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Anatomy_Gray_2000	Anatomy_Gray	A lateral radiograph of a fracture of the head of the radius typically demonstrates the secondary phenomenon of this injury. When the bone is fractured, fluid fills the synovial cavity, elevating the small pad of fat within the coronoid and olecranon fossae. These fat pads appear as areas of lucency on the lateral radiograph—the “fat pad” sign. This radiological finding is useful because fracture of the head of the radius is not always clearly visible. If there is an appropriate clinical history, tenderness around the head of the radius, and a positive fat pad sign, a fracture can be inferred clinically even if no fracture can be identified on the radiograph, and appropriate treatment can be instituted. In the clinic	Anatomy_Gray. A lateral radiograph of a fracture of the head of the radius typically demonstrates the secondary phenomenon of this injury. When the bone is fractured, fluid fills the synovial cavity, elevating the small pad of fat within the coronoid and olecranon fossae. These fat pads appear as areas of lucency on the lateral radiograph—the “fat pad” sign. This radiological finding is useful because fracture of the head of the radius is not always clearly visible. If there is an appropriate clinical history, tenderness around the head of the radius, and a positive fat pad sign, a fracture can be inferred clinically even if no fracture can be identified on the radiograph, and appropriate treatment can be instituted. In the clinic
Anatomy_Gray_2001	Anatomy_Gray	In the clinic It is not uncommon for people who are involved in sports such as golf and tennis to develop an overuse strain of the origins of the flexor and extensor muscles of the forearm. The pain is typically around the epicondyles and usually resolves after rest and physical therapy. It may also be treated with injection of the patient’s own plasma, rich in platelets, into the tendon to promote tendon healing and repair. If pain and inflammation persist, surgical division of the extensor or flexor origin from the bone may be necessary. Typically, in tennis players this pain occurs on the lateral epicondyle and common extensor origin (tennis elbow), whereas in golfers it occurs on the medial epicondyle and common flexor origin. In the clinic	Anatomy_Gray. In the clinic It is not uncommon for people who are involved in sports such as golf and tennis to develop an overuse strain of the origins of the flexor and extensor muscles of the forearm. The pain is typically around the epicondyles and usually resolves after rest and physical therapy. It may also be treated with injection of the patient’s own plasma, rich in platelets, into the tendon to promote tendon healing and repair. If pain and inflammation persist, surgical division of the extensor or flexor origin from the bone may be necessary. Typically, in tennis players this pain occurs on the lateral epicondyle and common extensor origin (tennis elbow), whereas in golfers it occurs on the medial epicondyle and common flexor origin. In the clinic
Anatomy_Gray_2002	Anatomy_Gray	In the clinic Osteoarthritis is extremely common and is usually most severe in the dominant limb. From time to time an arthritic elbow may undergo such degenerative change that small bone fragments appear in the articular cavity. Given the relatively small joint space, these fragments can result in an appreciable reduction in flexion and extension, and typically lodge within the olecranon and coronoid fossae. In the clinic Ulnar nerve injury at the elbow Posterior to the medial epicondyle of the humerus the ulnar nerve is bound in a fibro-osseous tunnel (the cubital tunnel) by a retinaculum. Older patients may develop degenerative changes within this tunnel, which compresses the ulnar nerve when flexed. The repeated action of flexion and extension of the elbow may cause local nerve damage, resulting in impaired function of the ulnar nerve. Accessory muscles and localized neuritis in this region secondary to direct trauma may also produce ulnar nerve damage (Fig. 7.76).	Anatomy_Gray. In the clinic Osteoarthritis is extremely common and is usually most severe in the dominant limb. From time to time an arthritic elbow may undergo such degenerative change that small bone fragments appear in the articular cavity. Given the relatively small joint space, these fragments can result in an appreciable reduction in flexion and extension, and typically lodge within the olecranon and coronoid fossae. In the clinic Ulnar nerve injury at the elbow Posterior to the medial epicondyle of the humerus the ulnar nerve is bound in a fibro-osseous tunnel (the cubital tunnel) by a retinaculum. Older patients may develop degenerative changes within this tunnel, which compresses the ulnar nerve when flexed. The repeated action of flexion and extension of the elbow may cause local nerve damage, resulting in impaired function of the ulnar nerve. Accessory muscles and localized neuritis in this region secondary to direct trauma may also produce ulnar nerve damage (Fig. 7.76).
Anatomy_Gray_2003	Anatomy_Gray	In the clinic Construction of a dialysis fistula Many patients throughout the world require renal dialysis for kidney failure. The patient’s blood is filtered and cleaned by the dialysis machine. Blood therefore has to be taken from patients into the filtering device and then returned to them. This process of dialysis occurs over many hours and requires considerable flow rates of 250–500 mL per minute. To enable such large volumes of blood to be removed from and returned to the body, the blood is taken from vessels that have a high flow. As no veins in the peripheral limbs have such high flow, a surgical procedure is necessary to create such a system. In most patients, the radial artery is anastomosed (joined) to the cephalic vein (Fig. 7.78) at the wrist, or the brachial artery is anastomosed to the cephalic vein at the elbow. Some surgeons place an arterial graft between these vessels.	Anatomy_Gray. In the clinic Construction of a dialysis fistula Many patients throughout the world require renal dialysis for kidney failure. The patient’s blood is filtered and cleaned by the dialysis machine. Blood therefore has to be taken from patients into the filtering device and then returned to them. This process of dialysis occurs over many hours and requires considerable flow rates of 250–500 mL per minute. To enable such large volumes of blood to be removed from and returned to the body, the blood is taken from vessels that have a high flow. As no veins in the peripheral limbs have such high flow, a surgical procedure is necessary to create such a system. In most patients, the radial artery is anastomosed (joined) to the cephalic vein (Fig. 7.78) at the wrist, or the brachial artery is anastomosed to the cephalic vein at the elbow. Some surgeons place an arterial graft between these vessels.
Anatomy_Gray_2004	Anatomy_Gray	After six weeks, the veins increase in size in response to their arterial blood flow and are amenable to direct cannulation or dialysis. In the clinic Fractures of the radius and ulna The radius and ulna are attached to the humerus proximally and the carpal bones distally by a complex series of ligaments. Although the bones are separate, they behave as one. When a severe injury occurs to the forearm it usually involves both bones, resulting in either fracture of both bones or more commonly a fracture of one bone and a dislocation of the other. Commonly, the mechanism of injury and the age of the patient determine which of these are likely to occur. There are three classic injuries to the radius and ulna: Monteggia’s fracture is a fracture of the proximal third of the ulna and an anterior dislocation of the head of the radius at the elbow.	Anatomy_Gray. After six weeks, the veins increase in size in response to their arterial blood flow and are amenable to direct cannulation or dialysis. In the clinic Fractures of the radius and ulna The radius and ulna are attached to the humerus proximally and the carpal bones distally by a complex series of ligaments. Although the bones are separate, they behave as one. When a severe injury occurs to the forearm it usually involves both bones, resulting in either fracture of both bones or more commonly a fracture of one bone and a dislocation of the other. Commonly, the mechanism of injury and the age of the patient determine which of these are likely to occur. There are three classic injuries to the radius and ulna: Monteggia’s fracture is a fracture of the proximal third of the ulna and an anterior dislocation of the head of the radius at the elbow.
