UPPER LIMB 2024......................pdf

UPPER LIMB
DXGC 6180 / Basic Medical Science
2023/2024
Dr Muhamad Alfakri Mat Noh
alfakri@um.edu.my
1

Lecture Outline
1. Bones and joints of upper limb
2. Muscles of upper limb
3. Nerves of upper limb
4. Vessels of upper limb
2

Introduction Upper Limb (1)
Upper Limb:-
• associated with the lateral aspect of the lower portion of the
neck and with the thoracic wall
• suspended from the trunk by muscles and a small skeletal
articulation between the clavicle and the sternum
(sternoclavicular joint)
• Based on the position of its major joints and component
bones, the upper limb is divided into
1. Shoulder - the area of upper limb attachment to the trunk
2. arm - the part of the upper limb between the shoulder and
the elbow joint;
3. forearm - between the elbow joint and the wrist joint; and
4. hand - distal to the wrist joint
3

Introduction Upper Limb (2)
• Significant areas of transition between the different parts of the limb
• Important structures pass through/related to each of these areas
1. Axilla
• irregularly shaped pyramidal space between shoulder and lateral surface of thoracic
wall
• Apex (inlet) opens directly into the lower portion of the neck.
• Floor - skin of the armpit forms the floor
• Major structures that pass between the neck and arm – subclavian vessels, brachial
plexus
2. Cubital fossa
• triangularly shaped depression formed by muscles anterior to the elbow joint
• brachial artery & median nerve - passing from the arm to the forearm passes through
this fossa
3. Carpal tunnel
• gateway to the palm of the hand at the proximal region of the hand
• Carpal bones - posterior, lateral, and medial walls form an arch
• each side of the arch is connected by flexor retinaculum (thick band of connective
tissue) forming the anterior wall of the tunnel
• The median nerve and all the long flexor tendons passing from the forearm to the
digits of the hand pass through the carpal tunnel. 4

Bones of upper limb 1
2
3
4
5
6
7
8
A. Bone of shoulder/pectoral girdle (1 & 2)
B. Bone of arm (3)
C. Bone of forearm (4 & 5)
D. Bone of hand (6, 7 & 8)
5

Clavicle
• a long, slender bone that lies horizontally across the root of the neck just
beneath the skin
• articulates with:-
1. the sternum and 1st costal cartilage medially and
2. the acromion process of the scapula laterally
• acts as a strut that holds the arm away from the trunk
• transmits forces from the upper limb to the axial skeleton
• attachment for muscles and ligaments
• Weak point = common site of fracture is the junction between medial 2/3
and lateral 3rd
• Common cause of # is falling on the outstretched hand
• If # is medial to coracoclavicular lig. = drop of shoulder
• If # lateral to coracoclavicular lig. = no drop of shoulder
6

Scapula
• flat triangular bone
• lies on the posterior chest wall between the 2nd and 7th ribs
• spine of the scapula projects backward
• lateral end of the spine is free and forms the acromion - articulates with
the clavicle (acromioclavicular jt.)
• superolateral angle of the scapula forms the pear-shaped glenoid
cavity/fossa - articulates with the head of the humerus (shoulder joint)
• The coracoid process projects upward and forward above the glenoid
cavity (attachment: short head of biceps, coracobrachialis & pec minor)
• Medial to the base of the coracoid process is the suprascapular notch
• The anterior surface of the scapula is concave and forms the shallow
subscapular fossa
• The posterior surface of the scapula is divided by the spine into the
supraspinous fossa above and an infraspinous fossa below
• The inferior angle of the scapula can be palpated easily in the living
subject and marks the level of the 7th rib and the spine of the 7th
thoracic vertebra
Anterior view
Posterior view 7

