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Complex Upper Limb Anatomy for Orthopaedic Exams
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Complex Upper Limb Anatomy for Orthopaedic Exams
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Language: EN.
Segment:0 .
Ladies and gentlemen, and a huge Thanks for joining us on this session. There's an awful lot for us to get through here. Just an introduction. Thank you for the kind words. My name is Tom cockrum, head of anatomy for the University and also the chief examiner for the University.
And I'm also a consultant, orthopedic oncology surgeon here at the Nuffield orthopedic center. The slides that you're about to see, I think, are all things that you could reasonably see in the Fox examination, and I'm going to try and take you through what I think are the really key points that you need to know. Now this is a slide that you all know. Well, you've all seen this.
These are the wiring diagrams, as I call them. And these are just to remind you about the nerve supply of the various muscles in the upper limb. So the Super slap ulnar nerve supply supersprint 8as and interest connectors from C5 and the auxiliary nerve supplies the deltoid and tiers minor, which is not shown in the diagram. So they're the principal abductors of the shoulder.
Elbow flexion and extension is produced by the musculocutaneous nerve. What I teach the students as the BBC, the British Broadcasting Corporation nerve that supplies the biceps, the brake careless and the correct brake areas. As we all know, the radial nerve supplies, the extensive compartments of the arm and the posture and atrocious nerve.
The derivation of this the forearm extensive compartments in terms of wrist extension and flexion. Well, that's supplied by all three of the major peripheral nerves the radial nerve, the medial nerve and the ulnar nerve. Just be aware and be able to describe what both the median and the ulnar nerve supply in the forearm, both on the radial and the ulnar side of the wrist.
The radial nerve coming from C6 and C7, the median nerve supplying flex pi radial C7 and the ulnar nerve supplied by C8 supplying flexor pi Allen on the ulnar side of the wrist. In terms of finger flexion and finger extension, that's the, of course, the intrinsic muscles of the fingers in the hand, as well as the long flexes and extends and again supplied by all three of those major nerves the radial, the median and the ulnar nerves.
And here we're talking about extensor digitorum limb communists on the dorsal surface of the forearm on the radial side of the hand, the flexor digitorum superficialis and flex, a digitorum profundus to the radial side of the hand and the ulnar nerve supplying the flexor digitorum unpreparedness to the ulnar side of the hand. So just be aware and be able to describe those in terms of finger abduction and finger abduction.
These are the intrinsic muscles we know the mnemonic, which is pard and dab, and know that the nerve supply is via the median nerve to the two radial lumbar calls and the ulnar nerve to the two ulnar lumbar calls. And both the Palmer and dorsal interossei will revisit that as we go through the lecture this evening. So a simple question might be what's the arrangement of the brachial plexus?
Lots of different ways of remembering this. I remember it with Ron Taylor drinks cold beer. And this reminds us that it's the roots C5 to T1, the trunks, the upper, middle, and lower trunks, the divisions via the anterior and posterior divisions, the chords, the lateral posterior medial chords, and then those terminal branches. So whether you're in the written exam or the vyver exam or any part of it, you just need to be thinking about where the lesion might be within the brachial plexus and try and think about how you would narrow it down to be more specific about where the problem is.
So here's the left sided brachial plexus. We won't dwell on this in too much detail. This is the one that we all frantically look at, including me the NIPE before the exam or the NIPE before the lecture, just to remind ourselves where all these various branches come off. And I think although you'd be expected to know the lumbosacral plexus for the lower limb, you certainly wouldn't be able to or be expected to draw every single branch of it.
But I think you would be expected to draw the brachial plexus, and there are several very good videos available on YouTube where people show their various techniques of drawing this. Just one top tip is that many of you will have learned how to draw either the left or the right brachial plexus. Remember that the examiner will be looking for that. So if they ask you to draw the brachial plexus, a particularly main thing to do, which can happen is they'll see which side you go to draw, for example, the left, and then they'll ask you to draw the right because they know that you're more uncomfortable drawing that side.
So just be able to draw both if you're going to be able to do it and you can't rely on what one candidate did in the exam, which is to draw one side and then flip the piece of paper over to show the other. Nice trick, but I'm afraid not good enough. So here's the brachial plexus. This is protected by the bony clavicle, so the clavicle lies anteriorly with the brachial plexus behind, and this forms an important bony protection, as well as a structural support to the anterior shoulder.
And just a reminder, I'm sure most of you will be aware of this, but if you're asked to identify the various parts of the brachial plexus, one of the very straightforward ways of doing so is to look for the letter M lying on the auxiliary artery. So you can see here that this makes a clear letter M. And fortunately, that's the median nerve in the center of that line, right at the front of the axillary artery.
So if you get given this kind of photograph, just be able to talk about the roots as they emerge from the spinal canal. The relationship of both the subclavian vein and subclavian artery just know where those lie and know where the brachial plexus emerges, of course, between silliness, medius and skinniness be able to describe Horner's syndrome, so this young lad has a very characteristic appearance of a hornish syndrome.
And of course, we remember the mnemonic, which is up, which stands for meiosis pupillary constriction anhydrous a lack of sweating with the dropped eyelids you can see on his left eye and end up thalamus, usually in more long standing hornish syndrome, where the eyeball is sunken into the orbit. And in fact, although this is a relatively rare condition, I did see this in my clinic just this week with a patient who presented with a lung tumor and caused that very textbook description of a Hornet syndrome, which we've all read about.
So just be able to describe that in some detail. Here's another clinical one, so what would be your differential diagnosis for this young patient who comes along to your clinic? Well, that's or fussier scapulohumeral dystrophy, a bit of a mouthful, but those abnormal position of the scapula is really a spot diagnosis. What about this patient, it's Black and white photograph of the left shoulder, and the examiner wants to know if this is a supraclavicular or an infraction vehicular injury in the absence of a rotator cuff tear?
Well, you can see that there's both super sonatas and interest bonitas muscular wasting, and therefore this must be a suprascapular nerve palsy. We know that the Super slap ulnar nerve supplies both the and impersonators and therefore must be a lesion of this nerve. So you want to really get to that answer very quickly for the examiner. Explain what you're seeing, and this is really a key slide for the fast.
Yes, this should probably have a red box around it because this piece of anatomy is something that comes up time and time again, both in the written questions and in the virus, and potentially even in the clinicals. So here's the nerve this we're looking at a section through the scapula here. Here's that important ligament the superior transverse scapula ligament, which lies across the top.
And here's the artery that passes over the top, but the nerve passes underneath, and therefore that's a potential site of nerve entrapment. If the nerve is trapped here, that's going to produce weakness of both and interest bonitas, as opposed to if the nerve is further down the spinal glenoid notch. As the nerve passes more directly and it will, then we then see only a palsy of the interest tinnitus.
So again, just want to have a look at just before the exam, perhaps be able to draw this. Certainly, be able to recognize it. So that you can identify where the lesion might lie. So remember water over the bridge. What are the major terminations of each chord you might want to just remember this slide, it does come up in the mckew questions later.
So in terms of the latter chord, that's the musculocutaneous nerve. The posterior cord is the radial and the auxiliary nerve. The medial call, the terminal branch of this is the ulnar nerve, and both the medial and lateral nerve will, of course, must be the median nerve. Let's move on, let's think about AC and stdlogicvector, joints and the clavicle. And again, another really key slide here, this should have another red box around it.
We're looking at the right shoulder. The coracoid process and the important structures around that. Now, as you all know, there are nine structures which either originate from or attached to the coracoid process. But what you're absolutely not going to do in the exam is say that there are nine structures because the immediate next question of the examiner will be to ask you to list and name all of those nine.
So the way that you're going to phrase it is, this is an image of the right shoulder. We can see the coracoid process. There are several important attachments and origins from the coracoid process, some of which are the following. And I would probably highlight the fact that pectoralis minor originates from the coracoid process from the second, third and fourth ribs. Of course, the conjoined tendon vitally important for us as orthopedic surgeons, which will revisit in the next few slides and then the conoil and trapezoid parts of the coracoclavicular ligament and then the coracoacromial ligament.
And again, vitally important. This is a really important structure to preserve shoulder stability, to prevent escape of the shoulder antero-supero-lateral. And there is that really annoying artery. That's the one that we've all prang when we're doing a shoulder arthroscopy, we inadvertently hit this and then that bleeds and we get the complete red out of the screen.
That's the branch of the coat chromium artery to come back to our conjoint tendon. All of the important brachial plexus lies underneath this. And so there's a safe side and a very dangerous side. Unfortunately, I have to spend a fair bit of time over on this side of the conjoint tendon. But for most of our shoulder surgery will try and stay over on the lateral side and sweep that stretch immediately, which will then protect our brachial plexus.
So remember, the superior restraint to the AC joint. Is that important? Karaka accumulate ligament. So a question might be which of the following steps is important when dividing a painful, massive rotator cuff tear? Hopefully, now we won't even need to read the answers. We're looking for that crucial structure, the co-occur coracoacromial ligament that we saw on the previous slide to make sure that humeral head can't escape.
Let's move on to the shoulder. Now this is a slide that comes up in the textbooks. And I must admit, when I was learning this, I didn't quite understand what this was trying to show. But this diagram is showing a bird's eye view looking down onto the shoulder. So we can see the humerus head in the center of the screen. Here's the glenoid. We know that this must be the front because the coracoid always points to the front.
We're looking right down along the length of the humerus, and we've drawn a line through the medial and lateral epicondyle, which gives us our retroversion of the humeral head. Now the really nice thing that you're going to say in the exam, if you get this kind of case before you take off the surgical head of the humerus, you're going to measure and look at the patient's natural retribution.
So that whenever you put an implant in, you're going to make sure that it's exactly matched to the patient's native position. Don't forget, of course, that the glenoid is orientated about five degrees posterity that's retrofitted, and those combine structures mean that the humeral head is reasonably well contained in what of course, we know is the most unstable joint in the body, looking down separately onto this gentleman's right sided shoulder.
Here we can see the rotator cuff from the top, the supersprint 8es lying over here, the infringement notice and the tiers minor be able to describe the order of those structures and the subscapularis tendon lying anteriorly. You'll note as well from the top of the shoulder here that this forms a triangle. Nature makes use of the fact that the triangle is the strongest structure, so the shape clavicle lies anteriorly.
Here's the spine of the scapula and underneath this is the bulk of the spinsters. Now, here's the slide that everyone dreads getting in the exam, either in the written paper or in the vyver. You could very well get given this slide, and it's important to have a strategy so that you can confidently work out those muscles and structures around the inside of the shoulder.
And I'll just give you my simple strategy for trying to work out what these are. Now, obviously, the glenoid lies in the center that doesn't particularly help you, but there are two landmarks that I'm looking for to tell us, which is the front and which is the back. So the first of these is the long headed biceps. Remember, the long headed biceps comes in at the 12 o'clock position at the top of the glenoid labrum and the long hand.
