Anatomy - Upper Limb

UPPER LIMB
ANATOMY
BONES OF
THE UPPER
LIMB
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Bones of the Upper Limb

The Clavicle
o
o
o
The clavicle is an S-shaped long bone, which forms part of the pectoral girdle
It articulates proximally with the sternum and distally with the acromion of scapula
Bony features include:
Acromial facet
Sternal facet
Impression for costoclavicular ligament
Subclavian groove
Conoid tubercle
Trapezoid line
o
Right clavicle
Smooth superior surface of the shaft, under the platysma muscle
Deltoid tubercle:
attachment of the deltoid
Acromial facet
Conoid tubercle, attachment of the

conoid ligament
which is the medial part of the
coracoclavicular ligament
Sternal facet
Subclavian groove:
site of attachment of the
subclavius muscle
Acromial facet
Impression for the

costoclavicular ligament
which binds the clavicle to
the first rib
Trapezoid line, attachment of the

trapezoid ligament
which is the lateral part of the
Rough inferior surface of the

shaft, over the first rib
FACTOIDS
-
Its occasionally pierced by a branch of the supraclavicular nerve
thicker and more curved in manual workers

weakest part is the junction of the middle and lateral thirds: most commonly fractured; more common in children
after a fracture, the sternocleidomastoid elevates the medial fragment of the clavicle, and the shoulder drops.
The lateral fragment of the clavicle gets pulled medially by the arm adductors, eg. pectoralis major
THE CLAVICLE IS THE FIRST LONG BONE TO OSSIFY in the embryo (5th-6th week)
Protects the neurovascular bundle supplying the upper arm, forming a bony boundary of the cervical canal
Transmits traumatic impact force from the upper limb to the axial skeleton
Contains NO MEDULLARY CAVITY
The Scapula
o
o
o
The clavicle is a triangular flat bone which lies on the posterolateral surface of the thorax
Proximally, it is curved to move over the chest wall, and distally it articulates with the clavicle at the
acromioclavicular joint, and with the head of humerus at the glenohumeral joint
Subscapular fossa
Spine of scapula,
Delotid tubercle on the spine of scapula
Acromion process of the spine of scapula
Facet for articulation with the clavicle
Supraspinous fossa
Infraspinous fossa
Coracoid process
Suprascapular notch
Glenoid cavity
Right Scapula
Suprascapular notch
Supraspinous fossa
Spine of the scapula
Head of scapula
Infraspinous fossa
Facet for the clavicle
Superior border:
THINNEST bone
Acromion
Body of scapula
(forms the head)
Coracoid process
Supraglenoid tubercle:
For attachment of long
head of biceps
This whole surface is the

subscapular fossa
Glenoid cavity:
4cm by 2-3 cm;
Faces anterolaterally
and slightly superiorly
Infraglenoid tubercle:
For attachment of long head of triceps
Medial (vertebral)border:
Thin bone
Lateral border: a thick bar

of bone, the stress-bearing
region of the scapula
The Humerus
o
o
o
the humerus is a long bone, the largest in the upper limb

it articulates proximally with the scapula at the scapulohumeral (glenohumeral) joint
it articulates distally with the ulna at the elbow joint
Bicipital groove
Greater tubercle
The humerus is in direct

contact with a bunch of
important nerves:
The Right Humerus
Lesser Tubercle
The anatomical neck is formed by a groove
distal to the head but proximal to the tubercles
The Axillary Nerve

At the surgical neck
The surgical neck is the narrow part past the tubercles
The Deltoid Tuberosity is where the deltoid attaches
The Radial Nerve
The Radial groove is where the radial nerve and deep

artery of the arm pass next to the humerus
At the radial groove
The sharp lateral

supracondylar
ridge
The Median Nerve
The sharp medial supracondylar ridge
The Lateral
Epicondyle :
attachment for
EXTENSORS
At the distal humerus

The Medial Epicondyle :
attachment for FLEXORS
The Ulnar
Nerve
At the medial
epicondyle
Olecranon Fossa : receives the

olecranon process of ulna
Trochlea articulates with the

trochlear notch of the ulna
Coronoid Fossa : receives the

coronoid process of the ulna
Capitulum : articulates with
the head of radius

The head of humerus
The anatomical neck
The greater tubercle
The lesser tubercle
Intertubercular groove bicipital groove
The surgical neck
The deltoid tuberosity
Radial Fossa: receives the

head of radius
The radial groove

The medial and lateral
supracondylar ridges
The medial and lateral
epicondyles
The olecranon fossa
The trochlea
The coronoid fossa
The radial fossa

The capitulum
The Humerus
common fracture sites and the position of the nerves relative to these
o
o
o
COMMONEST fracture site: the SURGICAL NECK

AXILLARY NERVE is injured by this
MID-SHAFT fracture: either transverse, from a direct blow, or spiral, from a fall on an outstretched arm
RADIAL NERVE is injured this way as it runs in the radial groove
INTERCONDYLAR FRACTURE: fall on a flexed elbow; the olecranon is driven into the olecranon fossa,
shattering it;
MEDIAN NERVE is damaged by this
ULNAR NERVE may be damaged by this
The greater tubercle can get avulsed, but there are no nerves around to be harmed by this
The Radius
o
o
o
o
o
o
o

the radius is a long bone, the shorter of the two in the forearm
proximally, the head of radius articulates with the capitulum of the humerus
the head also articulates with the radial notch of the ulna
the radial tuberosity separates the neck of radius from the body
The head of radius
The neck of radius

Radial tuberosity
The body of radius
head of radius
neck of radius
radial tuberosity
body of radius
radial styloid process
Dorsal markings on the distal radius,
ulnar notch
groove for extensor digitorum
and extensor indices
groove for extensor pollicis
longus
dorsal tubercle of radius
groove for extensor carpi
radialis
groove for extensor carpi
radialis longus and brevis
Ulnar notch: this is

where the head of the
ulna articulates
Posterior oblique line
Groove for extensor

pollicis longus
Dorsal tubercle of radius:
Listers tubercle
Groove for extensor carpi
radialis longus and brevis
Groove for extensor

digitorum and extensor
indices
Radial styloid process: MUCH LARGER
than the ulnar. It extends further distally
by about 1 fingers breadth.
Markings on the Dorsal Radius

o
o
o

extensor CARPI RADIALIS LONGUS and BREVIS
Dorsal tubercle of radius
extensor POLLICIS LONGUS
extensor DIGITORUM and extensor INDICES
Ulnar notch
ULNA
RADIUS
The Ulna
o
o
o
the ulna is a medial long bone, the longer of the two in the forearm.
Proximally, it articulates with the capitulum and trochlea of the humerus;
At the radial notch, it articulates with the head of radius

It stabilizes the forearm
The HEAD LIES DISTALLY.
The Olecranon
The Trochlear Notch
The Coronoid Process
The Radial Notch where the
head of the radius goes
The Tuberosity of the Ulna is
where the Brachialis attaches
Supinator fossa
Supinator crest
The deep part of

the supinator
attaches here

-
The head of ulna
The ulnar styloid process
Humerus and ulna: landmarks and articulations

o
o
o

o
o
the ulna and humerus articulate at the elbow joint

the articulations include:
articulation between the trochlea of the humerus and the trochlear notch of the ulna
articulation of the olecranon process and the olecranon fossa during extension
articulation of the coronoid process and the coronoid fossa during flexion
the surface landmarks include
the medial and lateral epicondyle
the olecranon
the posterior border of the ulna
Olecranon
Trochlear notch
Coronoid process
Radial notch
Tuberosity of ulna
Supinator fosa
Supinator crest
Head of ulna
Ulnar styloid process
The Articulated Carpus

o
o
o

o
o
o
the carpals are eight bones arranged in two rows

the carpus is convex anteriorly and concave posteriorly
these bones glide on each other, as well as the two rows gliding on each other, as well as gliding along the
radiocarpal joint.
Some Lovers Try Positions
That They Cant Handle:
Scaphoid, Lunate, Triquetrum, Pisiform,

Trapezium, Trapezoid, Capitate, Hamate.
The scaphoid, linate and triquetrum articulate with the radius.

Capitate Articulates with the 3rd metacarpal
Largest bone in the carpus
Trapezoid
Articulates with the 2nd
metacarpal
Hamate
Articulates with the 4th and 5th metacarpal
Tubercle of trapezium
Hook of Hamate
Trapezium
Articulates with the 1st and
2nd metacarpals
Tubercle of scaphoid
Pisiform
Scaphoid
Largest bone in the proximal row
Articular disk
Triquetrum
Lunate
5th 4th 3rd

Hamate
2nd
1st
Capitate Trape trapezium

zoid
1st
References: Moores Clinically Oriented Anatomy 5th edition
9
1st
1st
1st
MUSCLES
ATTACHMENT
SITES IN THE
UPPER LIMB
10
Muscle Attachment Sites in the Upper Limb

The Clavicle
Pectoralis major
Right clavicle
Deltoid tubercle:
attachment of the deltoid
Smooth superior surface of the shaft, under the platysma muscle
Deltoid
Axillary nerve
Acromial facet
Trapezius
Sternocleidomastoid and Trapezius innervated by the Spinal Accessory nerve
Sternocleidomastoid
Conoid tubercle, attachment of the
conoid ligament
which is the medial part of the
Sternal facet
Conoid ligament
Costoclavicular ligament
Acromial facet
Impression for the

costoclavicular ligament
which binds the clavicle to
the first rib
Subclavian groove:
site of attachment of the
subclavius muscle
Subclavius
Innervated by Nerve to Subclavius
Trapezoid line, attachment of the

trapezoid ligament
which is the lateral part of the
Trapezoid ligament
11
The Scapula
Trapezius
Right scapula: posterior

Levator scapulae
Supraspinatus
Deltoid
Deltoid and Teres Minor are
innervated by the Axillary nerve
Rhomboid minor
Levator Scapulae, Rhomboid minor
and Rhomboid Major are innervated
by the Dorsal Scapular Nerve
Supraspinatus and
Infraspinatus innervated
by the Suprascapular nerve
Long head of triceps
Infraspinatus
Rhomboid major
Teres Minor
Teres Major
Teres Major innervated by Lower Subscapular Nerve
Latissimus dorsi
Latissimus dorsi innervated by the Thoracodorsal nerve
Deltoid
Right scapula: anterior

Pectoralis minor
Innervated by the medial pectoral nerve
Biceps brachii:
short head
Serratus anterior
Serratus anterior is innervated by the
Long Thoracic nerve
Coracobrachialis and Biceps Brachii

are innervated by the
Musculocutaneous nerve
Coracobrachialis
Subscapularis
Subscapularis innervated
by the Upper and lower
Subscapular nerves

Innervated by the Radial nerve
12
The Humerus
Right Humerus: anterior
Supraspinatus
(greater tubercle)
Suprascapular nerve
Right Humerus: posterior

Subscapularis
(lesser tubercle)
Teres minor
Axillary nerve
Upper and lower Subscapular nerves
Infraspinatus
(greater tuberosity
Suprascapular nerve
Latissimus dorsi
Thoracodorsal nerve
The bicipital groove

Covered by the transverse
ligament
Teres major
Lower Subscapular Nerve
Triceps brachii:
Lateral head
Pectoralis major
Innervated by the Lateral and
medial pectoral nerves
Deltoid
Deltoid
Axillary nerve
Axillary nerve
All heads of the triceps are

innervated by the Radial nerve
Coracobrachialis
Triceps brachii:
Medial head
Brachialis
Brachioradialis
Radial nerve
Anconeus
Extensor carpi
radialis longus
Pronator teres
Flexor carpi ulnaris
Median nerve
Ulnar nerve
(Radial Nerve)
Radial nerve
Supinator
Deep branch of
radial nerve
Common extensor origin:

- Extensor carpi radialis brevis (deep branch of the radial nerve)
- Extensor digitorum (posterior interosseous nerve)
- Extensor digiti minimi(posterior interosseous nerve)
- Extensor carpi ulnaris (posterior interosseous nerve)
-
13
Common flexor origin:

- Flexor carpi radialis (Median nerve)
- Palmaris longus (Median nerve)
- Humeroulnar head of the FLEXOR DIGITORUM SUPERFICIALIS
(Median nerve)
The Radius and Ulna: Flexor compartment

Brachialis
Biceps brachii
Supinator
Flexor digitorum
superficialis
Deep branch of
radial nerve;
actually a part of the extensor
compartment
(Median nerve)
Flexor digitorum
superficialis
Pronator teres:
the ulnar head originates here
innervated by the Median nerve
(Median nerve)
Flexor carpii ulnaris

Pronator teres
Ulnar head originates here

Innervated by the Ulnar nerve
(Median nerve)
Flexor digitorum
profundis
Flexor pollicis longus
Radial half innervated by

the Median nerve
Ulnar Half innervated by
the ulnar nerve
Anterior interosseous nerve
Pronator quadratus
Brachioradialis
Radial nerve
ORIGINATES at the ULNA

INSERTS into the RADIUS
14
The Radius and Ulna: dorsal surface

Triceps brachii
Radial nerve
Anconeus
Radial nerve
Supinator
Deep branch of
radial nerve
Supinator
Deep branch of
radial nerve
Abductor pollicis longus

(posterior interosseous nerve)
Pronator teres
(Median nerve)
Extensor pollicis longus

Posterior oblique line
Extensor pollicis brevis

Extensor indices
15
The carpus and hand: palmar surface
Flexor digitorum superficialis

