THE UPPER EXTREMITY OR UPPER LIMB:

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THE UPPER EXTREMITY OR UPPER LIMB: Powered By Docstoc
					Anatomy 1                                                                             Fall 2008
Dr. Thomas

Competencies for the upper limb, axilla, shoulder and pectoral region

1. identify the structures forming the anterior, middle, posterior, and lateral walls,
the apex and the base of the axilla.
anterior wall: made of three muscles: pectoralis major, pectoralis minor, and subclavius
posterior wall: made up of three muscles: subscapularis, teres major and latissumus dorsi
medial wall: the serratus anterior and the intercostal muscles located between the ribs
lateral wall: coracobrachialis and biceps brachii muscles and the upper end of the
humerus

base: composed of skin, superficial fascia and axillary fascia

apex: is a narrow triangular interval leading into the neck, through which the axillary
vessels and brachial plexus of nerves proceed to the arm from the neck.

2. identify the contents of the axilla and their interrelationships to each other.
    1. axillary artery and its branches
    2. axillary vein
    3. the brachial plexus of nerves
    4. the axillary group of lymph nodes

The axillary sheath encloses the axillary artery and vein and the three cords of the
brachial plexus. These and the axillary lymph nodes are all embedded in a matrix of
axillary fat. The brachial plexus of nerves surrounds the axillary artery on its lateral and
medial aspects.

3. briefly discuss the axillary artery with its main branches in the axilla.
The axillary artery is the continuation of the subclavian artery and extends from the outer
border of the 1st rib to the lower border of the teres major muscle where it becomes the
brachial artery. The axillary artery is arbitrarily divided into three parts by the pectoralis
minor.
CPAD – Clavicular, pectoral, acromial, deltoid

Part 1: located between 1st rib and pectoralis minor and gives off one branch called the
superior thoracic artery.

Part 2: Situated behind pectoralis minor and gives rise to 2 branches: thoracoacromial
and lateral thoracic
a.) thoracoacromial: pierces the costa-coracoid membrane (clavipectoral fascia) and
divides into two branches to supply the pectoral and deltoid regions
b.) lateral thoracic artery: runs along the lateral border of pectoralis minor and supplies
the anterior and medial walls of the axilla and the mammary gland. This artery is also
known as the external mammary.

Part 3: the portion which extends between the lateral margins of the pectoralis minor and
the lower border of the teres major. It gives off three branches.


                                          Alice Fong                                           1
Anatomy 1                                                                           Fall 2008
Dr. Thomas

a.) subscapular artery: which supplies primarily the muscles of the posterior wall. Gives
rise to thoracodorsal and scapular circumflex
b.) anterior circumflex humeral artery
c.) posterior circumflex humeral artery: which along the axillary nerve passes through
the quadrilateral space bounded by the humerus, long head of the triceps, subscapularis
and teres major muscles and winds around the surgical neck of the humerus to
anastomose with the anterior circumflex humeral artery. The posterior circumflex gives
off an important anastomotic branch to the profunda brachii, a branch of the brachial
artery.

4. briefly describe the anastomoses around the head of the humerus and around the
scapula.
Around the head of the humerus: anterior and posterior circumflex humeral artery.
Around the scapula: deep branch of the transverse cervical artery. Suprascapular artery,
circumflex scapular and thoracodorsal artery.
Anastomoses with intercostal arteries

5. identify the aa supplying blood to the walls of the axilla.
Anterior wall:
Pectoralis major clavicular head – pectoralis branch of the thoracoacromial artery
pectoralis major sternocostal head – pectoralis branch of thoracoacromial and lateral
thoracic arteries (external mammary artery)
pectoralis minor – lateral thoracic artery (external mammary)
subclavius – clavicular branch of thoracoacromial artery

Posterior wall:
subscapularis – branches of subscapular artery
teres major – thoracodorsal artery
latissumus dorsi – thoracodorsal artery

Medial wall:
serratus anterior – upper: lateral thoracic artery, lower: thoracodorsal artery
intercostal muscles – intercostal arteries

Lateral wall:
coracobrachialis – muscular branches of brachial artery
biceps brachii – muscular branches of the brachial artery


6. identify the vv forming/giving rise to the axillary vein.
Begins at the lower border of the teres major where the basilica vein joins the brachial
vein. The axillary vein is situated on the medial side of the axillary artery and receives
the venous tributaries which correspond to the branches of the axillary artery. It also
receives commonly the thoraco-epigastic veins and thereby provides a collateral route
for the venous return if the inferior vena cava becomes obstructed.



                                          Alice Fong                                         2
Anatomy 1                                                                            Fall 2008
Dr. Thomas

7. briefly discuss the collateral venous route that is usually established by the
thoraco-epigastric veins.
The thoraco-epigastic veins is relatively direct lateral superficial anastomotic channel
which exists between the superficial epigastric vein and the lateral thoracic vein.
The axillary vein receives directly from the thoraco-epigastic vein. These veins
constitute a venous return in the presence of obstruction of the inferior vena cava.
Establishes an important communication between the femoral vein and axillary vein.

8. identify the principal tributaries of the axillary vein.
Its tributaries include the basilic vein and cephalic vein, which are both superficial veins.

9. identify the roots forming the brachial plexus.
 The five roots are the five anterior rami of the spinal nerves (C5-T1)

10. identify the locations of the roots, trunks, and the cords of the brachial plexus.
Roots: formed in the neck by the anterior primary rami of the 5th, 6th, 7th, and 8th cervical
and 1st thoracic nerves, together with small communication from the fourth cervical and
second thoracic nerves. The plexus is said to be divided into five different stages: roots,
trunks, divisions, cords, and nerves. The root and trunk stage is located in the neck, the
division are behind the clavicle, the cords and nerves are seen in the axilla

Trunks: In the neck – C5 and C6 unite to form the upper trunk
C7 forms the middle trunk
C8 and T1 form the lower trunk

Divisions: each of these trunks divides into anterior and posterior divisions

Cords: the anterior division of the upper and middle trunks join to form the lateral cord.
The anterior division of the lower trunk constitutes the medial cord.
All the posterior divisions unite to make up the posterior cord.

The cords are related to the 1st and 2nd part of the axillary artery and the nerves which
spring from the cords are located around the third part of the axillary artery.

11. identify both groups: the nn taking origin from spinal roots of the brachial
plexus, and the terminal branches (nn) of the brachial plexus.
Branches arising from the spinal roots:
    1. dorsal scapular nerve (C5): supplies the rhomboideus minor and major and
       levator scapulae muscles in the neck
    2. suprascapular nerve (C5-C6): supplies the supraspinatus and infraspinatus
       muscles in the scapular region.
    3. Nerve to subclavius (C5-C6): supplies the subclavius muscle
    4. long thoracic nerve (C5, C6, C7): supplies the serratus anterior muscle
Branches arising from the cords (terminal branches):
1. Lateral cord (C5-C7)
2. medial cord (C8-T1)


                                          Alice Fong                                            3
Anatomy 1                                                                          Fall 2008
Dr. Thomas

3. posterior cord (C5-T1)

12. identify the course and the distributions of all the terminal branches, for
example, the radial nerve is a terminal branch of the brachial plexus.
1. Lateral cord (C5-C7):
a. lateral pectoral nerve
b. lateral root of median nerve
c. musculocutaneous nerve

2. medial cord (C8-T1):
a. medial pectoral nerve
b. medial root of median nerve
c. medial cutaneous nerve of arm
d. medial cutaneous nerve of forearm
e. ulnar nerve

3. posterior cord (C5-T1):
a. subscapular nerve – upper and lower (C5, C6)
b. thoracodorsal nerve (nerve to latissimus dorsi) – (C6-8)
c. axillary nerve (C5-C6)
d. radial nerve (C5-T1)

13. identify the structures innervated by the nn arising from the roots/trunks of the
brachial plexus.
   1. dorsal scapular nerve (C5): supplies the rhomboideus minor and major and
       levator scapulae muscles in the neck
   2. suprascapular nerve (C5-C6): supplies the supraspinatus and infraspinatus
       muscles in the scapular region.
   3. Nerve to subclavius (C5-C6): supplies the subclavius muscle
   4. long thoracic nerve (C6-C7): supplies the serratus anterior muscle

14. briefly describe the erb-duchenne paralysis.
A birth type of paralysis due to excessive pulling or traction of the arm in delivery
resulting in stretching or tearing the upper trunk. This point is known as “Erb's point”
where C5,C6 unite to form the upper trunk which then divides into anterior and posterior
division. At this point the suprascapular nerve and the nerve to subclavius are also
given off. The paralysis which involves C5, C6 results in the following deformity: the
arm is medially rotated, adduction of the shoulder, extended at the elbow and the forearm
is pronated. Waiter's tip position.

