CLINICAL ANATOMY OF THEUPPER LIMB

Kaan Yücel M.D., Ph.D. 20.March.2012 Tuesday

CLINICAL ANATOMY OF THEAXILLA

Enlargement of Axillary Lymph NodesLymphangitis (inflammation of lymphatic vessels)Cause: An infection in the upper limbHumeral group – first to be involved

Enlargement of Axillary Lymph Nodes

Metastatic cancer of the apical group

adhere to axillary vein

excision of part of the axillary vein

Enlargement of the apical nodes

obstruction of the cephalic vein

superior to pectoralis minor

Enlargement of Axillary Lymph Nodes

Arterial Innervation and Raynaud’s Diseaseo The arteries of the upper limb are

innervated by sympathetic nerves through the brachial plexus.

o Vasospastic diseases involving digital arterioles, such as Raynaud’s disease, may require a cervicodorsal preganglionic sympathectomy to prevent necrosis of the fingers.

o The operation is followed by arterial vasodilatation, with consequent increased blood flow to the upper limb.

Aneurysm of Axillary ArteryThe first part of the axillary artery may enlarge (aneurysm of the axillary artery) and compress the trunks of the brachial plexus, causing pain and anesthesia (loss of sensation) in the areas of the skin supplied by the affected nerves.

Spontaneous Thrombosis of the Axillary VeinSpontaneous thrombosis of the axillary vein occasionally occurs after excessive and unaccustomed movements of the arm at the shoulder joint.

CLINICAL ANATOMY OF THEBRACHIAL PLEXUS

Dermatomes and Cutaneous Nerves of the Upper Limb

Checking the integrity of the spinal cord segments on the skin

Dermatome: Skin area supplied by a spinal segment

C3-C6 lateral margin of the limbC7 middle fingerC8-T2 medial margin of the limb

Shoulder PainThe skin over the point of the shoulder and halfway down the lateral surface of the deltoid muscle is supplied by the supraclavicular nerves (C3 and 4)

The afferent stimuli reach the spinal cord via the phrenic nerves (C3, 4, and 5).

Differential diagnosis time Inflammatory lesions involving the diaphragmatic

pleura or peritoneum Pleurisy Peritonitis Subphrenic abscess Gallbladder disease

Brachial Plexus InjuriesComplete lesions involving all the roots of the plexus are rare.

Incomplete injuries are common and are usually caused by traction or pressure; individual nerves can be divided by stab wounds.

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.

Result-Excessive traction or even tearing of C5 and 6 roots

Infants during a difficult delivery In adults after a blow to or fall on the shoulder

The actor Martin Sheen, however, is on record as mentioning a birth accident in which forceps "mangled" his shoulder.

shoulder dystocia

Nerves derived from C5 & C6 roots affected Suprascapular nerve Nerve to the subclaviusMusculocutaneous nerve Axillary nerve

Muscles paralyzed

• Supraspinatus (abductor of the shoulder) • Infraspinatus (lateral rotator of the shoulder)• Subclavius (depresses the clavicle)• Biceps brachii (supinator of the forearm, flexor of the

elbow, weak flexor of the shoulder)• Greater part of the brachialis (flexor of the elbow)• Coracobrachialis (flexor of the shoulder)• Deltoid (abductor of the shoulder) • Teres minor (lateral rotator of the shoulder)

Limb hanging by the side

Medially rotated [unopposed sternocostal part of pectoralis major]

Forearm pronated loss of biceps brachii action

Waiter’s tip position

Loss of sensation down the lateral side of the arm

Lower Lesions of the Brachial Plexus (Klumpke Palsy)Usually traction injuries caused by excessive abduction of the arm

First thoracic nerveMedian & ulnar nerves

Hand- Clawed appearance Hyperextension of metacarpophalangeal joints

Flexion of interphalangeal joints

Loss of sensation medial side of the armC8 nerve damaged, medial side of the forearm, hand, and medial two fingers.

Long Thoracic Nerve Injuries

Serratus anterior muscle

Blows to or pressure on the posterior triangle of the neck

During the surgical procedure of radical mastectomy

Difficulty in raising the arm above the head.

