Ernest F. Talarico, Jr., Ph.D.
Associate Director of Medical Education
Associate Professor of Anatomy & Cell Biology
Associate Faculty, Radiologic Sciences
Indiana University School of Medicine – Northwest Campus
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Objectives
• To gain a comprehensive understanding of
the osteology of the upper limb
• To understand and be able to discuss the
anatomy/anatomical relationships of the
upper limb (i.e., veins, arteries,
compartments, muscles)
• To understand the brachial plexus
• Apply the above to a case study of the
brachial plexus and medical imaging.
Upper Limb

Osteology
Brachium
Right Clavicle

Antebrachium

Carpus

Manus

Phalanges
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Fascia ☺ Compartment ☺ Lymphatics
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Veins and Lymphatics of the Upper Limb
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Muscles of the Brachiium
What is the view?
(anterior)
What is the innervation?
(Musculocutaneous n.)
Posterior
Radial n.
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Muscles of the Antebrachium
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Muscles of the Antebrachium
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Muscles of the Antebrachium
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Compartment & Muscles of the Manus
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An Area of Concern!
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Vessels
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1
2
3
(1) Lateral boarder of R1 and medial border of
pectoralis minor m.
• Superior (supreme) Thoracic a.
(2) Posterior to pectoralis minor m.
• Thoracoacromial a. (Acromial, Clavicular,
Pectoral, Deltoid)
• Lateral Thoracic a. (**** BREAST ****)
(3) Lateral border of pectoralis minor m. and the
inferior border of teres major m.
• Subscapular a. (largest)
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• Anterior & Posterior Circumflex Humeral
(P > A)
Anatomical
Relationships - Vessels/Nerves
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The Brachial Plexus
• Innervates all muscles of
superior extremity
• Sensory & motor nerves
• Anterior division fibers
supply flexors
• Posterior division fibers
supply extensors
Roots Trunks Divisions Cords Branches
Robert Taylor Drinks
Cold Beer
15
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Spinal Nerves (31 pairs)
 all are mixed nerves
(sensory and motor)
 4 fiber components
• Sensory
– GSA: general
somatic
afferent
– GVA: general
visceral
afferent
• Motor
– GSE: skeletal
– GVE: visceral
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Typical
Thoracic
Spinal Nerve
31 pairs of spinal
nerves:
8 cervical
12 thoracic
5 lumbar
5 sacral
1 coccygeal
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20
21
Brachial Plexus: Major Branches
• Musculocutaneous (C5-7)
•
Median Nerve (C6-T1)
•
Ulnar Nerve (C8-T1)
•
Axillary Nerve (C5-6)
•
Radial Nerve (C7-8)
22
Brachial Plexus: Major Branches
• Musculocutaneous
(C5-7)
– Biceps Brachii
(C5, C6)
– Coracobrachialis
(C5, C6, C7)
– Brachialis (C5, C6)
23
Brachial Plexus: Major Branches
• Median Nerve (C6-T1)
–
–
–
–
–
–
–
–
Pronator teres
Flexor carpi radialis
Palmaris longus
Flexor digitorum profundus
(lateral)
Flexor digitorum superficialis
Flexor pollicus longus
Pronator quadratus
and hand mm.
24
Brachial Plexus: Major Branches
• Ulnar Nerve (C8-T1, often C7)
 + 13 hand mm.
– Flexor digitorum profundus (medial)
– Flexor carpi ulnaris
25
Brachial Plexus: Major Branches
• Axillary Nerve (C5-6)
– Deltoid
– Teres minor
26
Brachial Plexus: Major Branches
• Radial Nerve (C5-T1)  12 + anconeus
–
–
–
–
–
–
–
–
–
–
–
Brachioradialis
Triceps brachii (C6, C7, C8)
Extensor carpi radialis longus
and brevis
Extensor digitorum
Extensor digiti minimi
Extensor carpi ulnaris
Supinator
Abductor pollicus longus
Extensor pollicus longus and brevis
Extensor indicus
27
Brachial Plexus: Other Nerves
•
Dorsal Scapular (C5)
– Rhomboideus major and minor
– Levator scapulae
•
Suprascapular (C5-6)
– Supraspinatus
– Infraspinatus
– Shoulder joint
•
Subclavian (C5-6)
– Subclavius
•
Lateral Pectoral (C5-C7)
– Pectoralis major and minor
28
• Upper Subscapular (C5-6)
– Subcapularis
• Thoracodorsal (C6-8)
– Latissimus dorsi
• Lower Subscapular (C5-6)
– Teres major
• Long Thoracic (C5-7)
– Seratus anterior
• Medial Pectoral (C8-T1)
– Pectoralis minor and
major
• Medial Brachial Cutaneous
• Medial Antebrachial
Cutaneous
29
30
Brachial Plexus
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Nerves
of the
Upper Limb
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CLNICAL CORRELATION
33
Medical Imaging
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Swan Neck Deformity
A swan neck deformity
describes a finger with a
hyperextended PIP joint
and a flexed DIP joint.
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How does this condition occur?
Conditions that loosen the PIP joint and allow it to hyperextend can produce a swan neck deformity of the finger.
Rheumatoid arthritis (RA) is the most common disease affecting the PIP joint.
The small (intrinsic) muscles of the hand and fingers can tighten up from hand trauma.
Various nerve disorders, such as cerebral palsy, Parkinson's disease, or stroke.
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Mallet
Finger
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How do these injuries of the DIP joint occur?
A mallet finger results when the extensor tendon is cut or torn from the attachment
on the bone. Sometimes, a small fragment of bone may be pulled, or avulsed, from
the distal phalanx. The result is the same in both cases: the end of the finger droops
down and cannot be straightened.
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Boutonniere
Injury
Boutonnière deformity