15. breifly discuss: klumpke’s paralysis and the cervical rib.
Klumpke's paralysis involves C8 and T1. Partial paralysis. Affects intrinsic muscles of
the hand. Lower/inferior trunk. Claw hand.
Cervical rib: In some cases of rudimentary cervical rib (enlarged transverse process of 7th
cervical vertebra) may elevate the lowest trunk (C8 and T1) forcing its way between the



                                         Alice Fong                                       4
Anatomy 1                                                                           Fall 2008
Dr. Thomas

nerve and the 1st rib causing pressure symptoms (e.g., numbness, tingling). *ribs are
developed from the transverse processes.

16. briefly discuss the clinical relevance of the communication between the nerve to
subclavius and the phrenic nerve.
The nerve to the subclavius from C5 or C5,C6 may sometimes carry a large contribution
to the phrenic nerve – which innervates the diaphragm. In such cases phrenic crushing or
cutting may not be immobilize the corresponding half of the diaphragm. Therefore the
operation of phrenic avulsion is sometimes preferred.
Pinching the phrenic nerve (C3,C4,C5) off. Peripheral nerves have the ability to
regenerate.

17. briefly describe the locations of the axillary lymph nodes.
These nodes are, for the purposes of description, divided into groups which are related to
the four walls, the base and apex of the axilla. They are as follows.

   1. lateral or brachial group: 4 or 5 in number and lie along the lower part of
      axillary vein and drain the upper limb.
   2. Medial or posterior pectoral group: about 3-4 in number and lie along the
      lateral thoracic artery and vein
   3. anterior or anterior pectoral group: 4 or 5 in number and situated along the
      edge of pectoralis major muscle. The medial and anterior groups of glands drain
      most of the mammary gland.
   4. Posterior or subscapular group: about 6-7 in number and located along the
      subscapular vessels. Drains the posterior part of the shoulder.
   5. Central: 3-5 in number, lie at the base of the axilla in the fatty tissue and receive
      lymph from the previous 4 groups. They form the largest groups and is often
      palpable on examination.
   6. Apical (infraclavicular) group: about 4 or 5 in number, they are situated at the
      upper border of pectoralis minor and behind the costocoracoid membrane. They
      receive the afferents from the central and other groups of glands. They also
      receive lymph directly from the breast. Efferents enter the Jugulo-subclavian
      venous confluence, or join a common lymphatic duct, or drain into the lower deep
      cervical nodes.

18. identify the areas drained by each of the lymph nodes identified in #17.
see above

19. identify the location of the mammary gland.
The breast or mammary gland is a modified gland of cutaneous origin. It therefore lies in
the superficial fascia and has no fibrous capsule or sheath.
From the anatomical or surgical point of view, the breast extends from the 2nd to 6th rib to
the vertical plane, and from the side of the sternum to the mid-axillary line in the
horizontal plane. Therefore 2/3rd of the gland lies on the pectoralis major muscle and
1/3rd on the serratus anterior. A small portion of the lower quadrant of the breast lies on
the aponeurosis of the external oblique muscle of the abdomen


                                         Alice Fong                                          5
Anatomy 1                                                                         Fall 2008
Dr. Thomas

20. identify the function of the ligaments of cooper.
The breast is made up of 15-20 units of glandular tissue, called lobules, which radiate
from the nipple into the surrounding fat. Each of these lobules have lactiferous ducts
which open independently on the nipple. The glandular tissue is connected with the
overlying skin by fibrous septa (ligaments of Cooper).
These ligaments help maintain structural integrity. The ligaments are firmly attached to
the dermis of the skin and anchor the breast to the subcutaneous tissue overlying the
retromammary space. As with all ligaments, over time they may lose strength and tension
in later years.

21. identify the arterial supply to the mammae.
   1. internal mammary: is the main source of arterial supply through its perforating
       branches in the 2nd, 3rd, 4th intercostal spaces.
   2. Lateral thoracic artery: supplies primarily the lateral and caudal portions of the
       breast.
   3. Lateral cutaneous branches of 2nd, 3rd and 4th intercostal arteries

22. explain in detail the role of the lymph and venous drainages of the mammary
gland with reference to spread of cancer (from this gland to other areas).
The lymphatic drainage of the breast is of great clinical significance owing to its role in
the spread of malignant tumors. The lymphatics of the breast may be divided into
cutaneous and parenchymal drainage.
     1. cutaneous drainage: radiates from the circumareolar plexus
a. lateral – to the anterior (pectoral axillary nodes)
b. superior – to the medial axillary nodes and apical (infraclavicular) nodes
c. medial – to the internal mammary nodes or parasternal nodes and cutaneous lymphatics
of the opposite side.
d. inferior – to the cutaneous lymphatics of the upper abdominal wall and liver
     2. parenchymal drainage: receives channels from the breast proper and skin of
         nipple and areolar which drain into the subareolar plexus (Sappey). Efferents from
         this drain into the anterior axillary nodes. In addition, the subareolar plexus
         communicates with the lymphatics of the deep fascia and constituttes the
         anatomical basis for the removal of a wide area in radical mastectomy.

Prognosis in cancer based on lymphatic drainage:
upper outer quadrant: MOST favorable
Lower outer quadrant: less favorable
upper inner quadrant: dangerous because of its proximity to the mediastinum
lower inner quadrant: MOST dangerous because of its proximity to the peritoneal cavity

Venous spread of cancer of breast: as the breast is drained by axillary, internal
mammary and intercostal veins, cancer of the breast spreads frequently by venous
channels to:
   1. lung through axillary vein and superior vena cava
   2. liver via the azogos veins



                                        Alice Fong                                         6
Anatomy 1                                                                          Fall 2008
Dr. Thomas

   3. bones of axial skeleton via the intercostal veins which communicates with the
      vertebral venous plexus

23. discuss the anatomical basis of physical signs in cancer of the breast.
   1. fixation or depression of overlying skin: due to the invasion of fibrous septa
       which extends from the skin to the lobules of the gland; by cancer cells producing
       shortening of the septa resulting in fixation or depression of skin
   2. fixation, retraction, or inversion of the nipple: due to neoplastic involvement of
       the lactiferous ducts
   3. fixation of the breast to the underlying muscle: seen in advanced cancer when
       the cancer has invaded the deep fascia of the pectoralis major muscle.

A sound knowledge of the anatomy of the breast is of utmost importance when one
realizes that carcinoma of the breast is twice as common as any other carcinoma in
women. The earliest sign of serious pathology in the breast is a lump in the breast. The
three signs indicated above are fairly advanced signs of cancer of the breast.

24. identify the locations, origins, insertions, functions, and innervations of the
superficial and deep groups of mm in the scapular and shoulder regions.
See chart

25. identify the mm responsible for both the shoulder and humeral movements.
Scapular movement
Elevation – Trapezius and levator scapulae
Depression – lower fibers of trapezius, pec minor and latissimus dorsi
Protraction – serratus anterior and pec minor
Retraction – trapezius and rhomboids
Rotation with glenoid cavity directed upwards – serratus anterior and trapezius
Rotation with glenoid cavity directed downwards – levator scapula, rhomboids and
pectoralis minor

Humeral movement: all these movements occur at the shoulder joint
flexion – by anterior portion of deltoid, pec major (clavicular head), coracobrachialis and
biceps brachii
extension – posterior part of deltoid, sternal costal fibers of pectoralis major and
latissimus dorsi. Teres major and triceps assist slightly.
Abduction – supraspinatus and middle fibers of deltoid
adduction – by pec major, teres major and latissimus dorsi
medial rotation – subscapularis, pec major and latissimus dorsi also assists
lateral rotation – infraspinatus, and teres minor and posterior fibers of deltoid

26. identify the rotator cuff mm and their clinical relevance.
Teres minor, subscapularis, infraspinatus, supraspinatus
These are the rotator cuff muscles of the shoulder joint because they form a cuff
(musculotendinous rotator cuff) for the shoulder joint. All the rotator cuff muscles,
except the supraspinatus muscle are rotators of the humerus.


