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    MSK IV: Upper Limb and Shoulder: Brachial Plexus

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    Kevin Yixi Ren
    1. The document summarizes the anatomy of the upper limb and shoulder, including muscles, nerves, and movements. Key points include: 2. The brachial plexus forms from nerve roots C5-T1 and divides into anterior and posterior divisions that innervate flexor and extensor muscles respectively. 3. Important nerves include the musculocutaneous, median, ulnar, axillary, and radial nerves. 4. The scapula is stabilized and rotated by muscles like the trapezius, serratus anterior, and rhomboids to allow shoulder movement.

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    MSK IV: Upper Limb and Shoulder: Brachial Plexus

    Uploaded by

    Kevin Yixi Ren
    73 views7 pages
    1. The document summarizes the anatomy of the upper limb and shoulder, including muscles, nerves, and movements. Key points include: 2. The brachial plexus forms from nerve roots C5-T1 and divides into anterior and posterior divisions that innervate flexor and extensor muscles respectively. 3. Important nerves include the musculocutaneous, median, ulnar, axillary, and radial nerves. 4. The scapula is stabilized and rotated by muscles like the trapezius, serratus anterior, and rhomboids to allow shoulder movement.

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    MSK 4

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    MSK 4

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    1. The document summarizes the anatomy of the upper limb and shoulder, including muscles, nerves, and movements. Key points include: 2. The brachial plexus forms from nerve roots C5-T1 and divides into anterior and posterior divisions that innervate flexor and extensor muscles respectively. 3. Important nerves include the musculocutaneous, median, ulnar, axillary, and radial nerves. 4. The scapula is stabilized and rotated by muscles like the trapezius, serratus anterior, and rhomboids to allow shoulder movement.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Download as docx, pdf, or txt
    73 views7 pages

    MSK IV: Upper Limb and Shoulder: Brachial Plexus

    Uploaded by

    Kevin Yixi Ren
    1. The document summarizes the anatomy of the upper limb and shoulder, including muscles, nerves, and movements. Key points include: 2. The brachial plexus forms from nerve roots C5-T1 and divides into anterior and posterior divisions that innervate flexor and extensor muscles respectively. 3. Important nerves include the musculocutaneous, median, ulnar, axillary, and radial nerves. 4. The scapula is stabilized and rotated by muscles like the trapezius, serratus anterior, and rhomboids to allow shoulder movement.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Download as docx, pdf, or txt
    of 7

    1

    MSK IV: Upper Limb and Shoulder

    In appendages, several muscles fuse together to form much larger


    group of muscles with the necessary power to move joints of
    appendages
    In the appendicular skeleton, nerves from 2-3 spinal levels innervate
    one muscle
    Each spinal level controls both flexor and extensor compartments (via
    interneurons that will relax extensors while flexors contract, and vice
    versa)

    Brachial Plexus
    Nerve roots from C5-T1
    Joining together of at least two vertebral levels
    Anterior flexor and posterior extensor divisions separate; flexors to
    front, extensors to back
    Flexors innervated by: musculocutaneous, median, ulnar nerves
    Extensors innervated by: = axillary, radial
    Flexor Compartment Nerves of the Upper Limb
    Musculocutaneous Nerve
    Deep branches innervate flexors of arm, crosses elbow joint, and
    becomes superficial cutaneous nerve to innervate skin on lateral
    forearm
    Median Nerve
    Extends past elbow, innervating flexors of forearm
    Crosses wrist joint, supplying a few thumb muscles, then becomes a
    superficial cutaneous nerve supplying medial aspect of thumb, and
    lateral two fingers
    Ulnar Nerve
    Innervates flexors of hand, abducts and adducts fingers
    Becomes superficial cutaneous nerve supplying ventral surface of
    medial two fingers
    Extensor Compartment Nerves of the Upper Limb
    Axillary Nerve
    Extends behind humerus to innervate deltoid muscles from posterior
    Then becomes superficial cutaneous, supply lateral arm
    Radial Nerve
    Innervates triceps
    Gives off deep branches innervating all extensors of forearm

