00:01
Okay, here we had
the scapula humeral joint
or more simply the shoulder joint.
00:07
Which parts of the
skeleton articulate here?
The humeral head and the
glenoid fossa of the scapula.
00:14
There's only about 25% coverage
of the humeral head,
so dislocation is very common.
00:19
The dislocation can be
posterior or anterior inferior
or the head dislocates down
into the axilla.
00:24
This second location is more common
and the head easily travels forward
under the coracoid process.
00:32
Now, where are the boundaries
of the joint capsule?
It extends from the glenoid to the
anatomical neck of the humerus.
00:39
The anatomical neck is proximal
to the greater tuberosity.
00:43
Think of a face, it's large,
like our large ears on the side
and the lesser tuberosity
is anterior like a small nose.
00:51
The joint capsule has
an axillary recess,
which enables many movements
in the shoulder joint.
00:56
In the anterior joint, we see the
subscapularis muscle and tendon,
which runs from the
subscapular fossa
to the lesser tuberosity.
01:04
Below this tendon there's
also a subscapular recess.
01:08
Both the axillary and subscapularis
recesses are important
and can clearly be seen
with contrast imaging.
01:13
The ligaments surrounding
the shoulder are very small.
01:16
We have our glenohumeral ligaments
arranged like this.
01:18
There's a superior,
medial, and inferior GHL.
01:22
There's also a
coracohumeral ligament
which helps prevent the humeral
head from subluxation downwards.
01:27
Because these ligaments
are thin and weak,
it's important
that we have a rotator cuff.
01:33
These four muscles are the
supraspinatus, infraspinatus,
teres minor, and subscapularis.
01:38
All four muscles,
the internal rotator and
the three external rotators
radiate into the joint capsule
and stabilize it.
01:48
So you can think of the
shoulder joint being constrained
by this rotator cuff.
01:51
Of course, other muscles are also
involved in the shoulder rotation,
such as the deltoid,
with its attachments
to the clavicle,
acromion, and scapular spine.
02:01
It radiates to the
deltoid tuberosity,
but does not enter
the joint capsule.
02:05
It's more of a rotational muscle
in the broader sense
and not considered part of
the actual rotator cuff.
02:11
Here we see the fascicles
of the brachial plexus
with the corresponding nerves
that arise from these fascicles.
02:17
From the brachial plexus
we do not see the spinal cord
segments of C5 through T1,
but we can see the
resulting three trunks.
02:24
Each trunk divides into a
ventral and dorsal portion.
02:27
The dorsal portions formed
the posterior division
behind the brachial artery.
02:35
And the ventral parts together
form a medial and lateral divisions.
02:40
How can the student
orient themselves to this?
There are two ways
to find the lateral division.
02:45
The first method is to search for
the nerve that lies in the middle,
the median nerve.
02:52
Because it's in the middle,
it's formed by confluence of
the medial and lateral divisions.
02:59
With this nerve identified,
you can trace the median nerve
proximally and laterally
where you'll come to
the lateral division.
03:08
The second option is to reference
the coracobrachialis muscle,
one of the three upper arm muscles.
03:14
It's pierced by the
musculocutaneous nerve,
the only nerve that originates
from the lateral division.
03:21
So remember,
the musculocutaneous nerve
comes from the lateral cord.
03:27
Now we're here on the median nerve,
which has contributions of both
the medial and lateral cord.
03:32
If we go up the medial cord,
we come to the
medial cord branch point.
03:36
Three nerves come
from the medial cord.
03:40
There's one larger nerve and
two smaller nerves seen here.
03:45
The thicker one is the ulnar nerve,
which travels immediately
on the unlar side
of the medial of a
condyle of the humerus.
03:52
It lies just under
the skin at this point
and can be easily injured.
03:56
The two thin branches
are for sensation
of the upper arm and forearm.
04:00
Namely the
medial brachial cutaneous nerve
and the
antebrachial cutaneous nerve.
04:08
To see the posterior cord we need
to go behind the brachial artery.
04:12
At this point we see two nerves.
04:14
One being the axillary nerve
which can be seen here.
04:16
It then pierces
the lateral axillary septum here
and travels backwards through
the lateral axillary space.
04:24
We can explain that later.
04:27
The other nerve we find here
is the radial nerve
which can be seen here.
04:31
The radial nerve travels along
the posterior aspect of the humerus
directly on the bone
between the medial and lateral
heads of the tricep muscle.
04:40
This nerve can be easily injured
by humerus fracture
as it runs here
in the spiral sulcus.
04:46
Now we look again at the posterior
cord of the brachial plexus.
