Upper limb

Stany Lobo PhD

 Bones of UL
Fracture clavicle
Commonly caused by an
indirect force transmitted
from an outstretched hand
Weakest point is jn. of middle
and lateral third
c/f
Medial fragment go up
(SCM)
Lateral fragment go down
(wt. of UL)
Fracture humerus
Nerve injury
Surgical neck of humerus
Axillary nerve
Radial groove
Radial nerve
Distal humerus
Median nerve
Medial epicondyle
Ulnar nerve
Fracture of Radius
 Carpal bones
Proximal row
Scaphoid , lunate , triquatral,
pisiform

Distal row
Trapezium, trapezoid, capitate,
hamate

Common bone dislocated:

Lunate
Common bone fractured:
Scaphoid
Venous drainage of upper limb

Two sets of veins

Superficial veins
Deep veins
They anastomose freely with each other
Provided with valves that are more
numerous in the deep veins than in the
superficial veins
 Superficial veins

Dorsal digital veins form

3 dorsal metacarpal veins
that end into a venous
network called
Dorsal venous arch
Lateral end of dorsal
network is joined by
lateral vein from thumb
and forms cephalic vein
Dorsal digital vein from
medial side of little
finger join medial end of
dorsal venous network to
form basilic vein
 Cephalic vein
Begins as a radial continuation
of dorsal venous network and
runs on lateral side of
forearm and front of elbow
Often connected with basilic
vein by median cubital vein in
front of elbow
Ascends along lateral surface
of bicep, pierces brachial
fascia, and lies in
deltopectoral groove with
deltoid branch of
thoracoacromial trunk
Pierces clavipectoral fascia
and empties into axillary vein
 Basilic vein
Arises from dorsum of
hand
Ascends on
posteromedial surface of
forearm and passes
anterior to medial
epicondyle
Pierces deep fascia of
arm and joins venae
comitantes of brachial
artery, to form axillary
vein at lower border of
teres major
 Median cubital vein
Connects cephalic vein to
basilic vein
Lies superficial to bicipital
aponeurosis, which separate
it from brachial artery
Connected to deep vein
through a perforator which
pierces bicipital aponeurosis
Ideal for intravenous
injections and blood
transfusion
 Axillary vein
Regarded as
continuation of basilic
vein
Venae comitantes of
brachial artery join
basilic vein to form
axillary vein at lower
border of teres major
Lateral group of
axillary lymph nodes is
related to it
 Arterial supply
Subclavian artery is
artery of upper limb
Continues as a single
trunk from its
commencement down
to elbow
Name changes
according to the
regions through
which it passes
 Subclavian artery
Extend from origin
to outer border of
1st rib
Axillary artery
Outer border of 1st
rib to lower border
of teres major
Brachial artery
Lower margin of
teres major to neck
of radius
 Axillary artery
Divided into 3 parts
by pectoralis minor
muscle
Gives 6 branches
One from 1st part
Two from 2nd part
Three from 3rd part
 Branches of axillary artery
1st part
Superior thoracic
artery
2nd part
Thoracoacromial,
(clavicular, acromial,
deltoid, pectoral),
lateral thoracic artery
3rd part
Subscapular, anterior
circumflex humeral
and posterior
circumflex humeral
artery
 Brachial artery

