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Seminar clinical anatomy of upper limb joints and muscles

This is not all, there are many more clinical anatomy in terms of condition such as Popeye Deformity with are not included here and Special Test such as Neer's Impingement and Hawkins Kennedy etc... with touches on the upper limb muscles and joints. Also not forgotten Long tendon test and so forth. In general, this is just a simplified slides. Tq

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Seminar clinical anatomy of upper limb joints and muscles

  1. 1. Clinical Anatomy of Upper Limb Joints and Muscles By : Gan Quan Fu, PT, MSc Human Anatomy (Batch 3)
  2. 2. Contents  Bones and Joints  Important Muscles of Upper Limb  Clinical Anatomy of Upper Limb Joints  Clinical Anatomy of Upper Limb Muscles  Clinical Anatomy of Nerve affect Upper Limb Muscles  Special Diagnostic Test  References
  3. 3. Nerves Relationship of Structures in Upper Limb Muscles Joints & Ligaments Bone  No structures in the Upper Limb act by it’s own, they are all related and integrated hence, diseases or disorder involving one structure will directly or indirectly affect the others.
  4. 4. Bones and Joints of Upper Limb Regions Bones Joints Shoulder Girdle Clavicle Scapula Sternoclavicular Joint Acromioclavicular Joint Bone of Arm Humerus Upper End: Glenohumeral Joint Lower End: See below Bones of Forearm Radius Ulnar Humeroradial Joint Humeroulnar Joint Proximal Radioulnar Joint Distal Radioulnar Joint Bones of Wrist and Hand 8 Carpal Bones 5 Metacarpal 14 Phalanges Intercarpal Joint Carpometacarpal Joint Metacarpophalangeal Joint Interphalangeal Joint
  5. 5. Important Muscles of Upper Limb Muscles Description Trapezius Attach scapula to trunk. Important in raising of arm high (over 90 degrees). Serratus Anterior Attach scapula to trunk. Important in forward punching. Deltoid Covering shoulder. Important in raising arm from the side (30 degrees – 90 degrees). Pectoralis Major Large muscle from front of chest to humerus. Important in bringing raised arm towards chest and moving arm forwards. Latissimus Dorsi Large muscle from middle of back to humerus. Important in bringing raised arm towards chest and moving arm backwards.
  6. 6. Important Muscles of Upper Limb Muscles Description Biceps Prominent muscle on the front of arm. Important in bending elbow and supinate forearm. Triceps Only muscles of the back of arm. Important in straightening the elbow. Brachioradialis Passing from lower end of humerus to lower end of radius. Important for holding elbow at desired angle. Flexor carpi radialis A landmark at front of wrist. Interossei & lumbricals For fine movement of fingers. Thenar muscles Small muscles of thumb Important for movement of opposition of thumb,
  7. 7. Shoulder Joint Dislocation  Most commonly dislocated major joint in body. ◦ Ball & Socket; Synovial Joint ◦ Large head of humerus to shallow glenoid cavity ◦ Capsule is lax (Wide ROM at cost of stability) ◦ Stability depends almost entirely on the strength of surrounding muscles (Rotator Cuff).  Commonly dislocated inferiorly. ◦ Anteriorly shoulder joint protected by subscapularis. ◦ Superiorly shoulder joint protected by supraspinatus. ◦ Posteriorly shoulder joint protected by teres minor and infraspinatus. ◦ Inferior aspect of shoulder joint completely unprotected.
  8. 8. Subacromial Bursitis  Shoulder joint in adducted position = No pain; Shoulder joint in abducted position = Pain ◦ Subacromial bursa is located inferior to acromion, above supraspinatus tendon. ◦ Pain occur when abduction because supraspinatus tendon comes in contact with inferior surface of acromion, inflammed bursa slips up underneath coraco-acromial arch and gets impinged between supraspinatus tendon and acromion.  Dawbarn’s Sign ◦ Pain when deltoid is pressed just below acromion process when arm is adducted. ◦ When arm abducted to 90 degrees pain cannot be elicited by pressure on the point because bursa slips up underneath acromion process.
