Block 1: Upper Limb and Back

Lecture 1: Anatomic principles and the Pectoral Region

• Anatomical position
• Sagittal, coronal, transverse planes
• Layers of the body
o Skin: epidermis, dermis; NOT the same thickness all over the body
 Functions of skin= protection, keeps insides in, temperature control, conveys info about the
external environment

o Fascia
 Superficial and deep
 Muscle
 Bone
Collectively, the skin, superficial and deep fascias, muscle and bone are components of the BODY WALL

Lecture 2: Axilla
• Breast
o Prominent superficial structure of anterial thoracic wall
o Overlying pectoral muscles
• Mammary gland
o Glandular tissue (modified sweat gland)
o May extend to armpit
• Ectodermal ridge
o Axilla to groin (embryonic/developmental)
• Congenital abnormalities
o Polymastia= aberrant breast/accessory breast
o Polythelia= residual/excess nipples
o Gynecomastia= enlargement of the breast (associated with young men with Klinefelter syndrome
XXY)
o Amastia= no breast formation
• Masectomy
o Radical masectomy= Breast, pectoralis major, pectoralis minor taken out, axillary dissection
o Modified radical masectomy= remove breast, leave pectoralis major/minor,
o Care taken to preserve the LONG THORACIC nerve or you get winged scapula
• Cooper’s ligaments- shortened in breast cancer  dimpled appearance
• Apex of the armpit
o Clavicle, scapula, first rib
• Costocoracoid membrane penetrated by LATERAL PECTORAL NERVE, CEPHALIC VEIN,
THORACOMIAL ARTERY (TLC)

Lecture 3: Innervation of the trunk and limbs

• Spinal nerves
o Nerve impulses travel along NEURONS, nerve impulses transmit between nerves by way of
SYNAPSES
o Sensory/Afferent information= from body to CNS
o Motor/Efferent information= from CNS to body
o Somatic= body, Visceral= viscera/internal organs
  Somatic components: 1 neuron system
• Somatic afferent perceive pain, temp, touch, etc
• Somatic efferent innervate skeletal muscle
 Visceral components: 2 neuron system (preganglionic and postganglionic)
• Visceral efferent innervates smooth muscle, cardiac muscle and glands
• Preganglionic impulses originate in lateral horn of the spinal cord
o Spinal cord level vs. vertebral level (remember that the nerve comes out above the vertebra)
o Typical parts of a spinal nerve
 Nerve roots: dorsal= sensory only, ventral= motor only
 Spinal ganglia
 Spinal nerve proper
 Primary rami: dorsal= supplies back, ventral= supplies lateral/ventral trunk and limbs
o Sympathetic nervous system (visceral efferent)
 Sympathetic trunk
 Communicating rami: white and gray
• Somatic sensory innervation= dermatomes
• Somatic motor innervation= myotomes

Lecture 4: The Brachial Plexus

• Ventral primary rami participate in nerve plexus formation
• Plexus  distribution of nerve fibers from different levels to each segment of the limb (formed by nerves
C5-C8 and T1)
• Major components
o Roots, trunks, divisions, cords, terminal branches
• Common injuries (compression, traction, penetrating wound)
o Trauma  paralysis or anesthesia that may be complete or incomplete
o Traction on the plexus  dorsal and ventral roots of the spinal nerves may be pulled out of the
spinal cord
 Upper trunk (C5, C6) traction (Duchenne paralysis)  excessive separation of shoulder
and neck
 Lower trunk (C8, T1) traction (Klumpke paralysis)  hyperabduction of upper limb
o Presence of cervical rib  compression of the plexus (lower trunk)
o Infraclavicular injuries
 Example: poorly fitting crutches injures posterior cord (often only radial nerve)  wrist
drop

Lecture 5: Superfical Back and Shoulder Region

• Skeletal components
o Pectoral girdle= clavicle + scapula DYNAMIC SUPPORT
o Functions: support base for limb motions, shock absorber, protects neurovascular structures
passing to arm
o Humerus held in articulation with the scapula ONLY by muscles
o Humerus is weakest at the surgical neck, radial nerve follows spiral groove
o Humeral head and the glenoid fossa of the scapula display poor congruence (do not fit together
well)
• Muscles: located dorsally on trunk, ALL are ventral primary rami innervated (branches of brachial plexus)
o Trapezius
 To test: shoulder shrugged against resistance
  Injury  winged scapula (CN XI)
o Latissimus dorsi
 To test: arm abducted 90 degrees and then adducted against resistance
o Levator scapulae
o Rhomboids
o Pectorals
o Serratus Anterior
 Paralysis (damage to LONG THORACIC NERVE)  winged scapula
o Deltoid
o Supraspinatus
o Infraspinatus
o Teres minor
o Teres major
o Subscapularis
• Scapula movement

