MEMBRUL SUPERIOR

U.M.F.Cluj-Napoca
Osteologie
Osteologie
Osteologie
Osteologie

Carpal Bones (4 proximal, lateral to
medial; 4 distal, lateral to medial)
"Some Lions Try Positions That They
Can't Handle":
Scaphoid, Lunate, Triquetrum, Pisiform,
Trapezoid, Trapezium, Capitate, Hamate.
TrapeziUM at the thUMb"
TrapeziOID is inSIDE"
Flexor carpi superficialis splits in two, to
permit profundus to pass through

Muschii membrului superior




Anatomy Mnemonics

Muscles Inserting into
Humerus
"A lady between two
majors"
Pectoralis major
attaches to lateral lip of
bicipital groove, the
teres major attaches to
medial lip of bicipital
groove, and the
latissimus dorsi
attaches to the floor of
bicipital
groove. The "lati" is
between two "majors"
Rotator Cuff
Muscles (3 greater
tubercle; 1 lesser
tubercle)
SITS:
Superspinatus,
Infraspinatus, Teres
minor, Subscapularis






The arteries of the upper limb

The axillary artery
Course: the axillary artery
commences at the lateral border
of the 1st
rib as a continuation of the
subclavian artery (see Fig. 60.1)
and ends at
the inferior border of teres major
where it continues as the brachial
artery. The axillary vein is a medial
relation throughout its course. It is
crossed anteriorly by pectoralis
minor which subdivides it into
three
parts:
First part (medial to pectoralis
minor).
Second part (behind pectoralis
minor)agives off the lateral
thoracic artery (which helps to
supply the breast) and the
thoracoacromial
artery (p. 75).
Third part (lateral to pectoralis
minor)agives off the
subscapular
artery which follows the lateral
border of the scapula and gives off
the circumflex scapular artery.

Axillary Artery Branches
Save The Lions And Protect
Species: Supreme/Superior
Thoracic Artery,
Thoracoacromial Artery,
Lateral Thoracic, Anterior
Circumflex Humeral, Posterior
Circumflex Humeral,
Subscapular (thoracodorsal
and circumflex scapular
Thoracoacromial Artery
Branches
"CAlifornia Police
Department": Clavicular,
Acromial, Pectoral, Deltoid

The brachial artery
Course: the brachial artery
commences at the inferior border of
teres
major as a continuation of the axillary
artery and ends by bifurcating
into the radial and ulnar arteries at the
level of the neck of the radius. It
lies immediately below the deep fascia
throughout its course. The
brachial artery is crossed superficially by
the median nerve in the midarm
from lateral to medial and hence lies
between the median nerve
(medial relation) and biceps tendon (lateral
relation) in the cubital fossa
(see Fig. 36.3).
Branches:
Profunda brachiiaarises near the
origin of the brachial artery and
winds behind the humerus with the radial
nerve in the spiral groove
before taking part in the anastomosis
around the elbow joint.
Other branchesainclude a nutrient
artery to the humerus and
superior and inferior ulnar collateral
branches which ultimately
take part in the anastomosis around the
elbow.



The venous and lymphatic drainage of the upper limb


Venous drainage of the upper limb

As in the lower limb the venous drainage
comprises interconnected
superficial and deep systems.
The superficial system: comprises the
cephalic and basilic veins.
The cephalic vein commences from the
lateral end of the dorsal
venous network overlying the anatomical
snuffbox. It ascends the
lateral, then anterolateral, aspects of the
forearm and arm and
finally courses in the deltopectoral groove
to pierce the clavipectoral
fascia and drain into the axillary vein.
The basilic vein commences from the
medial end of the dorsal
venous network. It ascends along the
medial then anteromedial
aspects of the forearm and arm to pierce
the deep fascia (in the
region of the mid-arm) to join with the
venae comitantes of the
brachial artery to form the axillary vein.
The two superficial veins are usually
connected by a median cubital
vein in the cubital fossa.
The deep veins: consist of venae
comitantes (veins which accompany
arteries).
The superficial veins of the upper limb are
of extreme clinical importance
for phlebotomy and peripheral venous
access. The most commonly
used sites are the median cubital vein in
the antecubital fossa and
the cephalic vein in the forearm.