Anatomy_Gray_2005	Anatomy_Gray	There are three classic injuries to the radius and ulna: Monteggia’s fracture is a fracture of the proximal third of the ulna and an anterior dislocation of the head of the radius at the elbow. Galeazzi’s fracture is a fracture of the distal third of the radius associated with subluxation (partial dislocation) of the head of the ulna at the wrist joint. Colles’ fracture is a fracture, and posterior displacement, of the distal end of the radius. Whenever a fracture of the radius or ulna is demonstrated radiographically, further images of the elbow and wrist should be obtained to exclude dislocations. In the clinic Transection of the radial or ulnar artery	Anatomy_Gray. There are three classic injuries to the radius and ulna: Monteggia’s fracture is a fracture of the proximal third of the ulna and an anterior dislocation of the head of the radius at the elbow. Galeazzi’s fracture is a fracture of the distal third of the radius associated with subluxation (partial dislocation) of the head of the ulna at the wrist joint. Colles’ fracture is a fracture, and posterior displacement, of the distal end of the radius. Whenever a fracture of the radius or ulna is demonstrated radiographically, further images of the elbow and wrist should be obtained to exclude dislocations. In the clinic Transection of the radial or ulnar artery
Anatomy_Gray_2006	Anatomy_Gray	In the clinic Transection of the radial or ulnar artery Adult patients may transect the radial or ulnar artery because these vessels are relatively subcutaneous. A typical method of injury is when the hand is forced through a plate glass window. Fortunately, the dual supply to the hand usually enables the surgeon to tie off either the ulnar or the radial artery, without significant consequence. In the clinic Fracture of the scaphoid and avascular necrosis of the proximal scaphoid The commonest carpal injury is a fracture across the waist of the scaphoid bone (Fig. 7.96). It is uncommon to see other injuries. In approximately 10% of individuals, the scaphoid bone has a sole blood supply from the radial artery, which enters through the distal portion of the bone to supply the proximal portion. When a fracture occurs across the waist of the scaphoid, the proximal portion therefore undergoes avascular necrosis. It is impossible to predict which patients have this blood supply.	Anatomy_Gray. In the clinic Transection of the radial or ulnar artery Adult patients may transect the radial or ulnar artery because these vessels are relatively subcutaneous. A typical method of injury is when the hand is forced through a plate glass window. Fortunately, the dual supply to the hand usually enables the surgeon to tie off either the ulnar or the radial artery, without significant consequence. In the clinic Fracture of the scaphoid and avascular necrosis of the proximal scaphoid The commonest carpal injury is a fracture across the waist of the scaphoid bone (Fig. 7.96). It is uncommon to see other injuries. In approximately 10% of individuals, the scaphoid bone has a sole blood supply from the radial artery, which enters through the distal portion of the bone to supply the proximal portion. When a fracture occurs across the waist of the scaphoid, the proximal portion therefore undergoes avascular necrosis. It is impossible to predict which patients have this blood supply.
Anatomy_Gray_2007	Anatomy_Gray	In the clinic Interruption of the blood supply to the lunate can lead to avascular necrosis of the lunate, known as Kienbock’s disease (Fig. 7.97). This can cause pain and stiffness and arthritis in the longer term. In the clinic A large median artery is an anatomical variant found in some individuals, where a persistent artery runs alongside the median nerve in one or both forearms and through the carpal tunnel. Individuals are at risk from heavy bleeding from deep cuts to the wrist. In the clinic	Anatomy_Gray. In the clinic Interruption of the blood supply to the lunate can lead to avascular necrosis of the lunate, known as Kienbock’s disease (Fig. 7.97). This can cause pain and stiffness and arthritis in the longer term. In the clinic A large median artery is an anatomical variant found in some individuals, where a persistent artery runs alongside the median nerve in one or both forearms and through the carpal tunnel. Individuals are at risk from heavy bleeding from deep cuts to the wrist. In the clinic
Anatomy_Gray_2008	Anatomy_Gray	In the clinic Carpal tunnel syndrome is an entrapment syndrome caused by pressure on the median nerve within the carpal tunnel. The etiology of this condition is often obscure, though in some instances the nerve injury may be a direct effect of increased pressure on the median nerve caused by overuse, swelling of the tendons and tendon sheaths (e.g., rheumatoid arthritis), and cysts arising from the carpal joints. Increased pressure in the carpal tunnel is thought to cause venous congestion that produces nerve edema and anoxic damage to the capillary endothelium of the median nerve itself. Patients typically report pain and pins-and-needles sensations in the distribution of the median nerve. Weakness and loss of muscle bulk of the thenar muscles may also occur. Gently tapping over the median nerve (in the region of the flexor retinaculum) readily produces these symptoms (Tinel’s sign).	Anatomy_Gray. In the clinic Carpal tunnel syndrome is an entrapment syndrome caused by pressure on the median nerve within the carpal tunnel. The etiology of this condition is often obscure, though in some instances the nerve injury may be a direct effect of increased pressure on the median nerve caused by overuse, swelling of the tendons and tendon sheaths (e.g., rheumatoid arthritis), and cysts arising from the carpal joints. Increased pressure in the carpal tunnel is thought to cause venous congestion that produces nerve edema and anoxic damage to the capillary endothelium of the median nerve itself. Patients typically report pain and pins-and-needles sensations in the distribution of the median nerve. Weakness and loss of muscle bulk of the thenar muscles may also occur. Gently tapping over the median nerve (in the region of the flexor retinaculum) readily produces these symptoms (Tinel’s sign).