04:51
It lies behind the brachial artery
and gives off
the radial and axillary nerves.
04:57
The axillary nerve disappears here
into the lateral axillary gap
in the lateral axillary space.
05:04
where I'm placing the forceps.
05:07
We're now looking at
it from the other side.
05:10
Here we see the forceps on the
dorsal side of the shoulder blade.
05:14
We see here the infraspinatus muscle
below the scapular spine,
the teres minor, the teres major,
and here is the
long head of the triceps.
05:25
Here we have the
square axillary gap
and here we have the
triangular medial axillary gap.
05:31
Remember, the square is lateral,
triangle is medial.
05:35
A simple learning aid
is to use your fingers.
05:38
You take your index
and middle finger of your left hand
in the index finger
of your right hand.
05:42
The humerus would be the side
and this would be
the long head of the triceps.
05:48
Finally,
this is the teres major muscle.
05:53
And up here,
I have the teres minor muscle.
05:55
You can see that we have
a triangular space medially
in the square axillary space
laterally.
06:02
In addition to the axillary nerve,
the posterior humeral
circumflex artery
runs through the
lateral axillary space.
06:09
It makes a circular arch around the
posterior aspect of the humerus.
06:14
Another artery,
the anterior circumflex artery
runs to the medial axillary space.
06:19
Occasionally,
the small subscapular nerve
runs in front of the
subscapularis muscle.
06:27
Here from the brachial plexus,
we see the muscular cutaneous nerve,
which comes from the lateral cord.
06:32
The small L for lateral
looks like a one.
06:35
So remember, only one nerve
comes from the lateral cord
but it does also contribute to the
lateral portion of the median nerve.
06:41
So we say one and a half
because it's a nerve,
the muscular cutaneous nerve,
and here radiation
namely the lateral radiation
to the radial portion
of the median nerve.
06:49
How does the
muscular cutaneous nerve travel?
Remember, it appears as the
coracobrachialis muscle belly.
06:55
This can be a compression point.
06:57
And then it runs into the
upper arm flexor group here
and innervates the
coracobrachialis,
the brachialis,
and the biceps brachii muscles.
07:07
It then travels distally.
07:09
And because it arises
from the lateral fascicle,
it supplies the
lateral forum sensitivity.
07:20
Now we come to the median nerve
which is in the middle of the arm.
07:24
It has a lateral contribution
from the lateral cord
and a medial contribution
from the medial cord.
07:33
The median nerve runs
along the upper arm
and pierces the
pronator teres muscle
between the radial and ulnar head.
07:42
This is the location of
pronator compression syndrome.
07:46
It then runs between
the superficial and deep flexors.
07:50
Then is seen here again
before finally traveling
into the wrist.
08:02
It travels deep
to the flex retinaculum
and under the transverse carpal
ligament within the carpal tunnel.
08:10
Before sending off sensory branches
to the palmar surface of the
radial three and a half fingers
and the dorsal surface
of the first three fingertips.
08:18
It innervates the
forearm flexor muscles
with the exception of
one and a half muscles.
08:23
The flexor carpi ulnaris
and the deep portion of the
flexor digitorum profundus.
08:29
These one and a half muscles are
innervated by the ulnar nerve.
08:32
The flexor carpi ulnaris
in its entirety
in the owner portion of the
flexor digitorum profundus.
08:39
Both are supplied
by the unlar nerve
because they are in the
ulnar side of the forearm.
08:45
The median nerve also
supplies hand muscles
primarily on the thinner aspect.
08:51
As a reminder,
the median nerve supply sensitivity
to three and a half fingers
on the hand
the thenar compartment,
and the dorsal side of the
distal three and a half fingertips.
09:03
It supplies motor to most
of the thenar muscles
and the first two lumbrical muscles.
09:09
It does not supply
that the thenar muscles
that pull the thumb to the ulna,
the adductor.
09:16
This is a learning aid.
09:17
The muscle that pulls the thumb
to the ulna is the adductor,
which we can see here with
its transverse and oblique heads.
09:25
It's therefore innervated
by the ulnar nerve.
09:28
The muscle that pulls
the thumb to the ulna
is supplied by the ulnar nerve.
09:32
This is the
abductor pollicis brevis.
09:34
In addition,
the flexor pollicis brevis
has a deep and superficial head.
09:38
The deep head lies deeper in
the sense of being more ulnar.
09:41
This is why the deep head
of the flexor pollicis brevis
is innervated by the ulnar nerve
while the superficial head is
supplied by the recurrent branch
of the median there.
09:49
As we discussed, it also supplies
the first two lumbricals muscles.
09:53
They originate from the
flexor digitorum profundus tendon.