                                         Alice Fong                                        7
Anatomy 1                                                                           Fall 2008
Dr. Thomas

The prime function of these muscles and the musculo-tendinous rotator cuff is to hold the
relatively large head of the humerus in the much smaller and shallow glenoid cavity of
the scapula. It provides support for the glenohumeral joint.

27. identify the components of the shoulder joint (bony and soft tissue)
Bony parts: consists of the shallow glenoid cavity of the scapula and the large convex
head of humerus, each is covered by the articular cartilage.

Soft tissue: Capsular ligament: IT is a lax fibrous layer uniting the bony parts, attached
superiorly to the circumference of the glenoid cavity and below the anatomical neck of
the humerus, except medially where it extends on to the shaft for about 2 cm below the
articular surface. It is reinforced by:
    1. coracohumeral ligament
    2. glenohumeral ligament
    3. glenoidal labrum: a fibrocartilage which deepens the glenoid cavity, affording a
        better receptive area for the head of the humerus.
    4. Transverse humeral ligament: which retains long head of biceps in the
        intertuvercular sulcus

Synovial membrane: lines the inside of the capsular ligament and sends two extensions –
one is the subscapular bursa and the other is a sheath for the long tendon of biceps.

28. briefly discuss the movements permitted at the shoulder joint.
Flexion, extension, abduction, adduction, medial rotation, lateral rotation, circumduction

29. identify the cutaneous innervation in the brachium and antebrachium.
Plate 481
Brachium (arm) – supraclavicular nerves (from cervical plexus – C3,C4), axillary nerve
(superior lateral brachial cutaneous nerve (C5,C6), radial nerve (inferior lateral brachial
cutaneous nerve (C5, C6), intercostobrachial nerve (T2) and medial brachial cutaneous
nerve (C8, T1,T2)
Antebrachium

30. identify the lobules and lactiferous ducts of the mammary gland.
The breast is made up of 15-20 units of glandular tissue, called lobules, which radiate
from the nipple into the surrounding fat. Each of these lobules have lactiferous ducts
which open independently on the nipple. The glandular tissue is connected with the
overlying skin by fibrous septa (ligaments of cooper).

31. describe bursitis and dislocations associated with the shoulder joint.
Subscapular bursa – communicates with the articular joint
subacromial (subdeltoid) bursa – facilitates movement of supraspinatus tendon.
Dislocation of glenohumeral joint:
    commonly dislocated due to its freedom of movement and instability
    mostly in downward direction: clinically described as anterior or posterior
       dislocations


                                         Alice Fong                                           8
Anatomy 1                                                                           Fall 2008
Dr. Thomas

    anterior dislocation: occurs most often athletes. Caused by excessive extension
       and lateral rotation of the humerus
supraspinatus tendonitis:
    depositions of calcium in the supraspinatus tendon.
    Causes increased local pressure that results in excruciating pain during abduction
       of the arm
subacromial bursitis:
    calcium deposit of the supraspinatus tendon may irritate the overlying
       subacromial bursa, producing an inflammatory reaction
    pain occurs during abduction: supraspinatus tendon is in intimate contact with the
       inferior surface of the acromion.



                       Arm, Forearm, Hand I

following the completion of the class discussion, self-study, and group discussions,
the participant should be able to:

1. identify the important landmarks on all bones of upper extremity;
    scapula
    humerus
    radius
    ulna

2. define the pectoral girdle, and identify its function;
    2 clavicles and 2 scapulae: connect the free parts of the upper limbs to the axial
skeleton. Stabilized by muscles

3. discuss the following details of the elbow joint: its components, movements,
muscle attachments, and the common basic clinical conditions associated with this
joint (class discussions and the blue-boxed areas in the text);
Ligaments: annular ligament, radio collateral ligament, ulnar collateral ligament
where the humerus articulates with the ulna and radius.
Trochlear notch of ulna grasps trochlea of humerus
head of radius moves on capitulum of humerus
flexion and extension
shares the same cavity the the superior radio-ulna joint
muscle attachments: (acting at the elbow) – brachialis, biceps brachii, brachioradialus,
forearm flexors (flexor carpi radialus, palmaris longus, flexor carpi ulnaris, flexor
digitorum superficialus).
Anconeus, triceps brachii
clinical notes: tennis elbow (aka elbow tendonitis) – inflammation of the periosteum of
the lateral epicondyle and common extensor attachment.
Dislocations – under age 14 more likely. Ulna and radius go posteriorly, humerus goes
anteriorly.

                                         Alice Fong                                        9
Anatomy 1                                                                             Fall 2008
Dr. Thomas

Effusions – increases in fluid posterior because anteriorly there isn't any room.
Avulsion – tearing of the ligament off the bone

4. discuss the classification, components, movements, muscle attachments of the
superior and inferior radio-ulnar joints;
superior radio-ulnar joint: radius and ulna. between radial notch of ulna and head of
radius. Pivot joint: pronation and supination
inferior radio-ulnar joint: joint at distal end of radius and ulna is separated from the wrist
by a disc of fibrocartilage attached to radius and ulna. The disc excludes the ulna from
the wrist joint. Pivot joint: pronation and supination
Muscle attachements:
Pronators: pronator teres and pronator quadratus
Supinators: biceps, supinator

5. identify the location and the function of the annular ligament;
attached to the ulna, encircles the head of the radius. Allows for movement of radius over
the ulna

6. describe the anatomical relationship between the superior radioulnar joint and
the elbow;
The superior radioulnar joint is inferior to the elbow joint. And together they compose
the cubital joint.

7. identify the innervation and the blood supply of the elbow, superior, and inferior
radio-ulnar joints;
Elbow:
Innervation – musculocutaneous, (median) radial, ulnar
Blood supply – anastomoses formed by branches the brachial artery (collateral arteries),
and recurrent branches of the radial and ulnar arteries.
Superior radio-ulnar joint:
Innervation – musculocutaneous and radial (supination), median (pronation)
Blood supply – anterior and posterior interosseous arteries
Inferior radio-ulnar joint:
Innervation - anterior (ulnar) and posterior interosseous (radial) nerves
Blood supply – anterior and posterior interosseous arteries

8. describe the wrist joint with reference to: its components, movements, the carpal
tunnel, carpal tunnel syndrome, innervation, and blood supply;
Wrist joint: between radius and disc of fibrocartilage and 3 carpal bones ( scaphoid,
lunate, and triquetrum). Collateral ligaments. Condyloid.
flexion, extension, adduction, abduction (ulnar and radial deviation)
Carpal tunnel: base and walls are carpal bones, roof – flexor retinaculum. Transmits the
median nerve and the tendons of flexor pollicis longus, flexor digitorum profundus,
flexor digitorum superficialis mm.
Carpal tunnel syndrome: compression of the median nerve, passes deep to the flexor
retinaculum. Causes numbness and tingling in the lateral part of the hand.


                                          Alice Fong                                        10
Anatomy 1                                                                                Fall 2008
Dr. Thomas



9. discuss colle’s fracture, scaphoid fracture, and lunate fracture;
colle's fracture: most common in people over 40, radius fractured 2 cm. Proximal to wrist
joint.
lunate displacement: may injure median nerve
scaphoid fracture: common in young people. Often missed both on clinical examination
and in first x-ray. Tenderness of in anatomical snuff box.