  9. 9. Frozen Shoulder  Pain and uniform limitation off all movements of shoulder joint, though there is NO evidence of radiological changes in joint.  Occurs due to shrinkage of capsule of shoulder joint (adhesive capsulitis).  Causes: ◦ When nor moving the shoulder joint for a period of time because of:  Pain  Injury  Chronic health condition
  10. 10. Painful Arc Syndrome  Pain in shoulder region and arm during abduction in mid-range (i.e. between 60- 120 degrees).  Complete freedom from pain during initial and terminal stages.  Causes: 1. Tear, inflammatory degeneration, or calcified deposits in supraspinatus tendon. 2. Subacromial bursitis. 3. Contusion and undisplaced fracture of greater tubercle of humerus.
  11. 11. Shoulder Separation (Acromioclavicular Subluxation)  Tearing of coracoclavicular and coracoacromial ligaments caused by downward blow on tip of shoulder.  Coracoclavicular and coracoacromial joint spaces become 50% wider than in normal contralateral shoulder.  Presenting features: 1. Injured arm hangs lower than normal (contralateral arm) 2. Noticeable bulge at tip of shoulder as a result of upward displacement of clavicle.
  12. 12. Carrying Angle  Extended forearm makes an angle with the arm, being deviated slightly laterally.  Anatomical factors responsible: ◦ Medial flange of trochlea is 6mm below than the lateral flange. ◦ Superior articular surface of coronoid process of ulnar is placed obliquely to long axis of Ulnar.  Varies from 5 to 15 degrees  Axis of elbow joint is transverse between radius & humerus, oblique between ulnar and humerus.  Diminishes or disappears when forearm pronated or flexed.  More pronounce in females than males due to wider pelvis.
  13. 13. Student’s Elbow or Miners’ Elbow  Inflammation of subcutaneous olecranon bursa (lying over the subcutaneous triangular area on dorsal surface of olecranon process of Ulna).  Causes a round fluctuating painful swelling of 1” or so in circumference over olecranon.  Occurs due to: 1. Repeated friction as occurs in students who read for long hours with head supported by hand and elbow resting on table. 2. Trauma during falls on elbow 3. Infection from abrasions of skin covering olecranon process.
  14. 14. Tennis Elbow  Repeated or violent extension of the wrist with forearm pronated (i.e. movements required during backhand strokes in lawn tennis), leads to tenderness over lateral epicondyle of humerus.  Possibly due to: ◦ Sprain of radial collateral ligament. ◦ Tearing of fibers of extensor carpi radialis brevis muscle. ◦ Inflammation of the bursa underneath extensor carpi radialis brevis ◦ Strain or tear of common extensor origin.
  15. 15. Pulled Elbow  Also known as radial subluxation.  Vulnerable for preschool children (1-3 years old).  Annular ligament is funnel-shaped in adults, but its sides are vertical in young children. (When child is suddenly lifted/pulled up when forearm is in pronated position, head or radius may slips out partially from annular ligament).  Pain and limitation of supination.
  16. 16. Aspiration of Elbow Joint  Locate the head of radius and capitulum of humerus. (flex elbow to 90 degrees, pronate and supinate forearm and feel with the thumb its rotation).  Insert needle in the palpable depression between proximal part of radial head and capitulum in a direction directly forwards, the joint being flexed to right angle and forearm semi pronated.  Safest and most direct approach. When elbow is distended with pus, the capsule bulges to either side of triceps and hence the pus can easily and effiviently be drained.