(Median nerve index and middle finger)
(Ulnar nerve ring and pinky fingers)
Inserts into the distal phalanges
Adductor pollices
(Median nerve)

(Median nerve)
Inserts into the middle phalanges

(Anterior interosseous nerve)
Flexor digiti minimi brevis

(deep branch of ulnar nerve)

Abductor digit minimi
Flexor pollicis brevis
(recurrent branch of Median nerve)
Abductor pollicis brevis
Opponens digit minimi
Opponens pollicis
(recurrent branch of Median
nerve)
Flexor carpii ulnaris
Unique among anterior

compartment muscles because it
is WHOLELY innervated by the
Ulnar nerve
Abductor digit minimi
Flexor Carpi radialis
(Median nerve)
Palmaris longus
(Median nerve)
Inserts into the flexor
retinaculum
Opponens pollicis brevis, abductor pollicis brevis and flexor pollicis brevis all originate from the flexor retinaculum
16
The carpus and hand: dorsal surface
Extensor digitorum
Extensor indices
Extensor digit minimi

Extensor carpi radialis longus

(radial nerve)
Extensor pollicis longus
Extensor carpi radialis brevis
Deep branch of radial nerve
Dorsal interossei
Deep branch of ulnar nerve
Extensor pollicis brevis

Extensor carpi ulnaris
Deep branch of radial nerve

17
MUSCLES,
INNERVATION AND
THE
COMPARTMENT OF
THE UPPER LIMB
18
Muscles, Innervation and the Compartments of the Upper Limb

Organized in an Unintentionally Difficult Manner
Fascia and compartments of the shoulder

PECTORALIS FASCIA
-
The only contents is Pectoralis Major;

Pectoralis fascia continue inferiorly as fascia of the anterior abdominal wall
It continues laterally-once it leaves the lateral edge of Pectoralis Major, it becomes AXILLARY FASCIA
AXILLARY FASCIA
-
Continuous with the CLAVIPECTORAL FASCIA

Forms the floor of the axilla
CLAVIPECTORAL FASCIA
-
Deep to the Pectoralis major muscle, the CLAVIPECTORAL FASCIA invests the subclavius muscle and pectoralis minor.
It forms the costocoracoid membrane above pectoralis minor, and the suspensory ligament of axilla below pectoralis
minor. The suspensory ligament drags the axillary fascia upwards when the arm is raised, forming the actual pit of the armpit
Pectoralis major, wrapped
up in pectoralis fascia
Clavicle
Subclavius
Lateral pectoral nerve
and Thoracoacromial artery
Costocoracoid membrane
Pectoralis minor
Suspensory ligament of axilla
Axillary fascia
Axillary fascia
Supraspinous, Infraspinous and Subscapular fascia

-
The supraspinatus, infraspinatus and subscapularis muscles are contained in their own little fascial compartments
Deltoid Fascia
-
The deltoid has its own fascia, continous with the pectoral fascia and infraspinatus fascia
It has numerous fascial septa which separate the fascicles of the deltoid
Supraspinatus
fascia
Spine of scapula
Clavicle
Deltoid fascia
Infraspinatus fascia
Pectoralis fascia
Infraspinatus fascia
Subscapularis
fascia
Fascial septa
Pectoralis fascia, infraspinatus fascia and deltoid fascia all continue down the arm to form the brachial fascia
19
THE AXILLA
o
A PYRAMIDAL space: has a flat apex, 4 walls, and a base.

Superior border of scapula
APEX
First rib
Clavicle
POSTERIOR
WALL
Scapula
Subscapularis
Teres major
Clavipectoral fascia
Pectoralis minor
LATERAL WALL
Intertubercular groove of
the humerus;
Thus also the tendon of
the long head of biceps
ANTERIOR WALL
Pectoralis major
Anterior axillary fold
MEDIAL WALL
Chest wall and
serratus anterior
CONTENTS
Axillary artery and its branches
Axillary vein and its tributaries- brachial vein, basilic vein and thoracoepigastric vein
Lymphatic vessels and axillary lymph nodes
Cords and branches of the brachial plexus
BOUNDARIES
- Apex
o Cervicoaxillary canal; passageway into the neck
o Bounded by the 1st rib, clavicle, and superior edge of the scapula
o The vessel and nerves gateway into the arm
- Base
o Axillary fossa: fat, fascia, skin
- Anterior Wall
o Pectoralis major, pectoralis minor, pectoral and clavipectoral fascia
o The inferior part is the anterior axillary fold
- Posterior wall
o Scapula and subscapularis
o Inferior border is the teres major and latissmus dorsi
20
Medial wall
- Rib cage, chest wall ribs 1-4 and
the intercostal muscles
- Serratus anterior
Lateral wall
- Narrow wall; intertubercular groove
of the humerus
The Medial Triangular Space, Lateral Triangular Space, and the Quadrangular Space
These are gaps in the posterior wall of the axilla. They allow vessels and nerves to exit the axilla posteriorly.
QUADRANGULAR SPACE
Subscapularis and Teres Minor
Surgical neck of Humerus
Contents:
AXILLARY NERVE
and
POSTERIOR CIRCUMFLEX HUMERAL ARTERY
Teres Major
Long Head of Triceps
Subscapularis and Teres Minor
Surgical neck of Humerus
Teres Major
LATERAL TRIANGULAR SPACE
MEDIAL TRIANGULAR SPACE
Contents:
Circumflex scapular artery
Teres Major
Surgical neck
of Humerus
Contents:
RADIAL NERVE
Long Head
of Triceps
and
PROFUNDA BRACHII
ARTERY (deep artery
of the arm)
Border of scapula,
Teres Minor and
Subscapularis

Teres Major
21
Anterior Axioappendicular Muscles of the Shoulder

There are 3 distinct groups of shoulder muscles:
ANTERIOR AXIOAPPENDICULAR MUSCLES 4 muscles which move the pectoral girdle
POSTERIOR AXIOAPPENDICULAR MUSCLES 4 muscles which attach the upper lumb to the skeleton of the trunk
SCAPULOHUMERAL MUSCLES 6 muscles which act on the glenohumeral joint
Pectoralis Minor
Anterior Axioappendicular muscles
Subclavius
All supplied by stupidly different nerves.
Pectoralis Major :
clavicular head
No pattern whatsoever.
Pectoralis Major
Two heads:
-
CLAVICULAR HEAD: lateral pectoral nerve

o
Pectoralis major:
sternocostal head
Originates from the medial half of the anterior

clavicle
STERNOCOSTAL HEAD: medial pectoral nerve
Originates from the anterior surface of the sternum,

and the first 6 costoclavicular cartilages
o
Also originates from the aponeurosis of the external
oblique muscle of the abdomen
INSERTS INTO THE LATERAL LIP OF THE INTERTUBERCULAR
GROOVE OF THE HUMERUS
o
Intertubercular groove
of the humerus
Its inferior border forms the anterior axillary fold

o Abducts and medially rotates the humerus
o Draws scapula anteriorly and inferiorly by
pulling on the humerus
The heads can act independently:

o Clavicular head alone acts to flex the humerus
o When flexed, the sternocostal head extends it
from its flexed position.
Pectoralis Minor medial pectoral nerve

-
Serratus Anterior
Innervation
Nerve to Subclavius:
Off the superior trunk
Originates at the 3rd, 4th and 5th ribs near the costal
cartilages
Inserts into the medial border and superior surface of the
coracoid process of scapula
Its job is to stabilize the scapula by pulling it anteriorly
and inferiorly against the chest wall
It also assists in elevating the ribs when breathing
All the vessels and nerves to the arm travel under the
pectoralis minor.
Subclavius nerve to subclavius
Subclavius
Lateral Pectoral nerve:

Branch of the lateral cord
clavicular head of
Pectoralis Major
Originates at the junction of the 1st rib and its costal cartilage
Inserts into the groove for subclavius on the inferior surface
of the middle third of the clavicle
Depresses and anchors the clavicle
Protects the subclavian vessels when the clavicle is fractured
Serratus anterior long thoracic nerve

-
Long Thoracic Nerve:

Off the roots of C5, 6 and 7
Serratus Anterior
Medial Pectoral nerve:
Branch of the medial cord
Pectoralis Minor; sternocostal head of Pectoralis Major
22
Originates from the lateral surfaces of the first 8 ribs

Inserts into the medial border of scapula
Protracts the scapula, holds it against the chest wall, and
rotates it superiorly (eg when reaching for something up high).
THE MAIN PROTRACTOR OF THE SCAPULA
One of the most powerful muscles in the pectoral girdle.
Its paralysis causes a winged scapula. Also, the arm cannot be
abducted past the horizontal position (the scapula doesnt
rotate upwards anymore)
If you insert your chest drain BELOW the mid-axillary line, you
will cause this sort of paralysis, which is embarrassing.
Posterior Axioappendicular Muscles of the Shoulder: the Extrinsic Group

There are 2 layers, the superficial and the deep.
Posterior Axioappendicular Extrinsic Muscles
The superficial group is trapezius and latissimus dorsi
The deep group is the levator scapulae and the rhomboids
Viewed from above
Also supplied by confusingly different nerves.
Trapezius spinal accessory nerve

-
Originates from
o
o
o
o
o
Superior part of
Trapesius
Inserts into :
o
o
o
Middle part of
Trapesius
The external occipital protuberance

Nuchal ligament
Medial third of superior nuchal line
Spinous processes of C spine and T-spine
he medial half of the anterior clavicle
Lateral third of the clavicle
Acromion of scapula
Spine of scapula
Has 3 distinct parts:
Floor of the intertubercular

groove, anteriorly on the
humerus
Middle part of
Trapesius
SUPERIOR (descending)part which elevates

the scapula
MIDDLE part which retracts the scapula
INFERIOR (ascending) part which
depresses the scapula
All the parts together act to rotate the scapula superiorly, so

the glenoid fossa faces up.
T7
Latissimus dorsi Thoracodorsal nerve
Latissimus dorsi
Originates from
o Inferior 6 thoracic vertebrae
o Thoracolumbar fascia
o Iliac crest
o Inferior 3 or 4 ribs
Inserts into the ANTERIOR surface of the humerus, at the floor

of the intertubrercular groove
Extends, adducts, medially rotates the humerus
Lifts the body up too the arms when climbing
Levator scapulae
Levator scapulae dorsal scapular and cervical nerves

-
Rhomboid Minor
Rhomboid Major
Innervation
Dorsal scapular nerve:

Off the roots of C5
Originates at the posterior tubercles of the spinous processes

of the C1, 2, 3 and 4 vertebrae
Inserts into the medial border of scapula, superior to the spine
Elevates that corner of the scapula, rotating it so the glenoid
cavity faces down
Extends the neck (when acting bilaterally) or flexes it laterally
(when acting unilaterally)
Rhomboid Minor dorsal scapular nerve
Rhomboid major and minor

Levator scapulae
Thoracodorsal Nerve:
Off the posterior cord
Latissimus dorsi
Originates from the nuchal ligament and the spinous processes

of C7 and T1
Inserts into the medial border of the scapula, at the root of the
scapular spine
Retracts the scapula
Rotates the scapula so the glenoid cavity faces down
Fixes the scapula to the thoracic wall
Rhomboid Major dorsal scapular nerve

-
.
23
Originates from the spinous processes of T2,3 4and 5

Inserts into the medial border of the scapula, from the root of
spine down.
Retracts the scapula
Rotates the scapula so the glenoid cavity faces down
Fixes the scapula to the thoracic wall
Posterior Axioappendicular Muscles of the Shoulder: the Intrinsic Group with Rotator Cuff muscles
These are the deltoid and teres major; and the 4 rotator cuff muscles (teres minor, supraspinatus, infraspinatus and subscapularis)
Deltoid
Posterior Axioappendicular Intrinsic muscles

Again, supplied by totally different nerves.
Deltoid axillary nerve

-
Supraspinatus
Originates from the lateral third of the clavicle, the

acromion, and the lateral spine of scapula.
Inserts into the deltoid tuberosity of humerus
THREE PARTS:
Anterior part flexes and medially rotates the

humerus
o Middle part abducts the humerus
o Posterior part extends and laterally rotates the
arm
o The middle part is multipennate; the others are
unipennate
It cannot initiate abduction on its own when the arm is fully
adducted- thus it needs supraspinatus to initiate the movement. It
becomes effective after about 15 degrees of abduction.
The deltoids anterior and posterior parts swing your arms while
walking.it also helps to keep the humeral head in the glenoid
fossa.
o
Infraspinatus
Subscapularis
Teres Major
Teres Minor
Iinsertion of deltoid, at the
Deltoid Tuberosity
Teres major lower subscapular nerve

Deltoid
Supraspinatus
Deltoid
Originates from the posterior surface of the inferior

angle of scapula
Inserts into the medial lip of the intertubercular groove
of humerus
Adducts and medially rotates the arm
Also keeps the head of humerus in the socket
Rotator Cuff Muscles
Whatever other actions they may have, they all help hold
the humeral head in the glenoid fossa
Supraspinatus suprascapular nerve
Infraspinatus
Subscapularis
Teres Major
Innervation
Upper Subscapular nerve
Axillary nerve:
Off the posterior cord
Lower Subscapular nerve
Teres Minor
Deltoid
Subscapularis
Subscapularis
Teres major
Teres Minor
Teres Major
Suprascapular nerve
Supraspinatus
Infraspinatus
Originates in the supraspinous fossa of the scapula