(buttonhole deformity) is a
deformity in which the middle
finger joint is bent in a fixed
position inward (toward the
palm) and the outermost finger
joint is bent excessively
outward (away from the palm).
This disorder most often
results from rheumatoid
arthritis but can also occur
from injury (such as deep cuts,
joint dislocation, or fractures)
or osteoarthritis
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•
A 34-year-old, African-American male, falls from the roof of a new
home under construction and lands on a cement boulder with impact on
the right, proximal one-third of the humeral diaphysis. Medical history
is significant for HTN, diabetes, and hypercholesterolemia.
Examination in the ER is remarkable for BP 168/90; T 99.9; P 90; R 28.
Bone is evident topographically near the deltoid tuberosity, and there is
bleeding. Inflammatory response is active and there is decreased
ROM; flexor and extensor reflexes are intact. CT reveals shattered
humeral diaphysis with displacement. Surgical intervention is
consistent with internal fixation and bone grafting using osseous tissue
from the ilium ground and mixed with sea coral. The anterior and
posterior circumflex humeral arteries were noted to be intact, and were
clamped during surgery to facilitate repair. Three weeks post-surgery,
the patient complains of significant pain near the site of injury. MRI
reveals AVN of the proximal humeral diaphysis. Which of the
following selections best explains the patient’s condition?
A.
B.
C.
D.
E.
nonunion of bone fragments
malpractice on the part of the surgeon
diabetes
muscle injury
neuropathy
•
Question
A 34-year-old, African-American male, falls from the roof of a new home under
construction and lands on a cement boulder with impact on the right, proximal
one-third of the humeral diaphysis. Medical history is significant for HTN,
diabetes, and hypercholesterolemia. Examination in the ER is remarkable for
BP 168/90; T 99.9; P 90; R 28. Bone is evident topographically near the deltoid
tuberosity, and there is bleeding. Inflammatory response is active and there is
decreased ROM; flexor and extensor reflexes are intact. CT reveals shattered
humeral diaphysis with displacement. Surgical intervention is consistent with
internal fixation and bone grafting using osseous tissue from the ilium ground
and mixed with sea coral. The anterior and posterior circumflex humeral arteries
were noted to be intact, and were clamped during surgery to facilitate repair.
Three weeks post-surgery, the patient complains of significant pain near the site
of injury. MRI reveals AVN of the proximal humeral diaphysis. Which of the
following selections best explains the patient’s condition?
Based on your knowledge of anatomy of the upper limb, what is the
most likely cause of the AVN and the patient’s pain?
A.
B.
C.
D.
E.
nonunion of bone fragments
malpractice on the part of the surgeon
diabetes
muscle injury
neuropathy
•
Question
A 34-year-old, African-American male, falls from the roof of a new
home under construction and lands on a cement bolder with impact on
the right, proximal one-third of the humeral diaphysis. Medial history is
significant for HTN, diabetes, and hypercholesterolemia. Examination
in the ER is remarkable for BP 168/90; T 99.9; P 90; R 28. Bone is
evident topographically near the deltoid tuberosity, and there is
bleeding. Inflammatory response is active and there is decreased
ROM; flexor and extensor reflexes are intact. CT reveals shattered
humeral diaphysis with displacement. Surgical intervention is
consistent with internal fixation and bone grafting using osseous tissue
from the ilium ground and mixed with sea coral. The anterior and
posterior circumflex humeral arteries were noted to be intact, and were
clamped during surgery to facilitate repair. Three weeks post-surgery,
the patient complains of significant pain near the site of injury. MRI
reveals AVN of the proximal humeral diaphysis. Which of the
following selections best explains the patient’s condition?
Based on your knowledge of anatomy of the upper limb, what is the
most likely cause of the AVN and the patient’s pain?
A.
B.
C.
D.
E.
nonunion of bone fragments
Objective: Is to test the student
malpractice on the part of the surgeon
doctor’s understanding of
diabetes
anatomical and vascular
muscle injury
relationships of the upper limb.
neuropathy
•
Question
A 34-year-old, African-American male, falls from the roof of a new
home under construction and lands on a cement boulder with impact on
the right, proximal one-third of the humeral diaphysis. Medical history
is significant for HTN, diabetes, and hypercholesterolemia.
Examination in the ER is remarkable for BP 168/90; T 99.9; P 90; R 28.
Bone is evident topographically near the deltoid tuberosity, and there is
bleeding. Inflammatory response is active and there is decreased
ROM; flexor and extensor reflexes are intact. CT reveals shattered
humeral diaphysis with displacement. Surgical intervention is
consistent with internal fixation and bone grafting using osseous tissue
from the ilium ground and mixed with sea coral. The anterior and
posterior circumflex humeral arteries were noted to be intact, and were
clamped during surgery to facilitate repair. Three weeks post-surgery,
the patient complains of significant pain near the site of injury. MRI
reveals AVN of the proximal humeral diaphysis. Which of the
following selections explains the patients condition?
Based on you knowledge of anatomy of the upper limb, what is the
most likely cause of the AVN and the patient’s pain?
A.
Confirmation B.
Reasoning C.
D.
E.
Elimination
nonunion of bone fragments
malpractice on the part of the surgeon
diabetes
muscle injury
neuropathy
Objective: Is to test the student
doctor’s understanding of
anatomical and vascular
relationships of the upper limb.