09:57
Here we have the tendons from
the flexor digitorum profundus.
10:00
Here we see
the one lumbrical cut off.
10:03
and we see the second lumbrical
here at the bottom.
10:06
The tendons of the
flexor digitorum profundus
become the first two lumbricals
and are innervated
by the median nerve
and lumbricals three and four
or by the ulnar nerve.
10:17
Now let's discuss the ulnar nerve.
10:19
It comes from the medial cord
as do the
medial brachial cutaneous nerve
which is no longer shown here.
10:26
in the medial antebrachial
cutaneous nerve,
which provides sensation to the skin
on the forearm and upper arm.
10:37
The ulnar nerve runs here
on the medial side
behind the intermuscular septum
which is not shown here.
10:48
It then passes under
the medial upper condyle
in the groove for the ulnar nerve.
10:53
At this point, it can be
easily damaged or entrapped
because it lies
just under the skin.
10:58
Of course it's through
the medial head of the triceps.
11:01
So dislocation of the
ulnar nerve can be caused
by strong muscle contraction.
11:05
This is very uncomfortable
and usually seen
when hockey players collide.
11:08
The ulnar nerve then continues
under the flexor carpi ulnaris.
11:11
This is a key muscles
innervated by the ulnar nerve.
11:16
Together with the ulnar portion
of the flexor digitorum profundus.
11:22
The ulnar nerve moves distally
into Guyon's canal,
which is not visible here
between the hook of the hamate
and the pisiform.
11:31
This is covered by
the palmaris brevis
which is also
no longer visible here.
11:35
It stretches from the ulnar skin
to the palmar aponeurosis.
11:38
Deep to the pisiform
we have the pisohamate
and the pisometacarpal ligaments
which form the floor
of Guyon’s canal,
the ulnar tunnel.
11:50
The ulnar nerve gives off the
dorsal branch of the ulnar nerve
which is sensation for the
ulnar two and a half fingers
on the dorsal surface.
12:10
The deep branch of the ulnar nerve
supplies the hypothenar muscles.
12:14
All the interosseous muscles,
and the third and fourth lumbricals.
12:18
Again, that's all
the interossei muscles,
lumbricals three and four,
and all the hypothenar muscles.
12:28
Here it gives sensation
for the palmar surface
of one and a half ulnar fingers.
12:36
So one and a half fingers
on the ulnar palmar
and then two and a half fingers
on the ulnar dorsal aspect.
12:44
Here again,
the dorsal branches sensation,
as well as the superficial branch.
12:53
The deep branch
is motor innervation
for the muscles
of the little fingertip,
the hypothenar muscles.
13:01
The lumbricals 3 and 4,
and all the interosseous muscles.
13:07
The ulnar nerve can be
compressed here in Guyon's canal
which is common in cyclists.
13:13
The nerve runs between
the pisiform and hook of the hamate.
13:17
It's covered by a muscle
that's no longer visible here
the Palmaris brevis,
which stretches from the ulnar skin
to the palmar aponeurosis.
13:26
The floor of the pieces of
form is formed by two bands,
the pisohamate
and the pisometacarpal ligament.
13:31
Together these borders form
the Guyon's canal.
13:35
There as we said with cyclists,
compression of the
ulnar nerve is possible.
13:39
They experienced corresponding
paresthesias and tingling
in one and a half fingers
on a palmar,
and two and a half fingers
on the dorsal.
13:50
Now, if the nerve is stimulated
up here at the middle of a condyle
you get a radiating paraesthesia
or electrifying feeling
in these fingers as well.
14:08
This is sometimes called
hitting your funny bone
because the patient shouts
and feels the sensation of a mouse
running down their arm.
14:18
Behind the brachial artery
lies the posterior cord.
14:23
This gives off the axillary nerve
that we see here.
14:28
As well as the radial nerve.
14:33
The axillary nerve runs through
the quadrilateral space.
14:36
This is the square space remember?
It's formed by the long head
of the triceps medially
the teres major muscle inferiorly,
the teres minor muscles superiorly
in the humerus laterally.
14:52
All of which together
form a square.
14:56
And here we see the axillary nerve
as it's intervening the deltoid
and teres minor muscles.
15:04
It also supplies sensation
to the deltoid skin
via the lateral superior
brachial cutaneous nerve.
15:10
Remember, the nerve travels around
the back of the proximal humerus.
15:14
So in the case of humerus fracture
at the surgical neck
distal to the greater
and lesser tuberosities,
the axillary nerve can be damaged.
15:23
The radial nerve runs
behind the brachial artery
and can be seen here
in the spiral groove
along the back of the humerus
between the medial and
lateral heads of the tricep.
