit –medial side

Hook of hamate

5th metacarpal –medial side

Flexor retinaculum

Abductor digitiminimi m.Abducts 5th digit.

Flexor digitiminimi brevism.Flexes 5th digit at MP jt.

Opponensdigiti minimim.Laterally rotates 5th metacarpal at CM jt.

148

Intrinsic Hand MusclesAdductor Compartment

Intrinsic Hand MusclesAdductor Compartment

Nerve: Deep ulnar n.

Adductor pollicis m. Oblique head

Transverse headAdducts thumb

Capitate, 2nd

and 3rd

metacarpals bases, shaft of 3rd MC

Proximal phalanx of thumb – medial side

149

Froment’s SignUlnar Nerve Damage

Froment’s SignUlnar Nerve Damage

150

CC

26

Intrinsic Hand MusclesMid-palmar Muscles


• Lumbricals (4)Attachments:

From tendons of FDP to lateral sides of extensor expansions of digits 2-5.

Nerves:Median n. – 1 and 2Deep ulnar n. - 3 and 4

Actions:Flex at MP joint and extend at IP joints of digits 2-5.

1234

151

Intrinsic Plus SplintIntrinsic Plus Splint

http://www.sammonspreston.com/app.aspx?cmd=get_product&id=73140

152

CC



• Palmar interossei (3)

Attachments:From 2nd, 4th, and 5th metacarpals to lateral band of extensor expansion of digits 2, 4, and 5.

Nerve:Deep ulnar n.

Actions:(PAD) Adduct fingers 2, 4, and 5 and extend at IP joints.

153



• Dorsal interossei (4)Attachments:

From adjacent metacarpals to lateral band of extensor expansion of digits 2, 3, and 4.

Nerve:Deep ulnar n.

Actions:(DAB) Abduct digits 2, 3, and 4 and extend at IP joints.

154

Innervation of Intrinsic Hand Muscles

Innervation of Intrinsic Hand Muscles

Median Nerve:o Recurrent br. to thenar muscles; digital

brs. to lumbricals #1 and #2.

Ulnar Nerve:o Deep br. to all other hand muscles.

155

Cutaneous Nerves of the HandPalmar Side

Cutaneous Nerves of the HandPalmar Side

Median n:• Palmar cutaneousbr.

• Common and proper digital brs.

Ulnar n: (superficial to flexor retinaculum)

• Palmar cutaneous br.

• Superficial ulnar n.

• Common and proper digital brs.

Radial n:• Sup. radial n.

156

Note: Palmar cutaneous br. of median nerve does not go through carpal tunnel, sensation is spared.

27

Cutaneous Nerves of the HandDorsal Side

Cutaneous Nerves of the HandDorsal Side

Ulnar n:• Dorsal br.

• Dorsal digital brs.

Radial n:• Superficial radial n.

• Dorsal digital brs.

Median n:

•Digital brs.

157

ReferencesReferences• Agur, A. M. R. & Dalley, A. F. (2009). Grant’s Atlas of Anatomy, 12th ed.

Maryland: Lippincott Williams & Wilkins.• Burke, S. L, Higgins. J. P., McClinton, M. A., Saunders, R. J., &

Valdata, L. (2006). Hand and Upper Extremity Rehabilitation. A Practical Guide. Missouri: Elsevier.

• Gilroy, A. M., MacPherson, B. R., & Ross, L. M. (2008). Atlas of Anatomy. New York: Thieme.

• Skirven, T. M., Osterman, A. L., Fedorczyk, J. M., & Amadio. P. C. (2011). Rehabilitation of the Hand and Upper Extremity, 6th ed. PA: Mosby.

• Moore, K. L., Dalley, A. F., & Agur, A. M. R. (2010). Clinically Oriented Anatomy, 6th ed. Maryland: Lippincott Williams & Wilkins.

• Pearl, M. L., Bessos, K., Wong, K. (1998). Strength deficits related to distal biceps tendon rupture and repair. American Journal of Sports Medicine, 26, 295-296.Michael L. Pearl

• Spriggs, L., Whitworth, R., & Swartz, W. Presentations from Medical Gross and Allied Health Gross Anatomy courses, LSUHSC, New Orleans, LA.

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