Extends from lower

border of teres major
to level of neck of the
radius just medial to
tendon of biceps
brachii where it divides
into radial and ulnar
artery
 Branches
Deep (profunda) artery
of arm
Superior ulnar
collateral
Inferior ulnar collateral
Radial and ulnar
Nutrient artery to
humerus
Muscular branches
 Brachial artery (Clinical)
Brachial pulsations felt
or auscultated in the
cubital fossa just
medial to the tendon of
biceps for recording
blood pressure
Artery can be
compressed any where
in its course but most
favorably in middle of
arm
Radial artery
Starts 1 cm below the
elbow at neck of radius
Descends along lateral
side of front of forearm
to wrist where
Its pulsations can be felt
between tendon of
flexor carpi radialis and
brachioradialis (radial
pulse)
It winds round
posteriorly and crosses
anatomical snuff box
 Pierces first dorsal
interrosseous muscle
and enters palm
Runs medially in palm
and forms deep
palmar arch by
uniting with deep
branch of ulnar
artery
Branches
Radial recurrent artery
Muscular branches
Superficial palmar
branch
Palmar carpal branch
Dorsal carpal branch
First dorsal metacarpal
a.
Arteria princeps pollicis
Arteria radialis indicis
Ulnar artery
Larger of two terminal
branches of brachial artery
Given off at the level of
neck of radius
Passes deep to pronator
teres muscle
Enters palm superficial to
flexor retinaculum and form
superficial palmar arch
after uniting with
superficial palmar branch of
radial artery
 Branches
Anterior and posterior
ulnar recurrent a.
Muscular branches
Common interosseous
artery
Anterior and posterior
interosseous branches
Palmar carpal branch
Dorsal carpal branch
Deep palmar branch
Deep palmar branch
 Important collateral
circulation of upper limb
Around scapula
Around elbow joint
Superficial palmar arch
Deep palmar arch
Palmar carpal arch
Dorsal carpal arch
 Anastomosis around scapula

Subclavian artery
Superficial cervical
artery ( OR dorsal
scapular artery, come
directly from
subclavian)
Suprascapular artery
Axillary artery
Subscapular artery
Circumflex scapular
artery
Anastomosis around elbow joint
 Anastomosis in hand (Arches)

Superficial palmar arch

Deep palmar arch
Allens test:
https://www.youtube.com/watch?v=gdgomN
6TsuE
 Superficial palmar arch
Continuation of ulnar
artery
Beyond pisiform bone
ulnar artery gives off a
deep palmar branch and
continues as superficial
palmar arch
Completed on lateral
side by superficial
branch of radial artery
 Branches of sup. palmar arch

Gives 4 branches
3 common palmar digital
arteries
These are joined by
branches of deep
palmar arch
1 proper palmar digital
artery for medial side
of little finger
 Deep palmar arch
Continuation of radial
artery
Completed on the medial
side by deep branch of
ulnar artery
Lies at the level of
proximal border of the
extended thumb
Deep branch of ulnar
nerve lies within its
concavity
 Branches

3 palmar metacarpal
arteries that join
common palmar digital
arteries of superficial
arch
3 perforating branches
communicate with
dorsal metacarpal
arteries
 MUSCLES OF THE PECTORAL REGION
Muscle Proximal attachment
Pectoralis Clavicular head: anterior surface
of medial half of clavicle
major
Sternocostal head: anterior
surface of sternum, superior
six costal cartilages,
aponeurosis of external
oblique muscle
Pectoralis 3rd5th ribs near their costal Medial border and Medial pectoral nerve Stabilizes scapula by
cartilages
minor
Subclavius Junction of 1st rib and its
costal cartilage
Serratus External surfaces of lateral Anterior surface of Long thoracic nerve Protracts scapula and
anterior parts of 1st8th ribs
Distal attachment Innervation Main Actions
Lateral lip of Lateral and medial
Adducts and medially
intertubercular pectoral nerves;
rotates humerus;
groove of humerus clavicular head (C5,
draws scapula
C6), sternocostal
anteriorly and
head (C7, C8, T1)
inferiorly
Acting alone,
clavicular head flexes
humerus and
sternocostal head
extends it from the
flexed position
superior surface of (C8, T1) drawing it inferiorly
coracoid process of and anteriorly against
scapula thoracic wall
Inferior surface of Nerve to subclavius Anchors and
middle third of (C5, C6) depresses clavicle
clavicle
medial border of (C5, C6, C7) holds it against
scapula thoracic wall; rotates
scapula
Muscles of arm
Anterior compartment of arm
Posterior compartment
Scapular region
Scapular muscles
 Muscles of forearm (ant. comp.)
Muscle Origin Insertion Nerve Supply Action
Pronator Teres
Humeral head Medial epicondyle of Lateral aspect of shaft Median nerve Pronation and flexion of forearm
humerus of radius
Ulnar head Medial border of coronoid process of ulna
Flexor carpi Medial epicondyle of Bases of second and Median nerve Flexes and abducts hand at wrist joint
radialis humerus third metacarpal bones
Palmaris longus Medial epicondyle of Flexor retinaculum and Median nerve Flexes hand
humerus palmar aponeurosis
Flexor Carpi Ulnaris
Humeral head Medial epicondyle of Pisiform bone, hook of Ulnar nerve Flexes and adducts hand at wrist joint
humerus the hamate, base at fifth
metacarpal bone
Ulnar head Medial aspect of olecranon process and posterior border of ulna
Flexor Digitorum Superficialis
Humeroulnar Medial epicondyle of Middle phalanx of Median nerve Flexes middle phalanx of fingers and assists in
head humerus; medial border medial four fingers flexing proximal phalanx and hand
of coronoid process of
ulna
Radial head Oblique line on anterior surface of shaft of radius
Flexor pollicis Anterior surface of shaft Distal phalanx of thumb Anterior interosseous Flexes distal phalanx of thumb
longus of radius branch of median nerve
Flexor digitorum Anteromedial surface of Distal phalanges of Ulnar (medial half) and Flexes distal phalanx of fingers; then assists in
profundus shaft of ulna medial four fingers median (lateral half) flexion of middle and proximal phalanges and
nerves wrist