Inserts into the superior facet of the greater tubercle of
humerus
Initiates abduction, and assists the deltoid with abduction of
the arm; its the only one that doesn't rotate the arm.
Infraspinatus suprascapular nerve

-
Originates in the infraspinous fossa of the scapula

Inserts into the middle facet of the greater tubercle of
humerus
Laterally rotates the arm
Teres Minor axillary nerve

-
Originates from the middle of the lateral border of scapula

Inserts into the inferior facet of the greater tubercle of
humerus
Laterally rotates the arm
Subscapularis upper and lower subscapular nerves

-
24
Originates in the subscapular fossa

Inserts into the lesser tubercle of humerus
Medially rotates and abducts the arm
Muscles and Nerves involved in the movements of the shoulder joint
flexion:
pectoralis major (clavicular head) medial and lateral pectoral nerve
deltoid (anterior part) axillary nerve
coracobrachialis musculocutaneous nerve
biceps femoris musculocutaneous nerve
extension:
deltoid (posterior part) axillary nerve
teres major lower subscapular nerve
abduction:
deltoid (central part) axillary nerve

supraspinatus suprascapular nerve
adduction:
pectoralis major medial and lateral pectoral nerve
latissimus dorsi thoracodorsal nerve
subscapularis - upper and lower subscapular nerve
infraspinatus suprascapular nerve
teres minor axillary nerve
medial rotation:
subscapularis
pectoralis major medial and lateral pectoral nerve
deltoid (anterior part) axillary nerve
latissimus dorsi thoracodorsal nerve
lateral rotation:
infraspinatus suprascapular nerve

long head of triceps radial nerve
coracobrachialis musculocutaneous nerve
short head of biceps musculocutaneous nerve
25
Fascia and compartments of the proximal arm

Section at a level just short of half-way along the humeris
Brachial Fascia
-
Encloses the upper arm like a sleeve

Superiorly, it is continuous with the deltoid fascia,
infraspinatus fascia and pectoralis fascia
Inferiorly, it is attached to the epicondyles of the
humerus and the olecranon of ulna
It is continuous with the antebrachial fascia the
fascia of the forearm
o It contains two SEPTA: the MEDIAL and
LATERAL INTERMUSCULAR SEPTA.
o The septa are attached to the supracondylar
ridges and to the shaft of humerus
o They separate the arm into the
ANTERIOR COMPARTMENT and the
POSTERIOR COMPARTMENT
Anterior compartment
Medial intermuscular septum
Posterior compartment
Lateral intermuscular septum
Anterior Compartment: FLEXORS

- Biceps Brachii
Supplied by the
MUSCULOCUTANEOUS
- Brachialis
- Coracobrachialis NERVE
- Median nerve
- Musculocutaneous nerve
The medial cutaneous nerve of forearm is not inside
the fascial sheath, but is still important enough to warrant a

brief mention.
The Basilic vein and the Cephalic vein are

usually superficial to the fascial planes
Cephalic vein
- Triceps Brachii
- Anconeus
- Radial nerve
Supplied by the
RADIAL NERVE
Deep artery of the arm (profunda brachii)
Superior ulnar collateral artery
Ulnar nerve as depicted here is in the posterior
(A branch of the brachial artery)
compartment; it travels anteriorly to the medial intermuscular

septum, until it pierces it about half-way down the humerus,
together with the superior ulnar collateral artery
Radial nerve
Biceps brachii
Lateral
intermuscular
septum
Posterior Compartment: EXTENSORS
Deep artery of the arm
Ulnar nerve
Median nerve
Triceps brachii
Brachialis
Medial
intermuscular
septum
Deltoid:
Not actually a part of the anterior
compartment, as it has its own
fascial compartment.
Basilic vein
Brachial artery
Coracobrachialis
Medial cutaneous
nerve of forearm
26
The innervation and mechanics of the flexor and extensor muscle compartments of the arm
Anterior Compartment: FLEXORS
All supplied by the MUSCULOCUTANEOUS NERVE
Biceps Brachii
Two heads:
-
SHORT HEAD:
o
o
Biceps Brachii
Supraglenoid tubercle
ligament
Brachialis
-
Transverse
humeral
ligament
LONG HEAD:
The lateral head.

Originates from the supraglenoid tubercle of the
glenoid fossa
The biceps inserts into the tuberosity of radius; and it also inserts
into the antebrachial fascia by virtue of the bicipital aponeurosis.
It does very different things depending on what position the
arm is in:
o
It supinates the forearm by pulling on the
aponeurosis, when the arm is pronated; it is the
MOST POWERFUL SUPINATOR of the forearm
o
when the forearm is supine if FLEXES the elbow joint
by pulling on the attachment to the radial tuberosity.
o
It is useless as a flexor when the forearm is pronated.
The short head resists dislocation of the shoulder
Coracobrachialis
-
Bicipital aponeurosis
Coronoid process and
the tuberosity of ulna
Tuberosity of radius
The medial head.

Originates from the tip of the coracoid process
o
o
Coracobrachialis
Tip of the coracoid
process
Some of the brachialis is

innervated by the radial nervethe half that is posterior to the
insertion of deltoid
Short head
Originates at the tip of the coracoid process of scapula

Inserts into the middle third of the medial humerus
Helps flex and adduct the arm
Resists dislocation of the shoulder: its a SHUNT muscle, it
resists the downward dislocation of the humeral head
Stabilizes the glenohumeral goint
A landmark it is pierced by the musculocutaneous nerve
Brachialis
Long head
Originates from the distal half of the anterior humerus

Inserts into the tuberosity of the ulna, and the coronoid process
Flexes the forearm in all positions its the PRIMARY FLEXOR
Posterior
Compartment: EXTENSORS
.
All
supplied by the RADIAL NERVE
Triceps Brachii
Infraglenoid tubercle
Lateral head
of triceps
LONG HEAD:
o
Originates from the infraglenoid tubercle
LATERAL HEAD:
o
Originates from the proximal humerus, more
proximal than the radial groove
MEDIAL HEAD:
o
Originates from the posterior surface of the humerus,
distal to the radial groove
The united triceps inserts into the olecranon of ulna
Medial head of triceps
It is the chief extensor of the arm.

The long head resists dislocation of the head of humerus,
especially during abduction
Anconeus
Anconeus
27
Originates from the posterior lateral epicondyle of humerus

Inserts into the lateral surface of olecranon
Assists the triceps in flexing the forearm, and stabilizes the
elbow joint. It also pulls the joint capsule out of the way of the
olecranon upon extension; otherwise it would get pinched in
the olecranon fossa . Many anatomists believe it to be a vestigial
and forgotten 4th head of the triceps.
Fascia and compartments of the distal arm

Section at the junction of distal third and proximal two thirds of the humerus
Biceps brachii
Coracobrachialis
Brachial artery
Cephalic vein
Lateral cutaneous nerve of

forearm which has just branched off
Median nerve
from the MUSCULOCUTANEOUS nerve
Brachialis
Posterior cutaneous nerve of
forearm which has just branched off
Basilic vein
from the RADIAL nerve
Medial cutaneous nerve

of forearm which arises
from the MEDIAL CORD of the

brachial plexus
Radial nerve
Lateral
head
Medial
head
Ulnar nerve
Long
head
Section at the level of the humeral epicondyles

Triceps brachii
Basilic vein
Cephalic vein
Brachial artery
Radial nerve which has pierced the

lateral intermuscular septum a little while
ago, and now travels between brachialis
and brachioradialis
Median nerve
Biceps brachii
Brachioradialis
Brachialis
PRONATOR TERES
which is important for

a number of reasons:
-
Forms the lateral border

of the cubital fossa
Innervated by the RADIAL NERVE
Flexes the forearm, unlike
the rest of the forearm extensor
compartment
Together with the Supinator, they
are the only extensor compartment
muscles which do not cross the wrist
and cause no movement there
Ulnar nerve
Triceps Brachii tendon
Anconeus
Which is unimportant, and arguably useless. In fact some anatomists believe it to a rudimentary 4th
triceps head. If it were missing, you would likely not notice.
28
THE CUBITAL FOSSA

ROOF OF THE FOSSA:
Antebrachial fascia, subcutaneous tissue, skin
Basilic Vein
CONTENTS OF THE ROOF:

Median cubital vein
Medial cutaneous nerve of forearm
Lateral cutaneous nerve of forearm
Medial cutaneous
antebrachial nerve
SUPERIOR BORDER:
An imaginary line between
the two epicondyles of the
humerus
Cephalic vein
Lateral cutaneous
antebrachial nerve
MEDIAL BORDER:
Pronator Teres
LATERAL BORDER:
Brachioradialis
FLOOR OF THE FOSSA:
Brachialis and Supinator
CONTENTS OF THE FLOOR
Superficial branch of the radial nerve
(as it runs under the brachioradialis)
Deep brach of the radial nerve
Median nerve as it enters the arm

between the heads of pronator teres
Deep Branch of the
radial nerve
Superficial branch of
the radial nerve
Brachial artery
BOUNDARIES:
-
SUPERIORLY: An imaginary line between the medial and lateral epicondyle

LATERALLY: brachioradialis
MEDIALLY: Pronator teres
FLOOR: brachialis and supinator
ROOF: deep fascia, bicipital aponeurosis, median cubital vein, medial and lateral cutaneous nerves of the forearm
CONTENTS:
-
Brachial artery
Deep veins of the arm which accompany the brachial artery
Biceps tendon
Median nerve
SUPERFICIALLY: median cubital vein, medial and lateral cutaneous nerve of the forearm
DEEP, in the floor: deep and superficial branches of the radial nerve
29
Fascia and compartments around the cubital fossa and distal forearm
Section at the level of the neck of radius
Antebrachial Fascia
-
Median cubital vein
Basilic vein
Cephalic vein
Extension of the brachial fascia

Also envelops the forearm like a sleeve
There are no intermuscular septa per se; the
muscles are all invested in their own fascia;
however there are still two recogniseable
compartments: the FLEXOR compartment and
the EXTENSOR compartment.
In 20% of people, the basilic vein branches off into a

median basilic vein, and when it joins the median
cephalic vein they form a clear M.
THERE ARE 17 MUSCLES CROSSING THE ELBOW JOINT.
Basilic vein
Cephalic vein
Median antebrachial vein
The BICEPS TENDON: one part blends with the antebrachial fascia;
The other part dives deep to attach to the radial tuberosity
Highly variable tributaries

Brachial artery which bifurcates at the level
of the radial head in the cubital fossa
Brachialis
Brachioradialis
Pronator teres which originates proximally to

the medial epicondyle, and forms the medial border
of the cubital fossa
Which forms the lateral

border of the cubital fossa
The Flexors of the forearm which originate

at the Common Flexor origin, at the medial
epicondyle of the humerus
The branches of the Radial Nerve
BrR
ECRL, B
ED
Superficial branch of the

radial nerve which travels
under brachioradialis down the
arm, where it supplies sensation
to the dorsum of the hand
Deep branch of the Radial Nerve which

will pierce the Supinator, penetrate the
interosseous membrane and become the
Posterior Interosseous Nerve
Biceps tendon
Radial artery
Ulnar artery
Daughters of the recently

bifurcated Brachial Artery
Median nerve which travels between the heads of P. teres

Pronator Teres
Brachioradialis
Flexor Digitorum Superficialis

(humeral head)
Extensor Carpi Radialis

Longus and Brevis
Flexor Carpi Radialis
Brachialis
Palmaris Longus
Neck of
Radius
ULNA
Flexor Carpi Ulnaris which is fully

innervated by the ulnar nerve, unlike the
rest of the flexors
Extensor Digitorum
Ulnar nerve, which runs between the two

heads of flexor carpii ulnaris
Annular Ligament
Flexor Digitorum Profundis
Anconeus
Half of which is innervated by the ulnar nerve, unlike the rest

of the flexors (which are all supplied by the Median nerve)
COMPARTMENTS IN THIS SECTION are not clear-cut or sensible.