15:35
With midshaft humerus fractures,
it can be easily injured.
15:40
It then travels distally here
where we see it again.
15:43
Now, as a pullback,
proximal and distal,
it'll come out here
on the form extensor side.
15:49
Its trunk also supplies
the brachioradialis
and extensor carpi radialis longus
because they're still
on the radial side of the humerus.
15:57
Then it splits into two branches.
16:00
The deep and superficial
radial nerve.
16:04
The deep radial nerve pierces
the supinator muscle here.
16:07
It can be compressed at this point
in the connective tissue.
16:11
It then dives deep and innervates
all the forearm extensors
So the trunk supplies
the brachioradialis
and extensor carpi radialis longus
because they originated
the proximal humerus
while the deep branch applies
all the other forearm extensors.***
The superficial radial nerve
uses the brachioradialis muscle
as a guide,
and supplies the sensitivity
to the two and a half fingers,
radio dorsally
with the exception of
the distal fingertips.
16:45
These are still supplied by the
median nerve coming from the front.
16:49
Now we come to the
six shoulder muscles.
16:52
Here we see the
back of the scapula.
16:54
Above the spine
on the supraspinous fossa
we see the supraspinous muscle.
16:59
In here we see the
infraspinous muscle below the spine.
17:02
Here the teres minor and
teres major muscles as well.
17:07
Here we see
the deltoid muscles laterally
and anterior to the scapula
originating from
the subscapular fossa
we see the
subscapularis muscle here.
17:25
The subscapularis muscle is
innervated by the subscapular nerve
from the supraclavicular portion
of the brachial plexus.
17:36
The muscle then runs deep
to attach the lesser tubercle.
17:42
This function is internal rotation
and it is in fact the
strongest internal rotator
of the shoulder joint.
17:49
It's also rotator cuff muscle
and helps protect and stabilize
the shoulder joint.
17:53
Remember the shoulder joint
is maintained by weak ligaments
and therefore needs
muscular stability.
17:58
The inferior portion of the muscle
can adduct the arm.
18:02
So internal rotation
and adduction.
18:08
The supraspinatus and
infraspinatus muscles
are both innervated by
the suprascapular nerve,
which also arises from
the supraclavicular part
of the brachial plexus
and can be seen here.
18:19
It runs under the
transverse scapula ligament
which bridges the scapular notch.
18:28
The supraspinatus muscle originates
in the supraspinous fossa.
18:31
It runs here onto the acromion
under the coracoacromial ligament
in the subacromial space
and insert on the upper facet
of the greater tuberosity
because it lies above
the abduction access
it abducts the arm.
18:46
And because it lies behind
the axis of rotation
it's an external rotator.
18:52
The infraspinatus muscle originates
from the infraspinatus fossa.
18:56
It travels down towards
the middle for a set
of the greater tuberosity
where it inserts.
18:59
It also does external rotation
and its lower insertion allows
it to assist with adduction
because it lies below
the adduction axis.
19:07
The supraspinatus above abduction.
The infraspinatus below adduction.
19:15
The teres minor muscle runs
from the lateral scapular border
to the lower facet of
the greater tuberosity.
19:21
Just like infraspinatus,
it does external rotation
and adduction.
19:26
As I said earlier,
the teres major muscle
which splits off
from the latissimus dorsi
is innervated by
the thoracodorsal nerve.
19:34
It runs medially past the humerus
and inserts on the crest
of the lesser tubercle.
19:40
It therefore causes
an internal rotation.
19:43
So the major does internal rotation,
the minor does external rotation.
19:50
And those were the two muscles here
together with
the long heads of the triceps
forming the quadrilateral
and triangular space.
20:00
Here we see the deltoid muscle.
20:03
The deltoid muscle
like the teres minor
is innervated by
the axillary nerve.
20:07
It originates from
the scapular spine,
the acromion,
and the anterior clavicle.
20:18
The insertion here is on the
lateral aspect of the humerus
on the deltoid tuberosity.
20:23
The acromial portion
performs abduction
because it lies above
the abduction access.
20:29
The scapular portion lies
posterior causing extension,
abduction,
and external rotation.
20:37
The clavicular portion
lies anteriorly,
allowing to form internal rotation,
flexion, and abduction.
20:43
The deltoid as the primary abductor
of the arm above 20 degrees.
20:48
Zero through 20
is primarily supraspinatus.
20:51
Above 120 degrees,
the scapular rotation
and external rotation
of the humerus
are necessary
to prevent bony impingement
and allow full abduction
of the humerus.
21:00
If the deltoid fails, such as
with an axillary nerve lesion,
then the humeral head
can subluxate.