Humerus
• articulates with:-
1. scapula at the shoulder joint and
2. radius and ulna at the elbow joint
• upper end of the humerus - head, which forms about one third of a sphere and
articulates with the glenoid cavity of the scapula - shoulder joint
• Immediately below the head is the anatomic neck
• Below the neck are the greater and lesser tuberosities, separated from each other
by the bicipital groove/intertubercular sulces
• surgical neck - the upper end of the humerus joins the shaft
• deltoid tuberosity - halfway down the lateral aspect of the shaft
• The lower end of the humerus (distal end/condyle) –
1. the medial and lateral epicondyles for the attachment of muscles and ligaments,
2. rounded capitulum for articulation with the head of the radius,
3. and the pulley-shaped trochlea for articulation with the trochlear notch of the
ulna
4. Above the capitulum is the radial fossa, which receives the head of the radius
when the elbow is flexed.
5. Above the trochlea anteriorly is the coronoid fossa, which during the same
movement receives the coronoid process of the ulna.
Anterior view
8

Humerus
• radial/spiral groove - behind and below the deltoid
tuberosity, accommodates the radial nerve
• olecranon fossa - above the trochlea posteriorly, receives
the olecranon process of the ulna when the elbow joint is
extended
Posterior view
9

Radius
Ulna
Interosseous membrane
Radius & Ulna
(forearm bone)
Radial tuberosity • The forearm contains two bones: the
radius and the ulna.
• Connected by interosseous membrane
10

Radius (1)
• lateral bone of the forearm
• small circular head - the proximal end of the radius
• concave upper surface of the head articulates with the capitulum of
the humerus (elbow joint)
• The circumference of the head articulates with the radial notch of
the ulna (proximal radioulnar joint)
• Neck - below the head, constricted
• radial tuberosity - below the neck; (insertion for biceps muscle)
• shaft of the radius, in contradistinction to that of the ulna, is wider
below than above
• sharp interosseous border medially for the attachment of the
interosseous membrane - binds the radius and ulna together
• styloid process - the distal end of the radius;
• ulnar notch of radius - on the medial surface of distal end -
articulates with the round head of the ulna (distal radioulnar joint)
• inferior articular surface (of distal end of radius) - articulates with
the scaphoid and lunate bones (wrist joint/radiocarpal jt.)
• On the posterior aspect - small tubercle/the dorsal
tubercle, which is grooved on its medial side by the
tendon of the extensor pollicis longus
11

Ulna
• medial bone of the forearm
• The proximal end of ulna
1. olecranon process of ulna
2. forms the prominence of the elbow
3. notch on its anterior surface, the trochlear notch, which
articulates with the trochlea of the humerus (elbow joint)
• coronoid process - below the trochlear notch
• radial notch - lateral to coronoid process, articulation with the
head of the radius (proximal radioulnar jt)
• The shaft of the ulna tapers from above down
• sharp interosseous border laterally for the attachment of the
interosseous membrane
• The posterior border of ulna bone is rounded and subcutaneous
and can be easily palpated throughout its length
• Head of ulna bone - small rounded, at the distal end of the ulna
• styloid process - projecting from medial aspect of the ulna head
• Its distal end articulates with the radius at the distal radioulnar
joint, but it is excluded from the wrist joint by the articular disc.
12

Bones of the Hand (1)
• eight carpal bones, made up of two rows of four
• Carpal bones: (from lateral to medial)
i. 4 proximal row (S – scaphoid; L – lunate; Tri – triquetral, P -
pisiform)
ii. 4 distal row (Tzm - trapezium, Tpz - trapezoid, C - capitate,
H - hamate)
• scaphoid bone is commonly fractured carpal bone
• Collectively the anterior surface of carpus showed concavity
• Attached to the sides of carpus flexor retinaculum/transverse
carpal ligament
• This arrangement forms an osteofascial tunnel, the carpal tunnel
• for the passage of the median nerve and the flexor tendons of
the fingers.
Anterior (Palmar) view
S
L
Tri
P
Tzm
Tpz
C
H
1st MC
5th MC
U R
Posterior (dorsal) view
1st MC 5th MC
S
L
Tri
Tzm
Tpz C H
U
R
13