-
This is an intersection of several compartments. The EXTENSOR compartment of the forearm is anterolateral, represented by
brachioradialis, extensor carpi radialis longus and brevis, and extensor digitorum. The FLEXOR compartment is posteromedial and
represented by pronator teres, palmaris longus, flexor carpi ulnaris, and flexor digitorum profundus and superficialis. The ANTERIOR
compartment of the arm is represented by the biceps tendon, and by brachialis.
Anconeus is a lonely representative of the POSTERIOR compartment.
30
Fascia and compartments of the middle forearm

Section at the level of the mid-forearm
Boundaries of the compartments:
Lateral border: radial artery
Interosseous membrane
Medial border: subcutaneous ulna
The border between layers 1-2 and layers 3-4 is the primary
neurovascular plane of the anterior compartment: the
neurovascular bundles exclusive to this compartment travel within it
FLEXOR COMPARTMENT
Palmaris Longus
This is the beefier compartment; twice as fat as the extensor compartment

(ulnar nerve)
Flexor carpi radialis

4 layers of muscles:
Median nerve
LAYER 1: pronator teres(not

shown, too proximal)

Palmaris longus
LAYER 2: Flexor digitorum
superficialis
Flexor
digitorum
superficialis
Flexor Pollicis
Longus
LAYER 3:Flexor pollicis longus

Flexor digitorum
profundis
LAYER 4:Pronator Quadratus

(not shown, too distal)
Flexor
digitorum
profundus
Anterior
Interosseous
Artery
Anterior Interosseous Nerve
Half of the Flexor Digitorum Profundus which is
innervated by the ulnar nerve, unlike the rest of the
flexors (which are all supplied by the Median nerve
Ulnar Nerve
Ulnar Artery
EXTENSOR COMPARTMENT
Lateral cutaneous
nerve of the forearm
Brachioradialis
Radial artery
Extensor carpi
radialis longus
Superficial branch of the radial nerve

Supinator
Extensor pollicis Brevis
Muscles of a similar purpose are

grouped together in compartments.
The EXTENSORS are posteromedial, and
the FLEXORS are anterolateral. They
spiral round the arm and eventually the
flexors become truly anterior and the
extensors become truly posterior.
Functionally, the forearm includes the

distal humerus because the muscles that
attach at the supracondylar ridges and
the epicondyles stretch along the
forearm to move the wrist and fingers.
BOUNDARIES OF THE COMPARTMENTS
Extensor carpi
radialis brevis
Extensor pollicis Longus

POSTERIORLY (proximal forearm) and

MEDIALLY (distal forearm), the
subcutaneous border of the ulna

ANTERIORLY (proximal forearm) and
then LATERALLY (distal forearm),
Extensor digitorum
the radial artery

Because neither of these boundaries
is crossed by motor nerves they are
used for surgical incisions
Posterior interosseous nerve

Posterior interosseous artery
Extensor indices
31
The Flexor Compartment of the Forearm

Pronator teres
Humeral head
Ulnar head is
hidden, but it
originates from
the coronoid
process
COMMON FLEXOR ORIGIN:

Pronator teres, humeral head
Palmaris longus
Flexor carpi ulnaris, humeral head
Flexor digitorum superficialis,
humeral head
LAYER 1:
All of these, except the ulnar head of pronator quadratus, attach to the medial humeral epicondyle at the
COMMON FLEXOR ORIGIN
Flexor carpi Ulnaris

Two heads, one originating
from the humerus, the
other from the olecranon
Inserts into the

Pisiform
Hook of hamate
Base of the 5th metacarpal

Humeroulnar head
(common flexor origin and the
coronoid process)
Radial head
PRONATOR TERES
Forms the medial border of the cubital fossa; its the most lateral of the first layer of muscles
Has an ulnar head and a humeral head
The humeral head originates from the COMMON FLEXOR ORIGIN
The ulnar head originates from the coronoid process
Median nerve: mainly Layers 1 and 2
Pronates and flexes the elbow
Pronator teres
FLEXOR CARPI RADIALIS
o
Originates from the COMMON FLEXOR ORIGIN
Palmaris longus
o
Inserts into the base of the 2nd metacarpal
o
Flexes and abducts the wrist
Anterior Interosseous nerve: mainly layer 3
o
About half-way down the forearm, its belly is replaced
Flexor digitorum profundus, lateral half
by a flat tendon which becomes cord-like at the wrist
o
It travels in the lateral carpal tunnel inside its own
Pronator quadratus
synovial sheath (it doesnt share)
Ulnar nerve:
o
The radial artery is just lateral to this tendon
flexor digitorum profundus, medial half
flexor carpi ulnaris
PALMARIS LONGUS
o
Originates from the COMMON FLEXOR ORIGIN
o
Inserts into the distal flexor retinaculum, and palmar aponeurosis.
o
Flexes and abducts the wrist, tenses the palmar aponeurosis
o
Its actually absent in 14% of people (usually on the left side). Those people dont miss it being gone.
o
The tendon of palmaris longus is a marker for where the median nerve is the tendon passes medially
to it, and then deep to it in the flexor retinaculum
o
o
o
o
o
Palmaris Longus
Flexor carpi
radialis
The belly is
replaced by
a flat tendon
which
becomes
cord- like at
the wrist
Median nerve
Lateral to the
palmaris
longus tendon
Radial
Artery
Lateral to the
flexor carpi
radialis
tendon
All supplied by the MEDIAN NERVE, except:
The flexor compartment Flexor Digitorum Profundis, ulnar half

has 4 discrete layers:
Flexor Carpi Ulnaris, whole
FLEXOR CARPI ULNARIS

o
o
o
o
o
Ulnar nerve
Has an ulnar and a humeral head

Humeral head originates from the COMMON FLEXOR ORIGIN; Ulnar head originates from the
olecranon, and posterior border of ulna
Inserts into the pisiform, hook of hamate and the 5th metacarpal.
Flexes and abducts the wrist; has its own synovial sheath
The tendon of flexor carpi ulnaris is a marker for the ulnar artery, which passes laterally to it at the wrist
LAYER 2
-
FLEXOR DIGITORUM SUPERFICIALIS

o
o
o
o
Flexor digitorum
profundus:
Supplied by
MEDIAN NERVE
ULNAR NERVE
LAYER 3
-
FLEXOR DIGITORUM PROFUNDUS

o
o
o
o
o
o
o
The flexors digitorum profundus and

superficialis are WEAKER when the
wrist is flexed, the tendons arent tense
The fast flexor of the fingers. Has two heads: humeroulnar head and radial head
The humeroulnar head originates from BOTH the COMMON FLEXOR ORIGIN and the coronoid process
of ulna; the radial head originates the proximal half of the radius
It inserts into shafts of the middle phalanges
It flexes the metacarpophalangeal joints and the proximal interphalangeal joints; it can flex each joint
independently of the others.
Its tendons are enclosed in the COMMON FLEXOR SHEATH together with the tendons of flexor
digitorum profundus
The slow flexor of the fingers

Originates from the interosseous membrane, and from the proximal three quarters of the anterior surface
of the ulna. It has two parts: medial and lateral parts;
The medial part is innervated by the ulnar nerve
Ulnar nerve
The medial part flexes the distal interphalangeal joints of the 4th and 5th digits
nd
rd
The lateral part flexes the distal interphalangeal joints of the 2 and 3 digits
All parts can flex the wrist joint as well as the fingers
The lateral part is innervated by the ANTERIOR INTEROSSEOUS NERVE (a branch of the median
nerve).
The tendon to the index finger tends to separate early; its the only one which can operate independently.
Unlike the flexor digitorum superficialis, the profundus flexes all the DIPs together.
FLEXOR POLLICIS LONGUS

o
o
o
o
Pronator Quadratus
Originates from the anterior surface of the radius and the nearby interosseous membrane
Inserts into the base of the distal phalanx of thumb. It has its own synovial sheal in the carpal tunnel
Also innervated by the ANTERIOR INTEROSSEOUS NERVE
It flexes the phalanges of the thumb; mainly the distal interphalangeal joint (its the only muscle that
flexes the DIP of the thumb)
LAYER 4
-
PRONATOR QUADRATUS
o
o
o
It originates from the distal quarter of the ulna, and inserts into the distal quarter of the radius
It is innervated by the ANTERIOR INTEROSSEOUS NERVE
It pronates the forearm (its the PRIMARY PRONATOR of the forearm) and its fibers hold the radius and
ulna together. When speed is needed, it is assisted by the Pronator Teres.
32
Extensor Compartment of the Forearm: Superficial layer

SUPERFICIAL LAYER OF EXTENSORS
All extend the forearm, wrist or fingers
two originate from the supracondylar ridge as well as the adjacent
EXCEPT BRACHIORADIALIS
intermuscular septum:
Brachioradialis is the solitary exception:

it is in the extensor compartment, but it flexes the forearm.
It is the only flexor innervated by the radial nerve.
All supplied by the RADIAL NERVE, or some branch thereof

two layers: the SUPERFICIAL and DEEP
Brachioradialis
o
o
o
o
o
o
radial nerve
Inserts at the lateral surface of the distal end of the radius
Flexes the forearm, in a feeble way, and mostly when the forearm
is pronated; it also acts as a shunt muscle to prevent subluxation
of the head of radius. its most active in quick movements, and in
movement against resistance.
Forms the lateral border of the cubital fossa
under it run the radial nerve and the radial artery
Distally, its tendon is covered by the tendons of Abductor Pollicis
Longus and Extensor Pollicis Brevis.
Extensor Carpi Radialis Longus
Brachioradialis
Common extensor origin
Extensor Carpi
Radialis Longus
o
o
o
o
o
radial nerve
Inserts at the dorsum of the 2nd metacarpal, at the base
extends and abducts the hand at the wrist
probably more involved in abduction than the ECRB
it is crucial in the clenching of the closed fist.
Four originate from the common extensor origin, at the lateral

epicondyle of the humerus
Extensor Carpi Radialis Brevis

o
o
o
o
o
o
Extensor Digitorum
Extensor Carpi Ulnaris
Extensor Digiti Minimi
o
Extensor Carpi
Radialis Brevis which
lies under the Extensor
Carpi Radialis Longus
o
o
Extensor Digitorum
The fattest muscle here
Tendon sheaths:
has its own; and so
does extensor digiti
minimi. The extensor
digitorum shares a
sheath with the tendon
of Extensor Indicis
Brachioradialis tendon
which lies under
the tendons of
Abductor Pollicis Longus
and
Extensor Pollicis Brevis
o
o
o
posterior interosseous nerve which is really the continuation of

the deep branch of the radial nerve
inserts at the extensor expansions of the fingers
THE EXTENSOR EXPANSIONS are triangular aponeuroses
which wrap around the metacarpal head, and the proximal
phalanx. They are united with the insertions of the lumbricals and
the interosseous muscles.
The tendons thus divide into a median band which passes to the
base of the middle phalanx, and two lateral bands which insert at
the base of the distal phalanx.
Extends the fingers, primarily at the metacarpophalangeal joint;
secondarily at the distal interphalangeal joint.
Occupies a lot of space in the extensor compartment
Shares an extensor tendon sheath with the Extensor Indicis
Just proximally to the metacarpophalangeal joints, the
tendons are linked by intertendinous connections which
prevent the fingers from being independently extended; thus
you can never fully extend a finger while the others remain
flexed. This is most true of the ring finger.

The common tendon
sheath of th extensors
carpi radialis: both travel
within the same sheath
o
o
o
o
o
The Tendon of Extensor

Digit Minimi divides into
two tendons; the lateral
one joins the extensor
digitorum tendon to the
little finger
deep branch of radial nerve

Inserts into the dorsum of the 3rd metacarpal at the base
extends and abducts the hand at the wrist
it is covered by the Extensor Carpi Radialis Longus
They also share the same extensor tendon sheath at the wrist
the brevis is more involved in extension than the longus
The Insertions of the Extensors

Carpi Radialis tendons:
Bases of the metacarpals
Longus inserts into the 2nd
Brevis inserts into the 3rd
Intertendinous connections which

unite the extensor digitorum
tendons and prevent the digits from
extending independently
33
posterior interosseous nerve

Divides into two tendons- the lateral one joins the pinky tendon of
the extensor digitorum, and then together with the medial one all
three insert into the extensor expansion of the pinky finger.
extends the pinky, primarily at the metacarpophalangeal joint;
secondarily at the distal interphalangeal joint.
this is really just a detached part of the extensor digitorum
However, it has its own tendon sheath

o
o
o
o
o
o
posterior interosseous nerve

yes it does originate at the common extensor origin; thats the
humeral head. There is also an ulnar head, which originates at the
ulnar border posteriorly, via an aponeurosis. This origin is also
shared with the Flexor Digitorum profundis and the Flexor Carpi
Ulnaris.
inserts at the dorsum of the base of 5th metacarpal
extends the hand at the wrist joint, and abducts it
It has its own tendinous sheath at the wrist
It is also crucial to the formation of the closed fist
Extensor Compartment of the Forearm: Deep layer

DEEP LAYER OF EXTENSORS
"true" deep layer
Supinator
o
o
Supinator
Attachments of the Supinator to the

Epicondyle of humerus
Radial collateral ligament
Annular ligament of radius
Ulnar Supinator crest and fossa
Ulnar posterior surface
o
o
o
Extensor Indicis
o
o
o
o
o
the Supinator wraps around the
radius to insert into the anterior
surface of it. Together with the
brachialis it forms the floor of
the cubital fossa
Extensor Pollicis Longus
these originate from the proximal, middle and distal thirds of the ulna (as a
generalization). They emerge in the surface in the furrow that forms in the
extensor compartment
o
o
Extensor Indices
Which shares an extensor
tendon sheath with the
Extensor Digitorum tendon

originates from the posterior surface of the distal third of
the ulna, and the interosseous membrane
inserts into the extensor expansion of the index finger
extends the index finger, enabling independent extension
helps extend the hand at the wrist
"outcropping" deep layer
o
o
deep branch of radial nerve which pierces it on its way

to transforming into the posterior interosseous nerve
originates from everywhere... the lateral humeral
epicondyle, the radial collateral ligament, the annular
ligament, the supinator fossa and the crest of ulna
inserts into the lateral posterior and anterior surfaces of
the proximal third of radius
it supinates the forearm, turning the arm to face anteriorly
and superiorly when the forearm is flexed. It is the
PRIME MOVER for slow unopposed suination
The supinator forms the floor of the cubital fossa together
with brachialis. It is a sheet-like muscle, and it envelops
the radius.

originates from the posterior surface of the proximal
radius and ulna, as well as the interosseous membrane
inserts into the base of the 1st metacarpal, and
occasionally also the trapezium.
abducts and extends the thumb at the carpometacarpal
joint
shares a common tendon sheath with the extensor
pollicis brevis at the wrist