Nerves of the upper limb
The brachial plexus (C5,6,7,8,T1)

The plexus arises as five roots.
These are the anterior primary rami of
C5,6,7,8,T1. The roots lie between
scalenus anterior and scalenus
medius.
The three trunks (upper, middle and
lower) lie in the posterior triangle
of the neck. They pass over the 1st rib
to lie behind the clavicle.
The divisions form behind the middle
third of the clavicle around the
axillary artery.
The cords lie in the axilla and are
related medially, laterally and
posteriorly
to the second part of the axillary
artery.
Terminal nerves arise from the cords
surrounding the third part of the
axillary artery.
Nerves of the upper limb
Pectoral Nerves
"Lateral is less,
medial is more"
Lateral pectoral
nerve goes
through pectoralis
major, while medial
pectoral nerve
goes
though both
pectoralis major
and minor.
Brachial plexus



The axillary nerve (C5,6)

Type: mixed sensory and
motor nerve.
Origin: it arises from the
posterior cord of the brachial
plexus.
Course: it passes through the
quadrangular space with the
posterior
circumflex humeral artery. It
provides: a motor supply to
deltoid and
teres minor; a sensory supply to
the skin overlying deltoid; and an
articular
branch to the shoulder joint.
Effect of injury: the axillary
nerve is particularly prone to
injury
from the downward displacement
of the humeral head during
shoulder
dislocations.
Motor deficitaloss of deltoid
abduction with rapid wasting of
this
muscle. Loss of teres minor
function is not detectable
clinically.
Sensory deficitais limited to the
badge region overlying the
lower half of deltoid.

The radial nerve (C5,6,7,8,T1)

Type: mixed sensory and motor.
Origin: it arises as a continuation of
the posterior cord of the brachial
plexus.
Course and branches: it runs with
the profunda brachii artery
between the long and medial heads of
triceps into the posterior compartment
and down between the medial and
lateral heads of triceps.
At the midpoint of the arm it enters the
anterior compartment by piercing
the lateral intermuscular septum. In the
region of the lateral epicondyle
the radial nerve lies under the cover of
brachioradialis and divides
into the superficial radial and posterior
interosseous nerves.
The branches of the radial nerve
include: branches to triceps,
brachioradialis
and brachialis as well as some
cutaneous branches. It terminates
by dividing into two major nerves:
The posterior interosseous
nerveapasses between the two heads
of supinator at a point three
fingerbreadths distal to the radial
head thus passing into the posterior
compartment. It supplies the
extensor muscles of the forearm.
The superficial radial nerveadescends
the forearm under the cover
of brachioradialis with the radial artery
on its medial side.

It terminate as cutaneous branches
supplying the skin of the back of the
wrist and hand.
Effect of injury (Fig. 31.2): e.g.
humeral shaft fracture resulting in
damage to the radial nerve in the
spiral groove.
Motor deficitaloss of all forearm
extensors: wristdrop.
Sensory deficitausually small due to
overlap: sensory loss over the
anatomical snuffbox is usually
constant.
The musculocutaneous nerve
(C5,6,7)
Type: mixed sensory and motor.
Origin: it arises from the lateral
cord of the brachial plexus.
Course: it passes laterally
through the two conjoined heads
of coracobrachialis
and then descends the arm between
brachialis and biceps,
supplying all three of these muscles
en route. It pierces the deep fascia
just below the elbow (and becomes
the lateral cutaneous nerve of the
forearm).

Radial Nerve
Innervations
"BEST":
Brachioradialis,
Extensors,
Supinator, Triceps.
