    Has superficial cutaneous branches along its entire length, innervating


    much of the skin on the posterior arm, forearm, and hand

    Narrowing of the Interscalene Triangle


    Scalene muscles attach to front and back of transverse processes of
    cervical vertebrae, and to the first and second rib
    Middle, posterior, and anterior scalene muscles form an interscalene
    triangle from where the brachial plexus and arteries emerge
    Contribute to lateral bending of cervical spine

    Supranumerary rib = development of extra rib in neck can raise the


    floor of interscalene triangle
    Affects C8, T1 spinal nerves
    Motor = finger abduction and adduction lost
    Sensory = loss of sensation of C8 and T1 dermatomes
    Motor and sensory loss would occur at both front and back of upper
    limb, as nerves are affected before brachial plexus divided into
    anterior and posterior divisions
    Extra rib can also prevent impair flow through subclavian artery
    Diagnose by taking brachial pulse, comparing with other side
    Scalene hypertrophy due to excessive exercise can narrow apex of of
    interscalene triangle, putting more pressure on top roots of brachial
    plexus

    Saturday Night Palsy


    Brachial plexus compression leading to paralysis and loss of sensation
    in upper limb
    Wrist drop = classic symptom
    Hyperabduction Syndrome
    Stretching of brachial plexus and arteries due to over-abducting the
    arm (such as when sleeping)
    This leads to paralysis of upper limb and paresthesia (pins and
    needles)
    Upper Brachial Plexus Cervical Nerve Root Injuries
    Erbs Palsy
    Affects upper brachial plexus (C5, C6), thus affects proximal
    musculature like shoulders
    Extensor compartment more affected than flexor compartment

    Due to difficult delivery, excessive pulling of head

    Klumpkes Palsy
    Affects lower brachial plexus (C8, T1), thus affects distal musculature
    like forearm and hand
    Difficult delivery, excessive pulling of upper limb

    Extrinsic Muscles of the Back


    Latissimus dorsi = widest muscle of the back
    Attaches to humerus
    Contracts to extend humerus
    Trapezius; muscles on both sides form trapezoid
    3 functional components; anterior, middle, posterior fibres
    Rhomboids = underneath trapezius, retracts and rotates scapula
    Movement of the Scapula
    Scapula is hung up by muscles
    Levator scapulae = originates from transverse processes of cervical
    vertebrae, attaching to top surface of scapula
    Upper trapezius fibres and levator scapulae contract to elevate scapula
    Lower trapezius fibres contracts to depress scapula
    Scapula Rotation
    Lower trapezius also rotates the scapula
    Fibres extend upward, attaching to spine of scapula over top
    This means that when the lower trapezius fibres contract, the
    scapulae actually rotate outward, which also stretches the
    rhomboids
    When upper limb is abducted, humerus bumps onto overhanging
    acromion, so scapula rotation by the lower trapezius fibres is
    important to hyperabduct the upper limb over top of head
    Rhomboids then contract, rotating scapulae back inward
    Essentially, rhomboids and lower trapezius fibres are antagonists

    Serratus anterior and pectoralis minor muscles contract to protract the


    scapula, or roll scapulae over surface of thoracic cage
    Middle trapezius fibres and rhomboids then retract the scapula

    Muscles of the Anterior Thoracic Wall

    Pectoralis major = flexor and adductor of the humerus = antagonist to


    latissimus dorsi
    Attaches to humerus
    Pectoralis minor underneath pectoralis major
    Attaches to coracoid process
    Contracts to protract (pull forward across ribcage) scapula
    Synergistic to serratus anterior

    Deltoid
    3 functional components; anterior, posterior, middle fibres
    Anterior deltoid fibres assist pectoralis major in flexion of humerus
    Posterior deltoid fibres assist latissimus dorsi in extension of humerus
    Middle deltoid fibres abduct humerus to 90 degrees
    To summarize
    Flexion of humerus at shoulder = pectoralis major + anterior deltoid
    fibres
    Extension of humerus at shoulder = latissimus dorsi + posterior deltoid
    fibres
    Shoulder Abduction
    Deltoid muscle extends from pectoral girdle, and drops over head of
    humerus at 90 degree angle
    This is a problem, as contractility of the muscle should be as parallel
    as possible to get maximal force
    Because the deltoid is at such a steep angle, middle deltoid fibres are
    not good initiators of abduction
    Instead, supraspinatus muscle contracts, initiating abduction to 20
    degrees, then middle deltoid takes over to complete abduction to 90
    degrees
    To hyperabduct, lower trapezius fibres then take over (externally
    rotating the scapulae)

