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Human Gross Anatomy Lecture 5 Part 1

by: Anais Ioschpe

Human Gross Anatomy Lecture 5 Part 1 BISC 2581

Marketplace > George Washington University > Anatomy > BISC 2581 > Human Gross Anatomy Lecture 5 Part 1
Anais Ioschpe
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GWU Human Gross Anatomy Lecture 5 notes from lecture, powerpoint, and handout.
Human Gross Anatomy
Jeffrey Rosenstein; Raymond Walsh;
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This 11 page Class Notes was uploaded by Anais Ioschpe on Saturday January 30, 2016. The Class Notes belongs to BISC 2581 at George Washington University taught by Jeffrey Rosenstein; Raymond Walsh; in Spring 2016. Since its upload, it has received 174 views. For similar materials see Human Gross Anatomy in Anatomy at George Washington University.


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Date Created: 01/30/16
Human Gross Anatomy Lecture 5 Part I on 28/1/16 Introduction to the Upper Limb— Hand Learning Objectives for the Lectures on the Hand 1) List the innervation and major actions of the intrinsic hand muscles 2) Explain the deficits in the hand following injury to median or deep ulnar nerve at the wrist 3) Describe the sensory and motor deficits typical of onset of carpal tunnel syndrome 4) Describe the skin areas of the hand whose sensory innervation is provided by the median ulnar, and superficial radial nerves. 5) Explain Klumpke’s palsy and why it is disabling 6) Describe the arterial supply at the wrist and hand. - Hand • The hand function is frequently affected is many ways not by just falling on an outstretched hand. It can be subjected to insidious trauma that cannot be directly observed. Remember that certain injuries up in the axilla can have dramatic effects on hand function. Nerves injured at the wrist or within the hand can cause various degrees of weakness (paresis_ or loss of function (paralysis) of the intrinsic hand muscles and produce distinctive deformities (that can be explained by understanding the action and innervations - Carpal Tunnel • The entry into the hand is through the carpal tunnel—a natural concavity of the wrist. • Remember that the anatomical arrangement of the carpal (wrist) bones forms a natural concavity. The flexor retinaculum is a thickened band of deep fascia in the palmar aspect of the wrist that is attached medially to the hamate and pisiform and laterally to the trapezium and scaphoid. The flexor retinaculum forms the roof of a tunnel-like space whose passage extends distally through the anterior part of the wrist— the carpal tunnel. • The major structures which pass through the carpal tunnel are: 9 tendons and 1 bone - The median nerve - The tendons of the three anterior forearm muscles which flex the thumb or the fingers that is, the tendon of flexor pollicis longus (used for tendon transplants) - the tendons of flexor digitoum superficialis and profundus—nine tendone and one nerve Page 1 of 11 • The flexor retinaculum retains the insertion tendons of three muscles in constant, close association with the underlying carpals during movements of the hand and its digits • Injury— Carpal Tunnel Syndrom -Entrapment or compression of the median nerve along its course through the carpal tunnel can produce median nerve damage from the mechanical deformation and/or iscemia. -Pain and sensory deficits within the distribution of the digital cutaneous branches of the median nerve are the initial neurologic symptoms (palmar surface of thumb, index, and middle finger). -Motor deficits associated with dysfunction of the (thumb) muscles (thenar eminence) occur subsequent to the onset of sensory deficits. The feeling of pins and needles (disuse atrophy). Conditions which produce such sensory and motor deficits are collectively referred to as the carpal tunnel syndrome -A broad spectrum of injuries, diseases, and conditions can produce carpal tunnel syndrome. • Fractures and dislocations of the wrist, chronic inflammatory conditions such as rheumatoid arthritis and gout, and particularly repetitive wrist movements (those involving forceful flexion of the hand) can produce the syndrome by persistent irritation of the tendons. This causes retention of tissue fluid and attendant swelling and compress the median nerve. Page 2 of 11 -Surgical procedure: theres a special instrument that cuts the flexor retinaculum and freezes the median nerve since its being compressed by fluid pressure. Where it works or not its the surgical procedure. Some people are too serve and the surgery does not help - Hand Musculature • The hand is the best studied by examining muscles arranged in specific groups, i.e. -Muscles of the thenar eminence -Muscles of the hypothenar eminence -Muscles of digits Ulnar artery Ulnar nerve • Thenar eminence -Intrinsic muscles of the thumb are all innervated by the recurrent branch of the median nerve (million dollar nerve)— if its gets damaged then you cant flex your thumbs -3 muscles in the thenar eminence • Abductor pollicis brevis: by its attachment on the lateral aspect of the proximal phalanx abducts the thumb • Flexor pollicis