ARMANDELBOW.

1、1Upper Limb V Arm and Elbow Brachial/AnteriorCubital Region; Elbow JointJohn Halle, Ph.D., PT August 24th, 2004 (8:00)Moore & Dalley:Clinically-Oriented Anatomy,4thed: pp. 668-672, 699-705, 720-733, 795-799; Table6.5.Sauerland: Grants Disseocrt, 12thed.: pp. 199-202Agur & Dalley: Grants Atlas of Ana

2、tomy, 11thed: Plates 6.1-6.2, 6.4-6.14, 6.17-6.63.rdHansen: Frank H. Netter, M.D., Atlas of Human Anatomy , 3 ed/Interactive Atlas (CD-ROM): Plates 403, 404, 408,412, 414-419, 421, 422, 430, 433, 434, 456-461, 464-466; C21-25, C346rdWeir & Abrahams: Imaging Atlas of Human Anatomy , 3 ed.: 67a, b & c

3、; 72; 81a, c & dRohen, Yokochi & L tjen-Drecoll: Color Atlas of Anatomy , 5thed.: 360-3, 367, 374-5, 379, 386-90, 394, 400-1, 405-9As a result of attending the audiovisual presentations, reading/viewing the textbook, atlas and notes, andparticipating in the lab experience, VSM I students should unde

4、rstand and be able to:1.On a skeleton or on a radiograph, demonstrate the bones & bony landmarks of the distal humerus, radius &ulna, and describe the movements, which occur at the elbow & radioulnar joints.2.Describe and demonstrate in anatomical or radiographic cross-sections, the organization of

5、the deep fascia ofthe arm and forearm, and the fascial compartments in terms of functional muscular groups contained,innervations of, and major vessels coursing within each compartment. This should include the specificmuscles in each compartment, their individual attachments and specifics regarding

6、their actions.3.Describe and identify (on a written examination, on an angiogram, or on the cadaver) the components of thecollateral circulation around the shoulder and elbow. Identify the portions of the axillary-brachial artery.4.Describe the pattern of drainage of the deep veins and the superfici

7、al and deep lymphatics of the arm andforearm. Describe the form in which deep veins of the limbs generally occur.5.Delineate the courses of the musculocutaneous, radial, median and ulnar nerves within the arm. Describe theclinical anatomy of each with regard to their course and distribution in the a

8、rm and through the cubital fossa(i.e., the most common sites of injury of each nerve, the structures affected, method of testing for, and clinicalmanifestations of the subsequent palsies).6.What structures delineate the cubital fossa? What structures lie within the cubital fossa? What is theirrelati

9、onship to one another?7.Define, locate, and demonstrate the following structures that comprise the elbow and proximal radioulnar joints:a) collateral ligaments, b) olecranon bursa, c) annular ligament, d) interosseous membrane, and e) articularcapsule8.Be able to describe the following as related to

10、 the elbow joint: a) movements and carrying angles, b) nervesupply, and c) bursae associated with the elbow joint.9.Describe subluxation (incomplete dislocation) and dislocation of the head of the radius. Within the description,be able to identify ligament(s) torn, direction the radius will typicall

11、y move, and the classic position held of theelbow and forearm.10. Describe the relationship of the median cubital vein to the brachial artery and the connective tissue thatseparates them.11. Define the following fractures of the humerus. For each fracture, identify which nerve is likely to be injure

12、d andwhat deficits would be observed as a result of this lesion? a) surgical neck, b) avulsion of the greater tubercle,c) transverse fracture, d) spiral fracture, and e) condylar fractures.Upper Limb VArm and ElbowBrachial/Anterior Cubital Region; Elbow Joint“Big Picture Overview”*The Arm - consists

13、 of the following: (Daileys COA Figure 6.5 aPdfete 418Netters)2*1 bone - humerus*2 muscle compartme nts+ an terior compartme nt- inn ervated by the musculocuta neous n erve (C5-6 to the motorcomp onents - has some C7 invo Ived with the sen sory comp onent of the lateral cutaneous n erve of the forea

14、rm)+ posterior compartme nt - i nn ervated by the radial n erve (C6-8)*Blood supply - main blood supply is derived from bran ches of the deep artery of the arm (profunda brachii artery), with some con tributi ons from the brachial artery.+ media n n erve+ ulnar n erve*The Elbow - con sists of the fo

15、llowi ng structures, spaces and characteristicsP(ate 6.12b GrantsJ18, as well as plates 417 and 41Netter ) s*3 bon es:+ humerus+ ul na+ radius*Cubital fossa - a tria ngular regi on located on the volar surface of the elbow*Common forearm flexor attachme nt - the medial epic on dyle, where many of th

