Arthrology of the Upper Limb

Arthrology of the Upper Limb

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Resources: 1) Anatomy of Movement. (AM) Blandine Calais-Germaine

(PT/dancer)

2. 
   Anatomy of Movement, The Exercises. BCG
   
3. 
   Atlas of Human Anatomy. Frank H. Netter.
   
4. 
   Clincally Oriented Anatomy, 3^rd. ed. Keith L. Moore
   
5. 
   Color Atlas of Anatomy, 3^rd ed. Rohen and Yokochi
   
6. 
   Upper extremity model from skeleton.
   

Main message: 1) Diagnoses and treatment always come back to the basic sciences: anatomy, physiology, neurology, biology, histology, microbiology, etc.

2) If you know the normal structure and function, you will immediately know what abnormal is.

3) If you know the anatomy, you can make up the technique that is appropriate for the dysfunctional tissue (Tufts University neurologist perspective).

2. 
   Anatomy lab is an unbelievable opportunity to discover a world that few have the opportunity to. These people have donated themselves to give you an education. Find a part that interests you and fully dissect it in your free time in lab – i.e. superior sagittal sinus, sphenoid, AC jt., axilla, etc.
   

8. 
   Joints of the Upper Limb
   

Plane – Glidying or sliding, i.e. acromion of scapulae and clavicle.

Pivot – Rotation, i.e. atlanto-axial joint.

Saddle – Concave and convex, i.e. carpo-metacarpal joint of the thumb.

Ball and Socket – Spheroidal within a socket, i.e. shoulder and hip.

Hinge(Ginglymus) – Flexion and extension only, i.e. elbow.

Condyloid – Bi axial joints allow movement in 2 directions, i.e. knuckles.
3 Features of a Synovial Joint:

Joint cavity

Articular cartilage

Articular capsule

1. 
   Sternoclavicular Joint [G626;M784-fig. 6.59, N401-402(AM 106)]
   

1. 
   Articulation: “modified” saddle type, diarthrotic synovial jt. Fibrocartilage on ends of bones. Synovial joints are the most common and important type functionally)
   

2. 
   Articular Capsule Ligaments:thick capsule ant./post. with a interclavicular ligament and a costoclavicular lig. Has a fibrocartilaginous disc
   

3. 
   Movements: of clavicle at this point(AM106)
   

4. 
   Neurovascular Bundle:Internal thoracic artery(54 Moore, 3^rd ed)[comes directly off the subclavian artery] and medial supraclavicular nerve (790 Moore, 3^rd ed.)[posterior to the SCM and anterior to the middle scalene](and n to subclavius) subclavius (AM116)is often a neglected mm – necessary in clinical evaluation. Has origin and insertion points – will affect blood supply to UE. Helpful in treating any disorder affecting he UE)[Hilton’s law-nerves supplying a joint also supply the muscles moving the joint and the skin covering the attachments of these mms.])
   

5. 
   Clinicals: will fracture before it will dislocate on most occasions. As you will find with many of the ligamentous attachments – the density makes it often times stronger than bone. (Functional changes of this joint will affect the apices of the lungs and vascular affects to the UE)
   

a. Articulation: plane, diarthrotic synovial jt.

Fibrocartilage on surfaces and angle of plane varies

(S-C and AC BOTH fibrocartilagenous) (Moore 3^rd Ed 609)

(Q: Which joint has an incomplete f-c disc?)

e. Clinicals: very common dislocation with clavicle passing superior to the acromial process of the scapula-referred to as “shoulder separation” (Effective treatment s/p injury is adjusting and KT (Kinesiotaping http://www.kinesiotaping.com). Will provide similar support as the integumentary system).

3. Glenohumeral (shoulder) Joint [G628-630;M789-791; N406; AM 112-113]

a. Articulation:ball & socket, diarthrotic synovial jt.

Hyaline cartilage on shallow glenoid fossa & covering head of humerus. Glenoid fossa extended with figrocartilaginous labrum(like a toilet plunger seal). Joint sacrifices stability to gain ROM (stabilization exercises for teres minor/infraspinatus, teres major/subscapularis include lateral recumbents internal and external rotations with low weight and low reps).

(Netter 398) aids joint capsule. Transverse humeral lig. (Netter 398) helps hold tendon of long head of biceps in place

(AM 119 scapular movement)

6. 
   Neurovascular Bundle: Suprascapular a (Netter 404)
   

Hilton’s Law: Suprascapular- (trunk C5-6),

Axillary- (terminal branch C5-6)

(Ne.405) Lat. Pectoral- (cord C5-7) are main

nerves.
(Brachial plexus memorize for boards)

7. 
   Clinical: Calcium deposits(hydroxyapatite), rotator cuff tears, dislocation(usually anterior & inferior), labrum damage. (labral tears can be difficult to diagnose, need MRI – best to refer earlier than later). Women who are smaller framed, peri-menopausal and elderly have greater chance of frank dislocation).
   

(Clinical evaluation important to look at support system of the supraspinatus, infraspinatus, teres minor, teres major, subscapularis, sublclavius and the most neglected mm in UE management – the pectoralis minor,with it’s 3 insertion points on ribs 3,4 and 5).

4. 
   Elbow Joint [G681-682;M795-802; N419, 421]
   

1. 
   Articulation: hinge, diarthrotic synovial jt. Hyaline cart.(not a great deal of weight bearing on that joint surface).
   

2. 
   Articular Capsule / Ligaments: capsule strengthened by medial/lateral(radial/ulnar) collateral ligs (Netter 412). Medial hd. of triceps and brachialis blend into capsule to “lift” it out of harms way
   

3. 
   Movements:flexion/extension(multiple small bursa) (although pronation and supination is provided by muscles with origins of the medial and lateral condyle Netter 414-5.)
   

4. 
   Neurovascular Bundle: from brachial, radial and ulnar aa(collaterals and recurrents), Hilton’s Law: radial, ulnar and musculocutaneous(and even some median)
   

5. 
   Clinicals: Carrying angle (women make better receivers in volleyball because of an increased CA), bursitis, valgus/varus
   

a syndesmosis type joint. United by fibrous tissue. Interosseous membrane mobilization makes a significant impact in carpal tunnel syndrome)

6. Wrist Joint[ N437-438]

1. 
   Articulation:condyloid type, diarthrotic synovial jt.
   

2. 
   Articular Capsules / Ligaments: thickened on all four sides. Has a fibrocartilagenous disc (Netter 427) from radius to ulna separating head of ulna from lunate and triquetral bone
   

3. 
   Movements:flexion/extension, ab/aduction (radial and ulnar deviation), & circumduction.
   

4. 
   Neurovascular Bundle: radial/ulnar aa, median, radial and ulnar nn(Hilton’s Law)
   

5. 
   Clinicals: effect of anteriorly displaced lunate on median nerve. CTS with a multitude of causes from restrictions
   

7. Intercarpal Joints[N 441]-plane gliding , synovial jts. Many ligaments (I encourage you to try and dissect one of the carpals out of the ligamentous mass). AM 150 gliding joints.

8. 
   Carpometacarpal / Intermetacarpal Joints: Netter 430 with the exception of thumb these are all plane, synovial joints. The trapezium to 1^st metacarpal is a saddle joint(ext/flex,ab/ad,opp,circum)
   

8. 
   Metacarpophalangeal / Interphalangeal Joints
   

Interphalangeal-hinge type-ext/flex