Lecture 6: The Back- Functional and Morphological Correlates

• The vertebrae
o General features: body, pedicles, laminae, spinous processes, transverse processes, articular
processes
o Regional characteristics
 Cervical vertebrae (atlas and axis) 7
 Thoracic vertebrae (facets for rib articulation) 12
 Lumbar vertebrae LARGE 5
 Sacral vertebrae (fused) 5
 Coccyx (fused) 3-4
o Epidural anesthesia- local anesthetic injected into sacral canal
• Joints of the spinal column
o Fibrous joints
 Posterior longitudinal ligament
 Anterior longitudinal ligament (prevents whiplash)
o Interarticular synovial joints
 Spondylolysis: weakness/bone defect  fracture  one bone slips over another
 Spondylolithesis: body of L5 slips forward on the body of sacrum
o Cartilaginous joints = intervertebral discs between the bodies of adjacent vertebrae
 Nucleus pulposus (liquid= compression force transmitter)
 Annulus fibrosis
 Age related changes: water content reduces with age, degeneration affects annulus
 Rupture of IV disc: nucleus pulposus protrudes  presses on spinal cord/nerves
• Affected nerve is one spinal cord level higher than the vertebral that is located
superior to the ruptured disk
• Considerations of the spinal column
o Kyphosis= humpback, exaggeration of the thoracic primary curvature
o Lordosis= backward bending, exaggeration of the lumbar secondary curvature (COMMON in
pregnant women)
o Scoliosis= crookedness, may be congenital, myopathic, idiopathic
o Sacralization and lumbarization of vertebrae
o Lumbar puncture (spinal cord does not extend full length of vertebral column)
  Insert needle between adjacent lamina, last pop is ligamentum flavum

Lecture 7: Upper Extremity

• Arm
o Anterior compartment (flexors)= biceps, brachialis, coracobrachialis (supplied by
musculocutaneous nerve)
o Posterior compartment (extensors)= triceps
o Patient with laceration:
 Test ulnar nerve: check abduction and adduction of little finger
 Test radial nerve: extension of fingers/wrist (look for wrist drop)
 Test median nerve: check flexion of fingers/wrist (specifically index finger flexion)
• Radial nerve runs along humerus: vulnerable spot!! Fracture  wrist drop
• Ulnar nerve runs on posteromedial aspect of elbow right on the bone: vulnerable spot! Injury 
parasthesia of ulnar nerve (affects little finger sensory/motor)
• Elbow: radial and median nerves (cast too tight puts pressure on these nerves)
• Radial and ulnar bursa: infection of thumb moves to little finger (communication= abscess near wrist
which allows for radial bursa and ulnar bursa to connect)
• Median nerve and brachial artery are buddies (run together)
o Brachial artery is main supply to the arm (continuation of axillary artery)

Lecture 8: Hand Anatomy

• Needed for functional hand
o Stability: bones and ligaments
o Viability: vascular supply
o Sensibility: nerves
 Radial nerve: controls all extensors of the arm and forearm, NO intrinsic muscles of the
hand
 Median nerve: controls thumb muscles
 Ulnar nerve: controls all of the intrinsic muscles of the hand (except thumb)
o Mobility: functional joints and muscles

Lecture 9: Upper Limb Innervation

• Median nerve damage
o Inability to flex digits 1,2,3 (hand of benediction)
o Carpal tunnel  inability to flex thumb
• Ulnar Nerve damage
o Claw hand (deformity of digits 4,5)

Lecture 10: Joints of the Upper Extremity: The Shoulder and Elbow
• Synovial joints
• Clavicle fractures
• Shoulder tradeoff: mobility vs. stability
• Rotator cuffs muscles: SITS (supraspinatus, infraspinatus, teres minor, subscapularis)
• Radial head subluxation= radial head dislocated (Nursemaid’s elbow)