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Organization of the Upper Limb

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Organization of the Upper Limb 3/5/2019 LEARNING OBJECTIVES 1. Describe the neuroanatomy from brain to fingertip. 2. Describe current concepts of peripheral nerve biology and healing. • Excellence in Education 3. Collect a good history & exam for common • for OTs and PTs peripheral nerve conditions. • Since 1990 4. Educate patients regarding their condition and treatments. 5. Participate more effectively in the patients’ care. • www.ddhands.com METHODS Questions during the Discussion Sessions: ▪ Write them on note cards as you think of 1. 14 lectures them 2. Two question and answer sessions 3. Networking Practical Matters: 4. Some repetition between talks ▪ Can everybody see? Hear? ▪ Room temperature? a. Bad news: unavoidable because of ▪ Cell phones, beepers multiple speakers ▪ Auditorium’s policy on food/beverage b. Good news: repetition is a good ▪ Restrooms learning tool ▪ Evaluation forms and certificates ▪ Ready, set, go… Organization of the Upper Limb • Some anatomy • Some topology John Elfar Penn State Hershey, • Some embryology Center for Orthopaedic Research and Translational Science Department of Orthopaedics and Rehabilitation Special thanks to: Robert S. Staron, Ph.D. • Goal is a framework for Summer Anatomy Immersion, Ohio University understanding anatomy in function. 1 3/5/2019 Gray’s Anatomy 37th ed Grant’s Atlas of Anatomy 8th ed Grant’s Atlas 8th ed Grant’s Atlas of Anatomy 8th ed Antr division: flexor comp. Postr division: ext comp. Wikipedia open license (accessed 2019) Netter’s Atlas of Human Embryology 2002 Muscle Anterior Grant’s Dissector 13th ed musculocutaneous n. Origin of Limb Compartments Humerus Muscles of the Upper Limb Dorsal muscle mass forms radial n. extensors and supinators in (including a portion Posterior upper limb, extensors and of the brachialis m.) Anterior abductors in lower limb. Ventral muscle mass forms median n. & ulnar n. flexors and pronators in Radius upper limb and flexors and Ulna adductors in lower limb. radial n. Posterior Morphogenesis guided by CT, (including ECRL & not myoblasts brachioradialis mm.) ulnar n. & median n. Anterior Split into individual muscles, 5th metacarpal cell death involved Posterior Carlson l999 Human Embryology Larsen 1993 2 3/5/2019 Hollinshead’s Textbook of Anatomy 5th ed Grant’s Dissector 13th ed 21. Brachial Plexus nd Rohen/Yokochi Color Atlas of Anatomy 2nd ed Netter’s Atlas 2 ed Extrinsic shoulder mm. Intrinsic shoulder mm. 1) trapezius m. 1) infraspinatus m. 2) latissimus dorsi m. 2) supraspinatus m. 3) levator scapulae m. 3) subscapularis m. 4) rhomboideus major m. 4) teres minor m. 5) rhomboideus minor m. 5) teres major m. 6) serratus anterior m. 6) deltoid m. Anterior thorax mm. 1) pectoralis major and minor mm. 2) subclavius m. hand – forearm – arm – shoulder distal proximal Grant’s Atlas of Anatomy 8th ed 3 3/5/2019 Extrinsic shoulder mm. 1) trapezius m. (spinal accessory n. - CN XI + C3 & C4) 2) latissimus dorsi m. (thoracodorsal n. - C6, C7, C8) 3) levator scapulae m. (C3 & C4 + dorsal scapular n. - C5) 4) rhomboideus major m. (dorsal scapular n. - C5) 5) rhomboideus minor m. (dorsal