21:06
Usually the head subluxation
is inferior relative to the glenoid.
21:16
Here we see the upper arm extensor.
21:18
the triceps brachii muscle.
21:21
Here is the long head
with the other heads traveling
to the medial and lateral sides.
21:25
Here we can see them more clearly.
21:26
This is the lateral head.
21:28
And if we look deeper,
we see the medial head.
21:31
The long head is the
only one that crosses two joints.
21:34
This means that it works
in the elbow joint
and in the shoulder joint.
21:38
The innervation of the triceps
is via the radial nerve.
21:43
The radial nerve comes
from the posterior cord
supplies the posterior muscles
of the upper arm,
the triceps brachii,
and then travels distally between
the medial and lateral heads
and the spinal groove the humerus.
21:53
Again,
it can be easily damaged
with a midshaft humerus fracture
at this point.
21:58
The origin of the long head
is the inferior glenoid
on the infraglenoid tubercle.
22:11
Here you can see
the fibers running down
and with contraction
it allows extension and adduction
of the shoulder joint.
22:22
The lateral and medial heads
have no effect on the shoulder joint
because they originate
on the humerus.
22:27
The medial head
originates more distally
while the lateral head is
slightly more proximal and lateral.
22:32
Between them as the spiral groove.
22:35
The long, medial, and lateral heads
unite to form the triceps
and have a common insertion
on the olecranon of the ulna.
22:43
Function therefore is
extension of the elbow joint.
22:52
Here we can't see
the smalliconium muscle
splitting off the medial head.
22:56
It also can extend the elbow
and prevents pinching
of the joint capsule
during extension of the elbow.
23:03
We now come to the
upper arm flexors.
23:05
There are three primary muscles.
23:07
The biceps brachii, the brachialis,
and the coracobrachialis.
23:11
All three are innervated by
the musculocutaneous nerve
from the lateral cord.
23:15
Here we see the lateral contribution
of the median nerve.
23:18
Here's the lateral cord and here's
the musculocutaneous nerve.
23:22
It moves into the
coracobrachialis muscle,
pierces it,
and then travels down
to innervate the short head
and long head
of the biceps brachii.
23:33
The short head looks longer
because the long head travels
through the joint capsule
of the shoulder joint.
23:40
Down here we still have
the brachialis muscle.
23:45
The coracobrachialis
as the name suggests,
has its original in
the coracoid process
and it travels medially
inserting interior medially
midway down the humerus.
23:55
In terms of its function,
it's also sometimes referred to
as one of the belt knotter muscles.
23:59
It does adduction, flexion,
and internal rotation.
24:03
The adduction, internal rotation,
and flexion.
24:09
Now the biceps brachii muscle
has a short head
which originates
from the coracoid process.
24:15
It travels down
and unites with the long head.
24:21
It has the same function
as the coracobrachialis muscle
in the shoulder joint.
24:24
Flexion, internal rotation,
and adduction.
24:29
The long head which appears
shorter here
comes from inside
the shoulder joint.
24:33
It originates from
the supraglenoid tubercle
runs through the
shoulder joint capsule
and passes between the
greater and lesser tubercle
within the intertubular sulcus.
24:42
This sulcus is is covered by
the transverse humeral ligament.
24:46
It then runs distally
combining with the short head
and ultimately inserts
onto the radial tuberosity
and superficial biceps aponeurosis.
24:55
The aponeurosis is also called
the lactose fibrosus
and it radiates
the antebrachial fascia.
25:05
The function of the long head
is forearm supination,
as well as
shoulder flexion and abduction.
25:20
The short and long heads flex the
elbow joint and supinate the forearm
as the radial tuberosity
is medial to the radius.
25:27
Importantly,
this supination is strongest
when the elbow joint is bent.
25:37
The biceps is the strongest
supinator of the forearm.
25:41
Again, the biceps brachii muscle
can flex the elbow joint.
25:49
Because the insertion
is on the medial radius
at the radial tuberosity,
it can supinate.
25:55
With the elbow extended,
the bicep loses
the ability to supinate.
25:58
The more one bends, the better
the supination effect becomes
with the maximum
when the elbow joint
is bent at 90 degrees.
26:04
We use this advantage
subconsciously
when screwing in a screw
with the screwdriver.
26:09
In addition,
we have the aponeurosis,
the lactus fibrosus
which conjoined with
the antebrachial fascia.
26:16
We see here the
vessels are covered.
26:19
There are some cases where
the lactus fibrosus is too strong
and can lead to
circulatory disorders
as well as paraesthesiais
and the distribution
of the median nerve.
