Вы находитесь на странице: 1из 47

Objectives

• Skeleton • structures in the


• anatomical land marks, region of wrist
• cutaneous nerves,
• carpal tunnel
• dermatomes
• superficial veins •Eg.s of clinical aspects.
• lymphatics
• compartments and
the structures in them
• Space of Parona.
Cubital fossa merges the arm to
forearm.
Bounderies of cubital
fossa:
Base - line joining the
epicondyles
Medial - pronator teres.M
Lateral – brachioradialis.M
Roof -skin,
-fascia and
-bicipital aponeurosis
Floor - capsule of elbow joint,
brachialis.M
supinator.M
Contents in the cubital fossa-- medial to
lateral
• Median nerve
• Brachial artery
(with terminal branches)
• Biceps brachii tendon
• Structures on the roof ;
• Basilic and cephalic veins
• Cutaneous nerves of forearm

(medial and lateral.)


Median cubital vein and its communications.

Note; radial.N and terminal branches- deep to lateral bounde


 Skeleton- Radius ulna and interosseous
membrane
 Anatomical/surface land marks
– Medial and lateral epicondyles
– Olecrenon
– Head of radius
– Subcutaneous border of ulna
– Lower ends of radius and ulna
– Styloid processes of radius and ulna
– Dorsal tubercle of radius
– Visible and palpable tendons.
Cutaneous nerves of forearm--
Medial, lateral &
posterior cutaneous nerves of forearm.
Posterior view Anterior view
Dermatomes of
forearm

C5
Superficial
veins
Cephalic vein From dorsal venous
Basilic vein arch
Superficial forearm veins
Median cubital.v
Median cephalic.v
Median basilic.v

Peripheral intravenous
access.
Superficial lymphatics follow the superficial veins;

- medial side- go to
supratrochlear / epitrochlear
nodes and then to the lateral
group of axillary nodes

- Lateral side - go to
infraclavicular nodes
Compartments of the forearm:

• Flexor (anterior) compartment,

• Extensor (posterior) compartment


Flexor compartment;

Superficial Muscles:
1. Pronator teres, M.N
2. Flexor carpi radialis,M.N

3. Palmaris longus, M.N


4. Flexor digitorum-

superficialis, M.N
5. Flexor carpi ulnaris. U.N

1 and 2 = C6 7

3, 4 and 6 = C7 8
Superficial muscles arises from -

-Medial epicondyle of humerus=common flexor origin.

In addition three of them have additional origin,

-Fl. Dig.Suprficialis --med.Lig of elbow, radius & ulna.

-Pronator teres – humerus and ulna.

-Fl. Car. Ulnaris -- ulna.


Superficial muscles - origin and
insertion
Flexor compartment-

Deep muscles.

Flexor digitorum
profundus-

Flexor pollicis
longus,

Pronator quadratus,
Origin and insertion of deep
muscles:
Flexor digitorum profundus-
Flexor pollicis longus,
Pronator quadratus,
Anterior aspect
Deep muscles ; nerve
supply

1.Flexor digitorum profundus,


medial part - ----
Ulnar.N
lateral part– anterior
interosseous .N

2. Flexor pollicis longus,


anterior interosseous.N

3. Pronator quadratus,
anterior interosseous.N.
Action of muscles of flexor compartment-
On joints from elbow to distal inter-phalangeal
joints.
Superficial Muscles: Deep muscles
- Flexor digitorum profundus,

Pronator teres, - Flexor pollicis longus,

Flexor carpi radialis, - Pronator quadratus,
 Palmaris longus,

 Flexor digitorum-

superficialis,
 Flexor carpi ulnaris,

Note thumb has only one interphalangeal


joint.
Nerves of flexor compartment of
forearm.

Median nerve,
C5,6,7,8,T1

Anterior
interosseous .N.
= a branch of median
nerve

Ulnar nerve, C7,8,T1.

Course and relations in this


compartment.
Branches of median nerve
in the anterior compartment of
forearm;
- branches to superficial muscles,

- anterior interosseous branch to


-deep muscles(except medial part of
flex.dig.pro)
-inferior radio-ulnar joint

- articular branches to elbow, sup. radioulnar and


wrist joints,

- palmar cutaneous branch.


Branches of ulnar nerve in the forearm.
- muscular branches to
flexor carpi ulnaris,
flexor digitorum profundus-medial part,

- articular branch to elbow and wrist joints,

At the wrist gives


- dorsal branch,
- Superficial and deep branches.
Blood vessels in the anterior
compartment .
-Radial.A
-Ulnar.A
-Anterior interosseus. A
-Median artery
(persistant part of axial
artery of fetal limb).