  17. 17. Prolonged Immobilisation of Hand  Performed in an optimum position of hand where ligaments are at their maximum length.  If joints are immobilized in any other position for a prolonged period (i.e. 3-6 weeks), ligaments will be shorten and may never regain their normal length, leading to permanent joint stiffness.  Optimum position of hand: ◦ Wrist dorsiflexed by 15-25 degrees ◦ Metacarpophalangeal joints are flexed by 60-90 degrees ◦ Interphalangeal joints are flexed by 5 degrees ◦ Thumb is held in opposition
  18. 18. Preferred site for Intramuscular Injection Deltoid Muscles ◦ Well-developed in most adults and easily accessible. ◦ Injection given in the lower half to avoid injury to axillary nerve. ◦ Exact site of injection: Needle should be inserted in center of triangle. ◦ Place 4 fingers across deltoid muscle with top finger kept along acromial process, injection site is 3 fingers breadth below acromial process.
  19. 19. Paralysis of Serratus Anterior  Functions of Serratus Anterior ◦ Keeps medial border of scapula in contact with chest wall. ◦ Important role in abduction of arm and elevation of arm above horizontal. ◦ Pulls scapula forward as in throwing, pushing and punching.  Effects of paralysis of serratus anterior ◦ Medial border of scapula stands out from the chest wall, particularly when patient is asked to press against a wall in front of him (winged scapula). ◦ Inability to raise arm above head. ◦ Inability to carry arm forward in breast stroke swimming (Swimmer’s Palsy).
  20. 20. Ruptured Supraspinatus  Active initiation of abduction is not possible.  Patient gradually develop a trick of tilting his body towards injured side so that the arm swings away from the body due to gravity leading to 15 degrees initial abduction. Later deltoid and scapular rotators come into play to do the required job.  Sometimes may also lift arm on the side of injury with opposite hand to cause initial abduction
  21. 21. Golfer’s Elbow  Repetitive use of superficial flexors of forearm, strains their common flexor origin with subsequent inflammation of medial epicondyle (medial epicondylitis).  Characterised by pain on medial side of elbow.
  22. 22. Supination and Pronation (Screwing & Unscrewing movements)  Supination is more powerful than pronation because it is an antigravity movement.  Supination is achieved by powerful muscles such as biceps brachii and supinator.  Pronation is achieve by less powerful muscles like pronator teres and quadratus. Gravity also helps movements of pronation.
  23. 23. Touching Live Electrical Wire  In normal position, fingers are partially flexed because flexor muscles in hand are stronger than extensor.  On touching a live electrical wire, the hand closes tightly (flexed and fixed) and holds on to the wire. ◦ On touching live wire, body gets strong stimulus, making all muscles contract. ◦ Since flexor muscles in hand are stronger than extensors, there is a preponderance of flexion of the hand. ◦ Consequently, the hand gets close tightly and holds on the electrical wire.
  24. 24. Suprascapular Nerve Entrapment  Entrapment may occur as it passes through suprascapular notch or in spinoglenoid notch.  Effects: ◦ Typical dull posterior and lateral shoulder pain. ◦ Tenderness, 2.5cm lateral to midpoint of spine of scapular ◦ Weakness of shoulder abduction and external rotation due to involvement of supraspinatus and infraspinatus muscles.
  25. 25. Axillary Nerve damage  Axillary nerve usually damaged by fractures of surgical neck of humerus or due to an inferior dislocation of shoulder joint.  Effects: ◦ Loss or weakness of abduction of shoulder (between 15 degrees to 90 degrees) due to paralysis of Deltoid. ◦ Rounded contour/profile of shoulder is loss due to paralysis of deltoid ◦ Sensory loss over lower half of the outer aspect of shoulder ‘regimental badge area’. Paralysis of teres minor is not easily demonstrated clinically.
  26. 26. Lesion of Musculocutaneous Nerve  Sometimes damaged in fracture of humerus.  Effects: ◦ Weakness of elbow flexion due to paralysis of biceps brachii, and medial two-third of brachialis. ◦ Weak supination of forearm with the elbow flexed at 90 degrees in mid-prone due to paralysis of biceps brachii. ◦ Sensory loss over lateral half of anterior surface of forearm due to involvement of lateral cutaneous nerve of forearm.