26:29
Here we see the brachialis.
26:33
It's originally on the
medial side of the humerus
opposite the insertion
of the cork or brachialis.
26:43
It travels down to the ulna and
serving on the ulnar tuberosity.
26:48
Its function is
primarily elbow flexion,
but it does help prevent
the elbow joint capsule
from being pinched when bending.
26:56
We now come to the
three forearm extensor muscles.
27:00
First, the radial extensor group
that runs down the radius laterally.
27:06
Then we have the
superficial group of extensors
that runs towards
the ulna and little finger.
27:14
And finally,
the deep forearm extensor group
that runs on
the radial and thumb side.
27:19
The radial extensor group consists
of the brachioradialis muscle,
the extensor carpi radialis longus,
and the extensor carpi
radialis brevis muscle.
27:28
The brachioradialis
originates most laterally
from the supracondylar ridge
of the distal humerus.
27:33
Then slightly distal,
you find the origin of the
extensor carpi radialis longus
and then the
extensor carpi radialis brevis.
27:41
As all three run over the elbow,
they assist with elbow flexion.
27:48
The brachioradialis,
as the name suggests,
inserts onto the radius and thus
has no effect on the wrist joint.
27:55
Conversely,
the extensor carpi radialis longus
inserts on the base of
the second metacarpal.
28:01
The extensor carpi radialis brevis
inserts on the base
of the third metacarpal.
28:06
By crossing
the wrist and hand joints
behind the flex x axis
they function in wrist extension.
28:13
They also can secondarily
assist in fists closing.
28:16
When the wrist is extended,
the flexors are given
a mechanical advantage.
28:20
This allows a much
stronger finger flexion.
28:23
To remember this,
you can say longus and brevis
are the two fists
in the radial extensor group.
28:30
In addition,
the brachioradialis also performs
pronation and supination
because it crosses the axis
of rotation of the forearm.
28:38
This axis of rotation runs from
the radial head downward diagonally
through the ulnar head.
28:45
The brachioradialis can supinate
and if the other muscles bring
the forearm into hyper supination,
it can pronate the
forearm back to neutral
so it's capable of
pronation or supination
depending on the starting
position of the forearm.
28:59
The extensor carpi radialis longus
can also have a small
supination effect.
29:03
This is sometimes
called spoon supination
like when one is eating soup.
29:10
The extensor carpi radialis longus
pulls more to the radial side here,
and it's involved
in radial abduction.
29:20
One more point.
29:22
Flexion here is mainly done
with a pronated forearm.
29:27
If we hang on a horizontal bar
while supinated
the primary muscle of elbow
flexion will be the biceps.
29:39
So elbow flexion while
the forearm is in pronation
allows the radial forearm
extensors to play a larger role.
29:47
So, supination on a horizontal bar
trains primarily the
biceps and the brachialis.
29:53
Now let's discuss the superficial
group of forearm extensors
which traveled towards
the little finger
on the ulnar side.
30:00
There are three muscles
in this group.
30:02
All of which originate from
the lateral epicondyle.
30:07
The superficial group
has a more distal origin
than the previous group.
30:14
This ultimately prevents them from
having any significant function
across the elbow joint.
30:21
The first muscle is the
extensor digitorum communis
which runs down here.
30:26
Approximately, it's mostly joined
by the extensor indicis.
30:31
Here, between them,
we often find the so called
intertendinous connections.
30:36
The tendons also have
different insertions.
30:38
Some insert on the second finger,
sometimes even partially
on the first.
30:43
Some of the tendons insert
on the fourth finger,
and sometimes
partially on the fifth.
30:47
It can vary.
30:48
So just remember,
the extensor digitorum communis
with its accessory connections
function as finger extension.
30:55
Some argue they do very slight
extension in the elbow joint
but this is nominal at best.
31:00
The next muscle
is the extensor digiti minimi,
which we see here.
31:06
The little finger wants
to be something special,
but it only has one muscle,
hence extensor digiti minimi.
31:13
The third muscle is the
extensor carpi ulnaris muscle.
31:16
If a muscle is called carpi,
it means it inserts onto the carpus.
31:21
This muscle inserts onto the base
of the fifth metacarpal.
31:24
The extensor carpi ulnaris,
the extensor carpi digiti minimi,
and the partial extensions of
the extensor digitorum communis
can in addition to extension
also do ulnar deviation
or moving the hand
towards the ulna.
31:44
Now let's discuss
the five deep forearm muscles,
which run towards the thumb.
31:50
The first is named the supinator.
31:52
It acts at the elbow joint
and has the strongest supination
with the elbow fully extended.
31:57
Now another special consideration.