Anatomy_Gray_2009	Anatomy_Gray	Initial treatment is aimed at reducing the inflammation and removing any repetitive insults that produce the symptoms. If this does not lead to improvement, nerve conduction studies will be necessary to confirm nerve entrapment, which may require surgical decompression of the flexor retinaculum. In the clinic The palmar fascia can become abnormally thickened in certain individuals, causing the fingers to progressively develop a fixed flexion position. This results in loss of dexterity and function, and in severe cases requires surgical removal of the abnormal tissue. In the clinic The anatomical snuffbox is an important clinical region. When the hand is in ulnar deviation, the scaphoid becomes palpable within the snuffbox. This position enables the physician to palpate the bone to assess for a fracture. The pulse of the radial artery can also be felt in the snuffbox. In the clinic	Anatomy_Gray. Initial treatment is aimed at reducing the inflammation and removing any repetitive insults that produce the symptoms. If this does not lead to improvement, nerve conduction studies will be necessary to confirm nerve entrapment, which may require surgical decompression of the flexor retinaculum. In the clinic The palmar fascia can become abnormally thickened in certain individuals, causing the fingers to progressively develop a fixed flexion position. This results in loss of dexterity and function, and in severe cases requires surgical removal of the abnormal tissue. In the clinic The anatomical snuffbox is an important clinical region. When the hand is in ulnar deviation, the scaphoid becomes palpable within the snuffbox. This position enables the physician to palpate the bone to assess for a fracture. The pulse of the radial artery can also be felt in the snuffbox. In the clinic
Anatomy_Gray_2010	Anatomy_Gray	In the clinic De Quervain’s syndrome is an inflammatory disorder that occurs within the first dorsal extensor compartment and involves the extensor pollicis brevis tendon and abductor pollicis longus tendon and their common tendon sheath (Fig. 7.102). Patients typically present with significant wrist pain preventing appropriate flexion/extension and abduction of the thumb. The cause of this disorder is often overuse. For example, the syndrome is common in young mothers who are constantly lifting young children. Other causes include inflammatory disorders such as rheumatoid arthritis. In the clinic	Anatomy_Gray. In the clinic De Quervain’s syndrome is an inflammatory disorder that occurs within the first dorsal extensor compartment and involves the extensor pollicis brevis tendon and abductor pollicis longus tendon and their common tendon sheath (Fig. 7.102). Patients typically present with significant wrist pain preventing appropriate flexion/extension and abduction of the thumb. The cause of this disorder is often overuse. For example, the syndrome is common in young mothers who are constantly lifting young children. Other causes include inflammatory disorders such as rheumatoid arthritis. In the clinic
Anatomy_Gray_2011	Anatomy_Gray	In the clinic Tenosynovitis is inflammation of a tendon and its sheath. The condition may be caused by overuse; however, it can also be associated with other disorders such as rheumatoid arthritis and connective tissue pathologies. If the inflammation becomes severe and ensuing fibrosis occurs, the tendon will not run smoothly within the tendon sheath, and typically within the fingers the tendon may stick or require excess force to fully extend and flex, producing a “triggering” phenomenon. In the clinic Trigger finger is a common disorder of late childhood and adulthood and is typically characterized by catching or snapping and occasionally locking of the flexor tendon(s) in the hand. Trigger finger can be associated with significant dysfunction and pain. The triggering is usually related to fibrosis and tightening of the flexor tendon sheath at the level of the metacarpophalangeal joint. In the clinic	Anatomy_Gray. In the clinic Tenosynovitis is inflammation of a tendon and its sheath. The condition may be caused by overuse; however, it can also be associated with other disorders such as rheumatoid arthritis and connective tissue pathologies. If the inflammation becomes severe and ensuing fibrosis occurs, the tendon will not run smoothly within the tendon sheath, and typically within the fingers the tendon may stick or require excess force to fully extend and flex, producing a “triggering” phenomenon. In the clinic Trigger finger is a common disorder of late childhood and adulthood and is typically characterized by catching or snapping and occasionally locking of the flexor tendon(s) in the hand. Trigger finger can be associated with significant dysfunction and pain. The triggering is usually related to fibrosis and tightening of the flexor tendon sheath at the level of the metacarpophalangeal joint. In the clinic
Anatomy_Gray_2012	Anatomy_Gray	In the clinic To test for adequate anastomoses between the radial and ulnar arteries, compress both the radial and ulnar arteries at the wrist, then release pressure from one or the other, and determine the filling pattern of the hand. If there is little connection between the deep and superficial palmar arteries, only the thumb and lateral side of the index finger will fill with blood (become red) when pressure on the radial artery alone is released. In the clinic	Anatomy_Gray. In the clinic To test for adequate anastomoses between the radial and ulnar arteries, compress both the radial and ulnar arteries at the wrist, then release pressure from one or the other, and determine the filling pattern of the hand. If there is little connection between the deep and superficial palmar arteries, only the thumb and lateral side of the index finger will fill with blood (become red) when pressure on the radial artery alone is released. In the clinic
Anatomy_Gray_2013	Anatomy_Gray	In the clinic In many patients, venous access is necessary for obtaining blood for laboratory testing and administering fluid and intravenous drugs. The ideal sites for venous access are typically in the cubital fossa and in the cephalic vein adjacent to the anatomical snuffbox. The veins are simply distended by use of a tourniquet. A tourniquet should be applied enough to allow the veins to become prominent. For straightforward blood tests the antecubital vein is usually the preferred site, and although it may not always be visible, it is easily palpated. The cephalic vein is generally the preferred site for a short-term intravenous cannula. In the clinic The ulnar nerve is most commonly injured at two sites: the elbow and the wrist. At the elbow, the nerve lies posterior to the medial epicondyle. At the wrist, the ulnar nerve passes superficial to the flexor retinaculum and lies lateral to the pisiform bone.	Anatomy_Gray. In the clinic In many patients, venous access is necessary for obtaining blood for laboratory testing and administering fluid and intravenous drugs. The ideal sites for venous access are typically in the cubital fossa and in the cephalic vein adjacent to the anatomical snuffbox. The veins are simply distended by use of a tourniquet. A tourniquet should be applied enough to allow the veins to become prominent. For straightforward blood tests the antecubital vein is usually the preferred site, and although it may not always be visible, it is easily palpated. The cephalic vein is generally the preferred site for a short-term intravenous cannula. In the clinic The ulnar nerve is most commonly injured at two sites: the elbow and the wrist. At the elbow, the nerve lies posterior to the medial epicondyle. At the wrist, the ulnar nerve passes superficial to the flexor retinaculum and lies lateral to the pisiform bone.
Anatomy_Gray_2014	Anatomy_Gray	At the elbow, the nerve lies posterior to the medial epicondyle. At the wrist, the ulnar nerve passes superficial to the flexor retinaculum and lies lateral to the pisiform bone. Ulnar nerve lesions are characterized by “clawing” of the hand, in which the metacarpophalangeal joints of the fingers are hyperextended and the interphalangeal joints are flexed because the function of most of the intrinsic muscles of the hand is lost (Fig. 7.114). Clawing is most pronounced in the medial fingers because the function of all intrinsic muscles of these digits is lost while in the lateral two digits, the lumbricals are innervated by the median nerve. Function of the adductor pollicis muscle is also lost.	Anatomy_Gray. At the elbow, the nerve lies posterior to the medial epicondyle. At the wrist, the ulnar nerve passes superficial to the flexor retinaculum and lies lateral to the pisiform bone. Ulnar nerve lesions are characterized by “clawing” of the hand, in which the metacarpophalangeal joints of the fingers are hyperextended and the interphalangeal joints are flexed because the function of most of the intrinsic muscles of the hand is lost (Fig. 7.114). Clawing is most pronounced in the medial fingers because the function of all intrinsic muscles of these digits is lost while in the lateral two digits, the lumbricals are innervated by the median nerve. Function of the adductor pollicis muscle is also lost.