scapular n. - C5) 6) serratus anterior m. (long thoracic n. - C5, C6, C7) Anterior thorax mm. med/lat 1) pectoralis major ( C5-T1) & minor (C6-C8) mm. pect nn. ed 2) subclavius m. (n. to subclavius m. - C5, C6) th Grant’s Atlas 8 Grant’s Grant’s Atlas of Anatomy 8th ed Netter’s Atlas 2nd ed Netter’s Atlas of Human Anatomy 2nd ed Intrinsic shoulder mm. 1) infraspinatus m. (suprascapular n. - C5, C6) 2) supraspinatus m. (suprascapular n. - C5, C6) 3) subscapularis m. (upper + lower subscapular nn. - C5, C6) 4) teres minor m. (axillary n. - C5, C6) 5) teres major m. (lower subscapular n. - C5, C6) 6) deltoid m. (axillary n. - C5, C6) ed th Grant’s Atlas 8 Grant’s Grant’s Atlas of Anatomy 8th ed 4 3/5/2019 rotator cuff musculature Netter’s Atlas of Human Anatomy 2nd ed Netter’s Atlas 2nd ed Anterior Grant’s Dissector 13th ed Grant’s Dissector 13th ed Muscle musculocutaneous n. Compartments Humerus of the Upper Limb - arm radial n. (including a portion Posterior of the brachialis m.) Anterior median n. & ulnar n. Radius Ulna radial n. Posterior (including ECRL & brachioradialis mm.) ulnar n. & median n. Anterior 5th metacarpal Posterior brachium musculocutaneous n. (C5-C7) antr compartment postr compartment biceps brachii m. triceps brachii m. biceps brachii m. (C5, C6) long head lateral head brachialis m. (C5, C6) short head medial head brachialis m. long head coracobrachialis m. (C5-C7) coracobrachialis m. anconeus m. Netter’s Atlas of Human Anatomy 2nd ed 5 3/5/2019 Grant’s Dissector 13th ed axillary n. (C5-C6) deltoid m. (C5, C6) teres minor m. (C5, C6) radial n. (C5-T1) triceps brachii m. (C6-C8) anconeus m. (C7, C8) (brachialis m. C5, C6) Netter’s Atlas of Human Anatomy 2nd ed Anterior Grant’s Dissector 13th ed Anterior Grant’s Dissector 13th ed Muscle musculocutaneous n. Muscle musculocutaneous n. Compartments Humerus Compartments Humerus of the Upper of the Upper Limb - forearm Limb - forearm radial n. radial n. (including a portion Posterior (including a portion Posterior of the brachialis m.) Anterior of the brachialis m.) Anterior median n. & ulnar n. median n. & ulnar n. (FCU & ulnar ½ Radius Radius FDP) Ulna Ulna radial n. Posterior radial n. Posterior (including ECRL & (including ECRL & brachioradialis mm.) ulnar n. & median n. brachioradialis mm.) ulnar n. & median n. Anterior Anterior 5th metacarpal 5th metacarpal Posterior Posterior antebrachium antr compartment postr compartment pronator teres m. brachioradialis m. flex. carpi radialis m. ext. carpi radialis longus m. palmaris longus m. ext. carpi radialis brevis m. flex. carpi ulnaris m. ext. carpi ulnaris m. extensor digitorum m. flex. digit. superf. m. extensor digiti minimi m. flex. digit. profund. m. extensor indicis m. flex. pollicis longus m. abd pollicis longus m. pronator quadratus m. ext. pollicis longus/brevis m. supinator m. Grant’s Dissector 13th ed 6 3/5/2019 antebrachium ulnar n. (C7-T1) antr compartment (median & ulnar nn.) pronator teres m. (C6, C7) flex carpi ulnaris m. flex. carpi radialis m. (C6, C7) medial ½ FDP palmaris longus m. (C7, C8) flex. carpi ulnaris m. (C7, C8) flex. digit. superf. m. (C7, C8, T1) + 14 intrinsic hand flex. digit. profund. m. (C7, C8, T1) muscles flex. pollicis longus m. (C8, T1) pronator