Common sheath for the
tendons of the extensor
pollicis brevis and abductor
pollicis longus
o
o
o
o
o
o
o

originates from the posterior surface of the distal third of
the ulna, and the interosseous membrane
inserts into the dorsum of the base of the proximal
phalanx of the thumb
extends the proximal phalanx of the thumb at the
metacarpophalangeal joint; also extends the
carpometacarpal joints of the thumb.
partly covered by the abductor pollicis longus
its tendon is immediately medial to the APL
these two tendons form the anterior boundary of the
anatomical snuffbox.

o
o
o
Extensor digitorum tendon
Extensor expansion
Medial band attaches to the base of
the middle phalanx
o
o
Lateral bands attach to the

base of the distal phalanx
The hood which attaches to the palmar tendon
34

originates from the posterior surface of the middle third
of the ulna, and the interosseous membrane
inserts into the dorsum of the base of the distal phalanx
of the thumb
extends the distal phalanx of the thumb; also extends
the metacarpophalangeal and the carpometacarpal joints
of the thumb. It also rotates the thumb laterally.
It enjoys its own tendon sheath at the wrist; it passes
medially over the dorsal tubercle of radius, using it as a
pulley.
the EPL forms the posterior border of the anatomical
snuffbox
APL inserts into the base of 1st metacarpal

EPB inserts into the base of proximal phalanx
EPL inserts into the base of distal phalanx
Flexor and Extensor Tendons at the Wrist: level of the Distal Radioulnar Joint
Flexor Digitorum Profundus
Palmaris Longus
Ready to merge with the
palmar aponeurosis
Flexor Pollicis Longus
Median Nerve
Ulnar Artery
Ulnar nerve
Radial Artery
Flexor Carpi Ulnaris can cover the ulnar
artery and obscure its pulsation
ULNA
RADIUS

Extensor Digitorum
Extensor Indices

The Extensor Retinaculum

-- attaches
Attaches to the lateral border of the radius
-
Does NOT attach to the border of the ulna, because the ulna moves too much.
Instead, attaches to the pisiform and the triquetrum
Also attaches to the ridges of the radius, thus forming osseofibrous tunnels for the above tendons to run
through
There are 6 tunnels in total:
1. One for abductor pollicis longus and extensor pollicis brevis
2. One for extensor carpi radialis longus and extensor carpi radialis brevis
3. One for extensor pollicis longus
4. One for extensor digitorum and extensor indices
5. One for extensor digiti minimi
6.
One for extensor carpi ulnaris
35
The Carpal Tunnel and its Contents

This is a narrow enclosed space. Needless to say, if anything in here swells, the median nerve will get
compressed. It is the most sensitive structure in the carpal tunnel.
The lateral three and a half digits will get diminished sensation
Sensation on the thenar eminence will be spared because the palmar cutaneous branch splits
from the median nerve long before the flexor retinaculum
The movement of the thenar muscles is controlled by a terminal motor branch of the median nerve,
and so the thenar muscles will atrophy in carpal tunnel syndrome
Ulnar Artery
Palmaris Longus
Ulnar Nerve
Hypothenar muscles
Thenar muscles
TRAPEZIUM

HAMATE
TRAPEZOID

CAPITATE
Radial Artery
Crossing over to the
dorsum of the hand
Extensor Digiti minimi

Extensor Digitorum
Extensor Indices
Tuberosity of
Trapezium
Hook of Hamate
Flexor retinaculum
Median Nerve
Tuberosity
of Scaphoid
Flexor Digitorum
Superficialis
Pisiform
The Flexor retinaculum is stretched between four

bony posts:
1) Hook of hamate
2) Pisiform bone
3) Tuberosity of scaphoid
4) Tuberosity of trapezium
36
A Summary of the Innervation of the Extensors and Flexors of the Forearm
Flexors
Extensors
All innervated by branches of the RADIAL NERVE

Radial nerve itself: innervates muscles with attachments proximal to
the cubital fossa
- Brachioradialis
- Extensor Carpi Radialis Longus
- Both of these originate at the supracondylar ridge
Deep branch of the radial nerve: a branch which splits off from
the radial nerve at the level of the humeral condyle in the cubital fossa; it
pierces the supinator muscle, and becomes the posterior interosseous nerve
- Extensor Carpi Radialis Brevis

- Supinator
Posterior interosseous nerve: travels along the posterior aspect
of the interosseous membrane; innervates most of the extensor muscles
Extensor digitorum
Extensor Indicis
Extensor Digiti minimi
Innervated by either the ULNAR or the MEDIAN nerves
Median nerve itself:

- Pronator Teres
- Palmaris Longus
- Flexor carpi Radialis
- Flexor Digitorum Superficialis
Anterior interosseous nerve, a branch of the median nerve:
- Flexor Digitorum Profundus - lateral half
- Flexor Pollicis Longus
- Pronator Quadratus
Ulnar nerve:
- Flexor Digitorum profundus, only the medial half
- Flexor Carpi Ulnaris
Ulnar nerve :
Innervates the muscles
directly adjacent to it along
its course down the arm
Radial nerve is in red
Deep branch of
the radial nerve
is in pink
Median nerve:
Innervates mainly the 1st
and 2nd layer of flexors
Anterior Inerosseous
nerve: innervates the 3
deepest muscles
Posterior interosseous nerve is in green
37
Fascia, Septa, Tendon Sheaths and the Potential Spaces of the Hand
These fascial layers are continuous with
the fascial sleeve of the forearm.
Centrally the fascia of the palm thickens
in the centre, where the palmaris
longs tendon attaches to it, which is
also where it merges with the flexor
retinaculum. This whole thickened
area is called the palmar aponeurosis.
Distally, the palmar aponeurosis divides
into four bands which attach to the
bases of the proximal phalanges, and
there it becomes a part of the
digital sheaths
All merge into the

Palmar Aponeurosis
Palmaris Longus tendon

Antebrachial Fascia
Flexor retinaculum
The Thenar Space
Palmar Aponeurosis
so thick and tough that any infections
in the palmar spaces will actually
cause the weaker DORSAL fascia to
bulge out.
In Dupuytrens contracture, the
palmar aponeurosis becomes nodular,
fibrosed, and thickened
Thenar fascia
The Midpalmar Space

Palmar Aponeurosis
Hypothenar fascia
Lateral fibrous septum of the palm

which stretches from the palmar
aponeurosis to the 3rd metacarpal
Medial fibrous septum of

the palm which stretches from the palmar
aponeurosis to the 5th metacarpal
Unlike the thenar

space, this one is
continuous with the
anterior compartment
of the forearm- it
communicates with it
via the carpal tunnel.
Digital Synovial Sheaths
Of the two septa, the LATERAL is the strongest
The common flexor sheath continues to the

5th digit. The other digits have their own
Digital Synovial Sheaths
Synovial sheath for Flexor
Pollicis Longus
Common flexor sheath: FDS and FDP
Synovial sheath for Flexor
Carpi Radialis
38
Compartments of the palm and their contents

Thenar compartment
Contains the thenar muscles
Adductor compartment
Contains only Adductor Pollicis
Central compartment
Contains the flexor tendons and their
sheaths, the lumbricals, the superficial
arterial palmar arch, and the digital
vessels and nerves
Hypothenar compartment
Contains the hypothenar muscles
Interosseous compartments
Contains the interossei muscles
Thenar Compartment
Flexor Pollicis Brevis: Superficial head
which is innervated by the MEDIAN NERVE
Central
Compartment
Deep Head which is innervated by the

DEEP BRANCH OF THE ULNAR NERVE
1st and 2nd Lumbricals which are unipennate and which are
innervated by the MEDIAN NERVE
3rd and 4th Lumbricals which are bipennate and which are
innervated by the DEEP BRANCH OF THE ULNAR NERVE
Abductor Pollicis Brevis
Abductor Digiti Minimi
Opponens Pollicis
Hypothenar
Compartment
Adductor Pollicis
Opponens Digiti Minimi
Adductor compartment
Flexor Digiti Minimi Brevis
1st Dorsal Interoissei

3rd Palmar Interoissei
1st Palmar Interoissei
2nd Dorsal Interoissei

2nd Palmar Interoissei
Interosseous compartment
rd
3 Dorsal Interoissei
39
4th Dorsal Interoissei
Thenar and Hypothenar muscles

There are 3 Thenar muscles, 3 Hypothenar muscles, 1 Adductor muscle, 4 Lumbricals, 4 dorsal interossei and 3 palmar interossei
ADDUCTOR POLLICIS, which has
2 heads, between the origins of which the
RADIAL ARTERY emerges to form the
deep palmar arch
Transverse head of Adductor Pollicics,
which originates from the 3rd metacarpal
Oblique head of Adductor Pollicics,
which originates from the 3rd metacarpal
as well as from the 2nd metacarpal, the
capitate bone, and all adjacent carpal
bones

Which originates from the
flexor retinaculum and the
hook of hamate, and inserts
into the medial border of
the 5th metacarpal
Adductor pollicis inserts into the lateral

part of the 1st proximal phalanx
Flexor pollicis brevis with two heads: the
superficial and the deep. The deep head is
innervated by the deep branch of the ulnar
nerve

Which originates from the flexor
retinaculum and the hook of
hamate, and inserts into the
medial side of the base of the 5th
proximal phalanx
Which originates at the
pisiform and inserts into the
medial side of the base of
base of 5th proximal phalanx

Both of these muscles originate from the
flexor retinaculum and the tubercles of
scaphoid and trapezium; they both insert
into the lateral aspect of the base of the
proximal phalanx of the thumb.
Flexor retinaculum
Opponens Pollicis
Also originates from the flexor

retinaculum and the tubercles of scaphoid and trapezium;
however it inserts into the lateral border of the 1st metacarpal.
Hypothenar Muscles
Thenar Muscles
In the HYPOTHENAR compartment

o
o
o
o
o
deep branch of ULNAR NERVE

originates from hook of hamate and the flexor retinaculum
inserts into the medial border of the 5th metacarpal
pulls the 5th metacarpal anteriorly, and rotates the 5th digit so
it can participate in opposition with the thumb
acts exclusively at the MCP joint

originates from hook of hamate and the flexor retinaculum
inserts into the medial side of the base of the 5th proximal
phalanx
flexes the proximal phalanx of the 5th digit
o
o
and the tubercles of scaphoid and trapezium; they both insert

o
deep branch of the Ulnar nerve
into the lateral aspect of the base of the proximal phalanx of the
TRANSVERSE HEAD originates from the anterior surface of the 3rd
thumb.
metacarpal
OBLIQUE HEAD originates from the bases of the 2nd and 3rd
metacarpals, from the capitate bone, and from any carpals around the
capitate.
Inserts into the medial side of the base of proximal phalanx of thumb.
There tends to be a sesamoid bone at the site of insertion.
Adducts the thumb towards the lateral border of the palm (presses
it against the palm)
In the THENAR compartment

Flexor Pollicis Brevis
Abductor digiti Minimi

o
o
o

o
o
o
In the ADDUCTOR compartment

Both ofPollicis
these muscles originate from the flexor retinaculum
Adductor
o
o
o

originates from the pisiform
inserts into the medial surface of the bae of the 5th proximal
phalanx
Abducts the 5th digit and assists in its flexion
It is the most superficial of the three hypothenar muscles
o
o
DEEP HEAD: deep branch of ULNAR NERVE

SUPERFICIAL HEAD: Recurrent branch of MEDIAN NERVE
originates from the flexor retinaculum and the tubercles of the
scaphoid and trapezium.
Inserts into the lateral aspect of the base of the proximal phalanx
of the thumb
Flexes the thumb: brings its tip towards the base of pinky
Abductor Pollicis Brevis: Recurrent branch of MEDIAN NERVE

There is also Palmaris Brevis; a useless little muscle which wrinkles
the skin of the palm; it originates at the flexor retinaculum and inserts
into the skin. The ulnar nerve innervates it.
IT IS NOT PART OF THE HYPOTHENAR COMPARTMENT
o
o
o

scaphoid and trapezium.
Inserts into the lateral aspect of the base of the proximal phalanx
of the thumb
Abducts and helps oppose the thumb
Opponens Pollicis Brevis: Recurrent b. of MEDIAN NERVE

o
o
40

scaphoid and trapezium; Inserts into the lateral side of the 1st
metacarpal.
Opposes the thumb: medially rotates and the pulls medially the
1st metacarpal. Acts exclusively at the MCP joint
Short muscles of the Hand

o there are 4 lumbricals, 4 dorsal interossei, and 3 palmar interossei; you count them starting at the THUMB
The LUMBRICALS
-
Originate from the tendons of the FLEXOR DIGITORUM PROFUNDIS

Sit in the central compartment of the palm
From the palm, cross over to the dorsum of the hand
Insert into the extensor expansions on the dorsum of the proximal
phalanges
The FIRST and SECOND lumbricals are innervated by the median
nerve. All other short muscles are innervated by the deep branch of the
ulnar nerve
The THIRD and FOURTH lumbricals are bipennate; the other two are
unipennate
FLEX the metacarpophalangeal joints
EXTEND the proximal interphalangeal joints
Together the short muscles all produce the Z movement of the fingers; the MCPs are
flexed, and the PIPs extended. This is the opposite of what happens in ulnar nerve palsy
(claw hand) when the MCPs are extended and the PIPs are flexed.
The DORSAL INTEROSSEI

-
Originate from the sides of two metacarpals (ALL of them are bipennate)
Sit in their own INTEROSSEOUS compartment of the hand
Insert into the bases of the proximal phalanges and into the extensor
expansions
ABDUCT the hand away from the axis of the middle finger (the axis as
shown)- hence DAB ( Dorsal Interosei ABduct)
Also help the lumbricals flex the MCPs and extend the PIPs
When the thumb is flexed, the first dorsal interossei can be seen as the
lump that appears on the dorsum of the hand.
The Interossei all live inside the INTEROSSEOUS compartment. The Palmar
interossei occupy the anterior (palmar )part of it, and the dorsal interossei are
more properly between the metacarpals.
The PALMAR INTEROSSEI

-
Originate from the palmar surfaces of the metacarpals

Sit in the anterior part of the INTEROSSEOUS compartment of the hand
Inset into the bases of the proximal phalanxes and into the extensor
expansions
ADDUCT the fingers towards the middle finger,
hence PAD- Palmar Interossei Adduct
There are only 3 palmar interossei; the deep part of the Flexor Pollicis
Brevis can be described as the 4th, because it does much the same
thing as the rest, and is innervated by the same nerve

41
THE ANATOMICAL SNUFFBOX

o A TRIANGULAR superficial structure
APEX:
The junction of the three tendons
1st metacarpal
Trapezium
MEDIAL BORDER:
Scaphoid
LATERAL BORDER:
Radius
BASE:
An imaginary boder, around about
where the radial styloid process is
CONTENTS:
Radial artery
Cephalic Vein
Scaphoid
Trapezium
Sometimes, Dorsal cutaneous
branch of the radial nerve
Is there an erotic mnemonic for this? No.

