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d-etre.blogspot.com Organization of the Upper Limb Organization of the Upper Limb Audrone Biknevicius, Ph.D. Dept. Biomedical Sciences, OU HCOM at Dubli Clinical Anatomy Immersion 2014
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Page 1: D-etre.blogspot.com Organization of the Upper Limb Audrone Biknevicius, Ph.D. Dept. Biomedical Sciences, OU HCOM at Dublin Clinical Anatomy Immersion 2014.

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Organization of the Upper LimbOrganization of the Upper LimbAudrone Biknevicius, Ph.D.

Dept. Biomedical Sciences, OU HCOM at DublinClinical Anatomy Immersion 2014

Page 2: D-etre.blogspot.com Organization of the Upper Limb Audrone Biknevicius, Ph.D. Dept. Biomedical Sciences, OU HCOM at Dublin Clinical Anatomy Immersion 2014.

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“Anatomical Tool-Kit”

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Page 3: D-etre.blogspot.com Organization of the Upper Limb Audrone Biknevicius, Ph.D. Dept. Biomedical Sciences, OU HCOM at Dublin Clinical Anatomy Immersion 2014.

3

Week 5

RULE #1Limbs are outgrowths of the ventral body wall that undergo distal growth and differentiation…

Week 7

and rotation

[More detailed limb embryology in MS course]

Page 4: D-etre.blogspot.com Organization of the Upper Limb Audrone Biknevicius, Ph.D. Dept. Biomedical Sciences, OU HCOM at Dublin Clinical Anatomy Immersion 2014.

The upper limbs are innervated by :

A. Dorsal rami of spinal nn.

B. Ventral rami of spinal nn.

4

50% 50%

Dorsal rami of spinal nn. Ventral rami of spinal nn.

Page 5: D-etre.blogspot.com Organization of the Upper Limb Audrone Biknevicius, Ph.D. Dept. Biomedical Sciences, OU HCOM at Dublin Clinical Anatomy Immersion 2014.

Developmentally-dorsal limb mm.

Developmentally-ventral limb mm.

Primitive Pectoral Limb

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DEVELOPMENTAL/EVOLUTIONARY BASIS

Page 6: D-etre.blogspot.com Organization of the Upper Limb Audrone Biknevicius, Ph.D. Dept. Biomedical Sciences, OU HCOM at Dublin Clinical Anatomy Immersion 2014.

• 90◦ lateral rotation (forearm mm. undergo incomplete rotation)

• Limb adduction6

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DEVELOPMENTAL/EVOLUTIONARY BASIS

Page 7: D-etre.blogspot.com Organization of the Upper Limb Audrone Biknevicius, Ph.D. Dept. Biomedical Sciences, OU HCOM at Dublin Clinical Anatomy Immersion 2014.

*

7

Developmentally-ventral muscles:• Lie anterior to the long bones in anatomical position

Developmentally-dorsal muscles: • Lie posterior to the long bones in anatomical position (* exceptions)

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RULE #2A: Ventral vs. dorsal limb mm.

Page 8: D-etre.blogspot.com Organization of the Upper Limb Audrone Biknevicius, Ph.D. Dept. Biomedical Sciences, OU HCOM at Dublin Clinical Anatomy Immersion 2014.

Anterior

Humerus

Posterior

Radius

Anterior

Posterior

5th metacarpal

Anterior

FOREARM

HAND

ARM

Ulnar

8

Upper LimbMuscle

Compartments

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Page 9: D-etre.blogspot.com Organization of the Upper Limb Audrone Biknevicius, Ph.D. Dept. Biomedical Sciences, OU HCOM at Dublin Clinical Anatomy Immersion 2014.

Anterior

Humerus

Posterior

Radius

Anterior

Posterior

5th metacarpal

Anterior

FOREARM

HAND

ARM

Ulnar

9

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No posterior compartment in the hand

Some posterior compartment mm. are found on the anterolateral aspect of the forearm (*brachioradialis, supinator)

*

Page 10: D-etre.blogspot.com Organization of the Upper Limb Audrone Biknevicius, Ph.D. Dept. Biomedical Sciences, OU HCOM at Dublin Clinical Anatomy Immersion 2014.

10

Spinal nerveDorsal primary ramusVentral primary ramus (C5-T1)

Anterior division

Posterior division

limb axis

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RULE #2B: Innervation of anterior vs. posterior compartment mm.

Page 11: D-etre.blogspot.com Organization of the Upper Limb Audrone Biknevicius, Ph.D. Dept. Biomedical Sciences, OU HCOM at Dublin Clinical Anatomy Immersion 2014.