The biceps will be passing anteriorly to the left hand side. The screen must be the anterior shoulder. This must be the posterior shoulder. The other feature that I'm looking for here is the coracoid process. So here's number six, the coracoid process. And you remember, we said that the coracoid process always points towards the front of the shoulder.
So that's our second confirmation that this must be the front of the shoulder joint. Here's the acromion, which lies superiority and therefore by definition, number two must be the silver Chrome will bursa. Well, now we've worked out which is the front and which is the back. It should be much more straightforward for us to label the relevant structures.
And of course, the rotator cuff surrounds the proximal humerus. So here's the supersprint 8es lying separately. Then we've got the subscapularis lying anteriorly that enforcement notice the next one round and tiers minor. Once you've done those, it's then easy to undertake the next layer of labeling. Remember the deltoid muscle surrounds the majority of the shoulder. The deltoid muscle is unusual, and it has both an A a middle and a posterior component.
And then we can see the picture. Eilish major tiers major latisha restores sight and triceps. If you get the chance, it's just worth highlighting to the examiner at this point that the triceps lies opposite the insertion of the long head of biceps. So the long hair the biceps inserts at the 12 o'clock position on the glenoid, the triceps long head originates from the 6 o'clock position.
So tangentially opposite to each other. You should be able to label the following insertion. So we're now slightly further down around the entire trabecular groove. Of course, pectoralis major must be the latter most structure, and the reason for this is that pectoral. This major lies anteriorly and therefore the other two structures must lie deep to this, and therefore it has to insert at the far lateral side.
So pectoralis major lying laterally. Latimer's lying in between the two and tiers major lying more medially to just be able to identify those structures. And of course, we have the groove running in between the greater and lesser tuberosity in which the long head of biceps will lie. What attaches to the lesser and the greater tuberosity of the humor? So again, we've got this superior and lateral view.
So to the greater tuberosity is the three muscles supersprint 8es interest pinatas and tiers minor to the lesser tuberosity just one muscle. The subscapularis supplied by the upper and lower subscapularis nerves. A patient with a subscapularis rupture would have what clinical findings expect them to have a positive Gerber's lift off test positive because they're unable to do it.
They'd also have weak internal rotation and they'd have increased passive external rotation. And you will get some of these in the exam, particularly in the clinicals. And of course, the relevance to this is that, particularly after an anterior approach to the shoulder, we really are fastidious about trying to repair the subscapularis so we don't leave the patient with this post-operative complication.
Name the static and dynamic restraints of the shoulder, so be able to just divide this up very logically in your discussion. So the static is the articular anatomy, so the relative shape of the bony glenoid, the glenoid labrum, which is made of type 2 fibrous cartilage and the structure of the labrum means that there's a negative articular pressure. The humeral head is sucked in towards the glenoid, making it much more difficult for it to dislocate.
It's surrounded by a thick, protective capsule, and it also has important ligaments. The dynamic stabilizes Ah, the rotator cuff, the biceps tendon and of course, the pre-program scapulothoracic motion. So which of the following anatomical structures provides a dynamic contribution to shoulder stability, where we know the answer now have got a nice ordered structure for it? It must be the rotator cuff.
Another red slide. So we're looking at the right shoulder and there's really key spaces now. Unfortunately, as many of you will be aware, because the British and European textbooks differ from the way they describe this to the American textbooks in the farke's. Whenever you get one of these spaces described, the writer or the examiner should define the space for you so that exactly what's being referred to.
Let's just discuss these in detail. So the quadrangular space defined by the inferior border of tiers minor and the superior border of Terry's major, is seen here and through that will pass the posterior and humeral artery and the axillary nerve. They will wind around the neck of the humerus to progressively supply the deltoid muscle. Here's the triangular interval that will carry the radial nerve and the profunda brachial artery.
And over here, the triangular space which we don't see very often but I see Drew my tumor surgery when we're taking out the scapula that contains the circumflex subscapular artery. So what you need to do is look at this slide just before the exam, look at the break of plexus, look at this slide and be able to draw out those boundaries for the examiner so that they know that you clearly understand not just what passes through them, but where they are.
So on the PDF, when you get this, that will be sent out after the presentation. This is another of those slides I would really highlight just to go back and look over. So this is a quadrangular space in a bit more detail. The deltoid has been reflected away, so we're looking at the back of the shoulder here. The patient is in the sloppy lateral position with a deltoid reflected out of the way.
Here's the axillary nerve emerging with the posterior circumflex humoral artery, and we can confidently say to the examiner that that's passing through the quadrangular space. So way of remembering it is that it's four syllables or words. The quadrangular space and passing through that is the posterior circumflex humoral artery and the axillary nerve. Just to show you in a little bit more detail, here's the axillary nerve and the artery passing through that quadrangular space.
Here's the very tight shoulder capsule seen posterior. So if we're doing a posterior approach to the shoulder, what we just need to try and do is to sweep those muscles away so that we can safely access the back of the shoulder. It's an absolute disaster for the patient if we inadvertently damage the axillary nerve and leave them with no deltoid function. It's really disabling for the patient to have that now returning to the front of the children just to remind you of the important blood supply as this comes down.
Remember, of course, that the subclavian artery arbitrarily changed its name to the axillary artery and will then become the brachial artery. We'll look at that further in the next few slides, but really, what this slide shows you is the important blood supply to the humeral head, and that is formed from both the anterior and posterior circumflex humoral arteries, which you can see arising off here.
And this important smaller branch, which has got the circle around it, this is the actuate artery and the artery artery provides the important blood supply to the anterior aspect of the humeral head. So the three portions of the auxiliary artery are the Supreme thoracic, which goes from the first rib to the medial edge of pectoralis minor. The thoracotomy will branch and lateral thoracic arteries deep to pectoralis minor and distal to pectoralis minor.
The subscapularis anterior circumvents humoral and posterior complex humoral. So the key takeaway from this slide is that it's the pectoral, this minor that divides it into the first, second and third portions. I think you're very unlucky if you get asked about the first and second part and their various branches. I think it's much more reasonable.
You will get asked about the terminal branches of the third part of the auxiliary artery. Here's just another view just to show us that important relationship to petrol is minor. As we said earlier on the presentation, petrol osmani usually rises from ribs to 3 and four, and this diagram also five that passes through the coracoid process, but the artery passes underneath that.
So if we need to get to that, then we must be prepared to potentially do a coracoid osteotomy to effect petrol this minor out of the way. And that will then give us clear access down to the artery and perform our repair. This just shows what can happen with the proximal humeral fracture, he's a neck fracture, and you can see that the distal fragment has moved me to the here and this is now tenting the brachial plexus.
And really, this is just to remind us all of the hazards of being in this area. When we're reducing these fractures, we must be really very careful about where we place our tail clips. And I often find that just a gentle finger reduction and a finger sweep is the most appropriate and safest way of moving the breaker place out of the way before gently reducing the fracture back into position.
Now moving a bit more deftly, and this slide is really important in terms of just reminding us about that important relationship to the conjoined tendon that we were looking at earlier. And if you remember the conjoined tendon passes from the coracoid process down into the arm, here's the brachial plexus emerging underneath it. So when we've exposed this, we need to put our finger into this position here and sweep the Briogeo plexus medially so that we're away from damage.
A few more important takeaway points here. So the main new vascular structures are the median and ulnar nerves, which which are really very medially in the arm before they pass across the elbow. Here's the radial nerve passing down through the spiral groove before it pierces the lateral intramuscular septum, about 7.5 centimeters above the lateral epicondyle and before it becomes a more anterior structure as it passes down into the forearm.
So what Archie runs the radial nerve. Or we looked at that earlier when we're talking about the relevant spaces, that's the profunda brachii. What nerve runs in between the basilic vein and the brachial artery that will be the median nerve and which nerve is medial to the basilic vein? That will be the medial antebrachial cutaneous or the medial cutaneous nerve of the forearm for the British and European textbooks.
Now this is a crucial cross section, and it sounds an obvious thing to say, but I have heard it in exams. You must make sure you decide whether you're looking at the upper or the lower limb. It's an absolute disaster in the fast, Yes. If you start talking about this as being a cross section through the thigh. When actually we're looking at a cross section through the arm, it's very embarrassing when the examiner points that out to you.
So how are you going to identify that? Because of course, they do look a little similar. There are a few key takeaways that help you identify. The humerus is a relatively triangle shaped structure, so the shaft of the humerus points forwards anteriorly and then the real key giveaways. This radial nerve like absolutely on the posterior, the like of which you do not have in the thigh here on the medial side of the arm is the main neurovascular compartment, and it always amazes me what a very compact space this lies in.
We all think of the median and the ulnar nerve as being actually quite well separated. But when you see this diagram, they're really very, very close together, just a centimeter apart and just separated by the neurovascular bundle. So in the right arm that we're looking down on from the top here, you can see that the danger area really lies between about 8 o'clock and 10 o'clock, all of those key structures lying within that region.
The muscular, cutaneous live eye is relatively anteriorly. That makes sense because as we said before, it's the BBC nerve, the British Broadcasting Corporation nerve, and that's going to have to supply the biceps, the brake Ellis and the curb radiators, which are all a structures here is that large posterior wad of the triceps supplied by the radial nerve. So in other words, another slide just to draw a star on here, just on the NIPE before the exam, just to make sure you revise the cross-sectional anatomy.
So what does the auxiliary nerve supply? Well, the auxiliary nerve comes from the posterior cord, and it will supply the tiers mine and the deltoid shown in the green square at the top of the screen here. Nothing else, more in the arm or the forearm. All of the action for the axillary nerve is very proximal in terms of the innervation of the forearm, the superficial flexes, the deep flexes and the superficial extends deep.
Its dancers are supplied, as we said at the start of the presentation by the median nerve except half a flexor carpal nourish the deep flexes supplied by the median nerve except the ulnar nerve half of flexor digitorum fundus, the superficial extensor supplied by the rage ulnar nerve and of course, the more distal branch, the posterior atrocious nerve and the deep extensor supplied by the posterior intereses nerve.
What does the radial nerve supply? Well, we remember the wiring diagram. Now, remember, the radial nerve is more unusual compared to the median and the ulnar nerve because it does supply structures within the arm. So here we supply the triceps, both the long lateral and medial head. It then goes on to supply the mobile world and around the break you'll break your radiators, ACL and ECB, and then it gives off the posterior interosseous nerve, which supplies the remaining hand and finger extensive.
And if you're going for the gold star, just remember that the terminal branch of this usually not always, but usually supplies extensive indices, which you can see going across your course to the index finger. This is a really key MSK question, which will come up both in the written paper and also in the virus in the clinicals, just that really important relationship.
You don't even need to read the question in detail here. You know what they're looking for. They're looking for that important relationship of about 15 centimeters posteriorly and 7.5 centimeters laterally. The closest answer we've got here is number two. That's our answer. So what does the median nerve supply? Here's the wiring diagram.