Pronator Anterior surface of shaft Anterior surface of shaft Anterior interosseous Pronates forearm
quadratus of ulna of radius branch of median nerve
 Forearm (post. comp.)
Muscle Origin Insertion Nerve Supply Action
Brachioradialis Lateral supracondylar Base of styloid process Radial nerve Flexes forearm atridge of humerus elbow joint;
ridge of humerus of radius rotates forearm to the midprone position

Extensor carpi radialis Lateral supracondylar Posterior surface of Radial nerve Extends and abducts hand at wrist joint
longus ridge of humerus base of second
metacarpal bone
Extensor carpi radialis Lateral epicondyle of Posterior surface of Deep branch of radial Extends and abducts hand at wrist joint
brevis humerus base of third metacarpalnerve
bone
Extensor digitorum Lateral epicondyle of Middle and distal Deep branch of radial Extends fingers and hand (see text for details)
humerus phalanges of medial nerve
four fingers
Extensor digiti minimi Lateral epicondyle of Extensor expansion of Deep branch of radial Extends metacarpal phalangeal joint of little finger
humerus little finger nerve
Extensor carpi ulnaris Lateral epicondyle of Base of fifth metacarpal Deep branch of radial Extends and adducts hand at wrist joint
humerus bone nerve
Anconeus Lateral epicondyle of Lateral surface of Radial nerve Extends elbow joint
humerus olecranon process of
ulna
Supinator Lateral epicondyle of Neck and shaft of Deep branch of radial Supination of forearm
humerus, anular ligament radius nerve
of proximal radioulnar
joint, and ulna
Abductor pollicis longusPosterior surface of shafts Base of first metacarpal Deep branch of radial Abducts and extends thumb
of radius and ulna bone nerve
Extensor pollicis brevis Posterior surface of shaft Base of proximal Deep branch of radial Extends metacarpophalangeal joints of thumb
of radius phalanx of thumb nerve
 Muscles of the hand

Thenar muscles-4
Hypothenar muscles-4
Lumbricals-4
Palmar interossei-3-4
Dorsal interossei-4
 Thenar muscles
Abductor pollicis brevis
Flexor pollicis brevis
Opponens pollicis
Adductor pollicis
All are supplied by recurrent
branch of median nerve
except adductor pollicis
which is supplied by deep
branch of ulnar nerve
 Hypothenar muscles
Abductor digiti minimi
Flexor digiti minimi
Opponens digiti minimi
PALMARIS brevis (by superficial br.)
All are supplied by ulnar nerve
Lumbricals