    Shoulder Adduction
    Latissimus dorsi and pectoralis major are stretched
    hyperabduction, so they contract to adduct the upper limb

    out

    at

    Shoulder Rotation
    External rotation = posterior deltoid fibres contract
    Internal and medial rotation = anterior deltoid fibres contract
    Protractors and Stabilizers of the Scapula
    Both serratus anterior and pectoralis minor contract to protract the
    scapula, or pull it forward along the ribcage
    Serratus anterior is attached to the medial border of the scapula
    (holding it onto the thoracic cage) and the ribs
    Nerve innervating serratus anterior = long thoracic nerve (roots in C56)
    Long thoracic nerve drops down between latissimus dorsi and
    pectoralis major, right down midaxillary line
    This nerve is very flat, and superficial
    Exception to the rule that nerves are deep, give off motor branches,
    then become superficial
    Innervates each slip of the serratus anterior from the superficial side
    Doesnt have any superficial cutaneous branches; skin on lateral
    thorax innervated by segmental intercostal nerves

    Trauma can easily crush the long thoracic nerve, impairing ability to
    protract scapula; scapula has no means of sticking to the back of the
    thoracic cage
    This leads to a winged scapula
    Ask patient to push on immovable object

    6
    Paralyzed serratus anterior muscle leaves only the pectoralis minor
    to pull the coracoid process forward, causing medial border of
    scapula to stick out backwards
    Dislocation of Acromioclavicular Joint
    3 bones of pectoral girdle = humerus, scapula, clavicle
    Humerus sits on shallow glenoid fossa, which allows for freedom of
    movement, but is prone to dislocation
    Ligaments named after the bony points they connect (acromion,
    coracoid process, clavicle)
    Shoulder Separation
    Force to the acromion forces it downwards, tearing acromioclavicular
    ligament, and in extreme cases, the other two as well
    Shoulder Dislocation
    Head of humerus pops out of glenoid fossa
    Pectoral muscles then pull head of humerus medially
    Head of humerus now covers coracoid process; you can no longer
    palpate the coracoid process via the divet below the clavicle
    Shoulder dislocation can put traction on the axillary and
    musculocutaneous nerves
    Look for sensory loss on areas of the arm supplied by these nerves

    Dislocation of glenohumeral joint


    Arm hyperabducted, then pulled upwards and backwards
    This tears the joint capsule between weakest part of the rotator cuff

    Rotator Cuf
    Attach humeral head to glenoid fossa
    Since humerus capable of circumduction = 4 muscles in rotator cuff
    **On the slide, posterior and anterior view should be switched
    Anterior view
    Subscapularis = on underside surface of scapula
    Posterior view
    Teres minor = below infraspinatus
    Infraspinatus = below spine of scapula
    Supraspinatus = above spine of scapula, initiator of arm abduction
    Torn rotator cuff can affect suprascapular nerve
    Suprascapular nerve inserts into a notch made by the superior
    transverse
    scapular
    ligament,
    supplying
    supraspinatus
    and
    infraspinatus
    Nerve can be entrapped due to inflammation of supraspinatus

    This leads to impairment of abduction initiation


    Since axillary nerve wraps around humeral neck, it can also be
    damaged from humeral fracture and dislocation, impairing deltoid
    function (abduction at 20-90 degrees)

    Stabilizers of Shoulder Joint


    Almost impossible to dislocate humerus superiorly; blocked by long
    head of biceps, rotator cuff, and acromion and coracoid process with
    their associated ligaments
    Weakest point = between heads of teres minor and subscapularis
    SITS = supraspinatus, infraspinatus, teres minor, subscapularis

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