  27. 27. Erb-Duchenne Paralysis  Brachial plexus injury at Erb’s point (C5, C6).  Maybe injured during childbirth, due to forcible downward traction of shoulder with lateral displacement of head to other side (Usually during forceps delivery).  Upper limb assumes typical policeman receiving a tip position or waiter’s tip position: ◦ Shoulder adducted and medially rotated. ◦ Elbow extended ◦ Forearm pronated
  28. 28. Erb’s Palsy (Muscle Affected) Muscle Paralysis Loss of Function Effects Deltoid Loss of abduction of shoulder Arm is adducted Supraspinatus, Infraspinatus & Teres Minor Loss of lateral rotation of shoulder Arm is medially rotated Biceps brachii & Brachialis Elbow is extended Loss of flexion of elbow Biceps brachii & Supinator Loss of supination Forearm is pronated
  29. 29. Klumpke’s Paralysis (Claw Hand)  Lower Trunk Injury of Brachial Plexus involving C8 and T1.  Maybe injured due to upward traction (i.e. force abduction in forcible breech delivery).  The lowest root of brachial plexus (T1) is the chief segment concerned with supply of intrinsic muscles of hand.  Effects: ◦ Fingers hyperextended at metacarpophalangeal joint and flexed at interphalangeal joints ◦ Adduction of Fingers is lost. ◦ Sensory loss occurs over medial side of forearm and hand.
  30. 30. Effects of Radial Nerve Injury Depends on site of lesion
  31. 31. Radial Nerve Injury (Axilla)  Causes: ◦ Prolonged use of crutches (Crutch Paralysis)  Effects: ◦ Loss of extension of elbow due to paralysis of triceps. ◦ Loss of extension of wrist due to paralysis of extensor muscles of forearm (Wrist Drop). ◦ Supination of forearm in elbow extension not possible (paralysis of supinator) ◦ Loss of sensation over:  Posterior surface of lower part of arm and narrow strip over back of forearm  Over lateral side of dorsum of hand and lateral 3½ fingers ◦ Loss of triceps and supinator reflexes.
  32. 32. Radial Nerve Injury (Radial Groove)  Causes: ◦ Fracture of shaft of humerus ◦ Improper intramuscular injection ◦ Prolonged pressure (Saturday night paralysis)  Effects: ◦ Triceps brachii is spared (extension of elbow is possible) ◦ Other effects are similar as those of a lesion of radial nerve in axilla
  33. 33. * Wrist drop is most outstanding feature of radial nerve injury.
  34. 34. Ulnar Nerve Injury  Usually injured at following sites: ◦ Elbow ◦ Cubital tunnel ◦ Wrist ◦ Hand  Effects depending on site of lesion
  35. 35. Ulnar Nerve
  36. 36. Ulnar Nerve Injury at Elbow  Easily damage (lies in ulnar groove behind medial epicondyle of humerus)  Causes: ◦ Fracture of medial epicondyle  Effects: ◦ Loss of flexion of terminal phalanges of ring and little finger due to paralysis of flexor digitorum profundus (medial half) ◦ Weakness of flexion and adduction of wrist due to paralysis of flexor carpi ulnaris ◦ Ulnar Claw Hand ◦ Loss of adduction and abduction of fingers due to paralysis of Palmar (adductors) and dorsal (abductors) interossei ◦ Loss of adduction of thumb due to paralysis of adductor pollicis. ◦ Flattening of hypothenar eminence and depression of interosseous space due to atrophy of hypothenar and interosseous muscles
  37. 37. Ulnar Nerve Injury at Cubital Tunnel (Cubital Tunnel Syndrome)  Cubital Tunnel – Formed by tendinous arch connecting 2 heads of flexor carpi ulnaris (arise from humerus and ulna)  Causes: ◦ Entrapment of ulnar nerve in this cubital tunnel (osseofibrous tunnel).  Effects same as ulnar nerve lesion in elbow
  38. 38. Ulnar Nerve Injury at Wrist  Ulnar Nerve at wrist lies immediately medial to ulnar artery and after giving dorsal branch to dorsum of hand, it enters the palm superficial to flexor retinaculum along with artery.  Often injured by penetrating wounds.  Effects similar as ulnar nerve injury at elbow except the flexor carpi ulnaris and flexor digitorum profundus (medial half) are not paralysed.