Originate from tendon of FDP

and insert in dorsal digital
expansion
Numbered from lateral to medial
side
1st and 2nd are supplied by median
nerve
3rd and 4th are supplied by ulnar
nerve
Action:
Flexion at metacarpophalangeal
joints and extension at
interphalangeal joints
 Dorsal/palmar interossei

Palmar interossei
Adductors of digits
Dorsal interossei
Abductors
Middle finger is axis of
movements
Supplied by deep branch of the ulnar
nerve
 Brachial plexus
Formed in the neck by anterior rami of
C5 to T1 spinal nerves
 General plan of distribution
1. Musculocutaneous nerve (C5,6,7): Supplies the
muscles of flexor compartment of the arm
 General plan of distribution
2. Median nerve (C5- T1): Supplies the muscles of
the flexor compartment of the forearm & few
muscles lateral part of the palm
 General plan of distribution
3. Ulnar nerve (C8,T1): Supplies the intrinsic muscles of
the palm and few muscles on the medial aspect of forearm.
 General plan of distribution
4. Radial nerve (C5-T1): Supplies the muscles of
extensor compartment of arm & forearm.
5.Axillary nerve (C5,6): Supplies the shoulder
muscles.
 General plan of distribution
Smaller branches
from roots,
trunks and cords:
Mainly supplies
the muscles
connecting limb
to the trunk
Few are purely
sensory
 How are they Injured?
Traumatic:
Automobile accidents,
sports injuries,
gunshots, penetrating
wounds, fractures,
dislocations, street
fights!
Tumors
Inflammation
Compression
 How are they Injured?
Obstetric:
During difficult child
birth
When injured:
Can cause sensory loss or
altered sensation along
the distribution of the
nerve
Restricts the movements
& functions
 Injury to Axillary nerve

Fracture of surgical neck

of humerus
Loss of abduction movement
of the shoulder
Sensory loss over the
lateral aspect of shoulder
 Radial nerve injury
Due to the fracture of the
shaft of the hummers
Crutch injury
Muscles of extensor
compartment of both arm &
forearm are paralyzed
Posterior interosseus
nerve*
Unable to extent elbow &
Wrist joints
Wrist drop
Sensory loss along the
posterior aspect of limb and
lateral aspect of dorsum of
the hand except nail bed
Superficial terminal
branch*
 Injury to the median nerve
Supracondylar fracture of humerus
Pronator syndrome
Carpel tunnel syndrome
Most of the muscles of flexor
compartment of forearm are
affected
Thenar & lateral 2 lumbricals are
affected
Flattening of thenar eminence
Flexion of thumb, index & middle
finger is completely lost
Sensory loss over the lateral
aspect of palm & nail bed of
lateral 3 digits
Benedict's sign /hand
Ape thumb deformity
Ulnar deviation of the wrist
 Injury to ulnar nerve
Fracture of the medial
epicondyle of the humerus
Cubital tunnel syndrome
Guyons canal syndrome
Handle bar neuropathy
Mainly intrinsic muscles of the
hand are paralyzed except thenar
and lateral 2 lumbricals
Adductor pollicis is paralyzed
Abduction & adduction of digits
are lost
Radial deviation of the wrist
Claw hand deformity
Sensory loss over the medial
aspect of hand and fingers [ one
and half] and medial aspect of
dorsum of the hand
 Injury to musculocutaneous nerve

Rarely injured
Weak elbow flexion
Sensory loss over the
lateral aspect of
forearm
 Erbs palsy

Injury to the upper

trunk:

Loss of shoulder
abduction
Loss of elbow flexion
Loss of supination
 Klumpkes paralysis

Injury to the lower

trunk:

Damage to the ulnar

nerve
Claw hand ( complete
claw)
All the small intrinsic
muscle of the hand are
paralysed.
 Winged scapula