16、e forearmflexors attach (more detail later)*Common forearm exte nsor attachme nt - the lateral epic on dyle, where many of the forearmexte nsors attach (more detail later)*The elbows circulati on is characterized by an exte nsive an astomosis (more detail later)*Hilt on s lawtates that the n erves s

17、uppl ying a joint also supply the muscles moving the joint orthe skin covering their attachments. Therefore, knowing muscles that cross the elbow providesin formati on about the inn ervatio n of the joint and the skin of the regi on of the elbow (moredetail later).Osteology*Components of the Scapula

18、 - viewed from an anterior perspective(ate 6.31b Grant)s*acro mion*coracoid process - mean scrowlike”*superior, margin/an gle*medial and lateral margi ns*in fragle noid tubercle - attachme nt for the long head of the triceps brachii*subscapular fossa*gle noid fossa*in ferior an gle - located at abou

19、t the T7 level*Scapula - viewed from a posterior perspectiveplate 6.31d, Grant )s*spine - base of the spine of the scapula is located at approximately T3*suprasp in atus fossa*in frasp in atus fossa*superior or suprascapular no tch Components of the Humerus - viewed from an anterior perspectiveFplat

20、e 403A Netters3*head*greater tubercle*lesser tubercle*crest of the greater tubercle and lesser tubercle*in tertubercular groove*deltoid tuberosity*lateral and medial suprac on dylar ridge*medial epic on dyle*lateral epic on dyle*medial con dyle*lateral con dyle*radial fossa*capitulum - lateral*coron

21、oid fossa*trochlea - medial*Note: The humerus has 3 borders (an terior, medial and lateral)*Humerus - viewed from a posterior perspective Plate 404A Netters)*groove for the radial n erve, as it winds around the humerus*olecra non fossa*trochlea*groove for the ulnar n erve, as it passes un der the me

22、dial epic on dyle*Radius - viewed from an anterior perspective Plate 422A Netters)*head - narrow end of the bone (at the elbow)*n eck*tuberosity of radius*an terior surface/margi n*in terosseous membra ne*styloid process*Ulna - viewed from an anterior perspective Still using Plate 422A Netters)*head

23、 - narrow end of the bone at the wrist*olecra non*trochlear no tch*coronoid process*radial no tch of ulna*an terior surface/margin of the ulna*tuberosity of ulna*styloid process of ulnaGeneral Orientation of the Free Upper Lim(Plate 456 Netter$*Surfaces - an terior and posterior Borders - medial and

24、 lateral Arm = one bone, the humerus4 Forearm = two bon es, the radius and ulna*Elbow = posterior aspect*Cubital fossa = an terior aspect*Forearm descriptions typically use the radial and ulnar border, since the forearm is so easily manipulated in space*Carrying angle - the angle made by the interse

25、ction of the long axis of the arm and forearm. It isnormally 10to 15in men, and greater than 15in women. The greater carrying angle in wome n isassociated with the typically wider pelvis, that assists with movi ng the forearm away from the bodywhe n carry ing heavy items.Muscle Groups and FasciaPlat

26、es 418A and 418BNetters*Muscle groups -Arm*flexor compartme nt of the arm = an terior compartme nt*exte nsor compartme nt of the arm = posterior compartme nt*Fascia*Superficial fascia of the arm = brachial fascia, that con sists of loose areolar tissue and variableamount of fat*Deep fascia of the ar

27、m = brachial fascia, that con sists of dense conn ective tissue, and twothicke nin gs: (1) lateral septa, and (2) medial septa. These two septa are boun daries that formthe compartme nts of the armDermatomes(Plate 465a Netter$*An area of skin supplied by one spinal root level, e.g., C5*Dermatomes ov

28、erlap con siderably which means that the loss of one spinal cord level(nerve root), usually does not result in the complete loss of sensation for that strip of skin.Typically, three adjace nt spinal cord levels must be lost before a sig nifica nt sen sory deficit isapparent (but, loss of one level o

29、ften results in some diminishment of sensation or an odd sensati on in the affected dermatome)*Dermatomes of the upper extremity.C3+ C4+ C5+ C6+ C7+ C8 + T1*Peripheral n erve cuta neous inn ervati on Plate 6.4a Gra nt)s*This is the region of skin innervated by a named peripheral nerve. Sensory defic

30、its that areassociated with the follow ing peripheral n erves whe n injured occur with in the upperextremity (thus not at the level of the nerve root exiting the foramina in the neck between twoadjace nt vertebrae), and typically have a differe nt patter n tha n the dermatomes.*Peripheral cuta neous