Remember to tell the examiner that the median nerve supplies nothing in the arm. All of the action for the median nerve is below the level of the elbow. So this will supply from the common flexor origin down into the forearm compartment and finally into the thinner compartment of the hand. This is the hlophe muscles. The lateral to lumbar cause the opponent's policies, the abductor pollicis Revit and the flexor pollicis service down here at the very distal parts of the.
Why don't forget prone quadrantids in the distal forearm in between the radius and the ulnar, the ulnar nerve similar in that sense, to the median nerve. Again, no supply appear in the arm. All of the action occurs below the elbow, and the examiner would expect you to be able to surface marked the path of the ulnar nerve as it passes from the axilo down in the medial arm behind the medial epicondyle passes through flexo-pronator pi ulnar claw and then down onto the ulnar side of the hand to go in this wide spread arch and supply the intrinsic muscles of the forearm and the hand.
Just a question just to be aware of the four joints that can produce a septic arthritis from direct metaphysical extension. They are the proximal femur, the distal fibula, the proximal humerus and the radial head. So you'll notice, therefore, that two of those important sites lie within the upper limb, so this could come up in the upper limb adult pathology section.
Where does the anterior humor line cross on a lateral radiograph of the child's elbow? Nice straight forward one. This will be through the middle third of the capital M. Just be able to identify that on a radiograph and the ligament is stabilizes of the elbow. These are really very important in terms of keeping the elbow correctly in position. The radial collateral ligament on the outermost side of the elbow and the annular ligament holding the radial head into position.
Of course, this is the site where we see a pulled elbow where the radial head dislocate through the angular ligament and then on the ulnar side, the ulnar collateral ligament, as well as the capsule tightly binding the elbow into joint. Just be able to describe those important attachments, and it is always surprising when people get muddled up with this. At farces level, you must know where the biceps attaches into. Of course, it's the radial tuberosity that allows a supination of the forearm by the biceps, and that the brachial this arises or insert sorry into the coracoid process, just distal to the capsule of the elbow in the proximal ulnar.
Be able to describe the common flexor origin, the common extensor origin, and be aware of where this thick into intramuscular septum arises between the two bones and of course, the vessel and the artery pass through here and then lie on top of that into muscular septum tennis elbow. And the structure we're thinking about is extensive car pi radial ish Vervisch. That's the one that we're going to be looking to release when we do our inertial and AIIS CHL release, we're going to do the inertial release to release that tendon here and release the tennis elbow.
So here's our next important cross sectional anatomy. I think you'd be a little more unlucky if you got this in the exam, but certainly be able to orientate yourself. And the key structure to be looking for here is, of course, the ulnar nerve as it passes behind the medial epicondyle. Be aware of those anterior structures that the neurovascular bundle.
Now lying relatively anterior in the forearm with the brachial artery in the brachial vein. Several superficial nerves lying more peripherally. Now everyone gets a little bit worried about where the basilic vein and the cephalic vein lie. So it's just a really easy way of remembering is that it's as simple as a-b-c. So the abdomen lies over here. Here's the abdomen.
The basilic vein lies more easily, so this must be the medial aspect of the forearm, and the cephalic vein lies more laterally. So we see that over on the radial side of the forearm, just be able to identify those superficial sensory nerves. We do not have time to dwell on those now, but they do tend to come up in the written exam, and the question will ask the relationship to these various veins as they pass through.
So the radial nerve enters the forearm between which two muscles. That's between brachial and break your radiators on the lateral side of the arm, the medial nerve flexor-pronator taris and lies between which muscles. Well, that really between FDS and FTP and the ulnar nerve lines between which muscles will. That will be between FCU and MFDP. So just a simple way of remembering it.
Here's the diagram. So the ulnar nerve lying in between FCU and FDP on the ulnar nerve side of the forearm and the median nerve supplying between FDS and FTP on the radial side. Cross-section anatomy exactly the same comments that we made earlier. When we're talking about the upper and lower limb, please don't say this is a leg. When you look at it, this is a forearm.
And the way to identify. That again, it's a relatively easy mistake to make, but in the forearm, it's really this huge bulk of anterior musculature, which is different in the leg. The posterior structure of the leg are much bigger. And these are two opposing triangles facing each other, separated by that into muscular septum, with the neurovascular bundle lying on top of that. And the median nerve lying relatively centrally.
Here's the posterior neurosis nerve lying in the dorsal extensor compartment, so just be able to look back and label some of those structures. So in terms of your forearm approaches, the examiner would expect you to be able to safely get into the forearm, so to get yourself in and get yourself out, obviously, of course, everyone knows the approach to the ulnar side is relatively superficial approach and will pass in a truly into nervous pain between the posterior atrocious nerve supplying ICU and the ulnar nerve supplying flexor carpal Maris.
But of course, on the radial side of the forearm, this is more difficult and depending on the fracture pattern, that's the one that we all get worried about. I still worry about approaching the radius through the forearm. There's an awful lot of structures which are really at risk and what the examiner will be looking for when you're describing these approaches is to really show a very safe and common sense approach.
So what you'll be saying here is that you'll make the superficial incision and then you'll largely use finger dissection to try and work your way safely down to the radius, moving these neuromuscular structures out of the way to really try and keep them as safe as possible. Cross-section of anatomy through the rest, again, really, really important. I just picked a slightly unusual view of the rest here. We're all used to that very standard view of the carpal tunnel, but this is a slightly different section, but you could very reasonably get this just again, be able to work out the various structures.
And really, the key I'm looking for here is this muscular structure here. This is prone to quadrants running between the radius and the ulnar. And then you can work out the other structures on top of that. Look for that median nerve. must be the largest nerve that you can see in this cross-section, so should be really easy to identify.
And then you can piece together the ulnar nerve and the branches of the posterior atrocious nerve, which by this stage will be really very small on the posterior compartment. So here's the median nerve is going down just to remind this as it goes down to supply the muscles of the thenar eminence. And there we go. Dead on time, Ruth, I think I'm going to hand over to you at this point.
We're going to do a quick poll here just to check everyone's been listening and then we're going to move on to some really exciting stuff. I hope it should be some of the cases that we've seen as challenges from my own unit. So Ruth, over to you with the quiz, OK, I'm going to start the poll now. And you say that, tom?
Yeah, that's great, so we'll read it through. So in addition to the deltoid, what other muscle does the axillary nerve supply? So hopefully nice and straightforward for you, it's the one that always gets forgotten. We don't see this lesion very often in clinical practice. Have a go at that one number to the terminal branch of the musculo cutaneous nerve.
You just scroll down. Ruth, if you can. Yeah, it's a terminal branch, we've got a few different options. That so the motor nerve supply of the lateral to lumbar knuckles, lateral to lumbar, of course, hopefully. Straightforward that's great, so that's good. Well, nearly everyone got the first one, right? That's great.
Yep, sir. Tiers minor. Remember, if you have the nerve palsy of the auxiliary nerve, not only would we expect to see weakness of the deltoid, but we also see a positive Hornblower sign because the patient won't be able to suspend their arm in their abduction and external rotation to the arm will fall forwards to the branch.
The musculocutaneous nerve perhaps a little less certain on this one, but yet that's the lateral cutaneous nerve of the forearm. Just want to revise. You sort of need to know that and the motor nerve supply of the lateral to Allen because, well, remember that comes down to the hlophe muscles. So that's the lateral to lumbar, because the opponent's policies, the abductor pollicis Revit and the flexor pollicis prévus.
So that's those, of course. You know, the question that everyone asks is, well, you know why? Why do we need to know the relevant anatomy? So here's the kind of case that we might expect to see. This is the case of the vanishing humerus. So here's a right proximal humerus. You can see the humor or hair, but you can see there's a big lytic lesion, which has destroyed the proximal humerus.
And that's exactly the kind of case that we'd expect to see here on the tumor unit. So this is a really brilliant 1 to be able to talk about with the examiner to think through what you're going to say and really have a strategy about how you're going to work the patient up and how you're going to investigate them. Now, hopefully, we'll be able to revisit this when we do another session on bone and soft tissue tumors.
So I'm going to try and stick a bit more to the relevant anatomy today. But really, preoperative design and preparation is the key. So we're using our engineers to think very carefully about the type of implant that we're going to put in. But we're also very much thinking about the surgical approach. So the structures that are going to be at risk here. So we're thinking about the fact, we'll have to do an extended deltopectoral approach that will have to move the conjoined tendon out of the way with the brachial plexus will be thinking about the fact that the auxiliary nerve is winding around the human on that care so very much at risk.
But as I'll show, the next few slides will be really thinking about what we can preserve about what soft tissue structures we can preserve to try and retain function in this. But it doesn't have to be about metal, doesn't have to just be about hardware. This is a young patient 25-year-old who presented with this aggressive Conder sarcoma of the mid shaft of the right humerus.
You see it really very aggressive lesion that's going to require very extensive resection. And this is one that even I now, after several years experience would really worry about in the NIPE and on the morning of surgery because there's an awful lot of clockwork that lies very, very close to this tumor. Now we've got the medial sided neurovascular structures that will be the median and the ulnar nerve over here, which I'll really be worrying about.
And of course, the radial nerve the radial nerve will be passing right next to that tumor. We'll obviously counsel the patient here that in all likelihood, unfortunately, the radial nerve may have to be resected during this. Now, in the past, we'd have typically resected this and put in a large piece of metal as an end of prosthetic replacement. But what we're trying to do for this patient is to place the free fibula graph.
So we borrowed a fibula. We've wedged that into the humeral head. We've left all of the soft tissue attachments around the proximal humerus just put in a little plate just to support this. Whilst this unites and then fixed modestly and that will gradually hypertrophy up and within a few years, that will hopefully be just as good as the patient's native humerus.
Now let's think about some of our intraoperative technique and the relevant anatomy. So here where we're going into the proximal humerus, then we're going to do an extended delta petrol approach. We'll take the cephalic vein either media or laterally, depending on which way it wants to go. And then we'll come down onto the proximal humerus itself. Now what we do here, rather like a mitral or an aortic valve replacement, is replace a whole series of sutures in the and 8es, the subscapularis the interest beneath us so we can reflect all of those muscles out of the way.
We also need to divide the long head of biceps, which will try and repair into the rotator interval as well. So I like to think of the surgery around the proximal humerus is really being very much a soft tissue procedure rather than a bony procedure. The bony procedure is really the easy bit. It's the soft tissue reconstruction that takes the real skill, and here's the tumor resected, so really quite a large tumor here is the humeral had.
This is where it's expanded after the bone is covered by muscle here. But we need to take this with a significant margin and his normal humerus down here. We might use constructions like this the mutaz tube to allow attachment of the soft tissues. But actually, now when I'm doing these reconstructions, I try and avoid implantation of a mesh and we just try and reconstruct the native anatomy.
So this is the approach here. Here's the proximal humerus going into position in this case, because of the extent of the resection, we did place a mutual tube. But the problem with this is it can get infected. It's very difficult to remove. Once it's got a problem and it can also become fibrosis, the need to quite a stiff shoulder. So where possible, now I try and avoid that.