Injury to the long

thoracic nerve:

Medical border of the

scapula becomes
prominent
Segmental innervation of the upper limb
 Sternoclavicular joint
Type: saddle type of synovial joint
Joint cavity divided by a disc
Ligaments
Capsule
Anterior sternoclavicular ligament
Posterior sternoclavicular ligament
Interclavicular ligament
Costo-clavicular ligament
Movement
Forward & backward movement in
medial compartment
Elevation&depression in lateral
compartment
Can compress the trachea if there is a
posterior dislocation
 Acromioclavicular joint

Plane variety of synovial

joint
Ligaments
Capsule
Coracoacromial
Coracoclavicular
Movement
Gliding
 Clinical Anatomy

Dislocation of AC Joint
Result from a hard fall on
shoulder or on
outstretched upper limb
Common in contact sports
such as football, soccer,
and hockey
Shoulder separation:
ACJ dislocation and
rupture of
coracoclavicular ligaments
Shoulder joint

Type
Ball and socket variety
of synovial joint
Articular surfaces
Glenoid cavity of
scapula
Head of humerus
 Ligaments
Capsular ligaments
Coracohumeral ligament
Transverse humeral ligament
Glenoidal labrum
 Bursae related to joint
Subacromian bursa (Subdeltoid bursa)
Coracoacromial arch, deltoid
superiorly and supraspinatus tendon,
joint capsule inferiorly
Reduces friction between
supraspinatus tendon and acromian
process
Subscapular bursa
Located between tendon of
subscapularis and neck of scapula
Usually communicates with cavity of
joint through an opening in capsule
 Stability of joint

Musculotendinous cuff
(rotator cuff) most
important
Suprasinatus, Infraspinatus,
Teres minor and
Subscapularis
Coracoacromial arch
Glenoidal labrum
deepens the glenoid
cavity
Movements
 Dislocation of shoulder joint
Ant-inferior is commonest
Usually caused by excessive
extension and lateral rotation of
humerus
A hard blow to humerus when
glenohumeral joint is fully abducted
Involves axillary nerve
 Subacromial bursitis
Leads to painful arc
syndrome
Pain between 50-130
degree of abduction
Usually develops in males
50 years of age and older
after unusual or excessive
use of shoulder joint
Rupture of Supraspinatus
tendon
 Elbow joint
Hinge type of synovial joint
Articular surfaces
Upper surface of head of
radius articulates with
capitulum
Trochlear notch of ulna
articulates with trochlea of
humerus
 Ligaments
Capsular ligament
Medial (ulnar) collateral ligament
Extends from medial epicondyle
of humerus to coronoid process
and olecranon of ulna
Has ant., post. and oblique bands
Lateral (radial) collateral lig.
Extends from lateral epicondyle
of humerus and blends distally
with annular ligament of radius
 Movements of elbow Joint
Flexion and extension
occur at elbow joint
Carrying angle
Long axis of fully
extended ulna makes an
angle of approximately
170 with long axis of
humerus
Obliquity of angle is
more in women than in
men
 Radioulnar joint
Superior radioulnar joint
Pivot joint
Annular ligament surround
head of radius
Musculocutaneous, median, and
radial nerve
Inferior radioulnar joint
Pivot joint
Supplied by anterior and posterior
interosseous nerve
Pronation and supination take place
at this joint
Interosseous joint-between shaft of
radius and ulna
 Pulled elbow

Subluxation of head of
radius from the
annular ligament when
forearm is pulled
suddenly in pronation
 Joints of Hand
Wrist joint (radio carpal joint)
Ellipsoid synovial
Articular surfaces
Superiorly
Lower end of radius
Triangular articular disc
Inferiorly
Scaphoid
Lunate
Triquatral
 Ligaments

Capsular ligament
Palmar (ant.) radiocarpal
lig.
Dorsal (post) radiocarpal
lig.
Lateral (radial) collateral
lig.
Medial (ulnar) collateral lig.
 Movements