brevis: flexes the metacarpophalangeal joint. • Opponens pollicis: rotates the thumb so that its palmar surface can be opposed to the palmar surface of the digits-opposition-touching of the thumb to each fingertip. Only humans have this muscle. Page 3 of 11 - An additional thumb muscle of great significance is the adductor pollicis— it is not in the thenar eminence but it is considered an intrinsic hand muscle. It takes up the fleshy space between the thumb and the index finger and moves (adducts) the thumb medially against the palm to be parallel to the fingers. It is innervated by the deep ulnar nerve. - ***Important: There are 8 muscles that operate the thumb. • 5 muscles intrinsic to the hand and 4 entrinsic. • Branches of the median, ulnar, and radial nerves are all involved in control of thumb movements. Diagnosis of an upper limb nerve injury often can be made by the position of the thumb— is it abducted, is it adducted or is it flexed ( “dropped”)? • You should be able to make the determination as to the likely position of the thumb following injury to each of the 3 nerves Page 4 of 11 - Hypothenar eminence • Intrinsic muscles of the little finger that appears as a “mirror image” of the thumb muscles. All are innervated by the deep ulnar nerve - Abductor digiti minimi - Flexor digiti minimi: flexes MP joint - Opponens digiti minimi: rotates to touch tip of thumb • Interossei - All innervated by the ulnar nerve - The interosseus muscles run between the metacarpals and are primarily responsible for abduction and adduction of the digits from the anatomical position. The 4 dorsal interossei are numbered 1 through 4. - The 1st dorsal interosseous is associated with the lateral side of the index finger, the 2nd dorsal interosseous with the lateral side of the middle finger, the 3rd dorsal interosseous wih the medial side of the middle finger, and the 4th dorsal interosseous with the medial side of the ring finger. - Each dorsal interosseous had two heads of origin; the heads originate fro mthe contiguous surfaces of two adjacent metacarpals. The two heads have a common tendon of insertion which passes anterior to the side of a finger’s metacarpophalangeal joint before inserting onto the same side of the finger’s dorsal extensor expansion. - The collective actions of the dorsal interossei can be described by the acronym DAB • Starting with the hand in the anatomical position, each Dorsal interosseous can ABduct its fingerEach dorsal interosseous can also help flex the finger at its metacarpophalangeal joint and extent the finger at its interphalangeal joint The dorsal interossei are all innervated by the deep branch of the ulnar nerve. - The 3 palmar interossei are numbered 1 through 3. The 1st palmar interoseous is associated with the medial side of the index finger, the 2nd palmar inerosseous with the lateral side of the ring finger, and the 3rd palmar interosseous with the lateral side of the little finger. Each palmar interosseous originals from the meracarpal of a finger. The tendon of insertion passes anterior to the side of a finger’s metacarophalangeal joint before inserting onto the same side of the finger’s dorsal extensor expansion . - The The collective actions of the palmar interossei can be presented by the acronym PAD. Page 5 of 11 • Starting with the fingers abducted, each Palmar intersseous can ADduct its finger. Each palmar interosseous can also help flex the finger at its metacarpophalangeal joint and extend the finger at its interphalangeal joints. The palmar interossei are all innervated by the deep branch of the ulnar nerve. Paralysis of the palmar interossei results in an ability to squeeze the fingers together along their sides such as firmly holding a sheet of paper between the fingers • Lumbricals - The 4 lumbricals are numbered 1 through 4. The 1st is associated with the index finger, the 2nd lumbrical with the middle finger, the 3rd lumbrical with the ring finger, and the 4th lumbrical with the little finger. Each lumbrical originates within the palm from tendons of flexor digitorum profundus. Each lumbrical extends from its origin by passing anterolaterally to the metacarpophalangeal joint of its finger, after which its inserts onto the lateral side of the finger’s extensor expansion. Each lumbrical can flex its finger at the metacarpophalangeal joint and extend its finger at the interphalangeal joints as in a child waving “bye-bye.” The 1st and 2nd lumbricals are innervated by the median nerve and the 3rd and 4th lumbricals are innervated by Page 6 of 11 the deep branch of the ulnar nerve. Note the difference in innervation it is the same as that of the flexor digitorum profundus in the forearm. • Extensor Expansion (Hood) - The tendons of all the muscles serve to extend the fingers blend together to form the dorsal extensor expansion (or hood). These tendons which cannot be individually dissected are largely responsible for fine and delicate movement of the digits and counter the strong flexors on the palmar surface. The expansion is formed by the tendons of the; extensor digitorum, extensor indicis and digiti minimi, the lumbricals and palmar and dorsal interossei. Page 