Venae comitantes of radial


and ulnar arteries join to
form venae comitantes of
brachial artery.
Deep lymphatics travel
along the deep blood vessel
and go to lateral group of
axillary nodes.
Anterior interosseous atrery supplies
anterior compartment .
Space of Parona
superficial to the pronator quadratus,
deep to the long flexor tendons,

upper limit- oblique origin of


flexor digitorum superficialis.

flexor tendon sheaths protrude


into this space

flexor sheath infections can


extend into this space.
Extensor (Posterior) compartment of forearm
Muscles:
Extensor carpi radialis
longus,

Extensor carpi radialis brevis,

Extensor digitorum,

Extensor digiti minimi,

Extensor carpi ulnaris,

Anconeus.
Supinator,

Abductor pollicis
longus,

Extensor pollicis
longus,

Extensor pollicis
brevis,

Extensor indicis.
Superficial extensors arise
from; -
common extensor origin on
lateral epicondyle of the
humarus

- some muscles are also


attached to
humerus, radius and ulna.
Extensor compartment muscles – origin and
insertion
Tendons go to the hand
under
the extensor retinaculum.
Individual and combination actions
Brachioradialis, Anconeus,

Ext.carpi radialis Supinator,


longus,
Abductor pollicis
Ext.carpi radialis longus,
brevis,
Extensor pollicis
Extensor digitorum, longus,

Extensor digiti minimi, Extensor pollicis


brevis,
Extensors are
Extensor essential
carpi for power of grip.
ulnaris,
Motor innervation:

- Radial nerve supplies (main nerve);


. Brachioradialis,
. Ext.carpi radialis longus.

- Nerve to medial head of triceps (given off in


spiral
groove) supplies anconeus. –

Posterior interosseous .N (branch of radial


nerve). supplies rest of the muscles of the
posterior compartment of the forearm.
Radial .N and Branches
in the forearm;

- posterior interosseous .N
(deep branch)

- articular branches to
radio-ulnar joint

- radial nerve continues as


superficial branch to
the dorsum of the hand.
Blood supply to extensor
compartment
Posterior interosseous artery---
supplies
upper 2/3rds
Anterior interosseous artery---
supplies
lower 1/3rd .
Region of the wrist
Between forearm and hand.

-Carpal tunnel;

anterior aspect

-Extensor tendons;

dorsal aspect

-Anatomical snuff
box;
Carpal tunnel
Space between flexor retinaculum & the carpal bones.
Structures passing through the carpal tunnel;

-Median nerve,
-Tendons of:
. Flexor digitorum superficialis,
. Flexor digitorum profundus,
. Flexor pollicis longus.
Structures passing through the roof of carpal tunnel;
-The tendon of flexor carpi radialis
-The ulnar nerve through Guyons tunnel.

Carpal tunnel
syndrome
Effects of
compression on
median nerve
in the carpal
tunnel.
Structures passing on the roof of the carpal tunnel;
 Tendon of palmaris longus,
 Palmar cutaneous branch of median nerve,
 Superficial branch of radial artery.
 Ulnar artery,
 Superficial veins,
Arterial blood supply in the region of the wrist
Anterior and posterior carpal arterial
arches.

The carpal branches of radial, ulnar, and anterior interosseous


arteries

The carpal arches communicate with dorsal metacarpal


arteries.

Veins- mainly via deep veins.


Six compartments of ext. retinaculum, lateral to
medial:
Abductor pollicis longus,
Extensor pollicis brevis. 1st

Ext.carpi radialis longus


Ext.carpi radialis brevis. 2nd

Ext.pollicis longus 3rd

Ext.digitorum
Ext.indicis 4th

Ext.digitiminimi 5th

Ext.carpi ulnaris. 6th


Anatomical snuff box- on the lateral
aspect
Bounderies:
Lateral,
- abductor pollicis
longus.
- extensor pollicis
brevis,
Medial,
Floor
- extensor pollicis
- longus.
base of 1st metacarpal
- scaphoid,
- trapezium
- styloid process of
radius.
Radial artery passes on the floor of
anatomical-
-snuff
box.
Roof of anatomical snuff box: - fascia and
skin.
Passing in the superficial fascia of the roof--
- cephalic vein
- cutaneous branch of radial nerve.
Clinical aspects

Deformities at the
wrist
- Manus varus = Wrist is fixed in adduction,
- Manus valgus = Wrist is fixed in abduction,
- Cystic swelling of synovial sheath--
ganglion
- Wrist drop = Damage to
- radial nerve
- posterior interosseous nerve.
- Injury to any structure.
- Extention of hand infections into Parona’s
space Etc.
Dinner fork deformity = Displaced fracture at wrist.
End of topic

Be careful