10. briefly describe the following joints:
A. intercarpal joints (aka midcarpal)
joint between 2 rows of carpals. Plane synovial joints – small gliding movements.
Innervation: anterior interosseous branch of the median nerve, dorsal and deep branches
of the ulnar nerve.
Blood supply: arteries from dorsal and palmar carpal arches
B. carpometacarpal
Carpometacarpal joint of thumb is MOST IMPORTANT (saddle joint allows for flexion
and extension, abduction and adduction, opposition).
The other CMC joints allow only slight gliding movements (plane synovial)
Innervation: branches of median, ulnar and radial nerves
Blood supply: dorsal and palmar metacarpal arteries and deep carpal and deep palmar
arches
C. metacarpophalangeal joints (aka knuckles)
Palmar (give leverage) and collateral ligaments
Condyloid joint – allows flexion, extension, adduction, abduction
Innervation: digital nerves of ulnar and median nerves
Blood supply: deep digital arteries that arise from the superficial palmar arches
D. interphalangeal joints (IP joint)
collateral ligament, palmar ligaments
hinge joint – allows flexion and extension only
Innervation: digital nerves of ulnar and median nerves
Blood supply: deep digital arteries that arise from the superficial palmar arches

11. what movements are permitted at the joints included in #10;
see above

12. describe the carpo-metacarpal joint of the thumb;
see above

13. identify the origins, insertions, functions, and innervations of all the mm. in the
flexor and the extensor compartments of the forearm;
Flexor Compartment of Forearm: Superficial
Pronator teres    Medial epicondyle   Middle of lateral   Median n (C6, C7)   Pronation of
                  and coronoid        surface of radius                       forearm, flexes the
                  process of ulna                                             elbow
Flexor carpi      Medial epicondyle   Base of 2nd         Median n. (C6, C7) Flexes wrist and
radialus                              metacarpal                             abducts hand



                                          Alice Fong                                            11
Anatomy 1                                                                                         Fall 2008
Dr. Thomas

Palmaris longus      Medial epicondyle     Palmar aponeurosis Median n. (C6, C7) Flexes wrist
Flexor digitorum     Humeroulnar head: Bodies of middle     Median n. (C7, C8, Flexes middle
superficialus        medial epicondyle, phalanges of medial T1)                phalanges of medial
                     ulnar collateral    4 digits
                     ligament, and
                     coronoid process of
                     ulna
                     radial head:
                     superior half of
                     anterior border of
                     radius
Flexor carpi ulnaris Humeral head:         Pisiform bone,      Ulnar n. (C7, C8)       Flexes wrist and
                     medial epicondyle     hook of hamate and                          adducts hand
                     ulnar head:           5th metacarpal bone
                     olecranon and
                     posterior border of
                     ulna

        Flexor Compartment of forearm: Deep
Flexor digitorum     Proximal 3/4th of   Bases of distal         Medial part: ulnar    Flexes distal
profundus            medial and anterior phalanges of medial     n (C8,T1)             phalanges of fingers
                     surface of ulna and 4 digits                Lateral part:
                     interosseous                                median n (C8 and
                     membrane                                    T1)
Flexor pollicis      Anterior surface of Base of distal          Anterior            Flexes phalanges of
longus               radius and adjacent phalanx of thumb        interosseous branch thumb
                     interosseous                                of median n (C8
                     membrane                                    and T1)
Pronator quadratus   Distal forth of       Distal forth of       Anterior            Pronates forearm
                     anterior surface of   anterior surface of   interosseous branch
                     ulna                  radius                of median n (C8
                                                                 and T1)

Extensor compartment of forearm: Superficial
brachioradialis      Proximal 2/3rd of   Lateral surface of      Radial n (C5, C6,     Flexes forearm at
                     supracondylar ridge distal end of           C7)                   elbow joint
                     of humerus          humerus
Extensor carpi       Lateral             Base of 2nd             Radial n (C6 and      Extend and abduct
radialis longus      supracondylar ridge metacarpal bone         C7)                   hand at wrist joint
                     of humerus
Extensor carpi       Lateral epicondyle    Base of 3rd           Deep branch of        Extend and abduct
radialis brevis      of humerus            metacarpal bone       radial n. (C7 and     hand at wrist joint
                                                                 C8)
Extensor digitorum Lateral epicondyle      Extensor              Posterior             Extends fingers at
                   of humerus              expansions of         interosseous n (C7    MCP and IP joints;
                                           fingers               and C8), a branch     extends hand at
                                                                 of the radial nerve   wrist joint
Extensor digiti      Lateral epicondyle    Extensor expansion Posterior                Extends little finger
minimi               of humerus            of little finger   interosseous n (C7       at MCP and IP
                                                              and C8), a branch        joints


                                               Alice Fong                                                  12
Anatomy 1                                                                                       Fall 2008
Dr. Thomas

                                                               of the radial nerve
Extensor carpi      Lateral epicondyle    Base of 5th          Posterior             Extends and
ulnaris             of humerus and        metacarpal bone      interosseous n (C7    abducts hand at
                    posterior border of                        and C8), a branch     wrist joint
                    ulna                                       of the radial nerve
Anconeus            Lateral epicondyle    Lateral surface of   Radial n. (C7, C8,    Assists triceps in
                    of humerus            olecranon and        T1)                   extending elbow
                                          superior part of                           joint, stabilizes
                                          posterior surface of                       elbow joint; abducts
                                          ulna                                       ulna during
                                                                                     pronation

Extensor compartment of arm: Deep
Supinator           Lateral epicondyle    Lateral, posterior,  Deep brach of         Supinates forearm
                    of humerus, radial    and anterior surface radial n (C5 and
                    collateral ligament   of the proximal      C6)
                    of elbow joint,       third of the radius
                    annular ligament of
                    superior radioulnar
                    joint, supinator
                    fossa, and crest of
                    ulna

Abductor pollicis   Posterior surfaces    Base of 1st          Posterior             Abducts and
longus              of ulna and radius    metacarpal bones     interosseous n (C7    extends thumb at
                    and interosseous                           and C8)               carpometacarpal
                    membrane                                                         joint
Extensor pollicis   Posterior surface of Base of proximal      Posterior             Extends thumb at
brevis              radius and           phalanx of thumb      interosseous n (C7    carpometacarpal
                    interosseous                               and C8)               and
                    membrane                                                         matacarpophalange
                                                                                     al joints
Extensor pollicis   Posterior surface of Base of distal        Posterior             Extends
longus              middle third of ulna phalanx of thumb      interosseous n (C7    metacarpophalange
                    and interosseous                           and C8)               al and
                    mebrane                                                          interphalangeal
                                                                                     joints of thumb
Extensor indicis    Posterior surface of Extensor expansion Posterior           Helps extend index
                    ulna and             of index finger    interosseious n (C7 finger
                    interosseous                            and C8)
                    membrane

14. identify all the terminal branches (five) of the brachial plexus in the arm
(include their roots and distribution);

musculocutaneous – lateral cord (C5, C6, C7)
axillary - posterior cord (C5, C6)
radial – posterior cord (C5, C6, C7, C8, T1*)
median – medial and lateral cords (C5*, C6, C7, C8, T1)
ulnar – medial cord (C7*, C8, T1)


                                              Alice Fong                                                13
Anatomy 1                                                                            Fall 2008
Dr. Thomas



15. discuss the brachial, radial, and ulnar arteries (sources, courses, and
distributions);
brachial: source - axillary.
Course – extends from the inferior border of the teres major mm. To bifurcation cubital
fossa
distribution – provides muscular branches and terminates by divided into the radial and
ulnar arteries at the level of the radial neck.
Radial: source – brachial
course – descends laterally from cubital fossa through the anatomical snuff box entering
the palm between the two heads of the first dorsal interosseous mm. And between the
head of the adductor pollicis muscle.
Distribution – gives rise to radial recurrent aa., palmar carpal branch, superficial palmar
branch, dorsal carpal branch, princeps pollicis arteries, radialis indicis artery.
Ulnar: source – brachial
course – descends from cubital fossa behind the ulnar head of pronator teres (lies
between the flexor digitorum superficialis and profundus mm, and enters hand anterior to
flexor retinaculum....lateral to pisiform and medial to hook of hamate).
Distribution – anterior and posterior ulnar recurrent aa., common interosseous artery,
palmar carpal branch, dorsal carpal branch, superficial and deep palmar branches.

16. discuss the anastomosis around the elbow (contributing aa and their position in
relation to the elbow);
Branches of the brachial and profunda brachii arteries anastomose with recurrent
branches from forearm arteries.
Importance of anastomoses: form the collateral circulation which serves as an extra blood
routes to the distal parts of the limbs, thus insuring an adequate blood supply to the distal
parts when there is acute angulation at the joints. Also, if the main channel is cut or
blocked these serve as alternate routes to supply blood distally.