Here's a fairly long and a prosthetic replacement, but it's really nicely in position. Post-operatively, sir, anatomically aligned. And what you're going to say to the examiners? Remember, the key thing you're going to say to the examiners before you do this is that you're going to measure the patient's native retroversion and you're going to try and match that when you put the end of prosthetic replacement into position.
You're then going to try and reconstruct all of these muscles around that proximal humerus to restore the natural anatomy and to try and give the patient as good a function as you absolutely possibly can. Even with careful surgical technique, we still do get these problems. Look at this. This is just between January 2013 and April 2013. The humeral had a subluxation, and I'm sure you've guessed what has happened here.
What's happened here is that where we've tried to repair the rotator cuff, the metal has found a way to get in between their soft tissue structures. The rotator cuff has gone either side, and it's subluxation superior. So have an answer in terms of the examiner asking you about rehabilitation when you've done the reconstruction, allow that reconstruction to bed in for the big reconstructions.
No active shoulder movement for about six weeks to let things really settle down and then passive assisted for about 6 to 10 weeks. Gentle pendulums for 10 weeks. And then gentle active motion avoiding positions of instability. Just beware the rapidly growing tumor. The ones that we really sort of tend to think about are the renal cell carcinoma, the thyroid and the myeloma.
I got caught out only the other week with a renal cell carcinoma. We were under pressure to get the patient done. I decided not to analyze the tumor. And we did have significant blood loss. And it really can be quite a hair raising experience. I wonder if any of you by now have noted the deliberate mistake in the angiogram. On the left hand side, you'll see that the registrar who put the humeral nail in the first place.
Unfortunately missed the distal locking bolt. I'm sure we've all been there. This is a really interesting case. This is a young patient. A 37-year-old who presents with this is the CT scan. You can see this increased activity around the mid shaft of the humerus on the left hand side. The good news for him is no other aggressive disease elsewhere, so we need to think of a surgical strategy to try and reset this.
And again, in the past, the cheaper for this would be to reset the proximal humerus to do a long proximal humeral replacement. But now we need to think about better options, about better reconstruction. So in this, we used a technique called the bridge. Here's a sort of direct lateral approach here. Obviously, the structure at risk is the radial nerve. So we've taken the radial nerve and move that after the way that gives us this gap, this into Callery resection and the really chop trick.
If you're going to talk to the examiner about this, the really key thing to mention here is that you must make a mark to mark your alignment between the proximal and distal parts before you take the section out. Otherwise, you have this disastrous situation where you take it out. And then you've got the two parts flailing in between. You do not know the correct orientation, so it usually or a pen to make a mark there.
Then you make up the bridge. So this is the tumor, which has been resected several of the companies make. Exempt implants. This then gets bolted together, so you have a variety of sizes and then that gets placed into the implants to reconstruct the gap. So guys, it's 5 to nine. I think I'll stop talking.
Hand over to the moderators. But I hope that just sort of reminds you of the importance of the anatomy of the upper limb. I think the anatomy of the upper limb is perhaps even more difficult than that of the lower limb. And in terms of operating, what makes it particularly difficult, but of course, interesting is that because the upper limb is smaller than the lower limb, all of those important structures live very, very close together.
So you've really got to understand the anatomy to be able to safely get in and out and avoid complications. Thank you very much. Thank you very much, Mr kostka. That was very interesting, comprehensive and very enlightening. Thank you. Certainly learned a lot from it. This is a very difficult subject.
And you mentioned you managed to break it down into an easy, small steps. So that is a real art. Thank you. May I present some of my invite? I will first invite on to help me with this. I have some questions posted by the audience, if you don't mind. We'll try and make them as brief as possible.
So the first question was about the safe zones for children's choir into the proximal humerus. Would you recommend certain areas to avoid passing the wires through for children if you are planning to do otherwise? Yeah, it's a very good point. I mean, you know, I'm not a pediatric orthopedic trauma surgeon, but if we just think about the relevant blood supply of the proximal humerus, let's see if we can find that pressure if we go back here.
So really, this is the sort of slide that you need to be thinking about and what you're trying to avoid here is damage to both the antero-supero-lateral vessel and the actuate artery. So really positions in, in and around the greater tuberosity reasonably safe distal to the auxiliary nerve and the anterior complex human artery also reasonably safe if you're going to use a attends nail.
But try and avoid this danger here, you don't want to give the child avascular necrosis of the humeral head. Absolutely then the next question you you've positioned, you put a picture of an fibular graft. The question was it an allograft or an autographed? Always, always in our unit from the same patient? So yeah, we I've got one next week, actually, we've got a young patient who's got a very aggressive tumor of the radius.
It's a really difficult case. I'm hoping Ruth, actually, if you invite me back to do the tumor session, I'd really love to show the delegates this tumor. It's very, very difficult. We've got to get into the forearm, get this tumor out and then we'll use the fibula. It's an amazing bone, the fibula, when we all walked on all fours, we needed our fibula to stabilize our legs and to allow push off.
But now that we're up on two feet, remarkably, we just don't need it. And when you see these patients back in clinic about 6 to 12 months later, having had the whole of their fibula removed, it is really incredible that actually they don't even have any abnormality of gait. It's really amazing. Beautiful the next question is about Henry's approach to the forearm.
Is it safe or would you recommend to detach the pranati terrorist during that to try and have a better approach to the bone? Yeah so let's just go, are we here? So I must admit, I don't detach anything. I am a great believer in gentle finger dissection. So obviously you've got to use a blade. I use a large blade to go through the skin, subcutaneous tissue.
And then through the fascia. And then really, I try and just use a finger to gently work my way down to try and get my way down onto the radius and just gradually move those structures sequentially out of the way. And one of the things I've learned over the years from my more experienced colleagues is that when you're a more junior season, you get very worried about seeing the nerves.
You know, you get very worried about seeing the sciatic nerve, about seeing the medial nerve, and you tend to think about your approaches so that you don't end up seeing those in tumor surgery. It's the opposite. We look for those nerves, we want to see them. We want to see the full length of those nerves so that we can safely move them out of the way. And that's see, that's really changed my surgical practice.
I now go looking for that median nerve. I want to see it. I want to feel safe as I go to sleep at NIPE that I've moved out of the way I want to see the length of it. I don't worry about making a long extensible approach, and then I just gently move it out of the way. I use a blunt retractor and then I can do my bony work. So don't be worried about looking for nerves. If you see a nerve and you're gentle with it, that can be just as safe as not trying to see it.
Tenotomy next is there is a question that came in part one which was posted by the yes, abdurrahman, he says what structures might be injured by a clavicle plate screw protruding lateral to the underlying artery? Let's have a look. So if we go back, where shall we go if we go to probably about slide 10? That was a good guess. So let's just take the question again, so we should be able to use this.
If you have a protruding screw lateral to the artery, which structures you would be worried about? Yeah, very good. Very good question. So you really see it from the slide here. This is the lateral call to the brachial plexus, or potentially even the musculocutaneous nerve with this sort of area here. So, yeah, you do need to be very careful about that.
I mean, fortunately, arterial perforation is relatively rare. It's the one that we all worry about. And just to answer your question a slightly different way. One of the questions the examiner might ask you was that if you were on your own and you were doing an open reduction internal fixation of a clavicle and you accidentally put your. Drilled into the artery or the vein. What would you do?
And you need to be really clear about how you will deal with that because that is a real emergency and obviously what you do is put the call out for the vascular surgeon. You need expert help quickly. I would get a colleague in as well, so don't deal with this on your own. If there's another orthopedic consult in another theater, you want to get them in to get some help quickly but surgically.
You need to be prepared to perform an emergency clavicle osteotomy. So that means either taking the plate off where you've already fixed the plate or quickly cutting through the clavicle to be able to reflect the clavicle out of the way. Then you can apply direct pressure to the artery until the vascular surgeon arrives. The auxiliary artery has subclavian artery is one of those arteries that doesn't just bleed.
It makes a noise as it bleeds because the blood flow is so immense. Obviously, as we all know, it's more catastrophic to put the drill into the vein rather than the artery the artery. You can usually get away with it. It will perforator and then close behind it. As has happened to me, the vein is much more dangerous. The vein will tend to tear.
You must not try to repair that yourself. That is for an experienced vascular, possibly even cardiothoracic surgeon. Excellent the next question was about the relative ease of use between Henry's and Thompson's approaches for the forum, which one would you prefer? How would you decide to go between the two? Now I think that's a very difficult question. It's a good question.
It's a difficult question to answer. I mean, I think I think what the question implies is, you know, is one or the other safer or are you particularly worried about doing either of them? I think the more you do, you just actually stop worrying about doing those kind of approaches. So I would just really very much look at the microfracture or the tumor configuration. I would think about how I was going to try and reduce my fracture, and then I would honestly just choose the most appropriate way in and often actually practically speaking, the funny thing is when you are approaching the forearm, we don't necessarily worry about the named muscles, we just worry about getting safely in and safely out.
excellent. Now I've got many other questions waiting. afraid I had to skip through some of them just leaving the more important ones because of time. Two more left. One is about the main blood supply to the radia. Sorry to the humeral head because there was some change in recent, you know, understanding of how the blood supply comes.
So is it more important, anterior or posterior? Well, that's a very good question, and I'm reluctant to give you a definitive answer because the problem is that some of the cadaveric studies have showed that it was initially the posterior second flex humoral artery and some the anterior. I think if you got that question, I would actually tackle it by just explaining in detail what the blood supply is that the reality of it is that we see a vascular crush of the humeral head relatively rare.
We honestly don't see that very commonly. Whatever approach we use, we try and preserve those, those vessels. I would just have that sort of debate with the examiners and try and quote a couple of the key papers. Absolutely I don't think that would be a pass/fail remark. Absolutely not. No, that would be 7 or eight. Exactly, exactly.
And last question is when you mentioned about patients retribution, when you are looking for a replacement. How would you determine that? Yeah OK. So so I would literally let's see if we can get that. Bird's eye view, sure, looking down at the. Sort of the humerus coming down.
Here we go. So I would literally stand over the top of the patient now in my theater. I know. And it would be different for all of us, but I know that the humor at the center of the humeral head is always pointing to the clock in the center of the X-ray screen. So I know that.
And then what I'm interested in looking down the top is where is the forearm pointing? Is it pointing to the scrub room? Is it pointing to the theater door? Where is it pointing? And so when I do my resection and then I place my new implant into the top, I'm simply going to match that anatomical position so that for the patient, I get exactly the same retroversion for them.
So it's the bird's eye view from the top of the shoulder. When you've got them in the beachwear position, you're looking directly down onto the humeral head. Absolutely thank you very much. I know that you have. You have to be somewhere. No, no, no, no, no. My great pleasure and thank you very much for inviting me. We are a pleasure to have you here today, and we will be certainly discussing with you for further lectures and take you on your offer.
My great pleasure. Yeah hopefully I get to meet you later in the year and we can take you through some bone and soft tissue tumor oncology without really getting requests from participants when it's going to be so full up soon. OK thank you very much, guys. Bye for now. Thank you very much. Mr kostka.