A PLEP Be lateral? (APL, EPB lat border)
EPL medial
A PLEP BEPL? APLE PBLEPL?
Apple Pee BE PL?
42
NERVES AND
VESSELS IN
THE UPPER
LIMB
43
The Courses of Nerves and Vessels in the Upper Limb

STRUCTURE OF THE BRACHIAL PLEXUS, and the consequences of injuries thereto
Supraclavicular
branches
Dorsal scapular nerve

Long thoracic nerve
Nerve to subclavius
Suprascapular nerve
Branches:
Posterior cord = 5 branches
Lateral cord = 3 branches
Medial cord = 5 branches
The Clavicle
Thoracodorsal nerve
Upper and lower
subscapular nerves
Branches
Medial pectoral nerve
Medial brachial cutaneous
Medial antebrachial cutaneous
Cords
Divisions Trunks
Roots
Three little
trivial
nerves
Anterior divisions supply flexors

Posterior divisions supply extensors
Injuries of the Brachial Plexus:
Superior parts: C5, C6: Erb-Duchenne Palsy

-
caused by an increased angle between neck and shoulder, eg. falling on your head.
Causes Waiters Tip position, where the limb hangs limp in a medially rotated position
Deltoid, biceps, brachialis and brachioradialis are paralysed. Lateral arm loses sensation
Caused by prolonged hyperabduction, eg. painting the ceiling; cords get pinched between coracoid process and pectoralis minor
tendon
Causes pain radiating down the arm, hand numbness, hand weakness, and erythema
caused when the arm is suddenly pulled superiorly, eg. when you grab something while falling vertically down
short muscles of the hand are affected, and you get a claw hand
Compression of the Cords
Inferior parts: C8, T1: Klumpke Paralysis
44
RELATIONSHIPS OF THE BRACHIAL PLEXUS

Medial Scalene
Anterior Scalene
ROOTS
enter the neck between the bodies
of the Anterior Scalene and the
Medial Scalene muscles
TRUNKS
enter the apex of axilla throught
the cervicoaxillary canal
DIVISIONS
form behind the clavicle, in the
cervicoaxillary canal
Subclavian artery
1st rib
CORDS
Form around the second part of
the axillary artery, and are
named according to their position
in relation to it.
Clavicle
Axillary artery: second part
Posterior cord
Lateral cord
Medial cord
Axillary nerve
Which curves upward to
innervate the Deltoid and
Teres Minor muscles
Posterior circumflex
humeral artery
Quadrangular space
Radial nerve
Profunda Brachii:
Deep Artery of the arm
Lateral Triangular Space
Which pierces the coracobrachialis
around here, and innervates the
anterior compartment of the arm
Ulnar nerve
Which lies medial to the brachial artery
Brachial artery
Median nerve
Which continues down the arm
lateral to the brachial artery
45
SUPPLY DISTRIBUTION OF THE BRACHIAL PLEXUS

Lateral cord
Lateral pectoral nerve
Pectoralis major
Anterior compartment of the arm:
Biceps, coracobrachialis, brachialis
Skin over the lateral forearm, once it
becomes cutaneous in the cubital fossa
MUSCULOCUTANEOUS NERVE
Anterior compartment of the forearm:

EXCEPT for the ulnar part of flexor digitorum profundis
Thenar muscles: EXCEPT adductor pollicis and the deep
part of flexor pollicis brevis
First and second lumbricals
MEDIAN NERVE
MedialLateral
cutaneous
nerve of arm
cord:
Medial cord
Skin on the medial surface of arm up to the elbow
lateral pectoral nerve

Skin on the medial surface of forearm up to the elbow
MUSCULOCUTANEOUS NERVE
lateral root of MEDIAN
NERVE
Pectoralis
minor and sternocostal part of pectoralis major
Medial pectoral nerve
o Medial cord forms
Intrinsic muscles of the hand, EXCEPT 1st and 2nd lumbricals and three of
ULNAR NERVE
the thenar muscles

Ulnar half of the flexor digitorum profundis to the pinky and ring fingers
Upper subscapular nerve
Posterior cord
Superior half of subscapularis
medial root of MEDIAN

NERVE
Inferior half of subscapularis AND teres major
Lower subscapular nerve
medial pectoral nerve
Glenohumeral
medial cutaneous nerve
of arm joint
Teres minor
medial cutaneous nerve
of forearm
Deltoid
AXILLARY
NERVE
ULNAR NERVE
Skin over the deltoid
RADIAL NERVE
ALL MUSCLES IN THE POSTERIOR

COMPARTMENT OF THE ARM AND FOREARM
Ski over posterior and inferolateral forearm
Some of the dorsum of the hand
o
o
Thoracodorsal nerve
o
o Posterior cord forms:
Latissimus Dorsi
Long Thoracic nerve

Supraclavicular branches
Dorsal scapular nerve
Nerve to subclavius
Suprascapular nerve
46
Serratus anterior
Rhomboids;
levator scapulae
Subclavius and
sternoclavicular joint
Supraspinatus
Infraspinatus
Glenohumeral joint
Course of the Median Nerve
Forms from the MEDIAL

and LATERAL cords of
the brachial plexus
Runs lateral to the brachial artery
Sits on top of the

coracobrachialis muscle
Coracobrachialis
Crosses anteriorly over the brachial artery
when it encounters the brachialis muscle
Then, runs medial to the brachial artery
Brachialis
Biceps
Runs under the biceps into the

cubital fossa
Gives a branch to the elbow joint;

THERE ARE NO OTHER
BRANCHES ABOVE THE ELBOW
Cubital fossa
Gives branches to the anterior
compartment muscles of the forearm
Enters the arm between the heads of

pronator teres
Gives rise to the ANTERIOR

INTEROSSEOUS NERVE
Travels down the forearm between the
two flexor digitorum muscles
Flexor digitorum profundis
The ANTERIOR
INTEROSSEOUS NERVE
Runs between the flexor
digitorum profundis and the
flexor pollicis longus, on top
of the interosseous
membrane, until it hit
pronator quadratus.
Becomes superficial at the wrist

Flexor Retinaculum
Palmar cutaneous
branch to the skin
of the palm
Recurrent branch
to the thenar
muscles
Supplies the 1st and 2nd lumbrical muscles

47
Course of the Radial Nerve

Starts as the direct continuation of the posterior cord
Runs posterior to the brachial artery,
On top of the long head of the triceps
Gives branches to innervate the long head and the lateral
head of tripceps brachii BEFORE it crosses the humerus
Crosses the humerus in the RADIAL GROOVE
with the deep artery of the arm
Inside the radial groove, behind the triceps, it gives rise
to the posterior cutaneous nerve of the arm and the
posterior cutaneous nerve of the forearm, which
pierce the lateral head of the triceps
Triceps Brachii, long head
The branch to the medial head of

the triceps also branches off behind
the humerus
Brachial artery

After crossing the humerus, it
pierces the lateral intermuscular
septum and descends between the
brachialis and the brachioradialis
RADIAL NERVE LESIONS

Fracture of the HUMERUS:
wrist drop due to extensor paralysis, as
well as a loss of sensation on the
dorsum of the hand
Brachioradialis
BRACHIALIS
Damage to the DEEP BRANCH:

Inability to extend the thumb and to
extend the MCP joints of the digits- but
NO SENSORY LOSS
Damage o the superficial branch
usually only results in a tiny area of
anaesthesia because of the overlap in
median and ulnar nerve territories
At the level of the lateral condyle, in the

cubital fossa, it divides into the deep and
the superficial branches
The SUPERFICIAL BRANCH
runs under brachioradialis all the
way down the arm
The DEEP BRANCH pierces the supinator
Supinator
Still Brachioradialis
Beyond the supinator, the

DEEP BRANCH becomes the
POSTERIOR INTEROSSEOUS NERVE
The SUPERFICIAL BRANCH

Eventually becomes superficial when
it emerges from beneath
brachioradialis, crosses the roof of the
anatomical snuffbox, and innervates
the dorsal skin of the hand
the POSTERIOR INTEROSSEOUS NERVE

winds laterally behind the radius and enters the
posterior compartment of the forearm
In the posterior compartment, it runs along the
interosseous membrane to innervate the extensor muscles
48
Course of the Ulnar Nerve

Arises from the medial cord of the brachial plexus
Runs medial to the brachial artery

Together with the superior ulnar collateral artery,
it pierces the medial intermuscular septum
- around the middle of the humerus
and then continues down the arm on top of the
medial head of triceps brachii
Triceps brachii: medial head
Travels behind the medial epicondyle, where it is

superficial and vulnerable ( funny bone)
Gives a branch to the elbow joint
Enters the arm between the two heads

of flexor carpi ulnaris
Gives branches to innervate the two

heads of flexor carpi ulnaris
the Palmar Cutaneous Branch of the ulnar
nerve arises midway along the arm, and
travels under the antebrachial fascia
directly above the ulnar artery
Then, travels down the arm between
the flexor carpi ulnaris and the
flexor digitorum profundis
FCU
the Palmar Cutaneous Branch

pierces the antebrachial fascia in the
distal third of the arm and
innervates the skin of the ulnar half
of the palm
Gives a branch to innervate the ulnar 2 digits

worth of flexor digitorum profundis
Travels on the radial side of the

flexor carpi ulnaris tendon
Ulnar
artery
Crosses under the flexor carpi ulnaris

tendon together with the ulnar artery at
the level of the wrist
Antebrachial fascia
Pisiform
Passes between the hook of hamate
and the pisiform (in Guyons canal)
to enter the hand
Hook of Hamate
49
Arteries of the Arm

The AXILLARY ARTERY begins at the border of the 1st rib as a continuation
of the subclavian artery
The FIRST PART stretches between the 1st rib
and the medial border of pectoralis minor.
It has only one branch the superior thoracic artery
Subclavian artery
First rib
Superior thoracic artery
Thoracoacromial artery
The SECOND PART lies under the pectoralis

minor; it has 2 branches:
The Thoracoacromial artery
The Lateral Thoracic artery
The THIRD PART stretches from the lateral border
of pectoralis minor to the inferior border of Teres
Major; it has 3 branches:
The Anterior circumflex humeral artery
The Posteror circumflex humeral artery
The Subscapular artery Axillary nerve
- circumflex humeral artery
Posterior
Which pierces the

costocoracoid membrane
deep to the clavicular head
of pectoralis major
Pectoralis major
Pectoralis minor
Lateral Thoracic artery
Which follows the lateral
border of pectoralis minor onto
the chest wall
Travels through the quadrangular space together

with the axillary nerve. Its the larger of the two.
Anterior circumflex humeral artery

Passes laterally deep to the coracobrachialis and
the biceps brachii
Teres Major
Profunda Brachii- deep artery of the arm
Passes dorsally between

subscapularis and teres major to
supply the dorsum of the scapula
Thoracodorsal artery
Passes through the lateral triangular space (with

the radial nerve) into the posterior compartment
of the arm. It is the largest branch of the
Brachial artery
Triceps brachii
Intermuscular septum
Biceps brachii
BRACHIAL ARTERY
Goes to the inferior angle of the scapula,

supplies mainly the latissimus dorsi
Subscapular artery
The branch with the greatest diameter but the
shortest length; soon divides into the thoracodorsal
and the circumflex scapular arteries
Travels from the edge of Teres Major to the cubital fossa, on top of the
medial intermuscular septum. Has 3 main branches:

which accompanies the ulnar nerve down the arm
Inferior ulnar collateral artery which arises 5cm proximal to
Under the bicipital aponeurosis,

the brachial artery divides into
the Radial and Ulnar arteries
the elbow crease, and anastomoses with the recurrent branches of

the ulnar artery
Ulnar Artery
Gives some recurrent branches, and then travels down the arm
under the superficial muscles of the forearm (deep to the pronator
teres, palmaris longus, and flexor digitorum superficialis)
Radial Artery
Travels down the arm under
the brachioradialis, along
with the radial nerve.
Lies lateral to the flexor carpi
radialis tendon.
Gives a recurrent branch.
Common interosseous artery is very short, because it bifurcates immediately