31、 n erves of the upper extremity+ Supraclavicular n erve+ Axillary n erve - superior lateral cuta neous+ Radial nerve - three components: (1) inferior lateral cutaneous, (2) posterior cutaneous nerve of the forearm, and (3) superficial radial n erve5+ Medial cuta neous n erve of the arm (brachial cut

32、a neous n erve) and medial cuta neous nerve of the forearm (an tebrachial cuta neous n erve) - these both are direct bran ches fromthe medial cord of the brachial plexus+ Lateral cuta neous n erve of the forearm (lateral an tebrachial cuta neous n erve - the sensory comp onent that is the con ti nu

33、ati on of the musculocuta neous n erve+ Media n n erve+ Ulnar n erveSupeficial Veins(Plate 466A Netters*Cephalic vein (found laterally in the forearm and arm, between the deltoid and pectoralis major)*pierces the clavipectoral fascia*empties into the axillary vein*Basilic (found on the medial side o

34、f the arm)*ulnar side of forearm*pierces brachial fascia and asce nds in an terior compartme nt of arm and empties into axillaryveinMuscles of the Anterior CompartmenPlate 414A Netter s*Coracobrachialis muscle*Origi n - tip of coracoid process*In serti on - middle 1/3rd of medial surface of humerus*

35、Actio n - flexi on and adducti on of the arm (affects the gle no humeral joi nt)*Nerve - Musculocuta neous (C5-6)C7*Brachialis muscle (Plate 414B Netters*Origi n - distal 1/2 of an terior surface of the humerus*In serti on - coronoid process and tuberosity of the ulna*Actio n - forearm flexi on (elb

36、ow) - most importa nt flexor of the elbow, regardless of the position of the forearm (workhorse of the moti on of elbow flexi on)*Nerve - Musculocuta neous (C5-6)C7*Biceps Brachii muscle - as its name implies, it has two headsPJate 414A Netter s*Origi n:+ short head - tip of coracoid process of scap

37、ula+ long head - supragle noid tubercle of the scapula - from this point, the tendon passesthrough the gle no humeral join t, is surro un ded by syno vial membra ne, and traversesthe intertubercular groove (the position of the tendon is maintained in this groove by thetran sverse humeral ligame nt)*

38、In serti on - in to the tuberosity of the radius and the fascia of the forearm via the bicipital aponeurosis*Actio n - sup in ates foream and, whe n it is sup in ated, flexes the forearm (Sup in at ing a pronated forearm is the primary actio n of the biceps brachii).*Nerve - Musculocuta neous (C5-6)

39、C7*MSR - biceps reflex, C5 primarily (C5-6)Muscles of the Posterior Compartmefftlate 415B and 415ANetters Triceps Brachii muscle6*Origi n:+ Long head - in fragle noid tubercle of scapula+ Lateral head - posterior surface of humerus, superior to the radial groove+ Medial head - posterior surface of h

40、umerus, in ferior to the radial groove. This is the truecounterpart of the brachialis muscle, and it is active with all voluntary elbow exte nsions*In serti on - proximal end of olecra non and fascia of the forearm*Action - forearm exte nsion (the elbow). The medial head is always active and the lat

41、eral andlong heads provide additi onal power*Nerve - radial (C6-8)*MSR - C7 primarily (C7-8)Anconeus muscle Plate 6.51b Grant ) s*Origi n - lateral epic on dyle of the humerus*In serti on - lateral side of the olecra non and superior part of the posterior surface of the ulna*Actio n - forearm exte n

42、sion and stabilizati on of the joi nt*Nerve - radial (C7-T1)Nerves of the Anterior Compartment of the Arffilates 456, 457, 458, 459, 460, 461ANetter) sMusculocuta neous n erve (C5-6C7) - the n erve of elbow flexi on, forearm sup in ati on, and itprovides the sensation for the lateral aspect of the f

43、orearm, once it emerges distally under thecover of the biceps brachii muscle (lateral cuta neous n erve of the forearm old n ame = lateral antebrachial n erve of the forearm)Media n n erve (C5-T1) - Proximally, located an terolateral to brachial artery in the arm, butbecomes medial to the brachial a

44、rtery in the cubital fossa. Sends a branch to the pronator teresmuscles (passes through the two heads of the pron ator teres), and en ters the flexor compartment of the wrist and hand. Provides sen sati on to the thumb, in dex, middle and 1/2 of the ring fin ger(palmar surface and tips of those fin