Practica clinica de zi cu zi
-cele mai importante progrese:
Razboiul II Mondial
-Sterling Bunell - Surgery of the Hand 1944
Manipulare
Sensibilitate
Gesturi
Protectie

Manipulare:
-mentinere independenta
--igiena personala
--munca

Sensibilitate :
-Homunculus senzitiv
--Portiune imensa de neocortex
dedicata mainii.

Gesturi:
-- Socializare


Protectie:
-- reflexa sau nu.

Rolurile mainii
Dublate de o importanta componenta psihologica.
Cuprinsul cursului
Anatomia clinica a mainii
Anatomie topografica Regiunile mainii


Osteologie
Importanta clinica

Inervatia mainii
Importanta clinica

Vascularizatia mainii
importanta clinica

Muschi- tendoane flexori - extensori
Importanta clinica

Mana
Notiuni de topografie
Doua portiuni :
1.Proximala:
-scheletul carpo-metacarpian.

2.Distala:
- cele 5 degete.


1. Regiune palmara
2. Regiune dorsala
Aponevroza palmara
Forma triunghiulara
Varful: tendonul palmarului
lung
3-4 bandelete
Ligamentul metacarpian
superficial
2 septuri in profunzime (spre
M3 si M5) = 3 loje profunde a
palmei.
Mana
Notiuni de topografie
3 loje profunde ale palmei:
1.Loja laterala : tenara.
2.Loja mediala:hipotenara
3.Loja mijlocie:mezotenara
2 straturi : tendoane flexori.
Teaca sinoviala digito-carpiana
Arcade vasculare
Nervii digitali comuni


Un strat muscular interosos.
Tabachera anatomica
Tabachera anatomica
Mana contine :

14 falange
5 oase metacarpiene
8 oase carpiene
Carpul : 8 oase asezate
pe doua randuri
Canalul carpian
OSTEOLOGIE
In total 27 de oase.
Contine 8 oase pe 2 randuri:
Scafoid-Semilunar-Piramidal-
Pisiform
Trapez-Trapezoid-Capitat-
Osul cu carlig

OSTEOLOGIE
Carpul
Contine 8 oase pe 2 randuri:
Scafoid-Semilunar-Piramidal-
Pisiform
Trapez-Trapezoid-Capitat-
Osul cu carlig

OSTEOLOGIE
Carpul


Peretele radial:
scafoid,tuberculul osului
trapez
Peretele ulnar : pisiform,osul
cu carlig
Podeaua: semilunar,capitat
Tavanul: retinaculul flexorilor

Tunelul carpian
Pereti.

Loja laterala:
-tendon flexor radial al
carpului
Loja lui Guyon:
-nervul ulnar
-artera ulnara
Loja mediana:
- nervul median
- restul tendoanelor flexorii
Tunelul carpian
Continut.

Tunelul carpian

Muschii eminentei tenare
Muschii eminentei
hipotenare
Muschii regiunii palmare
mijlocii:
Lumbricali
Interososi palmari
Interososi dorsali
Muschi
In total 5 grupe 19 muschi.

Muschii eminentei tenare


4 muschi in trei planuri :
Scurt abductor al policelui
Opozant al policelui
Scurt flexor al policelui
Adductor al policelui

Muschi
In total 5 grupe.
Muschii eminentei tenare


Inervatie:
Abductorul,opozantul,flexorul :
nervul median
Flexorul , adductorul: ulnar


Muschi
In total 5 grupe.
Muschii eminentei
hipotenare

4 muschi asezati in 3 planuri
Palmar scurt
Flexor scurt al degetului mic
Abductor al degetului mic
Opozantul degetului mic
Muschi
In total 5 grupe.
Muschii eminentei
hipotenare

Inervatie : nervul ulnar
Actiune: flexie falanga
proximala ; abductie in raport
cu axul mainii ; palmarul
scurt muschi atrofiat.
Muschi
In total 5 grupe.
Muschii regiunii palmare
mijlocii:
Lumbricali