• 5 metacarpal bones (MC) (1st to 5th) - base, a shaft, and a head
• bases of the MC bones articulate with the distal row of the carpal bones
(CMC jt)
• Heads of MC bone articulate with the (base of) proximal phalanges (MCP jt)
• three phalanges for each of the fingers but only two for the thumb
• 1st MC bone (thumb) - shortest and most mobile
• rotated medially through a right angle so that its extensor surface is directed
laterally (not backward as for other 4 digits)
Bones of the Hand (2)
• The first digit does not lie in the same plane as the others but
occupies a more anterior position (at rest position)
14

Joints - clavicle
Acromioclavicular joint
Articulation: between the acromion of the scapula and the lateral end
of the clavicle
(wedge-shaped fibrocartilaginous disc projects into the joint cavity)
Type: Synovial plane joint
A gliding movement takes place when the scapula rotates or when the
clavicle is elevated or depressed
Sternoclavicular joint
Articulation: sternal end of the clavicle, the manubrium sterni, and
the 1st costal cartilage
(fibrocartilaginous disc lies within the joint and divides the joint’s
interior into two compartments)
Type: Synovial double-plane joint
Movements: Forward and backward movement of the clavicle takes
place in the medial compartment. Elevation and depression of the
clavicle take place in the lateral compartment.
Acromioclavicular jt. Acromioclavicular
capsule &
ligament
HH
Coronal section through joint
15

Shoulder joint (1)
Articulation: between the rounded
head of the humerus (HH) and the
shallow, pear-shaped glenoid cavity
(GC) of the scapula
The articular surfaces (HH & GC) are
covered by hyaline articular cartilage,
and the glenoid cavity is deepened by
the presence of a fibrocartilaginous
rim called the glenoid labrum (GL)
Type: Synovial ball-and-socket joint
Capsule: This surrounds the joint and is attached medially to the margin of the glenoid cavity outside the labrum; laterally, it
is attached to the anatomic neck of the humerus. The capsule is thin and lax, allowing a wide range of movement. It is
strengthened by fibrous slips from the tendons of the (SuB) subscapularis, (SuP) supraspinatus, (I) infraspinatus, and (TMi)
teres minor muscles (the rotator cuff muscles).
Ligaments: weak A – acromion; C – coracoid process; D – deltoid
Movements: Flexion/ extension/ adduction/ abduction/ lateral & medial rotation/ circumduction
HH
GC
D
SuP
GL
GL
Joint opened: lateral view
GC
GL
SuP
SuB
I
TMi
scapula
A C
16

Shoulder Joint (2)
• Ligaments:
1. glenohumeral ligaments (capsular lig) are three weak bands of
fibrous tissue that strengthen the front of the capsule.
2. transverse humeral ligament strengthens the capsule and
bridges the gap between the two tuberosities
3. coracohumeral ligament strengthens the capsule above and
stretches from the root of the coracoid process to the greater
tuberosity of the humerus.
• Accessory ligaments - The coracoacromial ligament extends
between the coracoid process and the acromion. Its function is to
protect the superior aspect of the joint.
• Synovial membrane: lines the capsule and is attached to the
margins of the articularcartilage, It forms a tubular sheath
around the tendon of the long head of the biceps brachii, It
extends through the anterior wall of the capsule to form the
subscapularis bursa beneath the subscapularis muscle.
• Nerve supply: The axillary and suprascapular nerves
• bursa is a closed, fluid-filled sac that works as a cushion and
gliding surface to reduce friction between tissues of the body
17

Shoulder Joint – Range of motion
Flexion
Video source: Youtube channel Physiotutor and Sam Webster
Extension Abduction Adduction
Lateral/External rotation Medial/Internal rotation Circumduction
18

Movement of scapula
Rotation of scapula
19

ELBOW JOINT (1)
• Articulation: This occurs between the trochlea (T) and
capitulum (C) of the humerus and the trochlear notch
(TN) of the ulna (U) and the head of the radius (R). The
articular surfaces are covered with hyaline cartilage.
• Type: Synovial hinge joint
H
T
C
R
U
H
Anterior view Posterior view
O
R
U
In 90° flexion: lateral view In 90° flexion: medial view
R
C
U
H
R
U
H
O O
20