Winged scapulaThe vertebral border & inferior angle of the scapula will no longer be kept closely applied to the chest wall and will protrude posteriorly

Axillary Nerve Injuries

Posterior cord of the brachial plexus (C5 & 6)

Pressure of a badly adjusted crutch pressing upward into the armpit

Vulnerable @ quadrangular space Downward displacement of the humeral head in shoulder dislocations

Fractures of the surgical neck of the humerus

Axillary Nerve InjuriesDeltoid & teres minor paralysis

Loss of skin sensation over the lower half of the deltoid muscle

Radial Nerve Injuries@Axilla• Badly fitting crutch pressing up into

the armpit • Drunkard falling asleep with one arm

over the back of a chair• Fractures and dislocations of the

proximal end of the humerus MotorTriceps,anconeus, extensors of the wrist paralyzyedNo extension of elbow, wrist & fingers Wristdrop- flexion of the wrist

Supination ok intact biceps brachii (musculocutaneous nerve)

Radial Nerve Injuries @ AxillaSensory

A small loss of skin sensationDown posterior surface of lower part of the arm Down a narrow strip on the back of the forearmVariable 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.

Area of total anesthesia relatively small

because of the overlap of sensory innervation by adjacent nerves

Radial Nerve Injuries @ Spiral Groove of Humerus

Fracture of the shaft of the humerus

The pressure of the back of the arm on the edge of the operating table

Most common@ distal part of the groove

MotorWristdrop

SensoryVariable small area of anesthesia over the dorsal surface of the hand & dorsal surface of the roots of 3 ½ fingers

Radial Tunnel Syndromeo Tenderness & pain the forearm just below the elbow

oWatch out for lateral epicondylitis (tennis elbow)

o Differential diagnosis made on history & physical exam

oThe difference between these two conditions: where the elbow is most tender

oLateral to the elbow the radial nerve travels below the supinator muscle

Tennis Elbow (Lateral epicondiylitis)o Small area of chronic pain @ lateral

elbow

o Pain on wrist extension, pain when shaking hands, weakened grip

o More common 30 -50 yrs of age

o Many conditions for the cause; not only tennis

o Repeated use of of the forearm extensor muscles

extensor carpi radialis brevis lateral epicondyle to 2nd metacarpal

Injuries to the Deep Branch of the Radial Nerve

Motor nerve to the extensor muscles in the posterior compartment of the forearm

Fractures of the proximal end of the radius Dislocation of the radial head

Supinator (posterior interosseus nerve continuation of deep branch) & extensor carpi radialis longus (radial nerve) undamaged, and because the latter muscle is powerful, it will keep the wrist joint extended, and wristdrop will not occur.

No sensory loss- Motor nerve

Injuries to the Superficial Radial NerveSensory As in a stab wound;A variable small area of anesthesia over the dorsum of the hand & dorsal surface of the roots of the lateral 3 ½ fingers

Musculocutaneous Nerve Injurieso Rarely injured

o Protected beneath the biceps brachii muscle

o Injured high up in the arm;o Biceps & coracobrachialis paralyzed

brachialis muscle is weakened (also supplied by radial nerve).

o Flexion of the forearm at the elbow produced by the remainder of the brachialis & flexors of the forearm.

Musculocutaneous Nerve InjuriesSensory loss along the lateral side of the forearm

lateral cutaneous nerve of the forearmcontinuation of the musculocutaneous nerve beyond the cubital fossa

Median Nerve Injuries

Occasionally in the elbow in supracondylar fractures of the humerus

Most commonly injured by stab wounds or broken glass proximal to the flexor retinaculum:

Here it lies in the interval between the flexor carpi radialis & flexor digitorum superficialis tendons, overlapped by the palmaris longus.

Median Nerve Injuries @ the ElbowMotoro Pronator muscles of the forearm o Long flexor muscles of the wrist &

fingers paralyzed

Exceptionflexor carpi ulnaris & medial half of flexor digitorum profundus

Forearm in supine position; weak wrist flexion accompanied by adduction

No flexion @ interphalangeal joints of the index & middle fingers

Median nerve innervates:Most of the muscles in the anterior compartment of the forearm (except for the flexor carpi ulnaris muscle and the medial half of the flexor digitorum profundus muscle)

In the handThree thenar muscles associated with the thumbTwo lateral lumbrical muscles associated with movement of the index and middle fingers

Flex metacarpophalangeal joints & extend interphalangeal joints Skin over the palmar surface of the lateral 3 ½ digits and over the lateral side of the palm and middle of the wrist.

L

Median Nerve Injuries @ the ElbowAsk the patient to make a fisto Index finger, lesser extent

middle finger straighto Ring & little fingers flexo No flexion @ thumb’s terminal

phalanx flexor pollicis longus paralysis

Thenar eminence flattened thenar muscles wasted

Thumb laterally rotated & adducted

Hand flattened«ape-like» hand

Orator’s hand posture

Median Nerve Injuries @ the ElbowSensorySkin sensation loss Lateral half or less of the palm of the hand Palmar aspect of lateral 3 ½ fingers Vasomotor ChangesWarmer & drier skin arteriolar dilatation and absence of sweating resulting from loss of sympathetic control

Trophic ChangesDry skin and scalyNails crack easilyAtrophy of the pulp of the fingers

Median Nerve Injuries @ the WristMotor Thenar muscles paralyzedThenar eminence flattenedThumb laterally rotated & adductedNo opposition of the thumb

«ape-like» hand

First two lumbricals paralyzed

When the patient is asked to make a fist slowly, index & middle fingers tend to lag behind the ring & little fingers.