Segment:0 .
Ladies and gentlemen, and a huge Thanks for joining us on this session. There's an awful lot for us to get through here. Just an introduction. Thank you for the kind words. My name is Tom cockrum, head of anatomy for the University and also the chief examiner for the University.
And I'm also a consultant, orthopedic oncology surgeon here at the Nuffield orthopedic center. The slides that you're about to see, I think, are all things that you could reasonably see in the Fox examination, and I'm going to try and take you through what I think are the really key points that you need to know. Now this is a slide that you all know. Well, you've all seen this.
These are the wiring diagrams, as I call them. And these are just to remind you about the nerve supply of the various muscles in the upper limb. So the Super slap ulnar nerve supply supersprint 8as and interest connectors from C5 and the auxiliary nerve supplies the deltoid and tiers minor, which is not shown in the diagram. So they're the principal abductors of the shoulder.
Elbow flexion and extension is produced by the musculocutaneous nerve. What I teach the students as the BBC, the British Broadcasting Corporation nerve that supplies the biceps, the brake careless and the correct brake areas. As we all know, the radial nerve supplies, the extensive compartments of the arm and the posture and atrocious nerve.
The derivation of this the forearm extensive compartments in terms of wrist extension and flexion. Well, that's supplied by all three of the major peripheral nerves the radial nerve, the medial nerve and the ulnar nerve. Just be aware and be able to describe what both the median and the ulnar nerve supply in the forearm, both on the radial and the ulnar side of the wrist.
The radial nerve coming from C6 and C7, the median nerve supplying flex pi radial C7 and the ulnar nerve supplied by C8 supplying flexor pi Allen on the ulnar side of the wrist. In terms of finger flexion and finger extension, that's the, of course, the intrinsic muscles of the fingers in the hand, as well as the long flexes and extends and again supplied by all three of those major nerves the radial, the median and the ulnar nerves.
And here we're talking about extensor digitorum limb communists on the dorsal surface of the forearm on the radial side of the hand, the flexor digitorum superficialis and flex, a digitorum profundus to the radial side of the hand and the ulnar nerve supplying the flexor digitorum unpreparedness to the ulnar side of the hand. So just be aware and be able to describe those in terms of finger abduction and finger abduction.
These are the intrinsic muscles we know the mnemonic, which is pard and dab, and know that the nerve supply is via the median nerve to the two radial lumbar calls and the ulnar nerve to the two ulnar lumbar calls. And both the Palmer and dorsal interossei will revisit that as we go through the lecture this evening. So a simple question might be what's the arrangement of the brachial plexus?
Lots of different ways of remembering this. I remember it with Ron Taylor drinks cold beer. And this reminds us that it's the roots C5 to T1, the trunks, the upper, middle, and lower trunks, the divisions via the anterior and posterior divisions, the chords, the lateral posterior medial chords, and then those terminal branches. So whether you're in the written exam or the vyver exam or any part of it, you just need to be thinking about where the lesion might be within the brachial plexus and try and think about how you would narrow it down to be more specific about where the problem is.
So here's the left sided brachial plexus. We won't dwell on this in too much detail. This is the one that we all frantically look at, including me the NIPE before the exam or the NIPE before the lecture, just to remind ourselves where all these various branches come off. And I think although you'd be expected to know the lumbosacral plexus for the lower limb, you certainly wouldn't be able to or be expected to draw every single branch of it.
But I think you would be expected to draw the brachial plexus, and there are several very good videos available on YouTube where people show their various techniques of drawing this. Just one top tip is that many of you will have learned how to draw either the left or the right brachial plexus. Remember that the examiner will be looking for that. So if they ask you to draw the brachial plexus, a particularly main thing to do, which can happen is they'll see which side you go to draw, for example, the left, and then they'll ask you to draw the right because they know that you're more uncomfortable drawing that side.
So just be able to draw both if you're going to be able to do it and you can't rely on what one candidate did in the exam, which is to draw one side and then flip the piece of paper over to show the other. Nice trick, but I'm afraid not good enough. So here's the brachial plexus. This is protected by the bony clavicle, so the clavicle lies anteriorly with the brachial plexus behind, and this forms an important bony protection, as well as a structural support to the anterior shoulder.
And just a reminder, I'm sure most of you will be aware of this, but if you're asked to identify the various parts of the brachial plexus, one of the very straightforward ways of doing so is to look for the letter M lying on the auxiliary artery. So you can see here that this makes a clear letter M. And fortunately, that's the median nerve in the center of that line, right at the front of the axillary artery.
So if you get given this kind of photograph, just be able to talk about the roots as they emerge from the spinal canal. The relationship of both the subclavian vein and subclavian artery just know where those lie and know where the brachial plexus emerges, of course, between silliness, medius and skinniness be able to describe Horner's syndrome, so this young lad has a very characteristic appearance of a hornish syndrome.
And of course, we remember the mnemonic, which is up, which stands for meiosis pupillary constriction anhydrous a lack of sweating with the dropped eyelids you can see on his left eye and end up thalamus, usually in more long standing hornish syndrome, where the eyeball is sunken into the orbit. And in fact, although this is a relatively rare condition, I did see this in my clinic just this week with a patient who presented with a lung tumor and caused that very textbook description of a Hornet syndrome, which we've all read about.
So just be able to describe that in some detail. Here's another clinical one, so what would be your differential diagnosis for this young patient who comes along to your clinic? Well, that's or fussier scapulohumeral dystrophy, a bit of a mouthful, but those abnormal position of the scapula is really a spot diagnosis. What about this patient, it's Black and white photograph of the left shoulder, and the examiner wants to know if this is a supraclavicular or an infraction vehicular injury in the absence of a rotator cuff tear?
Well, you can see that there's both super sonatas and interest bonitas muscular wasting, and therefore this must be a suprascapular nerve palsy. We know that the Super slap ulnar nerve supplies both the and impersonators and therefore must be a lesion of this nerve. So you want to really get to that answer very quickly for the examiner. Explain what you're seeing, and this is really a key slide for the fast.
Yes, this should probably have a red box around it because this piece of anatomy is something that comes up time and time again, both in the written questions and in the virus, and potentially even in the clinicals. So here's the nerve this we're looking at a section through the scapula here. Here's that important ligament the superior transverse scapula ligament, which lies across the top.
And here's the artery that passes over the top, but the nerve passes underneath, and therefore that's a potential site of nerve entrapment. If the nerve is trapped here, that's going to produce weakness of both and interest bonitas, as opposed to if the nerve is further down the spinal glenoid notch. As the nerve passes more directly and it will, then we then see only a palsy of the interest tinnitus.
So again, just want to have a look at just before the exam, perhaps be able to draw this. Certainly, be able to recognize it. So that you can identify where the lesion might lie. So remember water over the bridge. What are the major terminations of each chord you might want to just remember this slide, it does come up in the mckew questions later.
So in terms of the latter chord, that's the musculocutaneous nerve. The posterior cord is the radial and the auxiliary nerve. The medial call, the terminal branch of this is the ulnar nerve, and both the medial and lateral nerve will, of course, must be the median nerve. Let's move on, let's think about AC and stdlogicvector, joints and the clavicle. And again, another really key slide here, this should have another red box around it.
We're looking at the right shoulder. The coracoid process and the important structures around that. Now, as you all know, there are nine structures which either originate from or attached to the coracoid process. But what you're absolutely not going to do in the exam is say that there are nine structures because the immediate next question of the examiner will be to ask you to list and name all of those nine.
So the way that you're going to phrase it is, this is an image of the right shoulder. We can see the coracoid process. There are several important attachments and origins from the coracoid process, some of which are the following. And I would probably highlight the fact that pectoralis minor originates from the coracoid process from the second, third and fourth ribs. Of course, the conjoined tendon vitally important for us as orthopedic surgeons, which will revisit in the next few slides and then the conoil and trapezoid parts of the coracoclavicular ligament and then the coracoacromial ligament.
And again, vitally important. This is a really important structure to preserve shoulder stability, to prevent escape of the shoulder antero-supero-lateral. And there is that really annoying artery. That's the one that we've all prang when we're doing a shoulder arthroscopy, we inadvertently hit this and then that bleeds and we get the complete red out of the screen.
That's the branch of the coat chromium artery to come back to our conjoint tendon. All of the important brachial plexus lies underneath this. And so there's a safe side and a very dangerous side. Unfortunately, I have to spend a fair bit of time over on this side of the conjoint tendon. But for most of our shoulder surgery will try and stay over on the lateral side and sweep that stretch immediately, which will then protect our brachial plexus.
So remember, the superior restraint to the AC joint. Is that important? Karaka accumulate ligament. So a question might be which of the following steps is important when dividing a painful, massive rotator cuff tear? Hopefully, now we won't even need to read the answers. We're looking for that crucial structure, the co-occur coracoacromial ligament that we saw on the previous slide to make sure that humeral head can't escape.
Let's move on to the shoulder. Now this is a slide that comes up in the textbooks. And I must admit, when I was learning this, I didn't quite understand what this was trying to show. But this diagram is showing a bird's eye view looking down onto the shoulder. So we can see the humerus head in the center of the screen. Here's the glenoid. We know that this must be the front because the coracoid always points to the front.
We're looking right down along the length of the humerus, and we've drawn a line through the medial and lateral epicondyle, which gives us our retroversion of the humeral head. Now the really nice thing that you're going to say in the exam, if you get this kind of case before you take off the surgical head of the humerus, you're going to measure and look at the patient's natural retribution.
So that whenever you put an implant in, you're going to make sure that it's exactly matched to the patient's native position. Don't forget, of course, that the glenoid is orientated about five degrees posterity that's retrofitted, and those combine structures mean that the humeral head is reasonably well contained in what of course, we know is the most unstable joint in the body, looking down separately onto this gentleman's right sided shoulder.
Here we can see the rotator cuff from the top, the supersprint 8es lying over here, the infringement notice and the tiers minor be able to describe the order of those structures and the subscapularis tendon lying anteriorly. You'll note as well from the top of the shoulder here that this forms a triangle. Nature makes use of the fact that the triangle is the strongest structure, so the shape clavicle lies anteriorly.
Here's the spine of the scapula and underneath this is the bulk of the spinsters. Now, here's the slide that everyone dreads getting in the exam, either in the written paper or in the vyver. You could very well get given this slide, and it's important to have a strategy so that you can confidently work out those muscles and structures around the inside of the shoulder.
And I'll just give you my simple strategy for trying to work out what these are. Now, obviously, the glenoid lies in the center that doesn't particularly help you, but there are two landmarks that I'm looking for to tell us, which is the front and which is the back. So the first of these is the long headed biceps. Remember, the long headed biceps comes in at the 12 o'clock position at the top of the glenoid labrum and the long hand.
The biceps will be passing anteriorly to the left hand side. The screen must be the anterior shoulder. This must be the posterior shoulder. The other feature that I'm looking for here is the coracoid process. So here's number six, the coracoid process. And you remember, we said that the coracoid process always points towards the front of the shoulder.