32:00
Here we see the radial nerve.
32:02
It has a superficial branch
which provides sensation
on the dorsal radial aspect
of two and a half fingers.
32:08
The deep branch on the other hand
pierces the supinator muscle
through the connective tissue
called the supinator arcade.
32:14
This point represents a potential
impingement location for the nerve,
resulting in
supinator compression syndrome.
32:20
The deep radial nerve then supplies
almost all the muscles
of the three forearm
extensor groups.
32:25
So the supinator muscle
is the first muscle
innervated by
the deep radial nerve.
32:30
The second muscle is
innervated down here.
32:32
It's the most lateral
or away from the body.
32:36
So,
A for Away,
and A for
Abductor pollicis longus.
32:40
Then comes the
extensor pollicis brevis
followed by the
extensor pollicis longus.
32:47
So A as an
Away from the body or lateral,
then extensor brevis,
then extensor longus.
32:55
So in total we have
longus, abductor, brevis extensor
longus extensor,
and finally the
extensor indicis muscle.
33:07
Now we come back to the supinator.
33:09
into which the
deep and radial nerve courses.
33:12
Remember that
supinator compression syndrome
can take place at the
connective tissue arcade.
33:17
The supinator originates
from the ulna and the humerus
and inserts onto the radius
which we can't clearly see here.
33:25
Its function is as follows.
33:27
When muscles
in the forearm pronate
the supinator becomes wrapping
away that when it contracts,
it can supinate the forearm
with the elbow extended.
33:37
The deep forearm extensor group
has its origin
not only deeper from the skin,
but also further
distal on the forearm
at the interosseous membrane
and the ulna.
33:49
We see them deeply here.
33:52
The superficial group originates
on the lateral epicondyle.
33:55
Interestingly,
playing tennis can cause irritation
at the tendon origin
resulting in lateral epicondylitis
or tennis elbow.
34:03
The deep group is spared
because of its distal origin.
34:10
Here we have the
abductor pollicis longus.
34:13
The abductor pollicis longus
travels out to the thumb.
34:17
It does some
abduction and extension.
34:21
Then we have the extensor
pollicis brevis next to it
which does some extension.
34:26
Then comes the extensor
pollicis longus accordingly.
34:29
It makes a sharp turn here
and this bend can lead to
what's called drummers palsy.
34:35
It can tear at this point
if it's overstrained.
34:39
Last but not least
the extensor indicis.
34:42
So these muscles all do extension
but because
they're on the radial side
they also assist with
radial wrist deviation
The abductor does
abduction of the thumb
and the two extensors do extension.
34:54
We now come to the superficial group
of forearm flexors.
34:58
Its origin is at the
medial epicondyle.
35:04
Here there may be
some tenant irritation
resulting in medial epicondylitis
or golfers elbow.
35:11
The following muscles
are the superficial forearm flexors.
35:15
First, we have the pronator teres
with the two ulnar heads.
35:20
The median nerve
travels between these heads
and can be irritated or compressed
causing pronator
compression syndrome.
35:27
Next up is
the flexor carpi radialis.
35:30
The tendons of this
muscle act as a landmark
for radial artery palpation
of the wrist.
35:35
The artery lies
lateral to the tendon
while the median nerve
passes medially
prior to entering the carpal tunnel.
35:46
The next muscle is
the palmaris brevis.
35:48
It attaches the
palmaris aponeurosis
and tightens it upon contracting.
35:53
In the ulnar side we have the
flexor carpi ulnaris muscle.
35:57
Flexor carpi radialis,
flexor carpi ulnaris.
36:01
In the middle we see
the palmaris longus
and appear the pronator teres.
36:05
The fifth superficial flexor muscle
lies under these three.
36:10
And we can see it here.
36:12
This is the flexor digitorum
superficialis muscle.
36:18
We can see that its tendons
are split at the end
and are pierced by the tendons
of the flexor digitorum
profundus muscle.
36:24
The flexor digitorum superficialis
is therefore sometimes called
the perforatus muscle.
36:33
The superficiality is perforated
by the profundus muscle.
36:39
Now remember,
with the superficial
forearm flexor group,
some can flex the elbow,
others flex only the wrist.
36:50
Some calls flexions in the MP joints
and some flex the proximal and
distal interphalangeal joints.
36:58
In addition, this group can do
radial and ulnar deviation
as well as pronation.
37:07
Now, which muscle does what?
The pronator teres muscle
does the pronation
and its humeral portion
does the elbow flexion.
37:20
The flexor carpi radialis muscle
can also pronate
the forearm as well.