Median Nerve Injuries

Perhaps most serious disability of all in median nerve injuries :

Loss of ability to oppose the thumb to the other fingers Loss of sensation over the lateral fingers

Delicate pincer-like action of the hand is no longer possible.

Ulnar Nerve Injuries

Most commonly injured at the elbow where it lies behind the medial epicondyleusually associated with fractures of the medial epicondyle

Most commonly injured at the wristwhere it lies with ulnar artery in front of flexor retinaculum

Ulnar nerve innervates:Flexor carpi ulnaris muscle & medial half of the flexor digitorum profundus muscle

All intrinsic muscles of the hand (except for the three thenar muscles and the two lateral lumbrical muscles)

Skin over the palmar surface of the little finger, medial half of the ring finger, and associated palm and wrist, and the skin over the dorsal surface of the medial part of the hand

Ulnar Nerve Injuries @ the Elbow

MotorFlexor carpi ulnaris & medial half of the flexor digitorum profundus paralyzed

ASK YOUR PATIENT TO MAKE A FIST

o No observation/thightening of the flexor carpi ulnaris tendon passing to the pisiform bone o No fxn of the profundus tendonsNo flexion of ring & little fingers’ terminal phalanges

Flexion of the wrist joint will result in abduction, owing to paralysis of the

flexor carpi ulnaris.

Ulnar Nerve Injuries @ the ElbowMedial border of the front of the forearm flattens

wasting of underlying ulnaris & profundus muscles

Small muscles of the hand paralyzed except thenar muscles & first 2 lumbricals -median nerve-

Ulnar Nerve Injuries @ the ElbowUnable to grip a piece of paper placed between the fingers

No adduction & abduction of fingers

No adduct the thumbParalyzed adductor pollicis

Extensor digitorum abduct fingers to a small extent, when metacarpophalangeal joints hyperextended

FROMENT’S SIGNAsk your patient to grip a piece of paper between the thumb & index finger:S/he does so by strongly contracting flexor pollicis longus & flexing the terminal phalanx

Ulnar Nerve Injuries @ the Elbow

Metacarpophalangeal joints hyperextended

Interphalangeal joints flexed

Lumbrical & interosseous muscles paralysis4th & 5th fingers

Ulnar Nerve Injuries @ the Elbow In longstanding cases the hand

assumes the characteristic “claw” deformity (Main en griffe).

Flattening of the hypothenar eminence

Loss of the convex curve to the medial border of the hand

Examination of the dorsum of the hand:

Hollowing between the metacarpal bones caused by wasting of the dorsal interosseous muscles.

Ulnar Nerve Injuries @ the ElbowSensoryLoss of skin sensation o Anterior & posterior surfaces of the medial

third of the hand

o Medial 1 ½ fingers

Vasomotor ChangesWarmer and drier skin

arteriolar dilatation & absence of sweating resulting from loss of sympathetic control

Ulnar Nerve Injuries @ the WristMotor Small muscles of the hand-except thenar & first 2 lumbricalsClawhand more obvious

flexor digitorum profundus not paralyzed, marked flexion of terminal phalanges

Ulnar Nerve Injuries @ the WristSensory

Main ulnar nerve & its palmar cutaneous branch usually severed Posterior cutaneous branch, arises from the ulnar nerve trunk about 2.5 in. (6.25 cm) above the pisiform bone usually unaffected

Sensory loss confined to o Palmar surface of medial 1/3 of the hand o Medial 1 ½ fingers o Dorsal aspects of middle & distal phalanges of the same fingers

Ulnar Nerve Injurieso With ulnar nerve injuries, the higher the lesion is the less obvious is the clawing deformity of the hand.

o Unlike median nerve injuries, lesions of the ulnar nerve leave a relatively efficient hand. Sensation over the lateral part of the hand is intact, pincer-like action of the thumb and index finger is reasonably good, although there is some weakness, owing to loss of the adductor pollicis.