So that's our second confirmation that this must be the front of the shoulder joint. Here's the acromion, which lies superiority and therefore by definition, number two must be the silver Chrome will bursa. Well, now we've worked out which is the front and which is the back. It should be much more straightforward for us to label the relevant structures.
And of course, the rotator cuff surrounds the proximal humerus. So here's the supersprint 8es lying separately. Then we've got the subscapularis lying anteriorly that enforcement notice the next one round and tiers minor. Once you've done those, it's then easy to undertake the next layer of labeling. Remember the deltoid muscle surrounds the majority of the shoulder. The deltoid muscle is unusual, and it has both an A a middle and a posterior component.
And then we can see the picture. Eilish major tiers major latisha restores sight and triceps. If you get the chance, it's just worth highlighting to the examiner at this point that the triceps lies opposite the insertion of the long head of biceps. So the long hair the biceps inserts at the 12 o'clock position on the glenoid, the triceps long head originates from the 6 o'clock position.
So tangentially opposite to each other. You should be able to label the following insertion. So we're now slightly further down around the entire trabecular groove. Of course, pectoralis major must be the latter most structure, and the reason for this is that pectoral. This major lies anteriorly and therefore the other two structures must lie deep to this, and therefore it has to insert at the far lateral side.
So pectoralis major lying laterally. Latimer's lying in between the two and tiers major lying more medially to just be able to identify those structures. And of course, we have the groove running in between the greater and lesser tuberosity in which the long head of biceps will lie. What attaches to the lesser and the greater tuberosity of the humor? So again, we've got this superior and lateral view.
So to the greater tuberosity is the three muscles supersprint 8es interest pinatas and tiers minor to the lesser tuberosity just one muscle. The subscapularis supplied by the upper and lower subscapularis nerves. A patient with a subscapularis rupture would have what clinical findings expect them to have a positive Gerber's lift off test positive because they're unable to do it.
They'd also have weak internal rotation and they'd have increased passive external rotation. And you will get some of these in the exam, particularly in the clinicals. And of course, the relevance to this is that, particularly after an anterior approach to the shoulder, we really are fastidious about trying to repair the subscapularis so we don't leave the patient with this post-operative complication.
Name the static and dynamic restraints of the shoulder, so be able to just divide this up very logically in your discussion. So the static is the articular anatomy, so the relative shape of the bony glenoid, the glenoid labrum, which is made of type 2 fibrous cartilage and the structure of the labrum means that there's a negative articular pressure. The humeral head is sucked in towards the glenoid, making it much more difficult for it to dislocate.
It's surrounded by a thick, protective capsule, and it also has important ligaments. The dynamic stabilizes Ah, the rotator cuff, the biceps tendon and of course, the pre-program scapulothoracic motion. So which of the following anatomical structures provides a dynamic contribution to shoulder stability, where we know the answer now have got a nice ordered structure for it? It must be the rotator cuff.
Another red slide. So we're looking at the right shoulder and there's really key spaces now. Unfortunately, as many of you will be aware, because the British and European textbooks differ from the way they describe this to the American textbooks in the farke's. Whenever you get one of these spaces described, the writer or the examiner should define the space for you so that exactly what's being referred to.
Let's just discuss these in detail. So the quadrangular space defined by the inferior border of tiers minor and the superior border of Terry's major, is seen here and through that will pass the posterior and humeral artery and the axillary nerve. They will wind around the neck of the humerus to progressively supply the deltoid muscle. Here's the triangular interval that will carry the radial nerve and the profunda brachial artery.
And over here, the triangular space which we don't see very often but I see Drew my tumor surgery when we're taking out the scapula that contains the circumflex subscapular artery. So what you need to do is look at this slide just before the exam, look at the break of plexus, look at this slide and be able to draw out those boundaries for the examiner so that they know that you clearly understand not just what passes through them, but where they are.
So on the PDF, when you get this, that will be sent out after the presentation. This is another of those slides I would really highlight just to go back and look over. So this is a quadrangular space in a bit more detail. The deltoid has been reflected away, so we're looking at the back of the shoulder here. The patient is in the sloppy lateral position with a deltoid reflected out of the way.
Here's the axillary nerve emerging with the posterior circumflex humoral artery, and we can confidently say to the examiner that that's passing through the quadrangular space. So way of remembering it is that it's four syllables or words. The quadrangular space and passing through that is the posterior circumflex humoral artery and the axillary nerve. Just to show you in a little bit more detail, here's the axillary nerve and the artery passing through that quadrangular space.
Here's the very tight shoulder capsule seen posterior. So if we're doing a posterior approach to the shoulder, what we just need to try and do is to sweep those muscles away so that we can safely access the back of the shoulder. It's an absolute disaster for the patient if we inadvertently damage the axillary nerve and leave them with no deltoid function. It's really disabling for the patient to have that now returning to the front of the children just to remind you of the important blood supply as this comes down.
Remember, of course, that the subclavian artery arbitrarily changed its name to the axillary artery and will then become the brachial artery. We'll look at that further in the next few slides, but really, what this slide shows you is the important blood supply to the humeral head, and that is formed from both the anterior and posterior circumflex humoral arteries, which you can see arising off here.
And this important smaller branch, which has got the circle around it, this is the actuate artery and the artery artery provides the important blood supply to the anterior aspect of the humeral head. So the three portions of the auxiliary artery are the Supreme thoracic, which goes from the first rib to the medial edge of pectoralis minor. The thoracotomy will branch and lateral thoracic arteries deep to pectoralis minor and distal to pectoralis minor.
The subscapularis anterior circumvents humoral and posterior complex humoral. So the key takeaway from this slide is that it's the pectoral, this minor that divides it into the first, second and third portions. I think you're very unlucky if you get asked about the first and second part and their various branches. I think it's much more reasonable.
You will get asked about the terminal branches of the third part of the auxiliary artery. Here's just another view just to show us that important relationship to petrol is minor. As we said earlier on the presentation, petrol osmani usually rises from ribs to 3 and four, and this diagram also five that passes through the coracoid process, but the artery passes underneath that.
So if we need to get to that, then we must be prepared to potentially do a coracoid osteotomy to effect petrol this minor out of the way. And that will then give us clear access down to the artery and perform our repair. This just shows what can happen with the proximal humeral fracture, he's a neck fracture, and you can see that the distal fragment has moved me to the here and this is now tenting the brachial plexus.
And really, this is just to remind us all of the hazards of being in this area. When we're reducing these fractures, we must be really very careful about where we place our tail clips. And I often find that just a gentle finger reduction and a finger sweep is the most appropriate and safest way of moving the breaker place out of the way before gently reducing the fracture back into position.
Now moving a bit more deftly, and this slide is really important in terms of just reminding us about that important relationship to the conjoined tendon that we were looking at earlier. And if you remember the conjoined tendon passes from the coracoid process down into the arm, here's the brachial plexus emerging underneath it. So when we've exposed this, we need to put our finger into this position here and sweep the Briogeo plexus medially so that we're away from damage.
A few more important takeaway points here. So the main new vascular structures are the median and ulnar nerves, which which are really very medially in the arm before they pass across the elbow. Here's the radial nerve passing down through the spiral groove before it pierces the lateral intramuscular septum, about 7.5 centimeters above the lateral epicondyle and before it becomes a more anterior structure as it passes down into the forearm.
So what Archie runs the radial nerve. Or we looked at that earlier when we're talking about the relevant spaces, that's the profunda brachii. What nerve runs in between the basilic vein and the brachial artery that will be the median nerve and which nerve is medial to the basilic vein? That will be the medial antebrachial cutaneous or the medial cutaneous nerve of the forearm for the British and European textbooks.
Now this is a crucial cross section, and it sounds an obvious thing to say, but I have heard it in exams. You must make sure you decide whether you're looking at the upper or the lower limb. It's an absolute disaster in the fast, Yes. If you start talking about this as being a cross section through the thigh. When actually we're looking at a cross section through the arm, it's very embarrassing when the examiner points that out to you.
So how are you going to identify that? Because of course, they do look a little similar. There are a few key takeaways that help you identify. The humerus is a relatively triangle shaped structure, so the shaft of the humerus points forwards anteriorly and then the real key giveaways. This radial nerve like absolutely on the posterior, the like of which you do not have in the thigh here on the medial side of the arm is the main neurovascular compartment, and it always amazes me what a very compact space this lies in.
We all think of the median and the ulnar nerve as being actually quite well separated. But when you see this diagram, they're really very, very close together, just a centimeter apart and just separated by the neurovascular bundle. So in the right arm that we're looking down on from the top here, you can see that the danger area really lies between about 8 o'clock and 10 o'clock, all of those key structures lying within that region.
The muscular, cutaneous live eye is relatively anteriorly. That makes sense because as we said before, it's the BBC nerve, the British Broadcasting Corporation nerve, and that's going to have to supply the biceps, the brake Ellis and the curb radiators, which are all a structures here is that large posterior wad of the triceps supplied by the radial nerve. So in other words, another slide just to draw a star on here, just on the NIPE before the exam, just to make sure you revise the cross-sectional anatomy.
So what does the auxiliary nerve supply? Well, the auxiliary nerve comes from the posterior cord, and it will supply the tiers mine and the deltoid shown in the green square at the top of the screen here. Nothing else, more in the arm or the forearm. All of the action for the axillary nerve is very proximal in terms of the innervation of the forearm, the superficial flexes, the deep flexes and the superficial extends deep.
Its dancers are supplied, as we said at the start of the presentation by the median nerve except half a flexor carpal nourish the deep flexes supplied by the median nerve except the ulnar nerve half of flexor digitorum fundus, the superficial extensor supplied by the rage ulnar nerve and of course, the more distal branch, the posterior atrocious nerve and the deep extensor supplied by the posterior intereses nerve.
What does the radial nerve supply? Well, we remember the wiring diagram. Now, remember, the radial nerve is more unusual compared to the median and the ulnar nerve because it does supply structures within the arm. So here we supply the triceps, both the long lateral and medial head. It then goes on to supply the mobile world and around the break you'll break your radiators, ACL and ECB, and then it gives off the posterior interosseous nerve, which supplies the remaining hand and finger extensive.
And if you're going for the gold star, just remember that the terminal branch of this usually not always, but usually supplies extensive indices, which you can see going across your course to the index finger. This is a really key MSK question, which will come up both in the written paper and also in the virus in the clinicals, just that really important relationship.
You don't even need to read the question in detail here. You know what they're looking for. They're looking for that important relationship of about 15 centimeters posteriorly and 7.5 centimeters laterally. The closest answer we've got here is number two. That's our answer. So what does the median nerve supply? Here's the wiring diagram.
Remember to tell the examiner that the median nerve supplies nothing in the arm. All of the action for the median nerve is below the level of the elbow. So this will supply from the common flexor origin down into the forearm compartment and finally into the thinner compartment of the hand. This is the hlophe muscles. The lateral to lumbar cause the opponent's policies, the abductor pollicis Revit and the flexor pollicis service down here at the very distal parts of the.