Flexion
Extension
Adduction
Abduction
Circumduction
Spaces of scapular region
Quadrangular
space
Superior
Subscapularis in front
Teres minor behind
Inferior
Teres major
Medial
Long head of triceps
Lateral
Surgical neck of humerus
Contents
Axillary nerve and post.
circumflex humeral vessels
Upper triangular space

Medial
Teres minor
Lateral
Long head of triceps
Inferior
Teres major
Contents
Circumflex scapular
vessels
Lower triangular
space
Medial
Long head of triceps
Lateral
Medial border of humerus
Superior
Teres major
Contents
Radial nerve and profunda
(deep) brachii vessels
 Triangle of auscultation

Boundaries
Medially
Lateral border of trapezius
muscle
Laterally
Medial border of scapula
Inferiorly
Upper border of latissimus
dorsi muscle

Site at which breathing

sound are heard most clearly
 Lumbar triangle (Petit)

Medially
Latissimus dorsi muscle
Laterally
External abdominal oblique
muscle
Inferiorly
Iliac crest
Floor
Internal abdominal oblique
muscle
 Cubital fossa
Boundaries
Lateral
Brachioradialis
Medial
Pronator teres
Base
Imaginary line joining two epicondyle
Apex
Where pronator teres is crossed by
brachioradialis
Contents
From medial to lateral
Median nerve
Terminal part of brachial artery
Biceps brachii tendon
Radial nerve
 Anatomical snuff box
Depression on lateral side of wrist
Bounded medially by tendon of
extensor pollicis longus
Laterally by abductor pollicis longus
and extensor pollicis brevis
Floor is formed by scaphoid,
trapezium and base of the first
metacarpal bone
Contents:
Cephalic vein
Radial artery
Dorsal cutaneous branch of radial
nerve
 Flexor retinaculum
Structures passing superficial to flexor
retinaculum
Tendon of palmaris longus
Palmar cut. br. of median nerve
Ulnar nerve and vessels
Structures passing deep to the flexor
retinaculum
Median nerve
Flexor Carpi radialis
Tendons of FDS & FDP
Tendon of flexor pollicis longus
Ulnar and Radial bursa

Clinical:
Carpal tunnel syndrome
 Dupuytrens contracture

Fibrosis commonly
involving
Ulnar side of palmar
aponeurosis
Causes thickening
and contraction of
aponeurosis
Commonly starts at root
of ring finger, draws
this finger into palm
Later on involves little
finger
 Guyon's canal
Guyon's canal (ulnar tunnel):
Pisiform
Hook of hamate
Pisohamate ligament
Ulnar nerve + artery

Guyon's canal syndrome:

Entrapment of ulnar nerve in Guyon's canal
Pain, numbness + tingling in ring + little fingers, followed
eventually by loss of sensation and motor weakness
Tennis elbow (lateral epicondylitis)

Chronic inflammation of the origin of

extensor muscles of forearm from lateral
epicondyle of humerus as a result of unusual
or repetitive strain

Tennis players + violinists

 Golfer's elbow (medial
epicondylitis)
Inflammation in the origin of flexor muscles
of forearm from medial epicondyle
 Students elbow:
Repeated excessive pressure
and friction of subcutaneous
olecranon bursa
 Volkmann's contracture
Ischemic muscular
contracture (flexion
deformity) of fingers +
wrist resulting from
ischemic necrosis of
forearm flexor muscles
caused by a pressure injury
- compartment syndrome /
tight cast

Muscles replaced by fibrous

tissue - contracts,
producing deformity
 Ulnar bursa

Common synovial
flexor sheath

Envelops tendons of
flexor digitorum
superficialis &
profundus muscles
 Radial bursa

Synovial sheath for

flexor pollicis
longus
Mallet finger (Hammer or baseball
finger)
Permanent flexion of distal phalanx

Avulsion of extensor tendon to distal

phalanx