ELBOW JOINT (2)
Elbow joint capsule:
Anterior attachments:-
1. Humerus: along the upper margins of the coronoid and radial
fossae → to the front of the medial and lateral epicondyles →
2. Ulna: below to the margin of the coronoid process of the ulna →
3. Radius: to the anular ligament, which surrounds the head of the
radius.
Posterior attachments:-
1. Humerus: to the margins of the olecranon fossa of the humerus
→
2. Ulna: below to the upper margin and sides of the olecranon
process of the ulna →
3. Radius: to the anular ligament
Synovial membrane:
• lines the capsule
• covers fatty pads in the floors of the coronoid, radial, and
olecranon fossae;
• continuous below with the synovial membrane of the proximal
radioulnar joint.
21

ELBOW JOINT (2)
• Ligaments - triangular
1. The lateral ligament (radial collateral lig)
• Attachments:-
1. lateral epicondyle of the humerus (apex)
2. upper margin of the anular ligament (base)
2. The medial ligament (ulnar collateral lig)
• Attachments; three strong bands:
1. anterior band, from the medial epicondyle of the
humerus → medial margin of the coronoid process;
2. posterior band, from the medial epicondyle of the
humerus → medial side of the olecranon;
3. transverse band, between the ulnar attachments of
the and & post bands/ (coronoid process &
olecranon)
[O – olecranon]
22

Proximal Radioulnar Joint
• Articulation: Between the circumference of the head of the radius and the
annular ligament and the radial notch on the ulna
• Type: Synovial pivot joint
• Capsule: encloses the joint, continuous with capsule of the elbow joint
• Synovial membrane: continuous with elbow joint;
• Annular ligament:
• attached to the anterior and posterior margins of the radial notch on
the ulna; forms a collar around the head of the radius.
• continuous above with the capsule of the elbow joint
• not attached to the radius
• Nerve supply: Branches of the median, ulnar, musculocutaneous, and
radial nerves
23

Distal Radioulnar Joint
• Articulation: Between the rounded head of the ulna and
the ulnar notch on the radius
• Type: Synovial pivot joint
• Articular disc:
1. Triangular, fibrocartilage
2. Attachments:- lateral side of the base of the styloid
process of the ulna (apex) → lower border of the ulnar
notch of the radius (base)
3. strongly unites the radius to the ulna
4. separates the distal radioulnar joint from the wrist jt.
24

Radioulnar joint - movement
Supination
Pronation
Video source: Youtube channel Corporis
25

Wrist Joint (Radiocarpal Joint)
• Articulation, Between:
1. the distal end of the radius and the articular disc (proximal) and
2. the scaphoid, lunate, and triquetral bones (distal)
• articular surface - ellipsoid concave-convex surface
• Type: Synovial ellipsoid joint
• Synovial membrane: lines the capsule; attached to the margins of the
articular surfaces
• joint cavity does not communicate with that of the DRJ or with the joint
cavities of the intercarpal joints
• Movements: flexion, extension, abduction, adduction, and circumduction
• Rotation is not possible because the articular surfaces are ellipsoid shaped
• The lack of rotation is compensated for by the movements of pronation and
supination of the forearm
• Nerve supply: Anterior interosseous nerve and the deep branch of the
radial nerve
26

Movements at the Wrist joint & Hand joints
Wrist joint:-
1. Flexion
2. Extension
3. Radial deviation = abduction
4. Ulnar deviation = adduction
5. Circumduction – combination of the
above
27