17. in case of the muscles identify the superficial and deep groups of mm. in both the
flexor and the extensor compartments of the forearm;
see above

18. identify the superficial and deep vv in the upper extremity;
Superficial: cephalic – lateral side. Which joins the axillary vein at the infraclavicular
fossa
basilic – which becomes the axillary vein
median cubital – untes these 2 veins at the elbow
        Deep veins: accompany the arteries (ulnar and radius)
19. briefly discuss the cubital fossa with its contents.
Hallow at front of elbow. It's a triangular area between pronator teres medially,
brachioradialus laterally and a line between humeral condyles.
Roof: deep fascia of forearm reinforced by bicipital aponeurosis passing from biceps
medially to blind with fascia of arm



                                          Alice Fong                                         14
Anatomy 1                                                                                 Fall 2008
Dr. Thomas

Floor: brachialis muscle. Contents from medial to lateral side are median nerve, brachial
artery, and origins of radial and ulnar, biceps tendon, radial nerve
clinical note: superficial to the bicipital aponeurosis is the median cubital vein in the
superficial fascia. This vein connects the basilic and cephalic veins and is used
extensively for intravenous transfusions and for the taking of blood samples.


                         Competencies for the arm, forearm, and hand ii:

Following the lecture and group/self study the participant should be able to:
1. Identify the mm. concerned with both grip and fine movements of the fingers
    and thumb;
extrinsic: those entering the hand from the forearm, their muscle bellies are in the
forearm, where they receive their innervation. The extrinsic muscles are concerned with
grip.
Intrinsic: small muscles of the hand are found in the palm. The intrinsic muscles control
the fine movements of fingers and thumb.

2. Briefly discuss why the skin in the palm is tighter than the skin in the dorsum of
the hand;
numerous fibrous bands attach superficial fascia to the deep fascia (palmar aponeurosis).
The thicker, hairless skin of the palm is therefore much less mobile than the skin on the
dorsum of the hand.

3. Identify both the location and function of the palmar aponeurosis;
this is the touch central part of the deep fascia, deep to skin and superficial fascia.
Palmaris longus tendon inserts into it. Septa extends into palm and to fingers.

4. Describe the Dupuytren’s contracture and define the terms: hypoesthesia,
paresthesia, and anesthesia;
Clinical note: Dupuytren's contraction – a progessive shortening and thickening of the
medial part of the palmar aponeurosis due to hypertrophy and hyperplasia. Produces
flexion of the ring and little finger. Cause unknown. Flexion deformity, dinner fork
deformity. Familia disorder
Hypoesthesia - refers to a reduced sense of touch or sensation, or a partial loss of
sensitivity to sensory stimuli
paraesthesia - is a sensation of tingling, pricking, or numbness of a person's skin with no
apparent long-term physical effect. It is more generally known as the feeling of "pins and
needles" or of a limb being "asleep" (although this is not directly related to the
phenomenon of sleep). The manifestation of paresthesia may be transient or chronic.
Anesthesia - the condition of having sensation (including the feeling of pain) blocked or
temporarily taken away. This allows patients to undergo surgery and other procedures
without the distress and pain they would otherwise experience.

5. Discuss the origins, insertions, actions, and innervations of both the thenar and
   hypothenar mm;

                                                 Alice Fong                                     15
Anatomy 1                                                                                      Fall 2008
Dr. Thomas



Thenar muscles of the thumb
Abductor pollicis   Flexor retinaculum   Lateral side of base Median n. (C8 and    Abducts thumb,
brevis              and tubercles of     of proximal          T1)                  helps oppose thumb
                    scaphoid and         phalanx of thumb
                    trapezium bones
Flexor pollicis     Flexor retinaculum   Lateral side of base Median n (C8 and     Flexes thumb
brevis              and tubercle of      of proximal          T1)
                    trapezium            phalanx of thumb
Opponens pollicis   Flexor retinaculum   Lateral side of 1st   Median n. (C8 and   Draws thumb
                    and tubercle of      metacarpal bone       T1)                 toward center of
                    trapezium                                                      and rotates it
                                                                                   medially (i.e.
                                                                                   opposes it).

Hypothenar muscles of the little finger
Abductor digiti     Pisiform bone        Medial side of base Ulnar n (C8 and       Abducts little finger
minimi                                   of proximal         T1)
                                         phalanx of little
                                         finger
Flexor digiti       Hook of hamate       Medial side of base Ulnar n (C8 and       Flexes little finger
minimi brevis       and flexor           of proximal         T1)
                    retinaculum          phalanx of little
                                         finger
Opponens digiti     Hook of hamate       Medial border of 5th Ulnar n (C8 and      Draws 5th
minimi              and flexor           metacarpal bone      T1)                  metacarpal
                    retinaculum                                                    anteriorly and
                                                                                   rotates it, bringing
                                                                                   the little finger into
                                                                                   opposition with the
                                                                                   thumb

The actions of these 2 groups of small muscles are indicated by their names. In addition
   they help to “cup” the palm and assist in the grip of a large object.


6. Identify all the long tendons of mm located in the palm;
4 tendons of flexor digitorum superficialis → fingers
4 tendons of flexor digitorum profundus → fingers
1 flexor pollicis longus → thumb
These tendons enter the hand deep to flexor retinaculum, flexor pollicis longus on the
    lateral side. They flex the wrist, fingers and thumb.


7. Describe the extensor expansions;
The expansion of the extensor tendon over the metacarpalphalangeal joint and is referred
   to by clinicians as the extensor hood. It provides the insertion of the lumbricals and
   interosseous muscles as well as the extensor indicis and extensor digiti minimi
   muscles.

                                             Alice Fong                                                   16
Anatomy 1                                                                         Fall 2008
Dr. Thomas



8. Define the retinaculum, and describe the carpal tunnel syndrome;
Flexor retinaculum – serves as an origin for muscles of the thenar eminence. Forms the
carpal tunnel on the anterior aspect of the wrist. From carpals on one end to the carpals
on the other side. Crossed superficially by the ulnar nerve, ulnar artery, palmaris longus
tendon, palmar cutaneous branch of the median nerve.
Carpal tunnel transmits the median nerve and the tendons of flexor pollicis longus, flexor
digitorum profundas, flexor digitorum superficialis.
Carpal tunnel syndrome is compression of the median nerve due to inflammation, passes
deep to the flexor retinaculum. Causes pain and paraesthesia (tingling, burning,
numbness). Causes numbness and tingling in the lateral part of the hand.

Extensor retinaculum – thickening of antebrachial fascia on the back of the wrist. Is
subdivided into compartments and places the extensor tendons beneath it. Is crossed
superficially by the superficial branch of the radial nerve.

9. Define both the fibrous and synovial flexor sheaths;
Fibrous flexor sheaths: from the metacarpal heads to the distal phalanges, each digit is
supplied with a strong, unyielding fibrous sheath in which the flexor tendons lie.
In the fingers the sheaths are occupied by two tendons: flexor digitorum superficialis
anterior to the flexor digitorum profundus.
In the thumb, one tendon, flexor pollicis longus, occupies the sheath.
Synovial flexor sheaths: in areas of friction the tendons are enclosed within synovial
sheaths. They are deep to the flexor retinaculum and within the fibrous flexor sheaths of
the finger and thumb.

10. Id, the locations and the course of the cephalic and the basilic vv in the forearm
    and the arm;
Basilic – source: dorsal venous arch
termination: formation of axillary vein with brachial vein.
Distribution: joined across the cubital fossa by the median cubital vein. Arises from the
ulnar side of the dorsal venous network of the hand, and it curves around the medial side
of the forearm, communicates the cephalic vein via the median cubital vein, and passes
up the medial side of the arm to form the axillary.
Cephalic: source: dorsal venous arch
Termination: axillary vein
Distribution: arises at the radial border of the dorsal venous arch of the hand, passes
upward in front of the elbow and along the lateral side of the arm; it empties into the
upper part of the axillary vein.

11. Identify the numbers, positions, actions, origins, insertions, and innervations of
    the lumbrical mm in the hand;
from each of the 4 profundus tendons a lumbrical muscle arises on the lateral (radial)
side;runs along the radial side of the metacarpophalangeal joint and reaches the extensor
expansion on the dorsum of the first phalanx (re: dorsal expansion -see below).
Action: flex metacarpophalangeal joints and extend interphalangeal joints.