Anatomy_Gray_2015	Anatomy_Gray	In lesions of the ulnar nerve at the elbow, function of the flexor carpi ulnaris muscle and flexor digitorum profundus to the medial two digits is lost as well. Clawing of the hand, particularly of the little and ring fingers, is worse with lesions of the ulnar nerve at the wrist than at the elbow because interruption of the nerve at the elbow paralyzes the ulnar half of the flexor digitorum profundus, which leads to lack of flexion at the distal interphalangeal joints in these fingers. Ulnar nerve lesions at the elbow and wrist result in impaired sensory innervation on the palmar aspect of the medial one and one-half digits. Damage to the ulnar nerve at the wrist or at a site proximal to the wrist can be distinguished by evaluating the status of function of the dorsal branch (cutaneous) of the ulnar nerve, which originates in distal regions of the forearm. This branch innervates skin over the dorsal surface of the hand on the medial side. In the clinic	Anatomy_Gray. In lesions of the ulnar nerve at the elbow, function of the flexor carpi ulnaris muscle and flexor digitorum profundus to the medial two digits is lost as well. Clawing of the hand, particularly of the little and ring fingers, is worse with lesions of the ulnar nerve at the wrist than at the elbow because interruption of the nerve at the elbow paralyzes the ulnar half of the flexor digitorum profundus, which leads to lack of flexion at the distal interphalangeal joints in these fingers. Ulnar nerve lesions at the elbow and wrist result in impaired sensory innervation on the palmar aspect of the medial one and one-half digits. Damage to the ulnar nerve at the wrist or at a site proximal to the wrist can be distinguished by evaluating the status of function of the dorsal branch (cutaneous) of the ulnar nerve, which originates in distal regions of the forearm. This branch innervates skin over the dorsal surface of the hand on the medial side. In the clinic
Anatomy_Gray_2016	Anatomy_Gray	In the clinic Around the elbow joint the radial nerve divides into its two terminal branches—the superficial branch and the deep branch. The most common radial nerve injury is damage to the nerve in the radial groove of the humerus, which produces a global paralysis of the muscles of the posterior compartment, resulting in wrist drop. Radial nerve damage can result from fracture of the shaft of the humerus as the radial nerve spirals around in the radial groove. The typical injury produces reduction of sensation in the cutaneous distribution, predominantly over the posterior aspect of the hand. Severing the posterior interosseous nerve (continuation of deep branch of radial nerve) may paralyze the muscles of the posterior compartment of the forearm, but the nerve supply is variable. Typically, the patient may not be able to extend the fingers.	Anatomy_Gray. In the clinic Around the elbow joint the radial nerve divides into its two terminal branches—the superficial branch and the deep branch. The most common radial nerve injury is damage to the nerve in the radial groove of the humerus, which produces a global paralysis of the muscles of the posterior compartment, resulting in wrist drop. Radial nerve damage can result from fracture of the shaft of the humerus as the radial nerve spirals around in the radial groove. The typical injury produces reduction of sensation in the cutaneous distribution, predominantly over the posterior aspect of the hand. Severing the posterior interosseous nerve (continuation of deep branch of radial nerve) may paralyze the muscles of the posterior compartment of the forearm, but the nerve supply is variable. Typically, the patient may not be able to extend the fingers.
Anatomy_Gray_2017	Anatomy_Gray	The distal branches of the superficial branch of the radial nerve can be readily palpated as “cords” passing over the tendon of the extensor pollicis longus in the anatomical snuffbox. Damage to these branches is of little consequence because they supply only a small area of skin. A 57-year-old woman underwent a right mastectomy for a breast cancer. The surgical note reported that all of the breast tissue had been removed, including the axillary process. In addition, the surgeon had dissected all lymph nodes within the axilla with their surrounding fat. The patient made an uneventful recovery. At the first follow-up appointment, the patient’s husband told the surgeon that she had now developed a bony “spike” on her back. The surgeon was intrigued and asked the patient to reveal this spike. At examination, the spike was the inferior angle of the scapula, which appeared to be sticking out posteriorly (“winged”). Raising the arms accentuated this structure.	Anatomy_Gray. The distal branches of the superficial branch of the radial nerve can be readily palpated as “cords” passing over the tendon of the extensor pollicis longus in the anatomical snuffbox. Damage to these branches is of little consequence because they supply only a small area of skin. A 57-year-old woman underwent a right mastectomy for a breast cancer. The surgical note reported that all of the breast tissue had been removed, including the axillary process. In addition, the surgeon had dissected all lymph nodes within the axilla with their surrounding fat. The patient made an uneventful recovery. At the first follow-up appointment, the patient’s husband told the surgeon that she had now developed a bony “spike” on her back. The surgeon was intrigued and asked the patient to reveal this spike. At examination, the spike was the inferior angle of the scapula, which appeared to be sticking out posteriorly (“winged”). Raising the arms accentuated this structure.
Anatomy_Gray_2018	Anatomy_Gray	The medial border of the scapula was accentuated and it was noted that there was some loss of bulk of the serratus anterior muscle, which attaches to the tip of the scapula. The nerve to this muscle was damaged. During the surgery on the axilla, the long thoracic nerve was damaged as it passed down the lateral thoracic wall on the external surface of the serratus anterior, just deep to the skin and subcutaneous fascia. Because the nerve was transected, it is unlikely that the patient will improve, but she was happy that she had an adequate explanation for the spike. A 25-year-old woman was involved in a motor vehicle accident and thrown from her motorcycle. When she was admitted to the emergency room, she was unconscious. A series of tests and investigations were performed, one of which included chest radiography. The attending physician noted a complex fracture of the first rib on the left. Many important structures that supply the upper limb pass over rib I.	Anatomy_Gray. The medial border of the scapula was accentuated and it was noted that there was some loss of bulk of the serratus anterior muscle, which attaches to the tip of the scapula. The nerve to this muscle was damaged. During the surgery on the axilla, the long thoracic nerve was damaged as it passed down the lateral thoracic wall on the external surface of the serratus anterior, just deep to the skin and subcutaneous fascia. Because the nerve was transected, it is unlikely that the patient will improve, but she was happy that she had an adequate explanation for the spike. A 25-year-old woman was involved in a motor vehicle accident and thrown from her motorcycle. When she was admitted to the emergency room, she was unconscious. A series of tests and investigations were performed, one of which included chest radiography. The attending physician noted a complex fracture of the first rib on the left. Many important structures that supply the upper limb pass over rib I.
Anatomy_Gray_2019	Anatomy_Gray	Many important structures that supply the upper limb pass over rib I. It is important to test the nerves that supply the arm and hand, although this is extremely difficult to do in an unconscious patient. However, some muscle reflexes can be determined using a tendon hammer. Also, it may be possible to test for pain reflexes in patients with altered consciousness levels. Palpation of the axillary artery, brachial artery, radial artery, and ulnar artery pulses is necessary because a fracture of the first rib can sever and denude the subclavian artery, which passes over it. A chest drain was immediately inserted because the lung had collapsed. The fractured first rib had damaged the visceral and parietal pleurae, allowing air from a torn lung to escape into the pleural cavity. The lung collapsed, and the pleural cavity filled with air, which impaired lung function. A tube was inserted between the ribs, and the air was sucked out to re-inflate the lung.	Anatomy_Gray. Many important structures that supply the upper limb pass over rib I. It is important to test the nerves that supply the arm and hand, although this is extremely difficult to do in an unconscious patient. However, some muscle reflexes can be determined using a tendon hammer. Also, it may be possible to test for pain reflexes in patients with altered consciousness levels. Palpation of the axillary artery, brachial artery, radial artery, and ulnar artery pulses is necessary because a fracture of the first rib can sever and denude the subclavian artery, which passes over it. A chest drain was immediately inserted because the lung had collapsed. The fractured first rib had damaged the visceral and parietal pleurae, allowing air from a torn lung to escape into the pleural cavity. The lung collapsed, and the pleural cavity filled with air, which impaired lung function. A tube was inserted between the ribs, and the air was sucked out to re-inflate the lung.
