Clinical Anatomy

Upper Limb

Upper Limb
Multi-jointed Structure with a very complex prehensile organ at the end By Convention Breast is discussed with the upper limb Upper limb can be divided into
Breast Bones & Joints Muscles & Tendons Vessels Nerves

Upper Limb

Breast

Modified sweat gland with 15 20 lobules draining ducts , Nipple & Areola Complex & Fat for Contour

Diseases of the Breast are very common. Benign More than malignant . Anatomy is essential to understand the Pathophysiology & Clinical features and to plan management

Upper Limb

Breast

- Examination

4 Quadrants Upper & lower / medial & Lateral Tethering of a lump - Lump attached to ligaments of the breast . When the Lump is pulled or arms are elevated skin over lump Is distorted Fixity to pect major is tested by contracting pect. Major

Axilla is examined with the patient seated & arm supported to relax the muscles . The 5 groups of nodes are examined Carefully
Winging of Scapula if the nerve to serratus anterior is damaged

Upper Limb

Breast

Breast (base) Extends from 2nd to 6th rib & Sternum to the Mid axillary line . Lymphatic Drainage to Axilla & Internal Mammary Nodes Very Important in Total Mastectomy for Breast Cancer

Axilla Is a pyramidal structure Apex outer border 1st Rib Anterior wall pect. major Posterior wall lat dorsi & subscapular muscles Medial wall - serratus anterior & ribs Lateral Wall _ Axillary Vein & Humerus Crucial Knowledge in Axillary Dissection for breast Cancer
Axilla divided into 3 area by pect. Minor (key to axilla) Very important prognostic information in breast cancer

Upper Limb

Upper Limb

Breast

Incisions

Biopsy & Benign Disease

Total Mastectomy

Upper Limb
Important surface markings
Clavicle, acromion of Scapula- to assess fractures and shoulder injuries Medial and lateral epicondyles of humerus&, Elbow - to asses dislocations & fractures of elbow Carpal tunnel -Compression of Median nerve

Radial artery & Brachial artery - pulse rate, BP & injuries

Thenar & Hypothenar eminence Median & Ulna nerve injuries Cephalic & Basilic veins - Venepuncture & feeding lines Anatomical snuff box - Scaphoid fracture

Upper Limb
Bones & Joints

Common Clinical problems are

Fracture Clavicle Fracture shaft of neck Humerus

Supracondylar fracture of Humerus

Fracture Forearm Fractures of Distal end of Radius Colles fracture Scaphoid fracture Dislocation of Shoulder

Dislocation of elbow

Upper Limb
Bones & Joints
Fracture Clavicle

Fractures
- Loss of Contour

Fracture shaft of neck Humerus - Radial & Axillary Nerve palsy Supracondylar fracture of Humerus - Damage to Brachial artery

Fractures of Distal end of Radius - Colles fracture

Scaphoid fracture

- Avascular necrosis

Upper Limb
Bones & Joints
Dislocations

Shoulder- common anterior dislocation - Fall on the hand - rare posterior dislocation - Forced internal rotation of abducted arm - Recurrent dislocations

Elbow - less common triangular relationship lost

Upper Limb
Tendons Flexor tendons Complex system of pulleys and ligaments
and Tendon Sheaths are involved in function. f.d superficialis & profundus Interdigitate and get attached to base of middle and terminal digit of phalanges Repair if damaged is difficult

5 Zones of injury

No Mans land

Upper Limb
Tendons
Ruptures of tendons Long head of biceps brachialis - ruptures in the Bicepital groove - Biceps bunches up in the forearm on flexion - no treatment

Mallet Finger - distal insertion of extensor longus ruptured -

Upper Limb
Boutonniere Deformity rupture of central slip of extensor expansion - needs repair

Trigger finger -

Usually affects the thumb can affect other fingers - constriction due to Stenosing tenosynovitis or tenovaginitis- Finger snaps on flexion

Upper Limb
Nerves
Brachial plexus injuries

Erbs palsy & Klumpkes palsy

Upper Limb
Nerves
Median nerve Injury common Carpal Tunnel Syndrome Cut injuries of Forearm Rarely in elbow fractures Impairment & Deformity depends on the site

Upper Limb
Nerves
Ulna - Common
Injured at elbow - main impairment is with the small muscles of the hand - produces the typical claw hand - ULNA CLAW + ulna sensory loss Ulna nerve thickening easily detected in leprosy

Radial - Injured with fractures of the humerus Causes the classical WRIST DROP due to paralysis of Extensor digitorum, sensory loss is limited to anatomical snuff box area

Upper Limb
Carpal Tunnel Syndrome Entrapment neuropathy

Typically affects a middle aged woman , pain & numbness at night.Exclude other causes . Motor defect - check APB Sensory defect - Radial 31/2 fingers

Upper Limb
Soft Tissues & Tendon insertions Spaces - Pulp space ,subungual space, Thenar space & mid palmar spaces - very important in infections & surgery Tennis Elbow - Tendonitis of extensor insertion at elbow Golfers elbow - Tendonitis of Flexor insertion at elbow Overuse injuries of the wrist - Tendonitis of abductor longus Rotator Cuff Injuries Painful arc Syndrome/Frozen Shoulder

Inflammation of Bursae