                                        Alice Fong                                      17
Anatomy 1                                                                                 Fall 2008
Dr. Thomas

Lumbricals 1 & 2   Lateral two tendons Lateral sides of    Median (C8, T1)     Flex digits at MCP
                   of flexor digitorum extensor expansions                     joints and extends
                   profundus           of digits 2 to 3                        IP joints
Lumbricals 3 &4    Medial 3 tendons of Lateral sides of    3rd and 4th, deep   Flex digits at MCP
                   flexor digitorum    extensor expansions branch of ulnar     and extend IP joints
                   profundus           of digits 4 to 5    (C8, T1)

12. Identify the nerve traveling with the posterior interosseous artery;
posterior interosseous nerve

13. Identify the artery traveling with the anterior interosseous nerve;
anterior interosseous artery

14. Describe both the superficial and deep palmer arches;
anteries: radial and ulnar arteries supply the hand by means of anterial arches, from
which arise arteries for the digits. Thereare main arches, both in the palm.
Superficial palmar arch: largest and most important.
Deep to palmar aponeurosis
formed by continuation of ulnar artery
completed by branch from radial artery
arch → digital branches to fingers
Deep palmar arch: lies on metacarpals and interossei, deep to long flexors
formed by radial artery, completed by a branch from the ulnar artery
branches → digital branches of superficial arch, to thumb and index fingers
There are anastomoses around the wrist

15. Identify the location at which the radial artery gains entry into the palm;
just above the wrist, the radial artery lies lateral to flexor carpi radialis tendon on the
anterior aspect of the wrist. Then the artery passes to dorsum of hand by passing deep to
the tendons of the anatomical snuffbox to plunge through the muscle (first dorsal
interosseous) between metacarpals of thumb and index finger. In this way it reaches the
deep region of the palm where it forms the deep palmar arch.
The pulse is commonly taken at the wrist.

16. Discuss a dermatome and identify the nerve (spinal roots) responsible for the
    cutaneous innervation to all areas of the upper extremity;
segmental innervation of skin. A dermatome is an area of skin supplied by the dorsal
root of a spinal nerve. The knowledge of dermatomes is important in lesions which occur
before the nerves are mixed up in the brachial plexus (i.e., spinal cord lesions, protruded
intervertebral discs, and in damage to the roots of the brachial plexus).
Plate 482 in Netters
17. Identify some of the common clinical conditions that can be indicated by your
    knowledge of the dermatomes;
The knowledge of dermatomes is important in lesions which occur before the nerves are
mixed up in the brachial plexus (i.e., spinal cord lesions, protruded intervertebral discs,
and in damage to the roots of the brachial plexus).


                                            Alice Fong                                           18
Anatomy 1                                                                           Fall 2008
Dr. Thomas

Dermatomes are useful in neurology for finding the site of damage to the spine. Viruses
that infect spinal nerves such as Herpes zoster infections (shingles), can reveal their
origin by showing up as a painful dermatomic area. Herpes zoster, a virus that is dormant
in the dorsal root ganglion, migrates along the spinal nerve to affect only the area of skin
served by that nerve. Symptoms are usually unilateral but in the immune suppressed, they
are more likely to become bilateral and symmetrical, meaning that the virus is present in
both ganglia of a dorsal root ganglion pair.

18. Identify the carpal bone found in the floor of the anatomical snuff box;
scaphoid (and trapezium)

19. Describe all the clinical conditions pertaining to the upper extremity; These are
    found in the blue- boxed areas of the textbook and in the supplemental notes;
breast cancer
fracture of the clavicle (SCM goes up, trap goes down)
colles' fracture of the wrist (fracture of lower end of radius, common in people over 40)
inferior dislocation of the humerus (may damage the axillary nerve and the posterior
humeral circumflex vessels).
Referred pain to the shoulder (probably indicates involvement with the phrenic nerve)
carpal tunnel syndrome
dupuytren's contracture (a progressive thickening and shortening of the medial part of the
palmar aponeorosis)
erb's duchenne (causing waiter's tip hand)
klumpke's paralysis (claw hand)
injury to posterior cord (aka crutch palsy, results in wrist drop)
injury to long thoracic nerve (paralysis of serratus anterior and produces winged scapula)
injury to musculocutaneous (results in weakness of supination and forearm flexion)
injury to axillary (caused by fracture of surgical neck of humerus, or inferior dislocation
of humerus, resulting in weakness of lateral rotation and abduction of arm)
injury to radial (caused by fracture to the midshaft of the humerus, resulting in wrist drop)
injury to ulnar nerve (caused by a fracture of the medial epicondyle and results in the
claw hand in which the ring and little fingers are hyperextended at the
metacarpophalangeal joints and flexed at the interphalangeal joints).
Injury to median nerve (may be caused by supracondylar fracture of humerus or
compression in the carpal tunnel, results in “ape hand” which is a characeristic flattening
of the thenar eminences)




20. Define felon/whitlow – not a criminal!!!
also called digital herpes simplex, finger herpes, or hand herpes—is a painful viral
infection occurring on the fingers or around the fingernails. Herpetic whitlow is caused
by infection with the herpes simplex virus (HSV).
Felons are closed-space infections of the fingertip pulp.



                                         Alice Fong                                        19
Anatomy 1                                                                                      Fall 2008
Dr. Thomas

21. Identify the attachments, actions, and innervations of all the intrinsic mm. of the
    hand;
see above tables
Adductor pollicis    Oblique head: bases Medial side of         Deep branch of      Adducts thumb
                     of 2nd and 3rd      proximal phalanx       ulnar nerve (C8 and
                     metacarpals,        of thumb               T1)
                     capitate and
                     adjacent carpal
                     bones
                     Transverse head:
                     anterior surface of
                     body of 3rd
                     metacarpal
Dorsal interossei (1 Adjacent sides of    Extensor              Deep branch of      Abducts fingers,
to 4)                two metacarpal       expansions and        ulnar nerve (C8 and also function with
                     bones                bases of proximal     T1)                 lumbricals
                                          phalanges of digits
                                          2-4
Palmar interossei (1 Palmar surfaces of   Extensor             Deep branch of       Adducts fingers and
to 3)                2nd, 4th, and 5th    expansions of digits ulnar nerve (C8 to   assist lumbricals in
                     metacarpal           and bases of         T1)                  flexing MCP and
                                          proximal phalanges                        extend IP joints



22. Identify the location of lymph collection in case of an infection in the volar
    surface of the hand;
any infection of the palm (volar) will be seen in the dorsum because of the movement of
lymph due to available space

23. Identify all the structures located deep to the flexor retinaculum;
Carpal tunnel: base and walls are carpal bones, roof – flexor retinaculum. Transmits the
median nerve and the tendons of flexor pollicis longus, flexor digitorum profundus,
flexor digitorum superficialis mm.

24. Describe the formation and course of the axillary vein;
Formed by the superficial basilic and the deep brachial.
A continuation of the basilic and brachial veins running from the lower border of the
    teres major muscle to the outer border of the first rib where it becomes the subclavian
    vein. Commonly receives the thoracoepigastric veins directly or indirectly and thus
    provides a collateral circulation if the inferior vena cava becomes obstructed.
25. Identify the regional names of the deep facia in the axilla, brachium,
    antebrachium, and the palm.
Axillary, brachial, antebrachial, palmar


COMPETENCIES FOR THE THORAX, LUNGS AND DIAPHRAGM:

1. Identify the following vertebral levels with relevance their anatomical
landmarks/clinical significance: T1 to T10, and T12.