Anatomy_Gray_2020	Anatomy_Gray	A tube was inserted between the ribs, and the air was sucked out to re-inflate the lung. The first rib is a deep structure at the base of the neck. It is not uncommon for ribs to be broken after minor injuries, including sports injuries. However, rib I, which lies at the base of the neck, is surrounded by muscles and soft tissues that provide it with considerable protection. Therefore a patient with a fracture of the first rib has undoubtedly been subjected to a considerable force, which usually occurs in a deceleration injury. Other injuries should always be sought and the patient should be managed with a high level of concern for deep neck and mediastinal injuries. A resident was asked to carry out a clinical assessment of a patient’s hand. He examined the following:	Anatomy_Gray. A tube was inserted between the ribs, and the air was sucked out to re-inflate the lung. The first rib is a deep structure at the base of the neck. It is not uncommon for ribs to be broken after minor injuries, including sports injuries. However, rib I, which lies at the base of the neck, is surrounded by muscles and soft tissues that provide it with considerable protection. Therefore a patient with a fracture of the first rib has undoubtedly been subjected to a considerable force, which usually occurs in a deceleration injury. Other injuries should always be sought and the patient should be managed with a high level of concern for deep neck and mediastinal injuries. A resident was asked to carry out a clinical assessment of a patient’s hand. He examined the following:
Anatomy_Gray_2021	Anatomy_Gray	A resident was asked to carry out a clinical assessment of a patient’s hand. He examined the following: The musculoskeletal system includes the bones, joints, muscles, and tendons. The resident looked for abnormalities and muscle wasting. Knowing which areas are wasted identifies the nerve that supplies them. She palpated the individual bones and palpated the scaphoid with the wrist in ulnar deviation. She examined the movement of joints because they may be restricted by joint disease or inability of muscular contraction. Palpation of both radial and ulnar pulses is necessary. The resident looked for capillary return to assess how well the hand was perfused. Examination of the nerves The three main nerves to the hand should be tested.	Anatomy_Gray. A resident was asked to carry out a clinical assessment of a patient’s hand. He examined the following: The musculoskeletal system includes the bones, joints, muscles, and tendons. The resident looked for abnormalities and muscle wasting. Knowing which areas are wasted identifies the nerve that supplies them. She palpated the individual bones and palpated the scaphoid with the wrist in ulnar deviation. She examined the movement of joints because they may be restricted by joint disease or inability of muscular contraction. Palpation of both radial and ulnar pulses is necessary. The resident looked for capillary return to assess how well the hand was perfused. Examination of the nerves The three main nerves to the hand should be tested.
Anatomy_Gray_2022	Anatomy_Gray	Examination of the nerves The three main nerves to the hand should be tested. The median nerve innervates the skin on the palmar aspect of the lateral three and one-half digits, the dorsal aspect of the distal phalanx, half of the middle phalanges of the same fingers, and a variable amount on the radial side of the palm of the hand. Median nerve damage results in wasting of the thenar eminence, absence of abduction of the thumb, and absence of opposition of the thumb. The ulnar nerve innervates the skin of the anterior and posterior surfaces of the little finger and the ulnar side of the ring finger, the skin over the hypothenar eminence, and a similar strip of skin posteriorly. Sometimes the ulnar nerve innervates all the skin of the ring finger and the ulnar side of the middle finger.	Anatomy_Gray. Examination of the nerves The three main nerves to the hand should be tested. The median nerve innervates the skin on the palmar aspect of the lateral three and one-half digits, the dorsal aspect of the distal phalanx, half of the middle phalanges of the same fingers, and a variable amount on the radial side of the palm of the hand. Median nerve damage results in wasting of the thenar eminence, absence of abduction of the thumb, and absence of opposition of the thumb. The ulnar nerve innervates the skin of the anterior and posterior surfaces of the little finger and the ulnar side of the ring finger, the skin over the hypothenar eminence, and a similar strip of skin posteriorly. Sometimes the ulnar nerve innervates all the skin of the ring finger and the ulnar side of the middle finger.
Anatomy_Gray_2023	Anatomy_Gray	An ulnar nerve palsy results in wasting of the hypothenar eminence, absent flexion of the distal interphalangeal joints of the little and ring fingers, and absent abduction and adduction of the fingers. Adduction of the thumb also is affected. The radial nerve innervates a small area of skin over the lateral aspect of metacarpal I and the back of the first web space. The radial nerve also produces extension of the wrist and extension of the metacarpophalangeal and interphalangeal joints and of the digits. A very simple examination would include tests for the median nerve by opposition of the thumb, for the ulnar nerve by abduction and adduction of the digits, and for the radial nerve by extension of the wrist and fingers and feeling on the back of the first web space.	Anatomy_Gray. An ulnar nerve palsy results in wasting of the hypothenar eminence, absent flexion of the distal interphalangeal joints of the little and ring fingers, and absent abduction and adduction of the fingers. Adduction of the thumb also is affected. The radial nerve innervates a small area of skin over the lateral aspect of metacarpal I and the back of the first web space. The radial nerve also produces extension of the wrist and extension of the metacarpophalangeal and interphalangeal joints and of the digits. A very simple examination would include tests for the median nerve by opposition of the thumb, for the ulnar nerve by abduction and adduction of the digits, and for the radial nerve by extension of the wrist and fingers and feeling on the back of the first web space.
Anatomy_Gray_2024	Anatomy_Gray	A 45-year-old man came to his physician complaining of pain and weakness in his right shoulder. The pain began after a fall on his outstretched hand approximately 6 months previously. The patient recalled having some minor shoulder tenderness but no other specific symptoms. He was otherwise fit and well. On examination of the shoulder, there was marked wasting of the muscles in the supraspinous and infraspinous fossae. The patient found initiation of abduction difficult and there was a weakness of lateral rotation of the humerus. The wasted muscles were the supraspinatus and infraspinatus. The cause of the muscle wasting was disuse. Muscle atrophy (wasting) occurs through a variety of disorders. Disuse atrophy is one of the most common causes. Examples of disuse atrophy include the loss of muscle bulk after fracture immobilization in a plaster cast. The opposite effect can also be demonstrated—when muscles are overused they become bulkier (hypertrophy).	Anatomy_Gray. A 45-year-old man came to his physician complaining of pain and weakness in his right shoulder. The pain began after a fall on his outstretched hand approximately 6 months previously. The patient recalled having some minor shoulder tenderness but no other specific symptoms. He was otherwise fit and well. On examination of the shoulder, there was marked wasting of the muscles in the supraspinous and infraspinous fossae. The patient found initiation of abduction difficult and there was a weakness of lateral rotation of the humerus. The wasted muscles were the supraspinatus and infraspinatus. The cause of the muscle wasting was disuse. Muscle atrophy (wasting) occurs through a variety of disorders. Disuse atrophy is one of the most common causes. Examples of disuse atrophy include the loss of muscle bulk after fracture immobilization in a plaster cast. The opposite effect can also be demonstrated—when muscles are overused they become bulkier (hypertrophy).