Brachial Plexus(right side; simplified)

Terminal Branches

“Roots of BP” (=ventral rami)

C5

C6

C7

C8

T1

Trunks

U

M

L

Cord

Lat

PostPost

Med

Divisions

Anterior (ventral) division

Posterior (dorsal) division

“Randy Travis Drinks Cold Beer”

11

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Page 12: D-etre.blogspot.com Organization of the Upper Limb Audrone Biknevicius, Ph.D. Dept. Biomedical Sciences, OU HCOM at Dublin Clinical Anatomy Immersion 2014.

Brachial Plexus(right side; simplified)

Terminal Branches

“Roots of BP” (=ventral rami)

C5

C6

C7

C8

T1

Trunks

U

M

L

Cord

Lat

PostPost

Med

Divisions

Anterior (ventral) division

Posterior (dorsal) division 12

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Radial n.

Musculocutaneous n.

Median n.

Ulnar n.

Page 13: D-etre.blogspot.com Organization of the Upper Limb Audrone Biknevicius, Ph.D. Dept. Biomedical Sciences, OU HCOM at Dublin Clinical Anatomy Immersion 2014.

AnteriorMusculocutaneous n.

Humerus

Radial n.

UlnaRadius

Median n. & Ulnar n.

Radial n.

5th metacarpal

Ulnar n. & Median n.

Anterior

Anterior

Posterior

Posterior

Posterior

MOTOR INNERVATION

Muscle Compartments of the Upper Limb

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Page 14: D-etre.blogspot.com Organization of the Upper Limb Audrone Biknevicius, Ph.D. Dept. Biomedical Sciences, OU HCOM at Dublin Clinical Anatomy Immersion 2014.

14

Musculocutaneous Nerve (arm)

http://emedicine.medscape.com/article/1877731-overview#aw2aab6b3

All mm. in anterior (flexor) compartment of arm

MRI of arm1.Biceps brachii m. 2.Brachialis m. 3.Brachial a. 4.Humerus. 5.Triceps brachii m.

www.med.umich.edu

Page 15: D-etre.blogspot.com Organization of the Upper Limb Audrone Biknevicius, Ph.D. Dept. Biomedical Sciences, OU HCOM at Dublin Clinical Anatomy Immersion 2014.

15

Radial Nerve (arm)

All mm. in posterior (extensor) compartment of arm

http://emedicine.medscape.com/article/1877731-overview#aw2aab6b3

Radial nerve

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Page 16: D-etre.blogspot.com Organization of the Upper Limb Audrone Biknevicius, Ph.D. Dept. Biomedical Sciences, OU HCOM at Dublin Clinical Anatomy Immersion 2014.

The brachialis m. is innervated by which division of the brachial plexus: :

A. Anterior division B. Posterior division

16

50%50%

Anterior division Posterior division

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Page 17: D-etre.blogspot.com Organization of the Upper Limb Audrone Biknevicius, Ph.D. Dept. Biomedical Sciences, OU HCOM at Dublin Clinical Anatomy Immersion 2014.

The brachialis m. is innervated by:

A. Median n.B. Musculocutaneous n. C. Radial n.D. Ulnar n.

17

25%

25%25%

25%

Median n. Musculocutaneous n. Radial n. Ulnar n.

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Page 18: D-etre.blogspot.com Organization of the Upper Limb Audrone Biknevicius, Ph.D. Dept. Biomedical Sciences, OU HCOM at Dublin Clinical Anatomy Immersion 2014.

The triceps brachii m. is innervated by:A. Musculocutaneous n. B. Radial n.

50%50%

Musculocutaneous n. Radial n.

Page 19: D-etre.blogspot.com Organization of the Upper Limb Audrone Biknevicius, Ph.D. Dept. Biomedical Sciences, OU HCOM at Dublin Clinical Anatomy Immersion 2014.

19

Radial Nerve (forearm)

All mm. in posterior (extensor) compartment of forearmAlso * brachioradialis and supinator mm.

http://emedicine.medscape.com/article/1877731-overview#aw2aab6b3

*

Page 20: D-etre.blogspot.com Organization of the Upper Limb Audrone Biknevicius, Ph.D. Dept. Biomedical Sciences, OU HCOM at Dublin Clinical Anatomy Immersion 2014.

20

Ulnar Nerve (forearm)

Limited mm. in anterior (flexor) compartment of forearm:-Flexor carpi ulnaris-Flexor digitorum profundus (medial ½)

http://emedicine.medscape.com/article/1877731-overview#aw2aab6b3

Med 1/2

Page 21: D-etre.blogspot.com Organization of the Upper Limb Audrone Biknevicius, Ph.D. Dept. Biomedical Sciences, OU HCOM at Dublin Clinical Anatomy Immersion 2014.