  39. 39. Ulnar Nerve Injury at Hand (Ulnar Tunnel Syndrome)  Ulnar nerve is compressed in the region where it passes deeply into the muscles of hypothenar eminence through Guyon’s Tunnel (Ulnar Carpal Tunnel). * Formed by pisiform medially, hook of hamate laterally and pisohamate ligament between these 2 bones.  Effects: ◦ Same as those observed in case of ulnar nerve injury at wrist except no loss of cutaneous sensation on ulnar side of hand.
  40. 40. Median Nerve Injury  Usually injured at following sites: ◦ Axilla ◦ Wrist ◦ Carpal Tunnel  Effects depending on site of lesion
  41. 41. Medial Nerve
  42. 42. Median Nerve Injury at Axilla  Motor Effects: ◦ Weakness of pronation of forearm due to paralysis of pronators. ◦ Deviation of wrist to Ulnar side on wrist flexion due to unopposed action of flexor carpi ulnaris. ◦ Weakness of flexion of distal phalanx of thumb and index finger. ◦ Wasting of thenar muscles due to paralysis. ◦ Loss of opposition of thumb due to paralysis of opponens pollicis. ◦ Loss of flexion and weakness of abduction of thumb. ◦ Ape-hand deformity  Sensory Effects: ◦ Loss of cutaneous sensations over palmar surface of lateral 3½ digits and radial two-thirds of palm
  43. 43. Ape-hand Deformity  Paralysis of thenar muscles: ◦ Opponens Pollicis ◦ Abductor Pollicis ◦ Flexor Pollicis  Presenting Features ◦ Thumb laterally rotated and adducted ◦ Loss of thenar eminence ◦ Loss of opposition of thumb
  44. 44. Median Nerve Injury at Wrist  Effects: ◦ Ape-hand Deformity ◦ Loss of cutaneous sensations over palmar surface of lateral 3½ digits and radial two-thirds of palm
  45. 45. Medial Nerve Injury at Carpal Tunnel (Carpal Tunnel Syndrome)  Compression of medial nerve in carpal tunnel.  More common in women than man.  Causes ◦ Tendosynovitis ◦ Bony encroachment (osteoarthritis/injury) ◦ Myxoedema, pregnancy, hypothyroidism etc conditions resulting in fluid accumulation. ◦ Weight gain.  Symptoms ◦ Painful paraesthesia and numbness affecting radial 3½ digits of hand. ◦ Wasting and weakness of thenar muscles. ◦ Loss of sensation or hypoaesthesia to light touch and pin prick over palmar aspect of radial 3½ digits and corresponding part of hand except skin over thenar eminence
  46. 46. Yergason Test  To determine if biceps tendon is stable in bicipital groove.  Steps: ◦ Instruct patient to fully flex elbow. ◦ Clinician grasp the flexed elbow in one hand while holding his wrist with other hand. ◦ External rotate patient’s arm as he resists, at the same time pull downward his elbow.  If biceps tendon is unstable in bicipital groove, it will pop out the groove and patient will experience pain; If stable, it remains secure and patient have no experience of discomfort.
  47. 47. Drop Arm Test  To detects any tears in the rotator cuff.  Steps: ◦ Instruct patient to fully abduct his arm. ◦ Asked patient slowly lower it to his side.  Of there are tears in rotator cuff (especially supraspinatus), arm will drop to side from a position of about 90° abduction.  Patient still will not be able to lower his arm smoothly and slowly no matter how many times he tries.  If he is able to hold his arm in abduction, gentle tap on forearm will cause arm to fall to his side.