Anatomy_Gray_2025	Anatomy_Gray	The supraspinatus and infraspinatus muscles are supplied by the suprascapular nerve (C5, C6), which originates from the superior trunk of the brachial plexus. Given that only these muscles were involved, it is highly likely that the muscle atrophy is caused by denervation. Denervation may result from a direct nerve transection, nerve compression, or a pharmacological effect on the nerve. The typical site for compression of the suprascapular nerve is the suprascapular notch (foramen) on the superior margin of the scapula. The patient’s apparently minor injury damaged the fibrocartilaginous glenoid labrum, which allowed a cyst to form and pass along the superior border of the scapula to the suprascapular notch (foramen), where the cyst compressed the suprascapular nerve. Surgical excision of the damaged glenoid labrum and removal of the cyst improved the patient’s symptoms.	Anatomy_Gray. The supraspinatus and infraspinatus muscles are supplied by the suprascapular nerve (C5, C6), which originates from the superior trunk of the brachial plexus. Given that only these muscles were involved, it is highly likely that the muscle atrophy is caused by denervation. Denervation may result from a direct nerve transection, nerve compression, or a pharmacological effect on the nerve. The typical site for compression of the suprascapular nerve is the suprascapular notch (foramen) on the superior margin of the scapula. The patient’s apparently minor injury damaged the fibrocartilaginous glenoid labrum, which allowed a cyst to form and pass along the superior border of the scapula to the suprascapular notch (foramen), where the cyst compressed the suprascapular nerve. Surgical excision of the damaged glenoid labrum and removal of the cyst improved the patient’s symptoms.
Anatomy_Gray_2026	Anatomy_Gray	Surgical excision of the damaged glenoid labrum and removal of the cyst improved the patient’s symptoms. A surgeon wished to carry out a complex procedure on a patient’s wrist, and asked the anesthesiologist whether the whole arm could be numbed while the patient was awake. Within 20 minutes the anesthesiologist had carried out the procedure after injecting 10 mL of local anesthetic into the axilla. The surgeon went ahead with the operation and the patient did not feel a thing. The anesthetic was injected into the axillary sheath. It would be almost impossible to anesthetize the wrist in the forearm because local anesthetic would have to be placed accurately around the ulnar, median, and radial nerves. Furthermore, all of the cutaneous branches of the forearm would also have to be anesthetized individually, which would take a considerable amount of time and probably produce subtotal anesthesia.	Anatomy_Gray. Surgical excision of the damaged glenoid labrum and removal of the cyst improved the patient’s symptoms. A surgeon wished to carry out a complex procedure on a patient’s wrist, and asked the anesthesiologist whether the whole arm could be numbed while the patient was awake. Within 20 minutes the anesthesiologist had carried out the procedure after injecting 10 mL of local anesthetic into the axilla. The surgeon went ahead with the operation and the patient did not feel a thing. The anesthetic was injected into the axillary sheath. It would be almost impossible to anesthetize the wrist in the forearm because local anesthetic would have to be placed accurately around the ulnar, median, and radial nerves. Furthermore, all of the cutaneous branches of the forearm would also have to be anesthetized individually, which would take a considerable amount of time and probably produce subtotal anesthesia.
Anatomy_Gray_2027	Anatomy_Gray	The nerves of the upper limb originate from the brachial plexus, which surrounds the axillary artery within the axilla. Importantly, the axillary artery, axillary vein, and brachial plexus lie within the sleeve-like covering of fascia termed the axillary sheath. By injecting the anesthetic into the space enclosed by the axillary sheath, all of the nerves of the brachial plexus were paralyzed. It is possible with a patient’s arm abducted and externally rotated (palm behind the head) to easily palpate the axillary artery and therefore locate the position of the axillary sheath. Once the axillary artery has been identified, a small needle can be placed beside the vessel and local anesthetic can be injected on both sides of it. The local anesthetic tracks along the axillary sheath in this region. The brachial plexus surrounding the axillary artery is therefore completely anesthetized and an effective local anesthetic “block” is achieved.	Anatomy_Gray. The nerves of the upper limb originate from the brachial plexus, which surrounds the axillary artery within the axilla. Importantly, the axillary artery, axillary vein, and brachial plexus lie within the sleeve-like covering of fascia termed the axillary sheath. By injecting the anesthetic into the space enclosed by the axillary sheath, all of the nerves of the brachial plexus were paralyzed. It is possible with a patient’s arm abducted and externally rotated (palm behind the head) to easily palpate the axillary artery and therefore locate the position of the axillary sheath. Once the axillary artery has been identified, a small needle can be placed beside the vessel and local anesthetic can be injected on both sides of it. The local anesthetic tracks along the axillary sheath in this region. The brachial plexus surrounding the axillary artery is therefore completely anesthetized and an effective local anesthetic “block” is achieved.
Anatomy_Gray_2028	Anatomy_Gray	“Could there be any complications?” asks the patient. Potential complications are a direct needle spike of the branches of the brachial plexus, damage to the axillary artery, and inadvertent arterial injection of the local anesthetic. Fortunately, these are rare in skilled hands. A 35-year-old woman comes to her physician complaining of tingling and numbness in the fingertips of the first, second, and third digits (thumb, index, and middle fingers). The symptoms were provoked by arm extension. Local anesthesia was also present around the base of the thenar eminence. The problem was diagnosed as median nerve compression.	Anatomy_Gray. “Could there be any complications?” asks the patient. Potential complications are a direct needle spike of the branches of the brachial plexus, damage to the axillary artery, and inadvertent arterial injection of the local anesthetic. Fortunately, these are rare in skilled hands. A 35-year-old woman comes to her physician complaining of tingling and numbness in the fingertips of the first, second, and third digits (thumb, index, and middle fingers). The symptoms were provoked by arm extension. Local anesthesia was also present around the base of the thenar eminence. The problem was diagnosed as median nerve compression.