21

Median Nerve (forearm)

All anterior (flexor) compartment mm. of forearm except:-Flexor carpi ulnaris m.-Flexor digitorum profundus m. (med ½)

http://emedicine.medscape.com/article/1877731-overview#aw2aab6b3

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Page 22: D-etre.blogspot.com Organization of the Upper Limb Audrone Biknevicius, Ph.D. Dept. Biomedical Sciences, OU HCOM at Dublin Clinical Anatomy Immersion 2014.

22

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RULE #2C

Page 23: D-etre.blogspot.com Organization of the Upper Limb Audrone Biknevicius, Ph.D. Dept. Biomedical Sciences, OU HCOM at Dublin Clinical Anatomy Immersion 2014.

The extensor digitorum m. lies in the posterior compartment, originates on the lateral epicondyle, and is innervated by:A. Median n.B. Musculocutaneous n. C. Radial n.D. Ulnar n.

25%

25%25%

25%

Median n. Musculocutaneous n. Radial n. Ulnar n.

Lateral epicondyle

Extensor digitorum m.

Page 24: D-etre.blogspot.com Organization of the Upper Limb Audrone Biknevicius, Ph.D. Dept. Biomedical Sciences, OU HCOM at Dublin Clinical Anatomy Immersion 2014.

24

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“Be specific”

Page 25: D-etre.blogspot.com Organization of the Upper Limb Audrone Biknevicius, Ph.D. Dept. Biomedical Sciences, OU HCOM at Dublin Clinical Anatomy Immersion 2014.

The flexor carpi radialis m. is in the anterior compartment, attaches to the medial epicondyle, and is innervated by:

A. Median n.B. Radial n.C. Ulnar n.

25

33%

33%

33%

Median n. Radial n. Ulnar n.

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Page 26: D-etre.blogspot.com Organization of the Upper Limb Audrone Biknevicius, Ph.D. Dept. Biomedical Sciences, OU HCOM at Dublin Clinical Anatomy Immersion 2014.

The flexor digitorum profundus m. is the anterior compartment, attaches to the medial epicondyle, and is innervated by:A. Median n.B. Median n. & Ulnar n. C. Ulnar n.

26

33%

33%

33%

Median n. Median n. & Ulnar n. Ulnar n.

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Page 27: D-etre.blogspot.com Organization of the Upper Limb Audrone Biknevicius, Ph.D. Dept. Biomedical Sciences, OU HCOM at Dublin Clinical Anatomy Immersion 2014.

The brachioradialis and supinator mm. lie in the anterior aspect of the forearm but attach to the lateral epicondyle of the humerus. They are innervated by:A. Median n.B. Radial n. C. Ulnar n.

27

33%

33%

33%

Median n. Radial n. Ulnar n.

www.pelhamrehab.com

Page 28: D-etre.blogspot.com Organization of the Upper Limb Audrone Biknevicius, Ph.D. Dept. Biomedical Sciences, OU HCOM at Dublin Clinical Anatomy Immersion 2014.

28

Median Nerve (hand)

Limited hand mm.:-Thenar mm.-Lateral two lumbricals

http://emedicine.medscape.com/article/1877731-overview#aw2aab6b3

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Page 29: D-etre.blogspot.com Organization of the Upper Limb Audrone Biknevicius, Ph.D. Dept. Biomedical Sciences, OU HCOM at Dublin Clinical Anatomy Immersion 2014.

29

Ulnar Nerve (hand)

All hand mm. not innervated by median n.

http://emedicine.medscape.com/article/1877731-overview#aw2aab6b3

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Page 30: D-etre.blogspot.com Organization of the Upper Limb Audrone Biknevicius, Ph.D. Dept. Biomedical Sciences, OU HCOM at Dublin Clinical Anatomy Immersion 2014.

30

What about the most proximal muscles of the upper limb?

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Page 31: D-etre.blogspot.com Organization of the Upper Limb Audrone Biknevicius, Ph.D. Dept. Biomedical Sciences, OU HCOM at Dublin Clinical Anatomy Immersion 2014.