45、gers dorsally)Ulnar n erve (C7C8-T1) - Located posteromedial to the brachial artery in the arm. At a pointapproximately 1/2 way down the arm, the nerve pierces the medial intramuscular septum, thentravels in the posterior compartme nt of the arm, pass ing behi nd (un der) the medial epic on dyleof t

46、he humerus (ulnar groove), i nto the forearm. This n erve will supply two muscles in the forearmand be the predo minant n erve supply to the intrin sics in the hand. The ulnar n erve supplies sensati on to both the palmar and dorsal surfaces of the little fin ger and the ulnar half of the ring finge

47、r.Radial n erve (C5-T1) - In the proximal arm, the radial n erve is located posterior to the brachialartery. Below the teres major, the radial n erve en ters the posterior compartme nt (al ong with theaccompa nying deep artery of the arm prof unda brachii artery), the n passes betwee n the lateralan

48、d medial heads of the triceps (lies in the radial groove directly on the humerus). Ultimately, theradial nerve spirals around and pierces the lateral intramuscular septum to lie in the an teriorcompartme nt of the arm, just proximal to the elbow. In the regi on of the lateral epic on dyle, theradial

49、 n erve divides into two bran ches that en ter the forearm: (1) superficial radial n erve (sensory onl y), that supplies sen sati on to the dorsum of the thumb, in dex, middle and 1/2 of the ringfin ger, except for the tips (supplied by the media n n erve), and (2) the deep radial n erve(posterior i

50、n terosseous n erve after pass ing through the sup in ator), that inn ervates the extensors of the forearm.7NOTE: Si nee the radial n erve lies directly on the humerus for a porti on of its course, it is morevuln erable to injury with fractures of the humerus.The Brachial Artery (Plates 6.49d Grants

51、 a nd 417 Nettrs*Is the direct con ti nu atio n of the axillary artery (n ame cha nges to the brachial as the arterypasses the lower border of the teres major). During its course through the arm, the brachial arterylies on the coracobrachialis and brachialis muscles.*Termin ates in the cubital fossa

52、, dividi ng in to the two major arteries of the forearm, the radial andulnar arteries*Major branch is the deep artery of the arm profunda brachii artery (that travels with the radial nerve) - this is the chief source of blood supply to the arm, with bran ches to the humerus, bran chescon tributi ng

53、to the an astamoses of the shoulder and elbow. Named bran ches that stem off of thedeep artery of the arm prof unda brachii artery in clude:*Radial collateral artery*Middle collateral artery*Superior ulnar collateral artery (arises in the middle of the arm and travels with the ulnar n erve,and*In fe

54、rior ulnar collateral artery (arises above the elbow, and provides an an astomosis with theposterior and an terior recurre nt arteries (from the ulnar artery) - this n etwork assists withblood flow around the elbow.The Brachial Veins(Plate 412 Netter ) s*The brachial veins are deep veins (collect bl

55、ood from deep tissue), paired, and they asce nd one oneach side of the brachial artery*They are derived from the union of the radial and ulnar veins, returning blood from the forearm*The brachial veins term in ate proximally into the axillary veinThe Cubital FossafPlates 6.49c, 6.49d and 6.49b Grant

56、s)*The cubital fossa is a space in the anterior aspect of the elbow that contains all the major nervesand vessels, except for the ulnar artery (that does not pass through this space since it passesposterior to the medial epic on dyle of the humerus)*Boun daries:*Floor - brachialis muscle*Roof - an t

57、ebrachial fascia*Medial boun dary - pron ator teres*Lateral boun dary - brachioradialis muscle*Contents of the cubital fossa:*Biceps tendon*Brachial artery (and beg inning bifurcatio n of the ulnar and radial arteries)*Median nerve (that may give off a branch anterior interosseous nerve, while still

58、 in the cubitalfossa)*Radial n erve (with both the superficial and deep comp onen ts)Basilic and cephalic veins8The Elbow Joint(Plate 419A Netters A compo und syno vial joint. Two bon es, the radius and the ulna, both articulate with the humerusbone.*Characteristics of the elbow joi nt:*The joint ca

59、vity is con ti nu ous with that of the proximal radio ulnar joint (Thus, a sin glecapsule)*The joi nt betwee n the humerus and the ul na is a uni axial hinge joi nt, permitti ng on ly flexi onand exte nsion*Elbow joint articular surfaces (Plate 419B Netters*Proximally, the articular surfaces con sis

60、t of the capitulum of the humerus and the trochlea ofthe humerus*Distally, the articular surfaces consist of the head of the radius and the trochlear notch of theulna*In the an atomical positi on, the humeroradial joi nt is located laterally, and the humero ulnarjoint is located medially*Elbow Joint