Joints of the Hand and Fingers (1)
1. Intercarpal Joints: Between individual bones of the each row of the carpus
2. Midcarpal joint: between proximal and distal rows of carpal bones
3. Carpometacarpal : between distal row of carpal and base of MC bone
4. Intermetacarpal joints : between base of MC bone
• Type: Synovial plane joints
• Ligaments: strong anterior, posterior, and interosseous ligaments
• Movements: A small amount of gliding movement is possible
5. Carpometacarpal Joint of the Thumb
• Articulation: Between trapezium and the saddle-shaped base of the 1st MC bone
• Type: Synovial saddle-shaped joint
• Capsule: The capsule surrounds the joint.
• Synovial membrane: This lines the capsule and forms a separate joint cavity.
• Movements: Flexion, Extension, Abduction, Adduction, Rotation (opposition)
28

6. Metacarpophalangeal (MCP) Joints
• Articulation: Between heads of the MC bones and the bases of the
proximal phalanges
• Type: Synovial condyloid joints
• Ligaments:
1. palmar ligaments - strong and contain some fibrocartilage; firmly
attached to the phalanx
2. deep transverse metacarpal ligaments, - attaches the palmar
ligaments; hold the heads of the metacarpal bones together (except
the 1st)
3. collateral ligaments -
• cord-like bands present on each side of the joints;
• passes downward and forward from the head of the metacarpal bone to the base of
the phalanx;
• taut when the joint is in flexion and lax when the joint is in extension
• Movements: Flexion, Extension, Abduction, Adduction
7. Interphalangeal Joints
• synovial hinge joints
• Movements: Flexion, Extension
Joints of the Hand and Fingers (1)
29

Movements at the Wrist joint & Hand joints
All fingers
1. Flexion
2. Extension
3. Abduction
4. Adduction
Thumb
1. Flexion - across the palm
2. Extension – movement of thumb away from the palm in lateral or
coronal plane
3. Abduction - movement of the thumb in an anteroposterior plane
away from the palm
4. Adduction - movement of the thumb in an anteroposterior plane
toward the palm
5. Opposition
30

Muscles of shoulder region
1. Muscles connecting UL to thoracic wall – pec major & minor,
subclavius, serratus anterior
2. Muscles connecting UL vertebral column – trapezius, latissimus
dorsi, rhomboid major & minor, levator scapulae
3. Muscles connecting scapula to humerus – supra/infra-spinatus,
teres major & minor, deltoid
31

(1) Muscles connecting UL to thoracic wall
Muscles attachments: origin (proximal att) and insertion (distal att)
when muscle contracts/in action, the insertion point will move towards point of origin
32

(2) Muscles connecting UL to vertebral column
34

(3) Muscles connecting scapula to humerus
36

Muscles of upper limb (4)
B
C
D
A
A – supraspinatus
B – infraspinatus
C – teres minor
D – teres major
E – subscapularis
Oblique parasagittal section of axilla
A
B
C
D
E
A, B, C and E – rotator
cuff muscle
37

ROTATOR CUFF
• Capsule of shoulder jt - capsule is thin and lax, allowing a wide
range of movement
• strengthened by fibrous slips from the tendons of the (SuB)
subscapularis [anteriorly], (SuP) supraspinatus [superiorly], (I)
infraspinatus [superiorly & posteriorly], and (TMi) teres
minor[posteriorly] muscles (the rotator cuff muscles)
• tendons of the rotator cuff muscles, fused to the underlying
capsule of the shoulder joint
• stabilizing the shoulder joint
• assists in holding the head of the humerus in the glenoid cavity of
the scapula during movements at the shoulder joint
• deficient inferiorly, and this is a site of potential weakness
• Humeral head may slip away from the glenoid
• Axillary nerve may be injured as closely related to surgical neck
A – acromion; C – coracoid process; D – deltoid
38

