Upper Extremity

Head, Face, & Throat

Anatomy

Head

• Bones

  • Head

    • Frontal

    • Ethmoid

    • Sphenoid

    • Two parietal

    • Two temporal

    • Occipital

• Brain

  • Cerebrum - memory, reasoning, intelligence, learning, judgment, emotions

  • Cerebellum - synergistic movements of skeletal muscles

  • Pons - sleep, posture, respiration, swallowing, bladder

  • Medulla oblongata - the lowest part of the brain stem; heart rate, breathing, blood pressure, coughing, sneezing, vomiting

• Meninges

  • Dura mater --> subdural space --> arachnoid mater --> subarachnoid space   --> pia mater

    • CSF between arachnoid and pia mater

Face

• Supraorbital ridges - frontal sinuses

• Facial skeleton

• Maxillary bone

• Mandible - teeth, larynx, trachea, upper airway, upper digestive tract

• Temporomandibular joint

Dental anatomy

• Crown - portion protruding from the gum

• Root - extends into the alveolar bone

• Dentin - underneath enamel and cementum

• Pulp - within the dentin

Nose

• The nasal septum divides the nasal cavity

Ear

• External

• Middle (tympanic membrane)

• Internal

• Eustachian tube - equalizes pressure between the middle and internal ear

• Auricle (pinna) - external

• External auditory canal (meatus)

Eye

• Eye protected by the sclera

• Cornea covers pupil

Head Evaluation and Injuries

• Retrograde amnesia - loss of memory of events that occurred before injury

• Anterograde amnesia - loss of memory of an event that occurred after injury

• PEARL - pupils equal and reactive to light

• Eye-tracking - nystagmus

• Blurred vision

• Balance testing

  • Romberg test

  • BESS

  • Coordination tests

  • Cognitive tests
     

• Skull fracture

• Cerebral concussions (mild head injuries)

• Post-concussion syndrome

• Second impact syndrome

• Cerebral contusion

• Malignant brain edema syndrome

• Epidural hematoma

• Subdural hematoma

• Migraine headaches

• Scalp injuries

Common Injuries

• Face

  • Mandible joint

  • Mandibular dislocation

  • Temporomandibular joint dysfunction

  • Zygomatic complex fracture

  • Maxillary fracture

  • Facial lacerations

• Dental

  • Tooth fractures

  • Tooth subluxation, luxation, avulsion

    • Wear a mouth guard and care for your teeth

• Nose

  • Nasal fractures and chondral separations

  • Deviated septum

  • Nosebleed

• Ear

  • Auricular hematoma (cauliflower ear)

  • Rupture of tympanic membrane

  • Swimmer's ear (otitis externa)

  • Middle ear infection (otitis media)

  • Impacted cerumen

• Eye

  • Orbital hematoma (black eye)

  • Orbital fractures

  • Foreign body in the eye

  • Corneal abrasions and lacerations

  • Hyphemia

  • Rupture of the Globe

  • Retinal detachment

  • Acute conjunctivitis

  • Hordeolum (sty)

• Throat

  • Contusions

  • Thyroid gland disorders

    • Hyperthyroidism - overproduction of thyroxine

    • Hypothyroidism - deficient secretion of thyroid hormone

Forearm, Wrist, Hand, & Fingers

Forearm

• Anatomy

  • Bones

    • Radius

    • Ulna

  • Articulations

    • Superior radioulnar - pivot joint

    • Middle radioulnar

    • Distal radioulnar

  • Muscles

    • Flexor carpi radialis - wrist flexion, radial deviation, assists elbow flexion, pronation

    • Palmaris longus - wrist flexion

    • Flexor carpi ulnaris - wrist flexion, ulnar deviation

    • Flexor digitorum superficialis - wrist flexion, finger flexion

    • Flexor digitorum profundus - wrist flexion, finger flexion

    • Flexor pollicis longus - flexes thumb, assists in wrist flexion

    • Pronator quadratus - hand pronation

    • Extensor carpi radialis longus - wrist extension, radial deviation

    • Extensor carpi radialis brevis - wrist extension, redial deviation

    • Extensor digitorum communis - wrist and finger extension

    • Extensor carpi ulnaris - wrist extension, ulnar deviation

    • Abductor pollicis longus - thumb abduction, radial deviation

    • Extensor pollicis brevis - thumb extension, ulnar deviation

    • Extensor pollicis longus - thumb extension, radial deviation

    • Extensor indicis - extends index finger

  • Nerve and blood supply

    • Medial nerve - flexors

    • Radial nerve - extensors

    • Brachial artery --> radial and ulnar arteries

• Injuries

  • Contusions

  • Forearm splints

  • Forearm fractures

  • Colles' fracture

  • Smith's fracture

  • Madelung deformity

Wrist, hand, fingers

• Anatomy

  • Bones

    • Scaphoid

    • Lunate

    • Triquetrum

    • Pisiform

    • Trapezium

    • Trapezoid

    • Capitate

    • Hamate

  • Articulations

    • Radiocarpal joints

      • UCL

      • RCL

      • Transverse carpal ligament

    • Carpal joints

    • Metacarpal joints

    • Phalangeal joints

  • Muscles

    • Lumbricales - MCP flexion, interphalangeal flexion

    • Doral interossei - abduction of fingers

    • Palmar interossei - adduction of fingers

    • Abductor pollicis brevis -  thumb abduction

    • Opponens pollicis - pulls thumb in front of palm to touch little fingers

    • Flexor pollicis brevis - flexion, thumb adduction

    • Adductor pollicis - thumb adduction

    • Palmaris brevis - Pulls on skin over hypothenar eminence, deepening the cup of the palm and improving grip