*

31

Developmentally-dorsal muscles: •Lie posterior to the long bones in anatomical position (* exception = brachioradialis, supinator)

Developmentally-ventral muscles:•Lie anterior to the long bones in anatomical position-or-•Arise from:

– coracoid ossification – sternum and costal cartilages

-or-•Arise from:

– scapular blade ossification– vertebral column

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RULE #2D

Page 32: D-etre.blogspot.com Organization of the Upper Limb Audrone Biknevicius, Ph.D. Dept. Biomedical Sciences, OU HCOM at Dublin Clinical Anatomy Immersion 2014.

Given the attachments of the latissimus dorsi muscle, its innervation will be from which of division of the brachial plexus:

A. Anterior division B. Posterior division

32

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Anterior division Posterior division

Page 33: D-etre.blogspot.com Organization of the Upper Limb Audrone Biknevicius, Ph.D. Dept. Biomedical Sciences, OU HCOM at Dublin Clinical Anatomy Immersion 2014.

C5

C7

C6

C8

T1

**

*

suprascapular n.supraspinatus & infraspinatus mm.

axillary n.

deltoid & teres minor mm.

upper subscapular n.thoracodorsal n.lower subscapular n.

subscapularis m.latissimus dorsi m.subscapularis & teres major mm.

Brachial Plexus(branches)

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Page 34: D-etre.blogspot.com Organization of the Upper Limb Audrone Biknevicius, Ph.D. Dept. Biomedical Sciences, OU HCOM at Dublin Clinical Anatomy Immersion 2014.

Given the attachments of the pectoralis muscles muscle, its innervation will be from which of division of the brachial plexus:

A. Anterior division B. Posterior division

34

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Anterior division Posterior division

Page 35: D-etre.blogspot.com Organization of the Upper Limb Audrone Biknevicius, Ph.D. Dept. Biomedical Sciences, OU HCOM at Dublin Clinical Anatomy Immersion 2014.

C5

C7

C6

C8

T1

radial n.

axillary n.

medial n.

musculoskeletal n.

suprascapular n.

upper subscapular n.thoracodorsal n.lower subscapular n.

medial pectoral n.

lateral pectoral n.

long thoracic n.

dorsal scapular n.

**

*

ulnar n.

rhomboid mm.

pectoralis mm.

pectoralis mm.

serratus anterior m.

Brachial Plexus(branches)

35

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Page 36: D-etre.blogspot.com Organization of the Upper Limb Audrone Biknevicius, Ph.D. Dept. Biomedical Sciences, OU HCOM at Dublin Clinical Anatomy Immersion 2014.

posterior anterior

Upper “roots” of the brachial plexus (C5-6 ventral rami) innervate proximal muscles (shoulder, elbow)

Lower “roots” of the brachial plexus (C8-T1 ventral rami) innervate distal muscles (hand)

RULE #3 Proximal-to-Distal Rule

Somatic motor nerve(GSE, with GSA)

Cutaneous nerves(GSA, GVE, GVA)

Page 37: D-etre.blogspot.com Organization of the Upper Limb Audrone Biknevicius, Ph.D. Dept. Biomedical Sciences, OU HCOM at Dublin Clinical Anatomy Immersion 2014.

37

MYOTOME- group of muscles innervated by a single spinal nerve root

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Page 38: D-etre.blogspot.com Organization of the Upper Limb Audrone Biknevicius, Ph.D. Dept. Biomedical Sciences, OU HCOM at Dublin Clinical Anatomy Immersion 2014.

38

Page 39: D-etre.blogspot.com Organization of the Upper Limb Audrone Biknevicius, Ph.D. Dept. Biomedical Sciences, OU HCOM at Dublin Clinical Anatomy Immersion 2014.

C5

C7

C6

C8

T1

Radial n.

Axillary n.

Medial n.

Musculoskeletal n.

Suprascapular n.

Upper & lower subscapular nn.Thoracodorsal n.

Medial pectoral n.

Lateral pectoral n.

Long thoracic n.

Dorsal scapular n.

**

*

Ulnar n.

Brachial Plexus(all branches)

* Nerve to subclavius** Medial brachial & antebrachial cutaneous nn. 39

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Page 40: D-etre.blogspot.com Organization of the Upper Limb Audrone Biknevicius, Ph.D. Dept. Biomedical Sciences, OU HCOM at Dublin Clinical Anatomy Immersion 2014.

“MIXED FUNCTIONAL MODALITIES”

Most terminal branches of the brachial plexus are mixed fiber nerves:

1.Somatic motor and somatic sensory (prioprioception) to skeletal mm.

2.Then, cutaneous innervation with somatic sensory and sympathetics to skin

posterior anterior

RULE #3

Somatic motor nerve(GSE, with GSA)

Cutaneous nerves(GSA, GVE, GVA)

Page 41: D-etre.blogspot.com Organization of the Upper Limb Audrone Biknevicius, Ph.D. Dept. Biomedical Sciences, OU HCOM at Dublin Clinical Anatomy Immersion 2014.