The Scapular–Humeral Mechanism
• Abduction of the arm involves (1) rotation of the
scapula (on chest wall) and (2) movement at the
glenohumeral (shoulder) joint
• As soon as abduction commences at the shoulder
joint, rotation of the scapula begins → For every 3°
of abduction of the arm, a 2° abduction occurs in the
shoulder joint and a 1° abduction occurs by rotation
of the scapula
• Initiation of abduction by supraspinatus
• Deltoid assists abduct up to 90°
• 120° of abduction of the arm, the greater tuberosity
of the humerus comes into contact with the lateral
edge of the acromion
• Further elevation of the arm above the head is
accomplished by rotating the scapula (on chest wall)
by trapezius & Serr Ant
• Movements of the scapula occur with reciprocal
movements at the sternoclavicular joint (leverage) –
abduction of arm followed by depression of
sternoclavicular jt 39

Muscles of the arm
B
C
B
A
Anterior view
D
Bicipital aponeurosis
Posterior view
A – bicpes brachii
B – Coracobrachialis
C – Brachialis
D - Triceps 41

Fascial Compartments of the Arm
• lower & mid-arm arm is enclosed in a sheath of deep fascia septum
(intermuscular septum)
• one on the medial side and one on the lateral side
• attached to humerus
• mid- and lower-arm is divided into an anterior and a posterior fascial
compartment
Contents of the Anterior Fascial Compartment of the Upper Arm
• Muscles: Biceps brachii, coracobrachialis, and brachialis
• Blood supply: Brachial artery
• Nerve supply to the muscles: Musculocutaneous nerve
• Structures passing through the compartment: Musculocutaneous, median,
and ulnar nerves; brachial artery and basilic vein (radial nerve is in the lower
part of the compartment)
Contents of the Posterior Fascial Compartment of the Upper Arm
• Muscle: The three heads of the triceps muscle
• Nerve supply to the muscle: Radial nerve
• Blood supply: Profunda brachii and ulnar collateral arteries
• Structures passing through the compartment: Radial nerve and ulnar nerve
• Structures Passing through the Posterior Fascial Compartment: ? ?
42

Intermuscular spaces and triangle of
auscultation
1. Quadrangular space –
• superiorly bounded by subscapularis and capsule of the shoulder
joint
• inferiorly bounded by teres major muscle
• medially bounded by the long head of the triceps and
• laterally by the surgical neck of the humerus
2. Upper triangular space
3. Lower triangular space
4. Triangle of auscultation
1
2
3
4
43

AXILLA
• or armpit; a pyramid-shaped space between the upper part of the arm
and the side of the chest
• It forms an important passage for nerves, blood, and lymph vessels as
they travel from the root of the neck to the upper limb
• Apex (upper end of the axilla):-
• directed into the root of the neck
• bounded by the clavicle, upper border of the scapula, and the
outer border of the 1st rib
• Base (lower end)
• bounded by the anterior axillary fold (formed by the lower border
of the pectoralis major muscle), posterior axillary fold (formed by
the tendon of latissimus dorsi and the teres major muscle), and
chest wall
• Anterior wall: pectoralis major, subclavius, and pectoralis minor muscles
• Posterior wall: subscapularis, latissimus dorsi, and teres major muscles
from above down
• Medial wall: upper four or five ribs and the intercostal spaces covered by
the serratus anterior muscle
• Lateral wall: By the coracobrachialis and biceps muscles in the bicipital
groove of the humerus
• The base is formed by the skin stretching between the anterior and
posterior walls
• The axilla contains the principal vessels and nerves to the upper limb and
many lymph nodes. 44

Contents of the Axilla
1. Axillary artery and its branches, which supply blood to the
upper limb;
2. Axillary vein and its tributaries, which drain blood from the
upper limb;
3. Lymph vessels and lymph nodes, which drain lymph from
the upper limb and the breast and from the skin of the
trunk, down as far as the level of the umbilicus
4. Brachial plexus, which innervates the upper limb
Clavipectoral Fascia
• strong sheet of connective tissue that is attached to the
clavicle,
• it splits to enclose the pectoralis minor muscle ,
• It continues downward as the suspensory ligament of the
axilla and joins the fascial floor of the armpit
45