    • Abductor digiti minimi - abduction of 5th finger

    • Flexor digiti minimi brevis - flexion of 5th finger

    • Opponens digits minimi - brings 5th finger out to touch thumb

  • Nerve and blood supply

    • Ulnar nerve - 4th and 5th finger

    • Radial nerve - thumb and thenar area

    • Median nerve - 2nd and 3rd finger

    • Radial and ulnar artery

  • Normal ROM

    • Wrist flexion - 80-90 degrees

    • Wrist extension - 75-85 degrees

    • Radial deviation - 20 degrees

    • Ulnar deviation - 35 degrees

    • Supination - 90 degrees

    • Pronation - 90 degrees

• Wrist Injuries

  • Wrist sprain

  • Triangular fibrocartilage complex injury (TFCC)

  • Tenosynovitis

  • Tendinitis

  • Nerve compression, entrapment, palsy

  • Carpal tunnel

  • DeQuervain's disease (Hoffman's disease)

  • Dislocation of lunate

  • Scaphoid fracture

  • Hamate fracture

  • Wrist ganglion

• Hand and Finger Injuries

  • Contusions/pressure injuries

  • Bowler's thumb

  • Trigger finger or thumb

  • Mallet finger

  • Boutonniere deformity

  • Swan neck deformity (distal)

  • Pseudoboutonniere deformity (proximal)

  • Jersey's finger

  • Dupuytren's contracture

  • Sprain

  • Dislocation

  • Fractures

  • Gamekeeper's thumb

  • Interphalangeal joint sprain

  • PIP dorsal dislocation

  • PIP palmar dislocation

  • MCP dislocation

  • Metacarpal fracture

  • Bennett's fracture

  • Distal phalangeal fracture

  • Middle phalangeal fracture

  • Proximal phalangeal fracture

  • PIP fracture/dislocation

  • Handlebar palsy

  • Paronychia/felon

Upper Body Musculature

Rotator Cuff Muscles

• supraspinatus

• infraspinatus

• teres minor

• subscapularis

Forearm - deep

• triceps brachii

• aconues

• flexor carpi ulnaris

• brachioradialis

• extensor carpi radialis longus

• supinator

• adductor pollicis longus

• extensor pollicis longus

• extensor pollicis brevis

• extensor indicis

• tendons of extensor carpi radialis, longus and brevis

Forearm - superficial

• triceps brachii

• anconues

• brachioradialis

• extensor carpi radialis longus

• extensor carpi radialis brevis

• abductor pollicus longus

• extensor pollicis brevis

• extensor pollicis longus

• flexor carpi ulnaris

• extensor carpi ulnaris

• extensor digiti minimi

• extensor digitorum

• extensor retinaculum

Shoulder muscles and bony anatomy

• scapula

• clavicle

• supraspinatus

• acromion

• subdeltoid bursa

• coracoid process

• humerus

• bicipital tendon

• subscapularis

• biceps brachii (long head and short head)

• triceps

• brachialis

Shoulder Anatomy

Anatomy

• Muscles

  • Levator scapulae - elevation, downward rotation

  • Rhomboid major - Adduction, stabilize, rotate scapula

  • Rhomboid minor - Adduction, stabilize, rotate scapula

  • Serratus anterior - upward rotation, protraction, depression, elevation

  • Trapezius - upper - elevates, lower - depresses, adduction and stabilize the scapula

  • Pectoralis major - flexion, adduction, internal rotation

  • Pectoralis minor - draws scapula anterior and down

  • Deltoid - all - abduction;

    • Anterior - flexion, internal rotation

    • Posterior - extension, external rotation

  • Coracobrachialis - flexion, abduction

  • Biceps brachii - flexion, abduction

  • Supraspinatus - abduction, slight external rotation

  • Infraspinatus - external rotation, slight adduction

  • Teres minor - external rotation

  • Subscapularis - internal rotation

  • Teres major - adduction, extension, internal rotation

  • Latissimus dorsi - adduction, extension, internal rotation

• Neurovascular supply

  • Brachial plexus - C5-T1 - axillary, musculocutaneous, subscapular, dorsal scapular, pectoral, radial

  • Subclavian --> axillary --> brachial artery

Evaluation

• Bones

  • Sternum

    • manubrium, body, xiphoid process

  • Clavicle

    • Medial 2/3 convex, lateral 1/3 concave (most common fracture site)