Anatomy_Gray_2029	Anatomy_Gray	The problem was diagnosed as median nerve compression. The median nerve is formed from the lateral and medial cords of the brachial plexus anterior to the axillary artery and passes into the arm anterior to the brachial artery. At the level of the elbow joint it sits medial to the brachial artery, both of which are medial to the tendon of the biceps. In the forearm the nerve courses through the anterior compartment and passes deep to the flexor retinaculum. It innervates most of the muscles of the forearm, the thenar muscles, the two lateral lumbricals, and the skin over the palmar surface of the lateral three and one-half digits and over the lateral side of the palm and the middle of the wrist. In this patient, the median nerve initially was believed to be trapped below the flexor retinaculum (carpal tunnel syndrome).	Anatomy_Gray. The problem was diagnosed as median nerve compression. The median nerve is formed from the lateral and medial cords of the brachial plexus anterior to the axillary artery and passes into the arm anterior to the brachial artery. At the level of the elbow joint it sits medial to the brachial artery, both of which are medial to the tendon of the biceps. In the forearm the nerve courses through the anterior compartment and passes deep to the flexor retinaculum. It innervates most of the muscles of the forearm, the thenar muscles, the two lateral lumbricals, and the skin over the palmar surface of the lateral three and one-half digits and over the lateral side of the palm and the middle of the wrist. In this patient, the median nerve initially was believed to be trapped below the flexor retinaculum (carpal tunnel syndrome).
Anatomy_Gray_2030	Anatomy_Gray	In this patient, the median nerve initially was believed to be trapped below the flexor retinaculum (carpal tunnel syndrome). Carpal tunnel syndrome is a common problem in young to middle-aged patients. Typically the nerve becomes compressed within the carpal tunnel. This syndrome may be associated with a number of medical conditions, such as thyroid disease and pregnancy. Occasionally a small ganglion or a tumor situated within the carpal tunnel can also compress the nerve. Other possibilities include tenosynovitis in patients with rheumatoid arthritis.	Anatomy_Gray. In this patient, the median nerve initially was believed to be trapped below the flexor retinaculum (carpal tunnel syndrome). Carpal tunnel syndrome is a common problem in young to middle-aged patients. Typically the nerve becomes compressed within the carpal tunnel. This syndrome may be associated with a number of medical conditions, such as thyroid disease and pregnancy. Occasionally a small ganglion or a tumor situated within the carpal tunnel can also compress the nerve. Other possibilities include tenosynovitis in patients with rheumatoid arthritis.
Anatomy_Gray_2031	Anatomy_Gray	Nerve conduction studies were performed to confirm the clinical findings. Nerve conduction studies are a series of tests that send small electrical impulses along the length of a variety of nerves in order to measure the speed at which the nerve conducts these pulses. The speed of the nerve pulse can be measured and is referred to as the latency. In our patient it was noted that the nerve had normal latency to the elbow joint; however, below the elbow joint there was increased latency. The nerve conduction studies indicated that the compression site was at the elbow joint.	Anatomy_Gray. Nerve conduction studies were performed to confirm the clinical findings. Nerve conduction studies are a series of tests that send small electrical impulses along the length of a variety of nerves in order to measure the speed at which the nerve conducts these pulses. The speed of the nerve pulse can be measured and is referred to as the latency. In our patient it was noted that the nerve had normal latency to the elbow joint; however, below the elbow joint there was increased latency. The nerve conduction studies indicated that the compression site was at the elbow joint.
Anatomy_Gray_2032	Anatomy_Gray	The nerve conduction studies indicated that the compression site was at the elbow joint. The clinical findings are not consistent with carpal tunnel syndrome. The clinician should have been alerted to this problem given that the patient experienced numbness over the thenar eminence of the hand. This clue indicates an understanding of the anatomy. Compression of the nerve within the carpal tunnel does not produce this numbness, because the small cutaneous branch that supplies this region is proximal to the flexor retinaculum. The nerve compromise was caused by the ligament of Struthers, which is an embryological remnant of the coracobrachialis muscle. It is an extremely rare finding. Occasionally it may ossify and cross the nerve, artery, and vein to produce compression in arm extension. Although this is very rare and unusual, it illustrates the complex course of the median nerve.	Anatomy_Gray. The nerve conduction studies indicated that the compression site was at the elbow joint. The clinical findings are not consistent with carpal tunnel syndrome. The clinician should have been alerted to this problem given that the patient experienced numbness over the thenar eminence of the hand. This clue indicates an understanding of the anatomy. Compression of the nerve within the carpal tunnel does not produce this numbness, because the small cutaneous branch that supplies this region is proximal to the flexor retinaculum. The nerve compromise was caused by the ligament of Struthers, which is an embryological remnant of the coracobrachialis muscle. It is an extremely rare finding. Occasionally it may ossify and cross the nerve, artery, and vein to produce compression in arm extension. Although this is very rare and unusual, it illustrates the complex course of the median nerve.
Anatomy_Gray_2033	Anatomy_Gray	After a hard day’s studying, two medical students decided to meet for coffee. The more senior student said to the freshman that he would bet him $50 that he could not lift a matchbook with a finger. The freshman placed $50 on the table and the bet was on. The senior medical student told the freshman to make a fist and place it in a palm-downward position, so that the middle phalanges of the fingers were in direct contact with the bar counter. He was then told to extend his middle finger so that it stuck forward while maintaining the middle phalanges of the index finger, the ring finger, and the little finger on the bar surface. A matchbook was placed on top of the freshman’s middle fingernail and he was told to flip it. He couldn’t. He lost the $50. Extension of the index, middle, ring, and little fingers is performed by the extensor digitorum muscle.	Anatomy_Gray. After a hard day’s studying, two medical students decided to meet for coffee. The more senior student said to the freshman that he would bet him $50 that he could not lift a matchbook with a finger. The freshman placed $50 on the table and the bet was on. The senior medical student told the freshman to make a fist and place it in a palm-downward position, so that the middle phalanges of the fingers were in direct contact with the bar counter. He was then told to extend his middle finger so that it stuck forward while maintaining the middle phalanges of the index finger, the ring finger, and the little finger on the bar surface. A matchbook was placed on top of the freshman’s middle fingernail and he was told to flip it. He couldn’t. He lost the $50. Extension of the index, middle, ring, and little fingers is performed by the extensor digitorum muscle.
Anatomy_Gray_2034	Anatomy_Gray	Extension of the index, middle, ring, and little fingers is performed by the extensor digitorum muscle. Placing the fist in a palm-down position on the table and pressing the middle phalanges onto the table effectively immobilizes the action of the extensor digitorum. The freshman was therefore unable to elevate his middle finger (which was sticking out). It is important to remember that if this same procedure is carried out leaving the index or little finger free to move, they do. This is because these two digits are extended not only by the extensor digitorum muscle but also by the extensor indicis muscle (index finger) and extensor digiti minimi muscle (little finger). A 70-year-old woman came to an orthopedic surgeon with right shoulder pain and failure to initiate abduction of the shoulder. Further examination revealed loss of muscle bulk in the supraspinous fossa. The supraspinatus muscle was damaged.	Anatomy_Gray. Extension of the index, middle, ring, and little fingers is performed by the extensor digitorum muscle. Placing the fist in a palm-down position on the table and pressing the middle phalanges onto the table effectively immobilizes the action of the extensor digitorum. The freshman was therefore unable to elevate his middle finger (which was sticking out). It is important to remember that if this same procedure is carried out leaving the index or little finger free to move, they do. This is because these two digits are extended not only by the extensor digitorum muscle but also by the extensor indicis muscle (index finger) and extensor digiti minimi muscle (little finger). A 70-year-old woman came to an orthopedic surgeon with right shoulder pain and failure to initiate abduction of the shoulder. Further examination revealed loss of muscle bulk in the supraspinous fossa. The supraspinatus muscle was damaged.
