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UPPER LIMB
COURSE CONTENT
COMPETENCIES
The first year medical student should be able to understand and describe the gross anatomy of the various regions, bones, joints, muscles, vessels and nerves of upper limb, demonstrate the actions of the muscle groups at various joints, correlate the anatomical basis of clinical manifestations of nerve injuries and fractures of upper limb and demonstrate the radiological anatomy of upper limb.
REGIONS
Mammary gland; Axilla; Cubital fossa; Fascial spaces of the hand
Definition, location, boundaries, contents (major), venepuncture
Level 2: Details with relations and functional importance of individual structures Fascial spaces – forearm space, radial bursa, ulnar bursa, palmar spaces Dupuytren’s contracture Hand as a functional unit - grips Nerve injury, carpal tunnel syndrome Level 3: Applied aspects: Axilla – Collaterals, lymph nodes (breast), axillary sheath (cervico-axillary canal), abscess drainage Palm – Comparative anatomy (thumb, palmaris brevis), position of rest and of function, collaterals Fascial spaces – Surgical significance
OSTEOLOGY
Identification, region, anatomical position, parts, joints formed, development; (For carpals, identification of individual carpals in an articulated hand)
Level 2: Description, attachments, relations; clavipectoral fascia; boundaries of anatomical snuff-box; salient features about carpals Level 3: Applied aspects: Clavicle – Line of force transmission, commonest site of fracture Scapula – Fracture scapula Humerus – Supracondylar spur, angle of humeral torsion, morphological neck, fractures - proximal end (neck), shaft, distal end (supracondylar) Radius – Colles’ fracture, Smith’s fracture Carpals, Metacarpals, Phalanges – Carpal tunnel syndrome, fracture scaphoid, Bennett’s fracture, mallet finger, trigger finger
ARTHROLOGY
Shoulder girdle; Shoulder joint; Elbow; Radioulnar joints; Wrist; First carpometacarpal joint Bones taking part, classification of joints, movement with muscles causing movements
Level 2: Midcarpal joint, metacarpophalangeal,interphalangeal joints; Details of structure with functional correlation e.g. axis of movements; Retinacula; Bursae
- subacromial bursitis; Dislocation (anterior, posterior, inferior); Fall on the outstretched hand Level 3: Applied aspects: Surgical approaches – shoulder joint; Elbow joint – subluxation of head of radius, tennis elbow, cubitus valgus, pulled elbow, carrying angle; Wrist joint; Radioulnar joints – changing axis during rotation
MYOLOGY
Attachments, nerve supply, actions of:
Pectoralis major, serratus anterior, trapezius, latissimus dorsi, deltoid, subscapularis, biceps brachii, brachialis, triceps brachii, pronator teres, pronator quadratus, flexor pollicis longus, flexor carpi radialis, flexor carpi ulnaris, flexor digitorum superficialis, flexor digitorum profundus, brachioradialis, extensor carpi radialis longus, extensor carpi radialis brevis, extensor carpi ulnaris, extensor digitorum, flexor pollicis longus, flexor pollicis brevis, abductor pollicis brevis, opponens pollicis, adductor pollicis
Level 2: Other muscles; Relations and functional correlation; Quadrangular and triangular spaces; Bicipital aponeurosis; Triangle of auscultation; Intramuscular injections
Level 3: Applied aspects – Volkmann’s ischaemic contracture
ANGIOLOGY
Axillary, brachial, radial, ulnar arteries; Veins; Lymphatics
Commencement, course, branches, termination, main area of distribution and drainage; Anastomosis - scapula, elbow, palmar arterial arch
Level 2: Relations and functional correlation, presence and absence of collaterals in certain areas, venous drainage and lymphatics of upper limb
Level 3: Applied aspects: Artery – Damage to vessels, Allen’s test (to determine, patency of radial and ulnar artery), Raynaud’s disease; Veins – Thrombosis; Lymphatics – Lymphangitis (red streaks), lymphadenitis; Development of arterial system, veins and lymphatics
NEUROLOGY
Nerves – Root value, origin, course, distribution of important nerves e.g. axillary, median, ulnar, musculocutaneous, radial
Brachial Plexus – Location, formation, distribution
Level 2: Root value of other nerves; Details of other nerves; Dermatomes; Ape hand, claw hand, wrist drop; Details of individual deformities
Level 3: Applied aspects: Nerve injury at various sites - radial, median, ulnar, axillary with motor and sensory loss; Winging of scapula, Erb’s palsy, Klumpke’s palsy, Crutch palsy, ulnar paradox; Tendon
reflex - biceps, triceps, brachioradialis; Limb bud, pre- and post-axial borders
CLINICAL, SURGICAL AND FUNCTIONAL ANATOMY
(Anatomical basis only)
NERVES
Brachial plexus – Formation; Injury to upper trunk - Erb’s paralysis; Axillary nerve damage
- IM injection in deltoid; Radial nerve – Wrist drop, IM injection in triceps, anatomical explanation of deformity; Median nerve – Carpal tunnel syndrome, ape hand, motor, sensory loss; Ulnar nerve – Claw hand, motor, sensory loss Level 2: Klumpke’s paralysis; Other causes of axillary nerve damage; Fracture surgical neck humerus; Sites of damage to the radial nerve; Anatomical explanation of the deformites referred to above Level 3: Brachial plexus block; Difference in the high / low injury – ulnar paradox
VESSELS
Artery - Axillary, brachial, radial; Palpable artery - radial pulse Veins – Cephalic, median cubital, basilic vein; Lymphatics Level 2: Anastomosis between axillary and subclavian arteries; Injury during IV injection into median cubital vein; Common sites of vene puncture; Lymphatics in relation to cancer of the breast Level 3: Involvement in supracondylar fracture of humerus; Venesection
BONES
Common sites of fractures of upper limb bones Level 2: Colles’ fracture, clavicle fracture Level 3: Surgical neck and supracondylar fracture of humerus
JOINTS
Shoulder – Anterior dislocation Level 2: Frozen shoulder Elbow – Posterior dislocation Superior radioulnar joint Level 2: Subluxation Wrist – Involvement following Colles’ fracture
MUSCLES
Trapezius – XI nerve injury, deformity; Rotator cuff muscles; Serratus anterior - Winging of scapula; Latissimus dorsi – Climbing; Abductors of the shoulder – Muscles in different ranges of abduction; Pronators / Supinators Level 2: Frozen shoulder, Trapezitis
FASCIA
Dupuytren's contracture
HAND
Palmar spaces; Hand grips