                                              Alice Fong                                                 20
Anatomy 1                                                                             Fall 2008
Dr. Thomas

T1: highest point of apex of lungs
T2: jugular notch of manubrium
T3: base of spine of scapula
T4: sternal angle (manubriosternal joint), aortic arch begins and ends, 2nd costal cartilage,
trachea ends and bronchi begin, right and left pleurae meet retrosternally
T5-T7: thoracic duct crosses from inferior right to superior left, posterior to esophagus
T8: inferior vena cava passes through the diaphragm, inferior sternal angel
T9: xiphisternal junction
T10: esophageal hiatus of the diaphragm
T12: abdominal aorta, aortic hiatus of the diaphragm


2. Id. The difference between the adult and the infants’thoracic cages.

3. Id. The components of the thoracic cage.
Formed by the thoracic vertebrae 1-12, the intervertebral discs, ribs 1-12 and the sternum.
There are 11 intercostal spaces.
Sternum: forms the median portion of the anterior thoracic wall. Its upper end supports
the clavicle, it's lateral margins articulate with the cartilages of the ribs. It consists of 3
parts: manubrium, body, and xiphoid process.
Body of sternum is shorter in females.
Ribs: elastic arches of bone and cartilages connected posteriorly to the vertebral column.
Usually there are 12 on each side. We distinguish true, false and floating ribs. The ribs
vary in their direction, their shape and their size.
Costal cartilages: are bars of hyaline cartilage connecting the anterio rib ends to the
sternum
infrasternal angle: formed by the joint cartilages of the 7-10 ribs of both sides and the
xiphisternal joint

4. Id. The structures passing through the thoracic inlet and outlet.
Thoracic inlet (superior thoracic aperture)
- Boundaries: 1st thoracic vertebrae, 1st rib, upper border of the manubrium sterni
- slopes down because of the oblique course of the 1st rib
- Contents: trachea, esophagus, great blood and lymph vessels, and nerves pass through
this entrance of thoracic cage
- Thoracic outlet syndrome: clinicians refer to the superior thoracic aperture as the
thoracic outlet to emphasize the arteries and T1 spinal nerves that emerge from the thorax
through this aperature to enter the lower neck and upper limps. Merging structures are
affected by obstructions of the superior thoracic aperture. Manifestations of the syndrome
involve the upper limb. Ex: costoclavicular syndrome: the subclavian artery and vein and
the brachial plexus were compressed between the clavicle and normal first rib by cervical
rib
Thoracic outlet (inferior thoracic aperture)
- boundaries: 12th thoracic vertebra, 12th rib, inferior costal margin
- it's closed by the diaphragm



                                          Alice Fong                                        21
Anatomy 1                                                                           Fall 2008
Dr. Thomas

5. Id. the osseous and cartilaginous structures attaching to the sternum and the
articulations formed by them.
     Upper end supports the clavicles
     lateral margins articulate with cartilages of the ribs

6. Id. The structures forming the costal margin.
the medial margin formed by the false ribs -- specifically, from the seventh rib to the
tenth rib.

7. Define the conditions: “ Pigeon chest, Funnel chest.
Normal chest – sternum projects anteriorly and inferiorly
Funnel chest – sternum projects inferiorly and posteriorly
Pigeon chest – sternum projects anteriorly, sides are flat (rib cage).
 ossification is not complete, there can be a hole in sternum

8. Define the terms: vertebrosternal and vertebrocostal in relation the ribs.
Each rib has 2 articulations with the vertebral column. Most are synovial joints.

9. Id. The parts of a typical vertebra and a typical rib
Typical rib: head, neck, body, costal cartilages, facets for articulation with vertebral
bodies, tubercle (with facets for articulation with transverse process), angle (where body
changes direction, costal groove (for vein, artery and nerve)
Typical vertebrae: pedicle, body, superior and inferior vertebral notches, superior and
inferior articular processes, spinous process, transverse process

10. Id the specific features of the thoracic vertebrae.
- spinous processes: long, overlap each other as they point inferiorly
- costal facets (demifacets): on bodies and 2 demifacets are located laterally on the body
(superior demifacet for articulation with corresponding rib, and inferior demifacet for
articulation with the rib right below it)
- exceptions: there are full facets on T1, T10-12

11. Briefly discuss the costotransverse and sternochondral joints.
Costotransverse joint: all except 11th and 12th are synovial joints.
Articulating parts: tubercle of the rib, transverse process of the corresponding vertebra
ligaments: costotransverse ligaments
sternochondral joint: most of them are synovial joints
articulating parts: costal cartilages of true ribs, sternum

12. Briefly describe the movements of the thoracic cage.
- range and type of movement of the ribs vary according to their different shapes and
anterior attachments
- dimensions: anterior/posterior, transverse, vertical
2 main movements – bucket handle and pump handle




                                          Alice Fong                                        22
Anatomy 1                                                                                      Fall 2008
Dr. Thomas

13. Define the bucket handle and pump handle movements.
Pump handle movement: The anterior ends of the ribs are elevated and depressed, also
travel forward and backward (pump handle)
- Correspondingly the body of the sternum moves forward and backward.
- increase the anterior-posterior diameter
- predominant movement of the true ribs
Bucket handle movement: the middle parts of the ribs are elevated/depressed
- enlarge the transverse diameter
- widen the infrasternal angle
- predominant movement of the lower ribs

14. Define an intercostals space and the location of the neurovascular bundle in it.
An intercostal space is a region bounded by two ribs.
One particular concept is that the neurovascular bundle has a strict order: V-A-N, or vein-
artery-nerve, from top to bottom (as illustrated). This neurovascular bundle runs high in
the intercostal space: therefore, the intercostal space should be penetrated as low as
possible by invasive procedures.

15. Id. The arrangements, attachments, actions and innervations of the intercostals
muscles.
Muscles of the thoracic wall
Intercostales externi Lower border of     Upper border of       Segmentally by    Maintain intercostal
                      ribs 1-11           ribs below, ribs 2-   intercostal nn.   space in breathing;
                                          12                                      elevate ribs during
                                                                                  inspiration
Intercostales interni Upper border of     Lower border of rib Segmentally by      See above.
                      ribs 2-12           above, ribs 1-11    intercostal nn      Expiration
Transverse thoracis Inner surface of      Lower and inner       See above         Depresses ribs,
                    lower half of         borders of 2-6 rib                      muscle of
                    sternum and           cartilages                              expiration
                    adjacent costal
                    cartilages
Subcostales          Inner surface of     Upper border of       See above         Aid in depressing
                     lower border of      ribs 9-12                               ribs
                     false ribs (8-11)
                     near angles
Levator costarum     Transverse           Outer surface         See above         Elevate and rotate
                     processes of C7 to   between tubercle                        the ribs
                     T12                  and angle of each
                                          rib below an origin
Serratus posterior   Ligamentum           Upper border of      See above          Elevates ribs;
superior             nuchae and spines    ribs 2-5 just beyond                    muscle of
                     of C7 and T1-4       angles                                  inspiration
Serratus posterior   Lumbar fascia and    Lower border of       See above         Draws ribs down
inferior             spines of T11-12     ribs 9-12                               and back; muscles
                     and L1, L2                                                   of expiration.
                                                                                  Depressing lower 4
                                                                                  ribs down


                                              Alice Fong                                               23
Anatomy 1                                                                               Fall 2008
Dr. Thomas

Diaphragm          Inner surfaces of   Central tendon    Phrenic nerve      Increases thoracic
                   xiphoid, lower 6                                         space and thereby
                   ribs and their                                           leading to the
                   cartilages, and 2                                        inspiration of air in
                   crura from the                                           breathing
                   lumbar vertebrae

16. Define the endothoracic fascia.
A thin layer of areolar (loose connective tissue) tissue lines the inner thorax

17. Id. The arterial supply and the venous drainage of the I/costal spaces.
Blood supply
Arteries:
1. internal thoracic (branch of subclavian artery)
Branches:
a. branches to mediastinum, pericardium and sternum
b. anterior intercostals, which anastomose with the posterior intercostals. The artery
terminates by dividing into the superior epigastric and musculophrenic arteries.
2. highest intercostal artery of the costocervical trunk. It gives rise to the 1st and 2nd
posterior intercostals which supply the corresponding intercostal spaces.
3. 9 posterior intercostal arteries which are branches of the aorta. They pass together
with the vein and nerve in the costal groove of the corresponding rib.
Branches:
a. a dorsal branch to muscles of back
b. lateral cutaneous branch
c. collateral branch

Veins:
Most of the veins join the azygos system of veins. Some of the upper veins join the
brachiocephalic veins.