Anterior interosseous artery travels down the arm along the interosseous
membrane, and when it reaches pronator quadratus, it pierces the interosseous
membrane and becomes dorsal (where it joins the dorsal carpal arch)
Posterior interosseous artery travels down the arm along the interosseous
membrane, and anastomoses with the anterior interosseous artery when they meet.
Flexor carpi radialis tendon
Superficial group of forearm flexors
Brachioradialis
Palmar carpal arch: anastomosis of the palmar carpal branches of the

ulnar and radial arteries
The Radial Artery winds around
dorsally, crosses the floor of the
anatomical snuffbox and pierces the
1st dorsal interossei to enter the palm
between the two heads of adductor
pollicis.
Dorsal carpal arch: anastomosis of the dorsal carpal branches of the

ulnar and radial arteries
Deep palmar arch: the more proximal arch
A continuation of the radial artery
Superficial palmar arch: the more distal arch
A continuation of the ulnar artery
50
Arterial Anastomosis around the Scapula
Thyrocervical artery
Suprascapular artery
Subclavian artery
Subscapular artery
Thoracodorsal artery
Dorsal scapular artery

Which is also the deep branch of the
transverse cervical artery
This point is labored because:

If the axillary artery is cut or ligated, an adequate collateral blood supply will arrive to the arm via the
dorsal scapular artery, and its anastomosis with the circumflex scapular artery.
However, if the axillary artery is ligated BELOW the third part of the axillary artery, there will not be any
collaterals, and the arm will become ischaemic.
51
Arterial Arches of the Hand
Proper palmar digital arteries
Common palmar digital arteries

Arise from the superficial arch
Palmar metacarpal arteries
Arise from the deep arch
Princeps Pollicis artery
Ulnar artery divides into the
SUPERFICIAL and the DEEP
Palmar arches
Anatomical snuffbox
Guyons canal
Superficial branch of the radial artery

Joins the superficial palmar arch
Dorsal branch of the radial artery
Joins the deep palmar arch
Radial Artery
Hooks around the scaphoid and
trapezium and enters the palm
between the 1st and 2nd
metacarpals
Ulnar Artery
Enters the hand via Guyons canal,
between the hook of hamate and
the pisiform
Branch to anterior
interosseous artery
Dorsal digital arteries

Perforating branches, which
join the deep palmar arch
Ulnar Artery
Dorsal carpal arch
Branch to anterior
interosseous artery
Radial Artery
52
Veins and lymphatic drainage patterns of the upper limb

Piercing the costacoracoid membrane- part
of the clavipectoral fascia
Cephalic vein:
- spends all of its time in subcutaneous tissues
- drains the radial dorsum of hand
Basilic vein:
- is subcutaneous right up until the middle of the
biceps; then it dives deep and runs parallel to the
brachial artery
- drains the ulnar dorsum of the hand
both merge to form the axillary vein
Piercing the brachial fascia
Median cubital vein:

- communicates between the two in the cubital fossa
Antebrachial vein:
- highly variable
- begins at the dorsum of the thumb
- sometimes divides into a median basilic vein, which
joins the basilic vein, and a median cephalic vein,
which joins the cephalic vein.
o
o
DRAINAGE OF THE PALM PASSES INTO THE DORSUM OF THE HAND

Vessels converge mainly on the basilic, but also the cephalic vein
o
Subclavian lymphatic trunk
Apical axillary nodes

nodes
Humeral (lateral) nodes
Basilic vein
Deltopectoral nodes
Cubital lymph nodes

Basilic
vein
cephalic vein
The superficial lymphatics follow the

superficial veins, mainly the basilic.
Ascend the arm next
Theis also the deep lymphatic system,
to the superficial veins
which follows the deep veins, and this system
of lymph vessels terminates at the humeral
Dorsum of hand
lymph nodes. The deep system drains all the
joints tendons and nerves.
palm
53
Spinal cord segments, Myotomes and Dermatomes and Myotomes of the upper Limb
Myotomes of the Upper Limb, and the muscles they influence
C5
C6
Brachioradialis
Biceps Brachii
Brachialis
A myotome is the group of muscles supplied by one spinal nerve segment
Flexion of the arm
five six, pick up sticks

Coracobrachialis
Also abduction and internal rotation of the shoulder
Deltoid
Teres Major
Infraspinatus
Supraspinatus
Rotator cuff muscles
Subscapularis
Teres minor
Extension of the arm
Triceps Brachii
C6
C7

Extensor Digitorum
Extensor Indicis
Palmaris Longus
Extension of the fingers

and the thumb
Except the pinky. The pinky is

extended by the C7-C8 segment;
but its still attached to the other
extensor tendons by a
ligamentous band, so weak
extension can still occur
Flexion of the wrist
Pronator teres
Supinator
C7
C8
Anconeus

Flexion of the fingersagain,
except the pinky finger. The pinky is

flexed by flexor digiti minimi C8 and T1
C8

Adductor Pollicis
Flexor Pollicis Brevis
Thumb movements:
Everything except extension
T1
Flexor Digiti Minimi

Flexion, abduction, opposition

of the pinky finger
Interossei
Lumbricals
So, all the hypothenar muscles.
Abduction and Adduction of the fingers
Palmaris brevis
Pronator Teres
Flexor Carpi Ulnaris
54
Segmental supply to arm movements and reflexes
Shoulder
Flexion, abduction, external rotation C5
Extension, adduction, internal rotation C6 C7 C8
Elbow
Flexion; BICEPS REFLEX
Flexion; TRICEPS REFLEX
C5 C6
C6 C7 C8
Forearm
Supination
C6
Pronation
C7 C8
Wrist
Flexion
C6 C7 C8
Extension
C6 C7 C8
Fingers and Thumb- long tendons

Flexion
C7 C8
Extension
C7 C8
Small Muscles of the Hand

Including some thenar and all hypothenar
All movements
In summary;
Small muscles are ONLY T1
Supination is ONLY C6
Shoulder abduction, extension and external rotation is ONLY C5
C7 and C8 participate in just about everything.
55
T1
Dermatomes of the Upper Limb

DERMATOMAL DISTRIBUTION
C4
C6
C5
C6
T1
T2
C8
6
6
C7
7
8
8
o
o
o
o
AREAS OF SHARP DEMARCATION:

o Anteriorly, C5 abuts T1 up until the wrist.
o T1 is the lonely thoracic dermatome which runs all the way down the anterior arm
C5 is the shoulder
C6 is the thumb
C7 is the index and middle finger
C8 is the ring and little finger

56
Cutaneous innervation of the upper limb

The patterns of cutaneous sensory nerve distribution
o The clavicle is an S-shaped long bone, which forms part of the pectoral girdle
o It articulates proximally with the sternum and distally with the acromion of scapula
o Bony features include:
Acromial facet
CUTANEOUS NERVES
Supraclavicular nerve
Superior lateral cutaneous nerve of the arm
Intercostobrachial nerve
Cutaneous branches of the Radial nerve

-inferior lateral cutaneous nerve of forearm
-posterior cutaneous nerve of forearm
Lateral cutaneous nerve of forearm,

Which in the arm is called the
Medial cutaneous nerve of the arm
Medial cutaneous nerve of the forearm
Medial cutaneous nerve of the forearm

Palmar cutaneous branch of
the RADIAL NERVE
Palmar cutaneous branch

of the MEDIAN NERVE

the ULNAR NERVE
Sensory innervation of the ring finger
PALMAR SIDE:
two halves:
o radial half supplied by the MEDIAN NERVE (palmar cutaneous branch)
the RADIAL NERVE
o ULNAR half supplied by the ULNAR NERVE (palmar cutaneous branch)
DORSAL SIDE:
Three parts:
o Whole ULNAR side: supplied by the ULNAR nerve (palmar cutaneous branch)
o Proximal RADIAL half : supplied by the RADIAL nerve
(palmar cutaneius branch, from the superficial branch)
o Distal radial side: MEDIAN NERVE (palmar cutaneous branch)
Palmar cutaneous branch
of the MEDIAN NERVE

the ULNAR NERVE
57
LIGAMENTS AND
JOINTS OF THE
UPPER LIMB
58
Ligaments and Joints of the Upper Limb

Sternoclavicular joint
Type of joint
Saddle type synovial joint; but it functions like a
ball-and-socket joint
ATYPICAL: fibrocartilage cover articular surfaces
Interclavicular ligament
Articulating surfaces
Sternal facet of clavicle, clavicular facet of manubrium

There is also an ARTICULAR DISC
Articular disc
Articular capsule
Surrounds the joint, including the clavicular epiphysis

Attached to the articular disc
Lined with synovial membrane, contains synovial fluid
Ligaments
Anterior and posterior sternoclavicular ligaments

Interclavcular ligament
Anterior sternoclavicular ligament
Stability factors
Not many muscles around, and the surfaces are

incongruous, so the joint relies on the ligaments for
stability.
Anterior and posterior sternoclavicular ligaments reinforce
it anteriorly and posteriorly
Interclavicular ligament reinforces it superiorly
Costoclavicular ligament reinforces it inferiorly
Articular disc limits medial displacement
Posterior sternoclavicular ligament
Movements
Flexion, extension, rotation, anterior and posterior

movement, circumduction
Articular disc: attached to the

anterior and posterior
sternoclavicular ligaments
Blood supply
Internal thoracic and subscapular arteries
Nerve supply
Nerve to subclavius
Medial supraclavicular nerve
Anterior sternoclavicular ligament
All joint stability depends on 3 factors:

1) shape of articulating surfaces; i.e. how
well the bones fit together
2) the ligaments
3) the tone of the surrounding muscles
59
Acromioclavicular joint
Type of joint
Plane type synovial joint
Acromioclavicular ligament
Acromial end of the clavicle, and the acromion process of

the scapula
Articular capsule
Attached to the margins of the articular surfaces

Lined with synovial membrane
Contains synovial fluid
Strengthened superiorly by fibers from the trapezius
Conoid ligament
Ligaments
Acromioclavicular ligament
Conoid ligament
Trapezoid ligament
Trapezoid ligament
Coracoacromial ligament
Stability factors
Stability is maintained by extrinsic ligaments, far from the

joint itself
Conoid and trapezoid ligaments anchor the clavicle to the
coracoid process, suspending the free limb and scapula
from the clavicle
Movements
The acromian rotates on the clavicle
Blood supply
Suprascapular and thoracoaromial arteries
Nerve supply
Lateral pectoral and axillary nerve
Subcutaneous lateral supraclavicular nerve
60
Coracoclavicular joint
Type of joint
Not really much of a joint, as the two bones dont really articulate.
There is a rare anatomical abnormality when they actually come
into contact, but normally the coracoid process attaches indirectly
to the clavicle by means of the strong coracoclavicular ligaments,
the conoid and the trapezoid.
Normally, none.
The superior surface of the coracoid process attaches to
the conoid and the trapezoid line of the clavicle by the
ligaments abovementioned
Articular capsule
No capsule
Ligaments
Conoid ligament
Trapezoid ligament
Stability factors
Conoid and trapezoid ligaments anchor the clavicle to the

coracoid process, suspending the free limb and scapula
from the clavicle
Movements
There is limited movement at this joint; the clavicle

rotates on the acromion.
Blood supply
Suprascapular and thoracoaromial arteries
Nerve supply
Lateral pectoral and axillary nerve
Subcutaneous lateral supraclavicular nerve
61
Glenohumeral joint
Type of joint
Ball and socket synovial joint
Humeral head articulates with the glenoid cavity.

