APPLIED ANATOMY

UPPER LIMB
Part one
Breast-Applied anatomy
 Developmental abnormalities are not
uncommon
 An abscess of the breast should be opened
by a radial incision to avoid cutting across a
number of lactiferous ducts. Such an abscess
may rupture from one fascial compartment
into its neighbours, and it is important at
operation to break down any loculi which thus
form in order to provide ample drainage.
App anatomy of breast cont.
 Dimpling of the skin over a
carcinoma of the breast results
from malignant infiltration and
fibrous contraction of Cooper’s
ligaments as these pass from
breast to skin, their shortening
results in tethering of the skin to
the underlying tumor. This may
also occur, however, in chronic
infection, after trauma and, very
rarely, in fibroadenosis, so that
skin fixation to a breast lump is not
App anatomy of breast cont.
 Retraction of the nipple, if of recent origin, is
suggestive of involvementof the milk ducts in the
fibrous contraction of a scirrhous tumour
 The excision of a breast carcinoma by radical
mastectomy involves the removal of a wide area of
skin around the tumour, all the breast tissue, the
pectoralis major (through which lymphatics pass to
the internal mammary chain), the pectoralis minor
(which lies as a gateway to the axilla), and the whole
axillary contents of fatty tissue and contained lymph
nodes. This excision also removes the bulk of the
lymphatics from the arm which pass along the
anterior and medial aspects of the axillary vein. A few
lymph vessels from the upper limb
 Bones
-Clavicle
 The weakest point along the clavicle is the junction of
the middle and outer third. Transmission of forces to the
axial skeleton on the shoulder or hand may prove
greater than the strength of the bone at this site and this
indirect force is the usual cause of fracture
 When fracture occurs, the trapezius is unable to
support the weight of the arm so that the characteristic
of the patient with a fractured clavicle is that of a man
supporting his sagging upper limb with his opposite
hand. The lateral fragment is not only depressed but also
drawn medially by the shoulder adductors, principally
the teres major, latissimus dorsi and pectoralis major
 The pronator teres is inserted midway along the
radial shaft. If the radius is fractured proximal to
this, the proximal fragment is supinated (by the
action of the biceps) and the distal fragment is
pronated by pronator teres. The fracture must,
therefore, be splinted with the forearm supinated so
that the distal fragment is aligned with the
supinated proximal end. If the fracture is distal to
the midshaft, the actions of biceps and the pronator
muscles more or less balance and the fracture is,
therefore, immobilized with the forearm in the
neural position
 The humerus
 the lower end of the humerus is angulated
forward 45° on the shaft. This is easily
confirmed by examining a lateral radiograph
of the elbow, when it will be seen that a
vertical line continued downwards along the
front of the shaft bisects the capitulum. Any
decrease of this angulation indicates
backward displacement of the distal end of
the humerus and is good radiographic
evidence of a supracondylar fracture.
 The radius and ulna
 The pronator teres is inserted midway along the
radial shaft. If the radius is fractured proximal to
this, the proximal fragment is supinated (by the
action of the biceps) and the distal fragment is
pronated by pronator teres. The fracture must,
therefore, be splinted with the forearm supinated so
that the distal fragment is aligned with the
supinated proximal end. If the fracture is distal to
the midshaft, the actions of biceps and the pronator
uscles more or less balance and the fracture is,
therefore, immobilized with the forearm in the
neural position .
The important role of pronator
teres in radial fractures. (a) In
proximal fractures, above the
insertion of pronator teres,
the distal fragment is
pronated. Such a fracture
must be splinted in the
supinated position. (b) When
the fracture is distal to
pronator teres insertion, the
action of this muscle on the
proximal fragment is
cancelled by the supinator
action of biceps. This fracture
is, therefore, held reduced in
the neutral position, midway
 The force of a fall on the hand produces different
effects in different age groups; in a child it may cause
a posterior displacement of the distal radial epiphysis,
in the young adult the shafts of the radius and ulna
may fracture, or the scaphoid may fracture whereas,
in the elderly, the most likely result will be a Colles’
fracture. In the last injury, the radius fractures
about 1|in (2.5|cm) proximal to the wrist joint; the
distal fragment is displaced posteriorly and usually
becomes impacted. The shortening which results
brings the styloid processes of the radius and ulna
more or less in line with each other.
 The olecranon process may be
fractured by direct violence but more
often it is avulsed by forcible
contraction of the triceps, which is
inserted into its upper aspect. In
these circumstances the bone ends
are widely displaced and operative
repair, to reconstruct the integrity of
the elbow joint, becomes essential.
A subcutaneous bursa is constantly
present over the olecranon and is
likely to become inflamed when
exposed to repeated trauma.
Students and coal miners share this
hazard so that olecranon bursitis
goes by the nicknames of ‘student’s
elbow’ or ‘miner’s elbow’.
 The bones of the hand
A fall on the hand may dislocate the rest of
the carpal arch backwards from the lunate
which, as commented on above, is wide-
based anteriorly (perilunate dislocation of the
carpus). The dislocated carpus may then
reduce spontaneously, only to push the
lunate forward and tilt it over so that its distal
articular surface faces forward (dislocation of
the lunate).
 The scaphoid may be fractured by a fall on the
palm with the hand abducted, in which position
the scaphoid lies directly facing the radius.The
blood supply of the scaphoid in one-third of cases
enters distally along its waist so that, if the
fracture is proximal, the blood supply to this small
proximal fragment may be completely cut off with
resultant aseptic necrosis of this portion of bone
 The carpal tunnel syndrome
 The carpal tunnel syndrome.’ The flexor retinaculum
forms the roof of a tunnel the floor and walls of which are
made up of the concavity of the carpus. Packed within
this tunnel are the long flexor tendons of the fingers and
thumb together with the median nerve (Fig. 126). Any
lesion diminishing the size of the compartment—for
example, an old fracture or arthritic change—may result
in compression of the median nerve, resulting in
paraesthesiae, numbness and motor weakness in its
distribution. Since the superficial palmar branch of the
nerve is given off proximal to the retinaculum,there is
usually no sensory impairment in the palm.
 Joints
The shoulder
 Dislocation of the shoulder
 Thewide range of movement possible at the
shoulder is achieved only at the cost of
stability, and for this reason it is the most
commonly dislocated major joint. Its inferior
aspect is completely unprotected by muscles
and it is here that, in violent abduction, the
humeral head may slip away from the
glenoid to lie in the subglenoid region,
whence it usually passes anteriorly into a
subcoracoid position
 Theaxillary nerve, lying in relation to
the surgical neck of the humerus
,may be torn in this injury.
 The head of the humerus is drawn medially
by the powerful adductors of the shoulder; its
greater tubercle, therefore, no longer remains
the most lateral bony projection of the
shoulder region, being replaced for this
honour by the acromion process. The normal
bulge of the deltoid over the greater tubercle
is lost; instead there is the characteristic
flattening of this muscle.
 Inreducing the dislocation by Kocher’s
method the elbow is flexed and the
forearm rotated outwards; this stretches
the subscapularis which is holding the
humeral head internally rotated. The
elbow is then swung medially across the
trunk, thus levering the head of the
humerus laterally so that it slips back
into place.
The deformity of shoulder dislocation. The dislocated
head of the humerus is held adducted by the shoulder
girdle muscles and internally rotated by subscapularis.
 In the Hippocratic method, the
foot is used as a fulcrum in the axilla,
traction and adduction being applied
to the forearm; in this way the
humeral head is levered outwards
into its normal position.
The elbow joints
 The joint capsule of the
right elbow—lateral aspect.
 The elbow joint is safely approached
by a vertical posterior incision which
divides the triceps expansion.
 As the capsule is relatively weak
anteriorly and posteriorly it will be
distended at these sites by an
effusion, particularly posteriorly,
since the anterior aspect is covered
by muscles and dense deep fascia.
Aspiration of such an effusion is
readily performed posteriorly on one
or other side of the olecranon.
 The annular ligament is funnel-shaped in
adults, but its sides are vertical in young
children. Asudden jerk on the arm of a
child under the age of 8 years may
subluxate the radial head through this
ligament (‘pulled elbow’). Reduction is
easily affected by firm supination of the
elbow which ‘screws’ the radial head
back into place.
 Posteriordislocation of the elbow may occur
as a result of the indirect violence of a fall on
the hand. Occasionally the coronoid process
of the ulna is fractured in this injury, being
snapped off against the trochlea of the
humerus. Characteristically, the triangular
relationship between the olecranon and the
two humeral epicondyles is lost
 Reduction is effected by traction to
overcome the protective spasm of
the muscles acting on the joint,
together with flexion of the elbow,
which levers the humero-ulnar joint
back into place.
The wrist joint
 Fractures of distal radius.
ADULTS CHILDREN