18. Briefly discuss the 12 intercostal nerves.
There 12 thoracic spinal nerves. After leaving the intervertebral foramen, each divides
into a dorsal and a ventral rami.
Ventral rami (intercostal nerves)
- do not form plexuses
- distributed to the corresponding intercostal spaces where they lie in the costal groove
between the artery
- at the anterior end of the space they piece the muscles and become cutaneous
-Branches: collateral branch, lateral cutaneous branch
Atypical intercostal nerves
- greater part of ventral ramus of T1 joins brachial plexus
- lateral cutaneous nerve of T2 supplies skin over axilla and arm – called
intercostobrachial nerve
- 7-12th intercostal nerves pass through the internal costal spaces, but then continues into
the abdominal wall – called subcostal nerve. It is related to the kidney



                                           Alice Fong                                           24
Anatomy 1                                                                           Fall 2008
Dr. Thomas

- Note that from the angle of the rib, the main intercostal blood vessels and nerves lie in
upper part of each intercostal space

19.Distinguish between the medial and median arcuate ligaments of the diaphragm.
Plate 195
Median arcuate ligament is a ligament under the diaphragm that connects the right and
left crura of diaphragm. the crura connect to form an arch, behind which is the aortic
hiatus.
Medial arcuate ligament: the medial arcuate ligament is an arch in the fascia covering
the upper part of the psoas major. It is attached to the side of the body of the first or
second lumbar vertebra; laterally, it is fixed to the front of the transverse process of the
first and, sometimes also, to that of the second lumbar vertebra.
It lies between the lateral arcuate ligament and the midline median arcuate ligament.
The sympathetic chain enters the abdomen by passing deep to this ligament.


20. Id. The structures passing through the diaphragm.
3 main openings through which the aorta, esophagus and inferior vena cava leave the
throacic cavity. Smaller structures passing through the diaphragm are the phrenic,
splanchnic and thoraco-abdominal nerves and various blood vessels.

21. Briefly describe how the diaphragm is peripheral attached to the thoracic cage.
A thin muscolotendinous partition between the thoracic and abdominal cavity. It is
domed shaped. The central part of the daphragm is tendinous. The peripheral part is
muscular and arises from the whole circumference of the thorax. Corresponding to their
origin we distinguish the following parts.
Sternal part: comprises just 2 fleshy slips from the xiphoid process
Costal part: arises from the inner surfaces of the lower 6 costal cartilages and
corresponding ribs.
Lumbar part (two parts):
Origin: a) tendonous arches over the quardratus lumborum and psoas major. These arches
are called the lateral and medial lumbroscostal arches or lateral and medial arcuate
ligament.
b.) musclar slips arising from the vertebral column. They are called the right crus and left
crus. Both crura unite in the midline. This tendonous union is called the median arcuate.
The aorta discends behind this ligaments

22. Define the following: cervical, costal, diaphragmatic, mediastinal, parietal and
visceral pleura.
Cervical
Costal
Diaphragmatic
mediastinal
parietal – is given different names depending on its location. We distinguish the cervical,
the diaphragmatic, the costal and the mediastinal pleura. The latter one is pierced by the
root of the lung


                                         Alice Fong                                           25
Anatomy 1                                                                             Fall 2008
Dr. Thomas

visceral pleura – is inseparably attached to the lung tissue

23. Id the pleural recesses that are not filled with lungs during quiet respiration.
Pleural recesses are potential spaces of the pleural cavity, which the lung occupies in
forced inspiration only. The largest recess is the costo-diaphragmatic recess.

24. Define the pulmonary ligament.
The root of the lung is covered in front, above, and behind by pleura, and that at its lower
border the investing layers come into contact. Here they form a sort of mesenteric fold,
the pulmonary ligament, which extends between the lower part of the mediastinal surface
of the lung and the pericardium.

25. Id the locations of: apex, base, borders and surfaces of both the lungs in the
anatomical position.
The lungs present an apex, a base, 3 borders and 2 surfaces

The apex: projects above the thoracic inlet into the root of the neck. It is related to the
subclavian, common carotid, brachiocephalic arteries, brachiocephalic veins, scalenes
medius, sympathetic trunk, 1st thoracic spinal nerve and superior intercostal arterties

The base: or diaphragmatic surface is related to the diaphragm.

The border: are anterior, inferior and posterior

Surfaces: 1. costal related to anterior, lateral and posterior thoracic wall
   2. medial consists of a vertebral and a mediastinal part
Each mediastinal surface presents the helium of the lung, where bronchi, pulmonary
vessels, nerves, lymphatics and brochial vessels enter and leave.


26. Name the structures forming the root of the lung.
Each lung lies free in its own thoracic cavity. Its only attachment is its roots. By “root of
the lung” we mean all structures entering and leaving the lung at the hilus. They connect
the lung with the trachea and heart. The root of the lung lies opposite T5, T6, T7. It is
ensheathed by a sleeve of a parietal pluera.
Each mediastinal surface presents the hilium of the lung, where bronchi, pulmonary
vessels, nerves, lymphatics and bronchial vessels enter or leave.
General arrangement at the hilium:
    1. bronchi posteriorly
    2. pulmonary vein (usually two on each side) anteriorly
    3. pulmonary arteries in between

The lungs of a stillborn child have the consistency of the liver and do not float in water.

27. Id the fissures, lobes, and bronchial segments of the right and left lungs.



                                          Alice Fong                                          26
Anatomy 1                                                                              Fall 2008
Dr. Thomas

The root of the lung is covered in front, above, and behind by pleura, and that at its
lower border the investing layers come into contact. Here they form a sort of
mesenteric fold, the pulmonary ligament, which extends between the lower part of
the mediastinal surface of the lung and the pericardium.
Impressions on mediatinal surfaces:
    1. right: arching over the root sof the lungs is agroove for the azygos vein which
       anteriorly run into a wide vertical groove for superior vena cave and above the
       azygos vein is rleated to the trachea and the vagus nerve. The large depression in
       front of the hilium is the depression for the right atrium. The small goove in front
       of the lower portion of the pulmonary ligament is for the inferior vena cava. The
       vertical groove above and behind the hillium of the lung accommadates the
       esphagus.
    2. Left: the large depression in front of the hilium is for the left ventricle. A wide
       and deep groove located above and behind the hilium of the lung is for the arch of
       the aorta and the descending aorta respectively. Two vertical grooves are
       extending from the anterior border to the groove for the arch of aorta –the anterior
       one is for the left common carotid and the posterior one is for the left subclavian
       arteries.

Lobes and fissures:
The left lung is divided into superior and inferior lobes by an oblique fissue which
extends from the costal to the mediastinal surface.
The right lung is divided into superior, inferior and middle lobes by two fissures. The
oblique fissue is similar to the one on the left side. The horizontal fissue separates the
right superior lobe from the middle lobe.
Abnormal lobes are quite common.

28. Differentiate between the pulmonary and bronchial arteries.
Two different systems:
    1.) pulmonary arteries bring the deoxygenated blood from the heart to the lung.
        Pulmonary veins transport the oxygen rich blood from the lungs back to the heart.
    2.) Bronchial vessels take care of the nutrition of the lung tissue
        a. right brachial artery usually arises from the 3rd right posterior intercostal artery
        b. left brachial arteries (two) originate from the descending aorta
        c. the deep bronchial veins which mainly drain the intrapulmonary tissue, joint to
        trunks, which empty into the pulmonary veins.
        d. the superficial bronchial veins collect blood from the area of the hilus, the
        extrapulmonary bronchi and lymph nodes of the hilus. They terminate in the
        azygos system mainly.
        e. anastomoses: there are important anastomoses between pulmonary arteries,
        bronchial arteries and pulmonary veins. They can be used to bypass the capillary
        network around the alveoli.

29. Id the specific pulmonary areas which drain into the azygos system of veins.
30. Briefly describe the lymphatic drainage of the right and left lungs



                                          Alice Fong                                         27
Anatomy 1                                                                          Fall 2008
Dr. Thomas

the lymph nodes of the lungs drain into the right and left bronchopulmonary lymph nodes
which empty into the tracheobroncial groups. Efferents of the latter ones contriubte to the
formation of the left and right bronchomediastinal trunks.

31. Id the areas to which bronchogenic carcinoma of the right and left hila is likely
to spread.
32. Define the position of each of the bronchopulmonary segments in the anatomical
position. (important information for auscultation and percussion.)
33. Id the lung impressions made by the great vessels: the heart, the azygos vein and
the esophagus.




                                         Alice Fong                                      28

				
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