Why don't forget prone quadrantids in the distal forearm in between the radius and the ulnar, the ulnar nerve similar in that sense, to the median nerve. Again, no supply appear in the arm. All of the action occurs below the elbow, and the examiner would expect you to be able to surface marked the path of the ulnar nerve as it passes from the axilo down in the medial arm behind the medial epicondyle passes through flexo-pronator pi ulnar claw and then down onto the ulnar side of the hand to go in this wide spread arch and supply the intrinsic muscles of the forearm and the hand.
Just a question just to be aware of the four joints that can produce a septic arthritis from direct metaphysical extension. They are the proximal femur, the distal fibula, the proximal humerus and the radial head. So you'll notice, therefore, that two of those important sites lie within the upper limb, so this could come up in the upper limb adult pathology section.
Where does the anterior humor line cross on a lateral radiograph of the child's elbow? Nice straight forward one. This will be through the middle third of the capital M. Just be able to identify that on a radiograph and the ligament is stabilizes of the elbow. These are really very important in terms of keeping the elbow correctly in position. The radial collateral ligament on the outermost side of the elbow and the annular ligament holding the radial head into position.
Of course, this is the site where we see a pulled elbow where the radial head dislocate through the angular ligament and then on the ulnar side, the ulnar collateral ligament, as well as the capsule tightly binding the elbow into joint. Just be able to describe those important attachments, and it is always surprising when people get muddled up with this. At farces level, you must know where the biceps attaches into. Of course, it's the radial tuberosity that allows a supination of the forearm by the biceps, and that the brachial this arises or insert sorry into the coracoid process, just distal to the capsule of the elbow in the proximal ulnar.
Be able to describe the common flexor origin, the common extensor origin, and be aware of where this thick into intramuscular septum arises between the two bones and of course, the vessel and the artery pass through here and then lie on top of that into muscular septum tennis elbow. And the structure we're thinking about is extensive car pi radial ish Vervisch. That's the one that we're going to be looking to release when we do our inertial and AIIS CHL release, we're going to do the inertial release to release that tendon here and release the tennis elbow.
So here's our next important cross sectional anatomy. I think you'd be a little more unlucky if you got this in the exam, but certainly be able to orientate yourself. And the key structure to be looking for here is, of course, the ulnar nerve as it passes behind the medial epicondyle. Be aware of those anterior structures that the neurovascular bundle.
Now lying relatively anterior in the forearm with the brachial artery in the brachial vein. Several superficial nerves lying more peripherally. Now everyone gets a little bit worried about where the basilic vein and the cephalic vein lie. So it's just a really easy way of remembering is that it's as simple as a-b-c. So the abdomen lies over here. Here's the abdomen.
The basilic vein lies more easily, so this must be the medial aspect of the forearm, and the cephalic vein lies more laterally. So we see that over on the radial side of the forearm, just be able to identify those superficial sensory nerves. We do not have time to dwell on those now, but they do tend to come up in the written exam, and the question will ask the relationship to these various veins as they pass through.
So the radial nerve enters the forearm between which two muscles. That's between brachial and break your radiators on the lateral side of the arm, the medial nerve flexor-pronator taris and lies between which muscles. Well, that really between FDS and FTP and the ulnar nerve lines between which muscles will. That will be between FCU and MFDP. So just a simple way of remembering it.
Here's the diagram. So the ulnar nerve lying in between FCU and FDP on the ulnar nerve side of the forearm and the median nerve supplying between FDS and FTP on the radial side. Cross-section anatomy exactly the same comments that we made earlier. When we're talking about the upper and lower limb, please don't say this is a leg. When you look at it, this is a forearm.
And the way to identify. That again, it's a relatively easy mistake to make, but in the forearm, it's really this huge bulk of anterior musculature, which is different in the leg. The posterior structure of the leg are much bigger. And these are two opposing triangles facing each other, separated by that into muscular septum, with the neurovascular bundle lying on top of that. And the median nerve lying relatively centrally.
Here's the posterior neurosis nerve lying in the dorsal extensor compartment, so just be able to look back and label some of those structures. So in terms of your forearm approaches, the examiner would expect you to be able to safely get into the forearm, so to get yourself in and get yourself out, obviously, of course, everyone knows the approach to the ulnar side is relatively superficial approach and will pass in a truly into nervous pain between the posterior atrocious nerve supplying ICU and the ulnar nerve supplying flexor carpal Maris.
But of course, on the radial side of the forearm, this is more difficult and depending on the fracture pattern, that's the one that we all get worried about. I still worry about approaching the radius through the forearm. There's an awful lot of structures which are really at risk and what the examiner will be looking for when you're describing these approaches is to really show a very safe and common sense approach.
So what you'll be saying here is that you'll make the superficial incision and then you'll largely use finger dissection to try and work your way safely down to the radius, moving these neuromuscular structures out of the way to really try and keep them as safe as possible. Cross-section of anatomy through the rest, again, really, really important. I just picked a slightly unusual view of the rest here. We're all used to that very standard view of the carpal tunnel, but this is a slightly different section, but you could very reasonably get this just again, be able to work out the various structures.
And really, the key I'm looking for here is this muscular structure here. This is prone to quadrants running between the radius and the ulnar. And then you can work out the other structures on top of that. Look for that median nerve. must be the largest nerve that you can see in this cross-section, so should be really easy to identify.
And then you can piece together the ulnar nerve and the branches of the posterior atrocious nerve, which by this stage will be really very small on the posterior compartment. So here's the median nerve is going down just to remind this as it goes down to supply the muscles of the thenar eminence. And there we go. Dead on time, Ruth, I think I'm going to hand over to you at this point.
We're going to do a quick poll here just to check everyone's been listening and then we're going to move on to some really exciting stuff. I hope it should be some of the cases that we've seen as challenges from my own unit. So Ruth, over to you with the quiz, OK, I'm going to start the poll now. And you say that, tom?
Yeah, that's great, so we'll read it through. So in addition to the deltoid, what other muscle does the axillary nerve supply? So hopefully nice and straightforward for you, it's the one that always gets forgotten. We don't see this lesion very often in clinical practice. Have a go at that one number to the terminal branch of the musculo cutaneous nerve.
You just scroll down. Ruth, if you can. Yeah, it's a terminal branch, we've got a few different options. That so the motor nerve supply of the lateral to lumbar knuckles, lateral to lumbar, of course, hopefully. Straightforward that's great, so that's good. Well, nearly everyone got the first one, right? That's great.
Yep, sir. Tiers minor. Remember, if you have the nerve palsy of the auxiliary nerve, not only would we expect to see weakness of the deltoid, but we also see a positive Hornblower sign because the patient won't be able to suspend their arm in their abduction and external rotation to the arm will fall forwards to the branch.
The musculocutaneous nerve perhaps a little less certain on this one, but yet that's the lateral cutaneous nerve of the forearm. Just want to revise. You sort of need to know that and the motor nerve supply of the lateral to Allen because, well, remember that comes down to the hlophe muscles. So that's the lateral to lumbar, because the opponent's policies, the abductor pollicis Revit and the flexor pollicis prévus.
So that's those, of course. You know, the question that everyone asks is, well, you know why? Why do we need to know the relevant anatomy? So here's the kind of case that we might expect to see. This is the case of the vanishing humerus. So here's a right proximal humerus. You can see the humor or hair, but you can see there's a big lytic lesion, which has destroyed the proximal humerus.
And that's exactly the kind of case that we'd expect to see here on the tumor unit. So this is a really brilliant 1 to be able to talk about with the examiner to think through what you're going to say and really have a strategy about how you're going to work the patient up and how you're going to investigate them. Now, hopefully, we'll be able to revisit this when we do another session on bone and soft tissue tumors.
So I'm going to try and stick a bit more to the relevant anatomy today. But really, preoperative design and preparation is the key. So we're using our engineers to think very carefully about the type of implant that we're going to put in. But we're also very much thinking about the surgical approach. So the structures that are going to be at risk here. So we're thinking about the fact, we'll have to do an extended deltopectoral approach that will have to move the conjoined tendon out of the way with the brachial plexus will be thinking about the fact that the auxiliary nerve is winding around the human on that care so very much at risk.
But as I'll show, the next few slides will be really thinking about what we can preserve about what soft tissue structures we can preserve to try and retain function in this. But it doesn't have to be about metal, doesn't have to just be about hardware. This is a young patient 25-year-old who presented with this aggressive Conder sarcoma of the mid shaft of the right humerus.
You see it really very aggressive lesion that's going to require very extensive resection. And this is one that even I now, after several years experience would really worry about in the NIPE and on the morning of surgery because there's an awful lot of clockwork that lies very, very close to this tumor. Now we've got the medial sided neurovascular structures that will be the median and the ulnar nerve over here, which I'll really be worrying about.
And of course, the radial nerve the radial nerve will be passing right next to that tumor. We'll obviously counsel the patient here that in all likelihood, unfortunately, the radial nerve may have to be resected during this. Now, in the past, we'd have typically resected this and put in a large piece of metal as an end of prosthetic replacement. But what we're trying to do for this patient is to place the free fibula graph.
So we borrowed a fibula. We've wedged that into the humeral head. We've left all of the soft tissue attachments around the proximal humerus just put in a little plate just to support this. Whilst this unites and then fixed modestly and that will gradually hypertrophy up and within a few years, that will hopefully be just as good as the patient's native humerus.
Now let's think about some of our intraoperative technique and the relevant anatomy. So here where we're going into the proximal humerus, then we're going to do an extended delta petrol approach. We'll take the cephalic vein either media or laterally, depending on which way it wants to go. And then we'll come down onto the proximal humerus itself. Now what we do here, rather like a mitral or an aortic valve replacement, is replace a whole series of sutures in the and 8es, the subscapularis the interest beneath us so we can reflect all of those muscles out of the way.
We also need to divide the long head of biceps, which will try and repair into the rotator interval as well. So I like to think of the surgery around the proximal humerus is really being very much a soft tissue procedure rather than a bony procedure. The bony procedure is really the easy bit. It's the soft tissue reconstruction that takes the real skill, and here's the tumor resected, so really quite a large tumor here is the humeral had.
This is where it's expanded after the bone is covered by muscle here. But we need to take this with a significant margin and his normal humerus down here. We might use constructions like this the mutaz tube to allow attachment of the soft tissues. But actually, now when I'm doing these reconstructions, I try and avoid implantation of a mesh and we just try and reconstruct the native anatomy.
So this is the approach here. Here's the proximal humerus going into position in this case, because of the extent of the resection, we did place a mutual tube. But the problem with this is it can get infected. It's very difficult to remove. Once it's got a problem and it can also become fibrosis, the need to quite a stiff shoulder. So where possible, now I try and avoid that.