7 of 11 - Arterial supply of the hand • The blood supply of the hand is mainly provided by two arterial arches which course through the palm of the hand: the superficial palmar arch and the deep palmar arch. Whereas the superficial palmar arch lies anterior to the tendons of flexor digitorum profundus and superficialis, the deep palmar arch lies posterior to these tendons. The superficial palmar arch is the direct continuation of the ulnar artery in the hand. The ulnar artery enters the hand by passing superficial to the flexor retinaculum. The ulnar artery gives off a deep branch immediately distal to the flexor retinaculum, (with the ulnar nerve) and then curves laterally through the palm as the superficial palmar arch. Page 8 of 11 • The superficial palmar arch generally anastomoses in the lateral half of the palm with the superficial branch of the radial artery. The major branches of the superficial palmar arch are the digital arteries that supply the fingers. The deep palmar arch is the direct continuation of the radial artery in the hand. The radial artery enters the dorsal side of the hand after winding around the lateral side of the wrist (and coursing through the anatomical snuffbox). The radial artery gives rise to a superficial branch upon entering the hand, and then curves medially through the palm as the deep palmar arch. The deep palmar arch generally anastomoses in the medial half of the palm with the deep branch of the ulnar artery. Princeps pollicis: which is a major artery of the thumb, typically arises from the radial • artery in the hand. Radialisindicis, which is a major artery of the index finger, typically arises from the radial artery in the hand. The Allen test is a physical test which can determine whether the ulnar and radial arteries provide a sufficient circulation to a patient’s hand. You can practice this test with a partner. Division of muscle innervation of the arteries Page 9 of 11 - How to test nerve damage • Median nerve: A quick test of the median nerve’s motors supply within the hand is to request the patient to touch the base of the little finger with the thumb: this maneuver cannot be executes if oppenen pollicis is paralyzed • Ulnar nerve: A quick test of the ulnar nerve’s motor supply within the hand is to request the patient to clench a piece of paper tightly between the middle and ring fingers as your attempt to dislodge the paper; the paper cannot be tightly clenches if the palmar and dorsal interossei are paralyzed - Damage can form in the axilla, arm, or forearm and may result in the paralysis of adductor pollicis, the 3rd and 4th lumbricals, all the palmar and dorsal interossei, abductor digiti minimi, flexor digiti minimi and opponens digiti minimi • Paralysis of the dorsal interossei and abductor digiti mini restricts the finger from being spread apart through abduction at their metacarpophalengeal joint • Paralysis of the 3rd and 4th lumbricals result in hyperextension of the ring and litle fingers at their metacarpophalangeal joint and flexion of these fingers at their interphangeal joints • Because the disfigured ring and little fingers assume the shape of a clar the affected hand is frequently referred to as a claw hand • Klumpke’s palsy: The muscles which may be partially or completely paralyzed by excessive traction on the lower parts of the brachial plexus include the upper limb muscles whose sole or major innervation is provided by C8 and/or T1 nerve fibers - IF significant damage is sustained by both C8 and T1 nerve fibers, the most important muscular actions compromised by such damage are those of the intrinsic hand muscles • This is because C8 and T1 are the only spinal nerves that provide innervation for not only the intrinsic hand muscles innervated by the deep branch of the ulnar nerve but also the intrinsic hand muscles innervated by the median nerve. Consequently, the loss of the action of both sets of intrinsic hand muscles eventually contorts the hand into a combination of a claw hand and an ape hand, namely, Klumpke’s palsy. Page 10 of 1 1 - RECAP— Nerve injuries • You should now understand and be able to discuss the various nerve injuries that cacn occur in the upper limb - Erb’s Palcy (C5, C6) - Radial nerve (wrist drop, Saturday Night Palsy) Wrist drop • Innervated the extensor muscles (snuffbox muscles) - Median nerve (“ape” hand” ) • Innervates the muscles that flex and rotate - Abductor pollicis breves - Flexor pollicis breves - Opponens pollicis • Lumbricals 1 and 3 (index and middle) Palsy Benediction • Palsy benediction: median nerve injury—Adductor pollicis is out • Ape hand: thenar eminans becomes flat - Ulnar nerve (“claw” hand) • Innervates the adductor muscles - Adductor pollicis - Abductor digit minimi - Flexor opponens digiti minimi Ape hand - Opponens digiti minimi • Lumbricals 3 and 4 (ring and little), Palmar (4), and dorsal (4) interossei • Claw hand: adducted thumb (diagnostic thumb) - Klumpke’s palsy (C8, T1) • Test question: wrist drop is an injury to the…(list muscles, tendons, nerves, etc) • “pan”- means nerve injury Claw hand Page 1 1 of 1


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