 Colle’s fracture. 1. Fracture distal

radial epiphysis
 Smith’s fracture. 2. Fracture distal
radial mataphysis
 Barton’s fracture.
 Radial styloid fracture.
 SMITH’S FRACTURE
 Thisis the reverse of Colle’s fracture,
the distal fragment is flexed rather
than dorsiflexed. It is uncommon. It
is due to a fall on the dorsum of the
palmar -flexed wrist or due to a
backward fall on the outstretched
hand
 BARTON’S FRACTURE:

 This is an intra articular fracture of

the distal radius with anterior
displacement of a small fragment
along with the carpus.
Redisplacement is very common after
closed reduction. The fracture is best
managed by open reduction and
application of an Ellis T – plate.
RADIAL STYLOID FRACTURE
(CHAUFFER’S FRACTURE):

 This injury occurs following a direct

blow on wrist or occasionally
following a fall on the wrist . The
fracture line is transverse extending
laterally from the articular surface of
radius and the fracture is more often
undisplaced.
 FRACTURES IN CHILDREN
 FRACTURE DISTAL RADIAL EPIPHYSIS :This is
child’s Colle’s fracture. Due to separation of the
distal radial epiphysis resulting in a displacement
similar to the Colle’s fracture.

 FRACTURE DISTAL RADIAL METAPHYSIS:

METAPHYSIS This may
occur at any level proximal to the epiphyseal
plate. The fracture may be of the greenstick
variety or may be complete.
 SCAPHOID FRACTURE

 The commonest injury of the carpus. Injury

occurs following a fall on the outstretched
hand, typically in young adults.
 Clinical features : patient presents with pain in
the wrist, but function of the wrist may not be
grossly impaired. On examination, there will
be a tenderness over the scaphoid in the
anatomical snuff box, a little swelling and no
bruising. These physical signs suggest a
‘sprained wrist’ rather than a fractures
Brachial plexus injuries
 Deformities of the hand.
 (a) Radial palsy -wrist drop.
 (b) Ulnar nerve palsy-‘main
engriffe’ or claw hand.
 (c) Median nerve palsy-
monkey’s hand’.
 (d) Volkmann’s contracture-
another claw hand deformity.
 The pale blue areas represent
the usual distribution of
anaesthesia.
 Dupuytren’s contracture results
from a fibrous contraction of the
palmar aponeurosis, particularly of
the 4th and 5th fingers.
Presented by
DANA
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