  48. 48. Apprehension Test for Shoulder Dislocation  To test for chronic shoulder dislocation.  Steps: ◦ Clinician abduct and externally rotate patient's arm to a position where it might easily dislocate  If patient's shoulder is ready to dislocate, the patient will have a noticeable look of apprehension and alarm on his face and will resist further motion.
  49. 49. Elbow Stability Test  To assess stability of medial and lateral collateral ligaments of elbow.  Steps: ◦ Clinician cup posterior aspect of patient's elbow in one hand and hold patient's wrist with the other. ◦ The hand on the elbow will act as fulcrum, other hand will force the forearm during the test. ◦ Instruct patient to flex his elbow few degrees while forcing his forearm laterally, producing valgus stress on joint’s medial side. ◦ Then do it in reverse direction.  Notice if any gapping collateral ligament with the clinician hand that act as fulcrum.
  50. 50. Tennis Elbow Test  To reproduce pain of tennis elbow.  Steps: ◦ Stabilize patient's forearm and instruct him to make a fist and to extend his wrist. ◦ Apply pressure with other hand to dorsum of his fist in an attempt to force his wrist into flexion.  If patient has tennis elbow, he will experience sudden severe pain at site of wrist extensors’ common origin (lateral epicondyle).
  51. 51. Bunnel-Littler Test  To evaluates the tightness of intrinsic muscles of hand (lumbricals and interossei). Also to determine if flexion limitation in proximal interphalangeal joint is due to tightness of intrinsic or joint capsule contracture.  Steps: ◦ Hold metacarpophalangeal joint in a few degrees of extension. ◦ Try to move proximal interphalangeal joint into flexion.  If in this position, the proximal interphalangeal joint can be flexed, the intrinsic are not tight and are not limiting flexion; However, if the proximal interphalangeal joint cannot be flexed, either the intrinsic are tight or there are joint capsule contracture.
  52. 52. Retinacular Test  Verifies tightness of retinacular ligaments. To determine if flexion limitation in distal interphalangeal joint is due to tightness of retinacular ligaments or to joint capsule contractures.  Steps: ◦ Hold proximal interphalangeal joint in neutral position and try to move distal interphalangeal joint into flexion. ◦ If joint does not flex, limitation is due either to joint capsule contracture or retinacular tightness. ◦ To distinguish either joint capsule contracture or retinacular tightness, flex proximal interphalangeal joint slightly to relax the retinaculum.  If distal interphalangeal joint flexes, the retinacular ligaments are tight. However, if the joint still does not flex, the distal interphalangeal joint capsule is probably contracted.
  53. 53. References  Ellis, H. (1997) Clinical Anatomy; A revision and applied anatomy for clinical student, 9th edn. Blackwell Science; United Kingdom.  Hoppenfeld, S. (1976) Physical Examination of the Spine and Extremities. Prentice-Hall; East Norwalk.  Singh, V. (2007) Clinical & Surgical Anatomy, 2nd edn. Elsevier; New Delhi.  Snell, R.S. (2007) Clinical Anatomy: An Illustrated Review with Questions and Explanations, 3rd Edn. Lippincott Williams & Wilkins; Philadelphia.
  54. 54. Acknowledgment  Thanks to Prof Dr Menon for developing my interest in Anatomy to continue my post graduate, taught me anatomy during my undergraduate and helping me to clear many of my doubts during my undergraduate years.  Thanks to Prof Dr Arulmoli (my post graduate Anatomy HOD), Prof Dr Wai Wai, Dr Jegadeesh, Dr Savinaya and all my post graduate anatomy lecturers.  Thanks to my undergraduate physiotherapist lecturers Mr Pathiban, Mr Vera Perumal, Mr Muthu, Mr Naga, Mdm Chan all my other undergraduate lecturers.  Thanks to my family and my darling Lim Yi Ting for the support.