Here's a fairly long and a prosthetic replacement, but it's really nicely in position. Post-operatively, sir, anatomically aligned. And what you're going to say to the examiners? Remember, the key thing you're going to say to the examiners before you do this is that you're going to measure the patient's native retroversion and you're going to try and match that when you put the end of prosthetic replacement into position.
You're then going to try and reconstruct all of these muscles around that proximal humerus to restore the natural anatomy and to try and give the patient as good a function as you absolutely possibly can. Even with careful surgical technique, we still do get these problems. Look at this. This is just between January 2013 and April 2013. The humeral had a subluxation, and I'm sure you've guessed what has happened here.
What's happened here is that where we've tried to repair the rotator cuff, the metal has found a way to get in between their soft tissue structures. The rotator cuff has gone either side, and it's subluxation superior. So have an answer in terms of the examiner asking you about rehabilitation when you've done the reconstruction, allow that reconstruction to bed in for the big reconstructions.
No active shoulder movement for about six weeks to let things really settle down and then passive assisted for about 6 to 10 weeks. Gentle pendulums for 10 weeks. And then gentle active motion avoiding positions of instability. Just beware the rapidly growing tumor. The ones that we really sort of tend to think about are the renal cell carcinoma, the thyroid and the myeloma.
I got caught out only the other week with a renal cell carcinoma. We were under pressure to get the patient done. I decided not to analyze the tumor. And we did have significant blood loss. And it really can be quite a hair raising experience. I wonder if any of you by now have noted the deliberate mistake in the angiogram. On the left hand side, you'll see that the registrar who put the humeral nail in the first place.
Unfortunately missed the distal locking bolt. I'm sure we've all been there. This is a really interesting case. This is a young patient. A 37-year-old who presents with this is the CT scan. You can see this increased activity around the mid shaft of the humerus on the left hand side. The good news for him is no other aggressive disease elsewhere, so we need to think of a surgical strategy to try and reset this.
And again, in the past, the cheaper for this would be to reset the proximal humerus to do a long proximal humeral replacement. But now we need to think about better options, about better reconstruction. So in this, we used a technique called the bridge. Here's a sort of direct lateral approach here. Obviously, the structure at risk is the radial nerve. So we've taken the radial nerve and move that after the way that gives us this gap, this into Callery resection and the really chop trick.
If you're going to talk to the examiner about this, the really key thing to mention here is that you must make a mark to mark your alignment between the proximal and distal parts before you take the section out. Otherwise, you have this disastrous situation where you take it out. And then you've got the two parts flailing in between. You do not know the correct orientation, so it usually or a pen to make a mark there.
Then you make up the bridge. So this is the tumor, which has been resected several of the companies make. Exempt implants. This then gets bolted together, so you have a variety of sizes and then that gets placed into the implants to reconstruct the gap. So guys, it's 5 to nine. I think I'll stop talking.
Hand over to the moderators. But I hope that just sort of reminds you of the importance of the anatomy of the upper limb. I think the anatomy of the upper limb is perhaps even more difficult than that of the lower limb. And in terms of operating, what makes it particularly difficult, but of course, interesting is that because the upper limb is smaller than the lower limb, all of those important structures live very, very close together.
So you've really got to understand the anatomy to be able to safely get in and out and avoid complications. Thank you very much. Thank you very much, Mr kostka. That was very interesting, comprehensive and very enlightening. Thank you. Certainly learned a lot from it. This is a very difficult subject.
And you mentioned you managed to break it down into an easy, small steps. So that is a real art. Thank you. May I present some of my invite? I will first invite on to help me with this. I have some questions posted by the audience, if you don't mind. We'll try and make them as brief as possible.
So the first question was about the safe zones for children's choir into the proximal humerus. Would you recommend certain areas to avoid passing the wires through for children if you are planning to do otherwise? Yeah, it's a very good point. I mean, you know, I'm not a pediatric orthopedic trauma surgeon, but if we just think about the relevant blood supply of the proximal humerus, let's see if we can find that pressure if we go back here.
So really, this is the sort of slide that you need to be thinking about and what you're trying to avoid here is damage to both the antero-supero-lateral vessel and the actuate artery. So really positions in, in and around the greater tuberosity reasonably safe distal to the auxiliary nerve and the anterior complex human artery also reasonably safe if you're going to use a attends nail.
But try and avoid this danger here, you don't want to give the child avascular necrosis of the humeral head. Absolutely then the next question you you've positioned, you put a picture of an fibular graft. The question was it an allograft or an autographed? Always, always in our unit from the same patient? So yeah, we I've got one next week, actually, we've got a young patient who's got a very aggressive tumor of the radius.
It's a really difficult case. I'm hoping Ruth, actually, if you invite me back to do the tumor session, I'd really love to show the delegates this tumor. It's very, very difficult. We've got to get into the forearm, get this tumor out and then we'll use the fibula. It's an amazing bone, the fibula, when we all walked on all fours, we needed our fibula to stabilize our legs and to allow push off.
But now that we're up on two feet, remarkably, we just don't need it. And when you see these patients back in clinic about 6 to 12 months later, having had the whole of their fibula removed, it is really incredible that actually they don't even have any abnormality of gait. It's really amazing. Beautiful the next question is about Henry's approach to the forearm.
Is it safe or would you recommend to detach the pranati terrorist during that to try and have a better approach to the bone? Yeah so let's just go, are we here? So I must admit, I don't detach anything. I am a great believer in gentle finger dissection. So obviously you've got to use a blade. I use a large blade to go through the skin, subcutaneous tissue.
And then through the fascia. And then really, I try and just use a finger to gently work my way down to try and get my way down onto the radius and just gradually move those structures sequentially out of the way. And one of the things I've learned over the years from my more experienced colleagues is that when you're a more junior season, you get very worried about seeing the nerves.
You know, you get very worried about seeing the sciatic nerve, about seeing the medial nerve, and you tend to think about your approaches so that you don't end up seeing those in tumor surgery. It's the opposite. We look for those nerves, we want to see them. We want to see the full length of those nerves so that we can safely move them out of the way. And that's see, that's really changed my surgical practice.
I now go looking for that median nerve. I want to see it. I want to feel safe as I go to sleep at NIPE that I've moved out of the way I want to see the length of it. I don't worry about making a long extensible approach, and then I just gently move it out of the way. I use a blunt retractor and then I can do my bony work. So don't be worried about looking for nerves. If you see a nerve and you're gentle with it, that can be just as safe as not trying to see it.
Tenotomy next is there is a question that came in part one which was posted by the yes, abdurrahman, he says what structures might be injured by a clavicle plate screw protruding lateral to the underlying artery? Let's have a look. So if we go back, where shall we go if we go to probably about slide 10? That was a good guess. So let's just take the question again, so we should be able to use this.
If you have a protruding screw lateral to the artery, which structures you would be worried about? Yeah, very good. Very good question. So you really see it from the slide here. This is the lateral call to the brachial plexus, or potentially even the musculocutaneous nerve with this sort of area here. So, yeah, you do need to be very careful about that.
I mean, fortunately, arterial perforation is relatively rare. It's the one that we all worry about. And just to answer your question a slightly different way. One of the questions the examiner might ask you was that if you were on your own and you were doing an open reduction internal fixation of a clavicle and you accidentally put your. Drilled into the artery or the vein. What would you do?
And you need to be really clear about how you will deal with that because that is a real emergency and obviously what you do is put the call out for the vascular surgeon. You need expert help quickly. I would get a colleague in as well, so don't deal with this on your own. If there's another orthopedic consult in another theater, you want to get them in to get some help quickly but surgically.
You need to be prepared to perform an emergency clavicle osteotomy. So that means either taking the plate off where you've already fixed the plate or quickly cutting through the clavicle to be able to reflect the clavicle out of the way. Then you can apply direct pressure to the artery until the vascular surgeon arrives. The auxiliary artery has subclavian artery is one of those arteries that doesn't just bleed.
It makes a noise as it bleeds because the blood flow is so immense. Obviously, as we all know, it's more catastrophic to put the drill into the vein rather than the artery the artery. You can usually get away with it. It will perforator and then close behind it. As has happened to me, the vein is much more dangerous. The vein will tend to tear.
You must not try to repair that yourself. That is for an experienced vascular, possibly even cardiothoracic surgeon. Excellent the next question was about the relative ease of use between Henry's and Thompson's approaches for the forum, which one would you prefer? How would you decide to go between the two? Now I think that's a very difficult question. It's a good question.
It's a difficult question to answer. I mean, I think I think what the question implies is, you know, is one or the other safer or are you particularly worried about doing either of them? I think the more you do, you just actually stop worrying about doing those kind of approaches. So I would just really very much look at the microfracture or the tumor configuration. I would think about how I was going to try and reduce my fracture, and then I would honestly just choose the most appropriate way in and often actually practically speaking, the funny thing is when you are approaching the forearm, we don't necessarily worry about the named muscles, we just worry about getting safely in and safely out.
excellent. Now I've got many other questions waiting. afraid I had to skip through some of them just leaving the more important ones because of time. Two more left. One is about the main blood supply to the radia. Sorry to the humeral head because there was some change in recent, you know, understanding of how the blood supply comes.
So is it more important, anterior or posterior? Well, that's a very good question, and I'm reluctant to give you a definitive answer because the problem is that some of the cadaveric studies have showed that it was initially the posterior second flex humoral artery and some the anterior. I think if you got that question, I would actually tackle it by just explaining in detail what the blood supply is that the reality of it is that we see a vascular crush of the humeral head relatively rare.
We honestly don't see that very commonly. Whatever approach we use, we try and preserve those, those vessels. I would just have that sort of debate with the examiners and try and quote a couple of the key papers. Absolutely I don't think that would be a pass/fail remark. Absolutely not. No, that would be 7 or eight. Exactly, exactly.
And last question is when you mentioned about patients retribution, when you are looking for a replacement. How would you determine that? Yeah OK. So so I would literally let's see if we can get that. Bird's eye view, sure, looking down at the. Sort of the humerus coming down.
Here we go. So I would literally stand over the top of the patient now in my theater. I know. And it would be different for all of us, but I know that the humor at the center of the humeral head is always pointing to the clock in the center of the X-ray screen. So I know that.
And then what I'm interested in looking down the top is where is the forearm pointing? Is it pointing to the scrub room? Is it pointing to the theater door? Where is it pointing? And so when I do my resection and then I place my new implant into the top, I'm simply going to match that anatomical position so that for the patient, I get exactly the same retroversion for them.
So it's the bird's eye view from the top of the shoulder. When you've got them in the beachwear position, you're looking directly down onto the humeral head. Absolutely thank you very much. I know that you have. You have to be somewhere. No, no, no, no, no. My great pleasure and thank you very much for inviting me. We are a pleasure to have you here today, and we will be certainly discussing with you for further lectures and take you on your offer.
My great pleasure. Yeah hopefully I get to meet you later in the year and we can take you through some bone and soft tissue tumor oncology without really getting requests from participants when it's going to be so full up soon. OK thank you very much, guys. Bye for now. Thank you very much. Mr kostka.
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