Muschi
In total 5 grupe.
-in numar de 4
-Atasati tendoanelor flexorului profund
a degetelor
-Insertia distala pe tendoanele
extensorului
-Inervatie : median pt. cei 2 laterali ;
ulnar pt. cei 2 mediali.
-Actiune : flexori ai falangei proximale
extensori ai celorlalte doua





Muschii regiunii palmare
mijlocii:
Interososi palmari
Muschi
In total 5 grupe.
Muschii regiunii palmare
mijlocii:
Interososi palmari
Muschi
In total 5 grupe.
Muschii regiunii palmare
mijlocii:
Interososi dorsali
Muschi
In total 5 grupe.
Muschii regiunii palmare
mijlocii:
Interososi dorsali
Muschi
In total 5 grupe.
Tendonul flexorului
superficial
Tendonul flexorului
profund
Tendoane flexori
Tunelul carpian

Tendonul flexorului
superficial
Tendonul flexorului profund
Tendoane flexori

Retinaculul extensorilor
6 compartimente
Tendoane extensori
.
Tendoane extensori
.
Tendoane extensori
.

Inervatie mana
Fata palmara :

Nervul median
Nervul ulnar
Nervul radial
Inervatie mana
Nerv median
Nerv radial
Nerv ulnar

Fata dorsala :

Nervul median
Nervul ulnar
Nervul radial
Inervatie mana
Nerv median
Nerv radial
Nerv ulnar

Picture Page Layout
Picture Page Layout
Picture Page Layout
Anestezie nerv median.
Picture Page Layout
Picture Page Layout
Anestezie nerv ulnar.
Anestezie mana:
- nerv ulnar
-nerv median

Picture Page Layout
Picture Page Layout
Anestezie nerv radial.


Anestezie nerv ulnar.
1.Nerv ulnar
2.Condil medial
humerus
3.Proces oleocranian


Anestezie nerv ulnar.
1.Nerv ulnar
2.Condil medial
humerus
3.Proces oleocranian

Anestezie nerv radial.

Anestezie nerv radial.

Anestezie nerv median.
Sectiune transversala deget
Bloc digital.
Mana contine :

Arcada palmara superficiala
Arcada palmara profunda
Artere digitale
Artere metacarpiene

Vascularizatie
Artera radiala
Artera ulnara



Vascularizatie

Vascularizatie

Vascularizatie
Sectiune transversala deget
1. Inspectie:
Pozitia degetelor normal usor flectate.
Un deget anormal de drept poate avea
afectat tendoanele flexorilor
Se cauta pozitii tipice ale mainii :
- Claw hand : afectare ulnar
Clinic
Examinarea mainii traumatizate:
1. Inspectie:

Se cauta pozitii tipice ale mainii :
- Afectare nerv radial:
Clinic
Examinarea mainii traumatizate:

1. Inspectie:

Se cauta pozitii tipice ale mainii :
- afectare nerv median ( mana simiana ape hand):
Clinic
Examinarea mainii traumatizate:
2. Testare senzoriala inainte de anestezie
a. Intepatura ; discriminare in 2 puncte.
b. testare toate teritoriile senzoriale
(median, ulnar, radial)
c. ambele margini ale degetelor


3. Motor
a. Profund blocare mana in extensie,se
solicita flectare varf deget
b. Superficial stabilizare degete in
extensie pt a neutraliza tendonul profund
Se solicita flexia degetului.
Clinic
Examinarea mainii traumatizate:
c. Ramurile motorii ale nervului median:
testare abductia palmara a policelui
contra rezistenta
d.Ramurile motorii ale ulnarului:
pacientul face extensie maxima degete
apoi le indeparteaza.
e. Tendoanele extensorilor
testare extensie
Clinic
Examinarea mainii traumatizate:
Tenorafii
Neurorafii
Clinic
Tratamente posibile:
Osteosinteze
Clinic
Tratamente posibile:
Reimplantare degete amputate
Indicatii absolute
Indicatii relative
Clinic
Tratamente posibile:
Va multumesc pentru atentie.