37:24
The flexor carpi radialis muscle
can also pronate the forearm
as well as wrist flexion
and radial deviation.
37:34
The palmaris longus partially
flexes the elbow joint
and tenses the
palmar aponeurosis.
37:46
The flexor carpi ulnaris muscle
does the ulnar deviation,
and flexion of the wrist.
37:56
Below them lies
the flexor digitorum superficialis.
38:00
It inserts on the central phalanx
and is then pierced from below
from the profundus
which extends up to
the distal phalanx.
38:08
Since it only inserts
up to the central phalanx
it cannot flex the DIP joints.
38:13
It does flex the
proximal interphalangeal joints,
the MP joint, and the wrist.
38:18
It can do this because it has
its origin on the medial epicondyle.
38:24
When it comes to the
deep forearm flexor group
here we have the
flexor digitorum superficialis,
lying atop the
flexor digitorum profundus.
38:38
We've already discussed
that it pierces the superficialis
and inserts onto
the distal phalanx.
38:43
Because of this, it's sometimes
called the perforans muscle
while the superficialis
is the perforatus muscle.
38:50
And because it inserts
on the distal phalanx,
it can flex the DIP joint.
38:55
Then fingers two through five
had the flexor digitorum profundus.
39:00
The thumb also needs a flexor,
and that's the
flexor pollicis longus.
39:04
And we see that here.
39:05
At the very bottom
we have the third muscle
lying between
the radius and the ulna,
the pronator quadratus.
39:10
So flexor digitorum profundus.
39:12
Here's the superficialis
and goes the distal phalanx
then the flexor pollicis longus
and deeper the pronator quadratus.
39:21
The deep forearm flexor group
lies more distal in the forearm.
39:25
So it's not only
deeper from the skin,
but also further down the arm.
39:31
It has its origin in the
interosseous membrane
and along the ulna.
39:35
The flexor digitorum profundus,
as we've already said
pierces the superficialis
and ends at the distal phalanx
so naturally
it flexes all the joints.
39:43
In the DIP,
the PIP,
the MP,
and the proximal wrist.
39:54
It flexes all but the elbow joint
because its origin is too distal.
40:01
Here we see the flexor
pollicis longus muscle again.
40:03
It also starts at the
interosseous membrane and ulna
and has no effect
on the elbow joint.
40:09
It then inserts on the radial
side of the abduction axis
allowing radial wrist deviation.
40:14
It then pulls medially
from the axis of the CMC joint
So that the CMC joint
or saddle joint
it allows thumb flexion.
40:20
It then inserts
at the distal tip of the thumb
allowing flexion at the phalanges.
40:24
At the very bottom we find the
pronator quadratus muscle again.
40:28
It courses between
the radius and ulna
and as the name suggests,
does forearm pronation.
40:34
The forearm flexors are
innervated by the median nerve
which runs up to the pronator
and then between the superficial
and deep flexor group.
40:45
Here's where it gives off
the sensation branches
for three and a half fingers
on the radial palmar side
and the distal dorsal skin
even though that's not shown here.
41:02
The only muscle that's not supplied
by the median nerve
is on the ulnar side.
41:05
The flexor carpi ulnaris muscle.
41:08
It's the primary muscle
supplied by the ulnar nerve.
41:13
But remember the ulnar nerve
also supplies the ulnar portion
of the flexor digitorum profundus.
41:20
So one and a half forearm muscles
are supplied by the ulnar nerve.
41:23
The rest are from the median nerve.
41:26
We now come to typography,
compression syndromes,
and guide muscles of
the upper extremity.
41:32
A compression syndrome
of the brachial plexus
is the so called
Thoracic Outlet Syndrome.
41:38
Like the five fingers of a hand,
it's made up of
five constriction points.
41:42
We can't see the
scalene neck muscles
but they cause interval compression
between the anterior
and medial scalene muscles
as the brachial
plexus passes through.
41:50
Second, a cervical process such as
an elongated anterior tubercle
of the seventh cervical vertebrae
is the second common location
for a lesion.
41:59
Third, one can have a
costoclavicular compression syndrome
between the clavicle
which is shown here
at the first costal rib.
42:06
Fourth,
the pectoralis minor muscle here
plays a role in
hyperabduction syndrome.
42:11
The arm is hyper abducted and
compression takes place primarily
from the pectoralis minor.
42:16
And last but not least,
not visible here either
is the so called long armpit arch.
42:21
A connective tissue
or muscular cord
which can occur
between the pec major
and the latissimus dorsi muscle.
42:27
These are the five points of
brachial plexus compression.
42:31
In this example,
we can only actually see
the pectoralis minor muscle
causing hyper abduction syndrome.