Anatomy_Gray_2035	Anatomy_Gray	Abduction of the humerus at the glenohumeral joint is initiated by the supraspinatus muscle. After the shoulder has been abducted to 10°–15°, the deltoid muscle continues the movement. The patient was able to abduct her arm by lowering and tilting the glenohumeral joint inferiorly to enable the deltoid to obtain its mechanical advantage. The loss of muscle bulk in the supraspinous fossa suggested muscle atrophy. Muscle atrophy occurs when a muscle is not used. The orthopedic surgeon thought that there was a tear of the supraspinatus tendon beneath the acromion. If this was so, the muscle would atrophy. The diagnosis was confirmed by ultrasound scan.	Anatomy_Gray. Abduction of the humerus at the glenohumeral joint is initiated by the supraspinatus muscle. After the shoulder has been abducted to 10°–15°, the deltoid muscle continues the movement. The patient was able to abduct her arm by lowering and tilting the glenohumeral joint inferiorly to enable the deltoid to obtain its mechanical advantage. The loss of muscle bulk in the supraspinous fossa suggested muscle atrophy. Muscle atrophy occurs when a muscle is not used. The orthopedic surgeon thought that there was a tear of the supraspinatus tendon beneath the acromion. If this was so, the muscle would atrophy. The diagnosis was confirmed by ultrasound scan.
Anatomy_Gray_2036	Anatomy_Gray	The diagnosis was confirmed by ultrasound scan. The patient was seated on a stool and her right shoulder was uncovered. The patient’s hand was placed over her right buttock, a position that acts to externally rotate and extend the shoulder, exposing the supraspinatus tendon for ultrasound scan examination. The ultrasound revealed a completely torn tendon with fluid in the subacromial subdeltoid bursa (eFig. 7.128). The patient underwent a surgical repair and made a good recovery. A 35-year-old baseball pitcher came to the clinic with a history of a recurrent dislocation of the shoulder (eFig. 7.129). An MRI scan was performed to assess the shoulder joint prior to any treatment. The MRI demonstrates the anatomical structures in multiple planes, allowing the physician to obtain an overview of the shoulder and to assess any intraarticular or extraarticular structures that may have been damaged and require surgical repair.	Anatomy_Gray. The diagnosis was confirmed by ultrasound scan. The patient was seated on a stool and her right shoulder was uncovered. The patient’s hand was placed over her right buttock, a position that acts to externally rotate and extend the shoulder, exposing the supraspinatus tendon for ultrasound scan examination. The ultrasound revealed a completely torn tendon with fluid in the subacromial subdeltoid bursa (eFig. 7.128). The patient underwent a surgical repair and made a good recovery. A 35-year-old baseball pitcher came to the clinic with a history of a recurrent dislocation of the shoulder (eFig. 7.129). An MRI scan was performed to assess the shoulder joint prior to any treatment. The MRI demonstrates the anatomical structures in multiple planes, allowing the physician to obtain an overview of the shoulder and to assess any intraarticular or extraarticular structures that may have been damaged and require surgical repair.
Anatomy_Gray_2037	Anatomy_Gray	The MRI demonstrated a divot in the posterosuperior aspect of the humeral head and a small fragment of bone and glenoid labrum that had become separated in the anteroinferior aspect of the glenoid cavity. Shoulder dislocation is not an uncommon problem and may occur as a “once-off” or with repetitive injury may be recurrent. Recurrent dislocations may be bilateral and symmetrical (a memory aid is “torn loose or born loose”).	Anatomy_Gray. The MRI demonstrated a divot in the posterosuperior aspect of the humeral head and a small fragment of bone and glenoid labrum that had become separated in the anteroinferior aspect of the glenoid cavity. Shoulder dislocation is not an uncommon problem and may occur as a “once-off” or with repetitive injury may be recurrent. Recurrent dislocations may be bilateral and symmetrical (a memory aid is “torn loose or born loose”).
Anatomy_Gray_2038	Anatomy_Gray	The MRI findings are typical for an anteroinferior dislocation, which is the most common type; moreover the MRI demonstrates the injuries that occur within the joint at the time of dislocation. These injuries include the abutment of the posterosuperior aspect of the humeral head on the anteroinferior aspect of the glenoid cavity. This type of injury, when recurrent, may avulse a small fragment of the glenoid labrum, and in some cases this may attach to a small fragment of bone (the Bankart lesion). When the shoulder is relocated, the integrity of the capsular attachment anteroinferiorly has been disrupted, potentially making the shoulder somewhat prone to further dislocation. An arthroscopic repair was performed.	Anatomy_Gray. The MRI findings are typical for an anteroinferior dislocation, which is the most common type; moreover the MRI demonstrates the injuries that occur within the joint at the time of dislocation. These injuries include the abutment of the posterosuperior aspect of the humeral head on the anteroinferior aspect of the glenoid cavity. This type of injury, when recurrent, may avulse a small fragment of the glenoid labrum, and in some cases this may attach to a small fragment of bone (the Bankart lesion). When the shoulder is relocated, the integrity of the capsular attachment anteroinferiorly has been disrupted, potentially making the shoulder somewhat prone to further dislocation. An arthroscopic repair was performed.
Anatomy_Gray_2039	Anatomy_Gray	An arthroscopic repair was performed. Arthroscopy of the shoulder is an established method for assessing the shoulder joint. Portals of entry are anterior and posterior and small holes in the capsule are made percutaneously. The shoulder joint is filled with saline, which distends it, allowing the arthroscope to move around the joint and inspect the joint surfaces, including the labrum. The labrum and its bony fragment were reattached and sutured using anchor sutures (somewhat similar to staples). The anterior aspect of the capsule was also tightened. The patient made an uneventful recovery. After the procedure the arm was held in internal rotation and remained adducted. Gentle exercise and physiotherapy were performed and the patient returned to playing baseball. 821.e1 821.e2 Conceptual Overview • Relationship to Other Regions Fig. 7.40, cont’d	Anatomy_Gray. An arthroscopic repair was performed. Arthroscopy of the shoulder is an established method for assessing the shoulder joint. Portals of entry are anterior and posterior and small holes in the capsule are made percutaneously. The shoulder joint is filled with saline, which distends it, allowing the arthroscope to move around the joint and inspect the joint surfaces, including the labrum. The labrum and its bony fragment were reattached and sutured using anchor sutures (somewhat similar to staples). The anterior aspect of the capsule was also tightened. The patient made an uneventful recovery. After the procedure the arm was held in internal rotation and remained adducted. Gentle exercise and physiotherapy were performed and the patient returned to playing baseball. 821.e1 821.e2 Conceptual Overview • Relationship to Other Regions Fig. 7.40, cont’d