CLINICAL ANATOMY OF THESHOULDER

Compression of axillary nerve & posterior circumflex humeral artery @ quadrilateral space o Downward displacement of the humeral head in shoulder

dislocations o Fractures of the surgical neck of the humerus Deltoid & teres minor paralysisLoss of skin sensation lower half of deltoid muscle

Quadrangular Space Syndrome

Excessive overhead activity of the upper limb may be the cause of tendinitis, although many cases appear spontaneously.

Rotator Cuff Tendinitis

Stabilizing the shoulder joint

Common cause of pain in the shoulder

Subacromial bursa-Supraspinatus

Good for the ease of friction during abduction of the shoulder

Subacromial bursitis, supraspinatus tendinitis, or pericapsulitis

Characterized by the presence of a spasm of pain in the middle range of abduction, when the diseased area impinges on the acromion.

Rotator Cuff Tendinitis

Rupture of the Supraspinatus Tendono In advanced cases of rotator cuff tendinitis, the necrotic

supraspinatus tendon can become calcified or rupture.

o Inability to initiate abduction of the arm

o However, if the arm is passively assisted for the first 15° of abduction, the deltoid can then take over and complete the movement to a right angle.

CLINICAL ANATOMY OF THEFOREARM & HAND

o Important clinically

o Even with a complete lesion of the median nerve, some muscles may not be paralyzed.

o Erroneous conclusion that the median nerve has not been damaged.

Communications Between Median & Ulnar Nerves

The common place:o Where radial artery lies on the anterior surface of distal end of the radius, proximal to the wrist, between flexor carpi radialis & brachioradialis tendons. o Here the artery is covered by only fascia and skin.

Measuring Pulse Rate

o Anatomical snuff box between extensor pollicus longus & brevis.

For straightforward blood testsMedian cubital vein

Cephalic vein for short-term intravenous cannula

Venipuncture

Why an important clinical region?

1) Palpating the scaphoid bone to asses a fracture – when hand is in ulnar deviation

2) Pulse of the radial artery

Anatomical snuffbox

Lateral border Abductor pollicis longus &Extensor pollicis brevis tendons

Medial borderExtensor pollicis longus tendon

Floor Scaphoid & trapezium, distal ends of the extensor carpi radialis longus &extensor carpi radialis brevis tendons

Radial artery passes via anatomical snuffbox, deep to extensor tendons of the thumb adjacent to scaphoid & trapezium

Anatomical snuffbox

Peripheral mono-neuropathy of the upper limbCompression of the median nerve as it passes through the carpal tunnel into wrist

Lies immediately beneath palmaris longus tendon and anterior to the flexor tendons

Carpal tunnel syndrome

Conditions Diabetes mellitusRheumatoid arthritisAcromegalyHypothyroidismPregnancy Tenosynovitis

Gradual onset of numbness and tingling in the median nerve

distribution of the hand

CLINICAL ANATOMY OF THEPECTORAL REGION

& MAMMARY GLANDS

Breast Quadrants

For the anatomical location and description of tumors and cysts, the surface of the breast is divided into four quadrants.

Mammography o Radiographic examination of the

breasts, mammography, is one of the techniques used to detect breast masses.

o A carcinoma appears as a large, jagged density in the mammogram.

o Surgeons use mammography as a guide when removing breast tumors, cysts, and abscesses.

Mastectomy –breast excision-

Simple mastectomy

Breast is removed down to the retromammary space.

Radical mastectomyMore extensive surgical procedure

Removal of the breast, pectoral muscles, fat, fascia, and as many lymph nodes as possible in the axilla and pectoral region.

Gynecomastia Breast hypertrophy in males after puberty

Relatively rare (<1%) • Age or drug related • Imbalance between estrogenic and androgenic hormones • A change in the metabolism of sex hormones by the liverRule out important potential causes, e.g. suprarenal or testicular cancers

Polymastia (supernumerary breasts) Only a rudimentary nipple & areola mistaken for a mole (nevus)Polythelia (accessory nipples)

AmastiaNo breast development

@ Axillary fossa or anterior abdominal wall

Extra breasts along a line from axilla to groinembryonic mammary crest milk line

CLINICAL ANATOMY OF THESUPERFICIAL MUSCLES

OF THE BACK

Site on the back where breath sounds may be most easily heard with a stethoscope

Auscultatory Triangle

Boundaries

Latissimus dorsi TrapeziusMedial border of the scapula

Levator scapulae connects the neck and shoulder

Pain when trying to turn the head to the side where it hurts, often turning the body instead of the neck to look behind Common causes• Turning the head to one side while

typing• Long phone calls without a headset• Sleeping without proper pillow

support with the neck tilted or rotated• Activities such as vigorous tennis,

swimming the crawl stroke

Stiff Neck