  • Scapula

  • Humerus

• Articulations

  • Sternoclavicular joint

    • 4 ligaments - anterior SC ligament, posterior SC ligament, costoclavicular ligament, interclavicular ligament

  • Acromioclavicular joint

    • AC ligament, coracoclavicular ligament, coracoacromial ligament, subacromial bursa

  • Scapulothoracic joint

  • Glenohumeral joint

    • Ball and socket; head of the humerus in the glenoid fossa

• Posture

  • Anterior

  • Lateral

  • Posterior

• Malalignments

  • Forward shoulder posture

  • Scapular winging

  • Forward head posture

• Normal ROM

  • Flexion - 170-180 degrees

  • Extension - 50-60 degrees

  • Abduction - 170-180 degrees

  • Adduction - n/a

  • ER - 90-100 degrees

  • IR - 70-80 degrees

  • Horizontal abduction - 120 degrees

• Neurological testing

  • Dermatomes

    • C4 - the upper trapezius

    • C5 - deltoid

    • C6 - radial wrist

    • C7 - the middle finger - palm side

    • C8 - ulnar wrist

    • T1 - inside of the arm

  • Myotomes

    • C5 - shoulder abduction

    • C6 - shoulder flexion

    • C7 - shoulder extension

    • C8 - finger flexion

    • T1 - interossei

  • Reflexes

    • C5 - biceps tendon

    • C6 - brachioradialis tendon

    • C7 - triceps tendon

• Throwing mechanics

  • Windup phase

  • Cocking phase

  • Acceleration phase

  • Deceleration phase

  • Follow-through phase

Injuries

• Clavicle fractures

• Scapular fractures

• Humerus fractures

• Sternoclavicular sprain

• Acromioclavicular sprain

• Glenohumeral joint sprain

• Acute subluxations

• Dislocations

  • Anterior

    • Hill-Sachs lesion

    • Bankart lesion

    • SLAP lesion - type I - type IV

  • Posterior

• Chronic instability

  • Anterior

  • Posterior

  • Multidirectional

• Shoulder impingement

  • Primary

  • Secondary

  • Internal

  • Coracoid

• Bursitis

• Adhesive capsulitis (frozen shoulder)

• Thoracic outlet compression syndrome

• Rotator cuff strain

• Rotator cuff tendinitis

• Rotator cuff tears

• Subacromial bursitis

• Long head biceps tendinitis

• Biceps brachii rupture

• Subluxing bicipital tendon

• Contusions

• Peripheral nerve injuries

Elbow Muscles and bony anatomy

• humerus

• Triceps

• Biceps

• Biceps tendon

• Articular capsule

• radial collateral ligament

• annular ligament

• radius

• ulna

Elbow Anatomy

Anatomy

• Bones

  • Humerus

  • Radius

  • Ulna

    • Convex capitulum with the concave head of the humerus

• Articulations

  • Humeroulnar joint - medial distal humerus - proximal ulna

  • Humeroradial joint - lateral distal humerus - proximal radius

  • The proximal radioulnar joint - radial notch of proximal lateral ulna - radial head - capitulum of the distal humerus

• Ligaments and capsule

  • Ulnar collateral ligament - 3 parts

  • Radial collateral ligament

  • Annular ligament

  • Capsule - thin

• Synovium, bursae, and neurovascular

  • Bicipital bursa

  • Olecranon bursa

  • Cubital tunnel - ulnar nerve

  • Radial tunnel - radial nerve

  • Cubital fossa - biceps tendon, brachial artery, median and radial nerves

  • Posterior triangle - medial and lateral epicondyle, olecranon process

• Muscles

  • Biceps brachii - flexion, supination

  • Brachioradialis - flexion

  • Brachialis - flexion

  • Triceps brachii - extension

  • Anconeus - extension

  • Supinator - supination

  • Pronator teres - pronation

Evaluation

• Carrying angle

  • Normal - males - 5 degrees; females 10-15 degrees

• Cubitus varus or valgus

• Cubitus recurvatum

• Normal ROM

  • Flexion - 145-155 degrees

  • Extension - 0 degrees

  • Supination - 90 degrees

  • Pronation - 90 degrees
     

• Joint mobilizations

  • Humeroulnar traction - increase elbow flexion and extension

  • Humeroradial inferior glides - increase joint space and flexion/extension

  • Proximal anterior radial glide - increase flexion

  • Proximal posterior radial glide - increase extension

  • Medial/lateral ulnar oscillations - increase flexion/extension

Injuries

• Contusion

• Olecranon bursitis

• Strains

• Ulnar collateral ligament

• Lateral epicondylitis

• Medial epicondylitis

• Elbow osteochondritis dissecans

• Little league elbow - valgus extension overload

• Cubital tunnel syndrome

• Dislocation

• Fractures

• Volkmann's contracture

• Medial pain

  • Forearm flexor tendonitis, medial epicondylitis, UCL sprain, or avulsion

• Lateral pain

  • Lateral epicondylitis, radiocapitular OCD

• Posterior

  • Triceps tendinitis, loose bodies, olecranon bursitis

• Anterior

  • Anterior capsule injury, flexor muscle strain