41

Musculocutaneous n.Tank e

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Page 42: D-etre.blogspot.com Organization of the Upper Limb Audrone Biknevicius, Ph.D. Dept. Biomedical Sciences, OU HCOM at Dublin Clinical Anatomy Immersion 2014.

42

Some purely cutaneous brs. of brachial plexusTank e

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Page 43: D-etre.blogspot.com Organization of the Upper Limb Audrone Biknevicius, Ph.D. Dept. Biomedical Sciences, OU HCOM at Dublin Clinical Anatomy Immersion 2014.

Segmental innervation(C5-T1)

Dermatomes

RULE #5: Dermatome vs. Cutaneous Nerve Distribution

Page 44: D-etre.blogspot.com Organization of the Upper Limb Audrone Biknevicius, Ph.D. Dept. Biomedical Sciences, OU HCOM at Dublin Clinical Anatomy Immersion 2014.

44

Foerster (1933) – based on clinical findings (used by neurologists)

Keegan and Garrett (1948) – based on limb development

Segmental (Dermatome) Innervation of Upper LimbM

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Page 45: D-etre.blogspot.com Organization of the Upper Limb Audrone Biknevicius, Ph.D. Dept. Biomedical Sciences, OU HCOM at Dublin Clinical Anatomy Immersion 2014.

45

Preaxial: C5-C7

Postaxial: C8-T1

Segmental (Dermatome) Innervation of Upper LimbM

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Thumb: C6

3rd Digit: C7

5th Digit: C8

Page 46: D-etre.blogspot.com Organization of the Upper Limb Audrone Biknevicius, Ph.D. Dept. Biomedical Sciences, OU HCOM at Dublin Clinical Anatomy Immersion 2014.

Dermatomes vs. Cutaneous Nerve Distribution

Terminalbranches

Cutaneous nn.

Segmental innervation(C5-T1)

Dermatomes

Page 47: D-etre.blogspot.com Organization of the Upper Limb Audrone Biknevicius, Ph.D. Dept. Biomedical Sciences, OU HCOM at Dublin Clinical Anatomy Immersion 2014.

Anterior Posterior47

Peripheral (Cutaneous ) Innervation of Upper LimbM

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Page 48: D-etre.blogspot.com Organization of the Upper Limb Audrone Biknevicius, Ph.D. Dept. Biomedical Sciences, OU HCOM at Dublin Clinical Anatomy Immersion 2014.

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Test for Peripheral Nerve Sensory Function:

Ulnar n. – Tip of 5th digit (little finger)Median n. – Tip of 2nd digit (index finger)

Radial n. – Webbing b/w thumb & index finger (dorsum)

Page 49: D-etre.blogspot.com Organization of the Upper Limb Audrone Biknevicius, Ph.D. Dept. Biomedical Sciences, OU HCOM at Dublin Clinical Anatomy Immersion 2014.

49

M

U

R

C6

C7

C8

Page 50: D-etre.blogspot.com Organization of the Upper Limb Audrone Biknevicius, Ph.D. Dept. Biomedical Sciences, OU HCOM at Dublin Clinical Anatomy Immersion 2014.

Stretch Reflex

apbrwww5.apsu.edu/

Reciprocal inhibition of antagonist muscles

Page 51: D-etre.blogspot.com Organization of the Upper Limb Audrone Biknevicius, Ph.D. Dept. Biomedical Sciences, OU HCOM at Dublin Clinical Anatomy Immersion 2014.

Bicipital reflex (C6 cord level) Triceps reflex (C7 cord level)

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Stretch Reflex

Page 52: D-etre.blogspot.com Organization of the Upper Limb Audrone Biknevicius, Ph.D. Dept. Biomedical Sciences, OU HCOM at Dublin Clinical Anatomy Immersion 2014.

IVD Root Sensory Loss Motor WeaknessC4-C5 C5 Shoulder Shoulder weakness

C5-C6 C6 Anterior upper arm, Forearm flexion

Lateral forearm, thumb Biceps reflex

C6-C7 C7 3rd digits Forearm extension Triceps reflex

Wrist extension Hand grip

C7-C8 C8 5th digits Wrist flexionMedial forearm Intrinsic

hand mm.

Source: Devinsky et al. Neurologic Pearls

UPPER LIMB RADICULAR SYNDROMES

Proximal

Distal

Cranial

Caudal


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