quadratus m. (C8, T1) Netter’s Atlas of Human Anatomy 2nd ed median n. (C5-T1) antebrachium postr compartment (radial n. C5-T1) brachioradialis m. (C5, C6) PT, FCR, PL, ext. carpi radialis longus m. (C6, C7) FDS, lat ½ FDP, ext. carpi radialis brevis m. (C6, C7 or C7, C8) FPL, PQ ext. carpi ulnaris m. (C7, C8) extensor digitorum m. (C7, C8) extensor digiti minimi m. (C7, C8) + 5 intrinsic hand extensor indicis m. (C7, C8) muscles abd pollicis longus m. (C7, C8) ext. pollicis longus/brevis m. (C7, C8) supinator m. (C5, C6) Netter’s Atlas of Human Anatomy 2nd ed Grant’s Atlas of Anatomy 11th ed radial n. (C5-T1) triceps brachii m., anconeus m. (brachialis m.) BR, ECRL, ECRB, ED, EDM, supinator, ECU, EI, AbdPL, EPL, EPB Netter’s Atlas of Human Anatomy 2nd ed 7 3/5/2019 Anterior Grant’s Dissector 13th ed Anterior Grant’s Dissector 13th ed Muscle musculocutaneous n. Muscle musculocutaneous n. Compartments Humerus Compartments Humerus of the Upper of the Upper Limb - hand Limb - hand radial n. radial n. (including a portion Posterior (including a portion Posterior of the brachialis m.) Anterior of the brachialis m.) Anterior median n. & ulnar n. median n. & ulnar n. (FCU & ulnar ½ (FCU & ulnar ½ Radius FDP) Radius FDP) Ulna Ulna radial n. Posterior radial n. Posterior (including ECRL & (including ECRL & brachioradialis mm.) ulnar n. & median n. brachioradialis mm.) ulnar n. & median n. Anterior Anterior (thenar mm. & 1st, 2nd lumbricals) 5th metacarpal 5th metacarpal Posterior Posterior intrinsic hand muscles (C8, T1) intrinsic hand muscles (median & ulnar nn.) 7 interosseii mm. (4 dorsal/3 palmar) 7 interosseii mm. (4 dorsal/3 palmar) 4 lumbrical mm. (1, 2, 3, 4) 4 lumbrical mm. (1, 2, 3, 4) palmaris brevis m. palmaris brevis m. adductor pollicis m. adductor pollicis m. three thenar mm. (OP, abd.PB, FPB) three thenar mm. (OP, abd.PB, FPB) three hypothenar mm. (ODM, abd.DM, FDMB) three hypothenar mm. (ODM, abd.DM, FDMB) upper limb - upper limb – cutaneous innervation dermatome pattern Netter’s Atlas of Human Anatomy 2nd ed Netter’s Atlas of Human Anatomy 2nd ed 8 3/5/2019 Anatomy is a Journey .The quicker you embark . What could be re-routed to the more of the journey serve another function? you will appreciate. Which surgeries are .It is not only about rational? And which John Elfar memorizing what inserts surgeries are ill-advised? Penn State Hershey, Center for Orthopaedic Research and Translational Science where and which nerve . Knowledge of anatomy can Department of Orthopaedics and Rehabilitation innervates which muscle. give subtle insights into Special thanks to: Adam Martin, MD .We think not only of function and possible UCLA Hand Fellow what exists, but what rehabilitation. could exist. Enjoy your journey. Outline Anatomy of Neuron • Microanatomy Cell body • Biology Dendrites • Nerve Injuries Receive incoming impulses – Physiology Axon – Classification Conducts outgoing impulses – Nerve response to injury Schwann cells, produce myelin sheath Courtesy Roadnottaken Wikimedia Anatomy of a Peripheral Nerve 1. Axon: basic subunit Sensory neuron . Nerve fiber = axon + Schwann cell + myelin 2. Fascicle: groups of axons 3. Peripheral nerve: Motor neuron groups
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