The cavity is deepened by the glenoid labrum.
About 1/3rd of the head actually sits in the cavity.
Articular capsule
Capsule
Coracohumeral ligament
Transverse humeral ligament
Attaches proximally to the margins of the glenoid

cavity, and distally to the anatomical neck of the
humerus.
IT HAS HOLES IN IT.
One hole admits the tendon of the long head of biceps
brachii, and the other communicates with the subscapular
bursa.
THE WEAKEST PART is the inferior part which is not
reinforced by the rotator cuff muscles
Ligaments
Glenohumeral ligaments: intrinsic ligaments, three fibrous

thickenings of the capsule, anteriorly
Coracohumeral ligament from the base of coracoid to
the anterior aspect of the greater tubercle
Transverse humeral ligament- acts as the roof over
the bicipital groove
Coracoacromial ligament- forms the roof over the
glenohumeral joint
Tendon of the long head of biceps

ligament
Stability factors
The joint is too shallow to be stable; stability is sacrificed to
mobility
The socket is deepened by the glenoid labrum
The joint is stabilized mainly by muscles:
supraspinatus
infraspinatus
teres minor
subscapularis
they hold the ball in the socket
the coracoacromial arch and supraspinatus tendon limit
superior displacement
supraspinatus and teres minor limit posterior displacement
subscapularis limits anterior displacement
Movements
Greatest freedom of movement of any joint in the body

Flexion/extension, abduction/adduction, medial and
lateral rotation, circumduction
Assisted by the movement of the pectoral girdle (the
scapula and the clavicle)
Blood supply
Anterior and posterior circumflex humeral arteries
Branches of the suprascapular artery
62
Nerve supply
Suprascapular, axillary and lateral pectoral nerves
Factors Influencing the Stability of the Glenohumeral Joint
MAINLY, THE ROTATOR CUFF: supraspinatus, infraspinatus, subscapularis and teres minor
They hold the head of humerus in the glenoid fossa
SOMEWHAT, THE LIGAMENTS:
Glenohumeral
Coracohumeral
Coracoacromial arch
SLIGHTLY, THE GLENOID LABRUM
Supraspinatus
Subscapularis
Bicipital groove
Teres major
Latissimus dorsi
Supraspinatus
Pectoralis major
Infraspinatus
Teres minor
Teres major
Latissimus dorsi
Attachment for the lateral head of triceps
63
Elbow Joint
Type of joint
typical synovial hinge joint
Trochlea of humerus articulates with the trochlear

notch of the ulna
Capitum of the humerus articulates with the head of radius
the surfaces are most congruent when the arm is halfway
pronated, and the elbow is flexed to a right angle
The anular ligament attaches to the

margins of the radial notch
Anular ligament
Articular capsule
laterally and medially, just attaches to the margins of the
articular surfaces
Anteriorly and posteriorly, the capsule comes up more
proximally, to enclose the coronoid fossa and the
olecranon fossa
Distally, it blends with the capsule of the proximal
radioulnar joint
Biceps tendon
Ligaments
all are intrinsic- thickened parts of the joint capsule

the lateral one is the Radial Collateral ligament
- blends distally with the annular ligament of
the radius; attaches to radial notch margins
the medial one is the Ulnar Collateral ligament
- triangular, fan-like
- the ANTERIOR band is the STRONGEST
- the POSTERIOR band is the weakest
- the slender and feeble OBLIQUE band
merely serves to deepens the socket for the
trochlea of the humerus
Anular ligament
Oblique cord
Stability factors
Major stability factor: bony alignment; The bones

articulate well, the olecranon fossa limits hyperextension,
and the coronoid fossa limits hyperflexion. The medial and
lateral collateral ligaments serve to limit abduction and
adduction- a minorstability factor
Oblique band:
deepens the trochlear socket
Posterior band: weakest band
Movements
It is PERMANENTLY ABDUCTED to 17 degrees:

= The carrying angle
= this angle is 10 degrees greater in women
= it DISAPPEARS when the arm is PRONATED
..but the elbow only allows flexion and extension
FLEXORS: biceps brachii, brachialis, brachioradialis
Anterior band: strongest, cord-like
BURSAE: under every muscle attachment the

most important are:
- Intratendinous olecranon bursa sometimes
inside the tendon of the triceps
- Subtendinous olecranon bursa between the
olecranon and the triceps tendon
- Subcutaneous olecranon bursa in the
subcutaneous tissue over the olecranon
EXTENSORS: Triceps Brachii, Anconeus

o
o
o
when the forearm is supinated, the biceps brachii helps flex it

when the forearm is pronated, the pronator teres helps flex it.
major flexor is the brachialis; minor flexor is brachioradialis
Blood supply
Derived from the anastomosis around the elbow joint
Nerve supply
64
Musculocutaneous, ulnar and median nerve
Proximal Radioulnar Joint
Type of joint
Pivot type synovial joint
The head of radius articulates with the radial notch of

the ulna
Articular capsule
The fibrous part blends into the elbow joint

The synovial part is continuous with the elbow joint
There is also a SACCIFORM RECESS of the joint, a

distal extension of it down the radius which allows the
radius to rotate without tearing the synovium
Ligaments
The ANULAR ligament encircles the head of the radius
Stability factors
The bones articulate well

The ANULAR ligament is the main stability factor,
preventing dislocation of the radial head.
The INTEROSSEOUS MEMBRANE also prevents
distraction of the radius
The joint is surrounded by muscles eg. brachioradialis and
brachialis, which contribute to its stability in a minor way
Movements
Pronation and supination

Supination is the palm turning up, as if to receive alms
The axis of rotation passes through the head of radius
and through the site of attachment of of radius and ulna
distally
THE RADIUS IS THE ONE THAT ROTATES
the ulna stays stationary
Blood supply
Supplied by the radial portion of the periarticular arterial

anastomosis of the elbow, which is the
anastomosis of radial and middle collateral arteries with
the radial and recurrent inteosseous arteries
Nerve supply
Supplied by the musculocutaneous, median and radial

nerves, where
pronation is work of the median
supination is the work of the radial and
musculocutaneous nerves
65
Distal Radioulnar Joint
Type of joint
Pivot type of synovial joint
The head of ulna articulates with the ulnar notch of the

medial distal radius
which separates the the cavity of the distal radioulnar
joint from the cavity of the wrist joint
Articular capsule
The synovial membrane extends supeiorly between the

radius and the ulna to form a SACCIFORM RECESS,
which accommodates for the twistng of the capsule.
Articular disc
Ligaments
Intrinsic ANTERIOR and POSTERIOR ligaments

strengthen the joint capsule
These are weak transverse bands
Ulnar styloid
Stability factors
The ARTICULAR DISC is the main uniting structure of the

joint, because it bings the ends of the radius and the ulna
together
Movements
During pronation, the radius crosses the ulna

During supination, the radius is parallel with the ulna
Supination is produced by Supinator
Pronation is produced by the Pronator Quadratus
as well as Pronator Teres
FCR, PL and brachioradialis also help when the
forearm is mid-pronated
Blood supply
Anterior and posterior interosseous arteries
Nerve supply
Anterior and posterior interosseous nerves
66
Radiocarpal joint
Type of joint
Condyloid (ellipsoid) type of synovial joint
Ulnarl
collateral
ligament
Three of the carpal bones (scaphoid, triquetrum and

lunate) articulate with the radius
The pisiform and the ulna dont participate
Articular capsule
Stretches from the distal ends of the radius and ulna, to the
proximal row of carpal bones (but not the pisiform)
Ligaments
The PALMAR radiocarpal ligaments stretch from the radius

to both of the two rows of carpal bones;
The DORSAL radiocarpal ligament does the same
these ligaments make sure the hand follows the radius in
its rotation
the ULNAR COLLATERAL LIGAMENT passes from the
ulnar styloid to the triquetrum
the RADIAL COLLATERAL LIGAMENT passes from the
radial styloid to the triquetrum
Articular disc
Stability factors
The radius articulates tightly with the carpus; the styloid

processes of the radius and ulna limit abduction and
adduction
The ligaments and tendons supply most of the stability
Movements
Palmar radiocarpal ligament
The movements of this joint are augmented by the slight

movements permitted by the intercarpal and midcarpal
joints. These are
flexion + extension (greater range of flexion than
extension)
flexion is produced by
FCR and FCU, Palmaris longus
APL, Flexors of the fingers and thumb
extension is produced by
ECRL, ECRB, and ECU
Extensors of fingers and thumb
adduction + abduction (ulnar and radial deviation)
greater range of adduction(ulnar) than of
abduction, because of the larger radial styloid.
Most abduction occurs at the midcarpal joint.
Adduction is produced by
Simultaneous ECU and FCU action
Abduction is produced by
APL, FCR, ECRL and ECRB together
Circumduction consists of successive flexion,
adduction, extension and abduction
Dorsal radiocarpall ligament
Blood supply: Branches of the dorsal and palmar carpal arch

Nerve supply: Anterior interosseous branch of the median nerve, posterior interossous branch of the radial nerve, and
dorsal and deep branches of the ulnar nerve
67
Intercarpal joints
Type of joint
Plane synocial joints
Joints between carpal bones of the middle row

Joints between carpal bones of the distal row
MIDCARPAL JOINT: between the proximal and distal rows
of the joints
PISOTRIQUETRAL JOINT: articulation between the
pisiform and the palmar surface of the triquetrum
Articular capsule
The articular cavity is common to all intercarpal and

carpometacarpal joints EXCEPT the thumb, which has its
own carpometacarpal capsule.
Ligaments
All the carpals are united with anterior, posterior and

interosseous ligaments
Stability factors
The ligaments above contribute most;

The fibrous articular capsule wraps the carpal bones up,
and keeps them together
Movements
Slight movemens which extent the range of motion

available at the radiocarpal joint
Blood supply
Dorsal and palmar carpal arches
Nerve supply
Anterior interosseous branch of the median nerve

Dorsal and deep branches of the ulnar nerve
68
Carpometacarpal and Intermetacarpal joints
Type of joint
Plane type synovial joints- EXCEPT the
carpometacarpal joint of the thumb, which is a saddle type joint
Distal surfaces of the carpal bones articulate with the
bases of the metacarpals
The important thumb joint is the articulation between the
trapezium and the bease of the first metacarpal
The INTERMETACARPAL joints ar adjacent metacarpals
articulating with each others bases
Articular capsule
The medial four carpometacarpal joints, and the three

intermetacarpal joints, are all enclosed by the same
articular capsule.
The thumb CMC joint has its own capsule
Ligaments
All thse bones are united by the palmar and dorsal

carpometacarpal ligaments, and by the intermetacarpal
ligaments.
The DEEP TRANSVERSE METACARPAL LIGAMENT and
the SUPERFICIAL TRANSVERSE METACARPAL
LIGAMENT (which is part of the palmar aponeurosis) both
work to prevent separation of the metacarpal bases
Stability factors
The above ligaments are he major stability factors
Movements
Almost no movement at the CMCs of the 2nd and 3rd fingers,

Slight movement at the 4th CMC
Moderate movement of the 5th CMC (flexion, extension and
rotation)
Blood supply
Periarticular arterial anasomoses of the wrist and hand
(basically, the arterial arches)
Nerve supply
Anterior interosseous branch of the median nerve,

posterior interossous branch of the radial nerve, and dorsal
and deep branches of the ulnar nerve
The carpometacarpal joint of the thumb is
independent it has its own synovial
capsule
69
Joint at the base of the thumb: First carpometacarpal joint

Type of joint
Saddle-type synovial joint
Trapezium and the base of the 1st metacarpal
Articular capsule
Coveres the articulating surfaces
Ligaments
anterior oblique (volar) ligament (AOL)
dorsoradial ligament,
posterior oblique ligament
intermetacarpal ligament.
Stability factors
Ligaments, mainly
Movements
Angular movements in any plane:

Flexion- extension
Adduction-abduction
(thus, circumduction)
opposition
Blood supply
Periarticular arterial anasomoses of the wrist and hand

(basically, the arterial arches)
Nerve supply
Anterior interosseous branch of the median nerve,

posterior interossous branch of the radial nerve, and dorsal
and deep branches of the ulnar nerve
70
Metacarpophalangeal and interphalangeal joints
Type of joint
Metacarpophalangeal joints are condyloid synovial joints
Interphalangeal joints are hinge joints

Bases and heads
Articular capsule
Joint capsules surround each joint, attaching to the margins
Ligaments
Each MCP ad ICP joint is reinforced by a medial and lateral

collateral ligaments
Each of these ligaments has two parts:
The dense cord-like part passes from one head to the next base;
the thin fan-like part passes anteriorly to fuse with the anterior
(palmar) part of the joint capsule
The cord-like parts are slack dring extension and taught

during flexion- this means you usually cannot spread (abduct)
the fingers when the fingers are fully flexed
The fan-like parts move like a visor over the underlying heads
The palmar ligament (thick part of the capsule) blend with the
digital sheaths and provide grooves for the flexor tendons to
glide in.
At the MCPs, THE PALMAR LIGAMENTS ARE UNITED by
the deep transverse metacarpal ligament
Stability factors
ligaments
Movements
MCPS: flexion, extension, adduction, abduction
Blood supply
Digital arteries
Nerve supply
Digital nerves from the median and ulnar nerves

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Anatomy - Upper Limb

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Anatomy - Upper Limb

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UPPER LIMB

Bones of the Upper Limb

Smooth superior surface of the shaft, under the platysma muscle

Conoid tubercle, attachment of the

Impression for the

Trapezoid line, attachment of the

Rough inferior surface of the

Its occasionally pierced by a branch of the supraclavicular nerve

thicker and more curved in manual workers

Spine of the scapula

This whole surface is the

Lateral border: a thick bar

the humerus is a long bone, the largest in the upper limb

The humerus is in direct

The Right Humerus

The Axillary Nerve

The surgical neck is the narrow part past the tubercles

The Deltoid Tuberosity is where the deltoid attaches

The Radial Nerve

The Radial groove is where the radial nerve and deep

At the radial groove

The sharp lateral

The Median Nerve

The sharp medial supracondylar ridge

At the distal humerus

Olecranon Fossa : receives the

Trochlea articulates with the

Coronoid Fossa : receives the

Bony features include:

Radial Fossa: receives the

The radial groove

The radial fossa

COMMONEST fracture site: the SURGICAL NECK

the humerus is a long bone, the largest in the upper limb

The head of radius

The neck of radius

Bony features include:

The body of radius

Ulnar notch: this is

Posterior oblique line

Groove for extensor

Groove for extensor

Markings on the Dorsal Radius

the humerus is a long bone, the largest in the upper limb

Proximally, it articulates with the capitulum and trochlea of the humerus;

At the radial notch, it articulates with the head of radius

The deep part of

Bony features include:

The head of ulna

The ulnar styloid process

Humerus and ulna: landmarks and articulations

the humerus is a long bone, the largest in the upper limb

the ulna and humerus articulate at the elbow joint

the medial and lateral epicondyle

the posterior border of the ulna

The Articulated Carpus

the humerus is a long bone, the largest in the upper limb

the carpals are eight bones arranged in two rows

Scaphoid, Lunate, Triquetrum, Pisiform,

The scaphoid, linate and triquetrum articulate with the radius.

5th 4th 3rd

Capitate Trape trapezium

Muscle Attachment Sites in the Upper Limb

Smooth superior surface of the shaft, under the platysma muscle