Muscles of the forearm
Based of compartment:-
1. Muscles of the Anterior Fascial Compartment of the Forearm
2. Muscles of the Lateral Fascial Compartment of the Forearm
3. Muscles of the Posterior Fascial Compartment of the Forearm
Based of function:-
1. Flexor-pronator group
2. Extensor-supinator group
46

Muscles of the Anterior
Fascial Compartment of the
Forearm
A. Superficial group
1. Pronator teres
2. Flexor carpi radialis
3. Flexor carpi ulnaris
4. Flexor Digitorum Superficialis
5. Palmaris longus
B. Deep group
7. Pronator quadratus
8. Flexor pollicis longus
9. Flexor Digitorum Profundus
1
2
3
4
5
4
3
7
8
8
9
2
5
Palmar carpal ligament
Flexor retinaculum
(transverse carpal ligament)
B
r
a
c
h
io
r
a
d
ia
li
s
E
C
R
L
Anterior view: Superficial layer
U
l
n
a
r
s
i
d
e
/
M
e
d
i
a
l
s
i
d
e
Ra
di
al
sid
e/
La
te
ra
l
sid
e
47

Muscles of the Posterior
Fascial Compartment of the
Forearm
A. Superficial group
1. ECRB
2. Ext digitorum
3. Ext digiti minimi
4. Ext carp ulnaris
5. Anconeus
B. Deep group
6. Supinator
7. Abd pollicis longus
8. Ext poll brevis
9. Ext poll longus
10. Extensor indicis
1
2
3
4
5
Posterior view: Superficial layer
7
8
Muscles of the Lateral Fascial Compartment of the Forearm:–
Brachioradialis and ECRL
1
6
7
8
9
10
Posterior view: Deep layer
B
r
a
c
h
i
o
r
a
d
i
a
l
i
s
E
C
R
L
5
48

The cubital fossa
• is a triangular depression, in front of the elbow
• Boundaries:-
• Laterally: The brachioradialis muscle
• Medially: The pronator teres muscle
• base - imaginary line drawn between the two epicondyles of the
humerus
• floor - by the supinator and the brachialis muscles
• roof – skin, fascia and bicipital aponeurosis
• Contents:-
1. the median nerve,
2. the bifurcation of the brachial artery into the ulnar and radial arteries,
3. the tendon of the biceps muscle, and
4. the radial nerve and its deep branch.
49

Small Muscles of the Hand
1. the eight interossei muscles,
2. the four lumbrical muscles,
3. the short muscles of the thumb, and
4. the short muscles of the little finger
5. Palmaris brevis
50

Interossei muscles
• Muscle between metacarpal bones
51

Lumbricals
• These muscles arise from tendon of Flexor Digitorum profundus and
inserted to extensor expansion
• No bony attachment
• Put hand in writing position
52

Short muscles of the thumb
• Thenar eminence muscles – Abductor Poll brevis, Flexor Poll brevis and opponens
pollicis
Add Poll
F
P
B
A
P
B
OP
53

Short muscles of the little finger
• Hypothenar muscles
Abd DM
Flex DM
Opp DM
54

Nerves of upper limb – brachial plexus
• Network of nerves located in the posterior triangle of the neck & extend in the axilla
(region of upper limb)
• Formed by anterior rami of C5, C6, C7, C8 and T1 spinal nerves (roots of brachial plexus)
• L – lateral cord, P – posterior cord, M – medial cord – in relation to axillary artery
• Mus – musculocutaneous n.; Ax – Axillary n.; Ra – radial n.; Mn – Median n.; U – ulnar n.
Roots
C5
C6
C7
C8
T1
Trunks
Divisions
Cords
Branches
Posterior
triangle of neck
Axilla
L
P
M
Mus
Ax
Mn
Ra
U
Netter image©; BDS 2020
55

Right anterior dissection of lower neck region Scalenes & Prevertebral muscles
SA
SM
Roots of brachial
plexus
1st rib
Clavicle
CCA
BA
SubA
AA
SM – scalene medius
SA – scalene anterior
SP – scalene posterior
AA- axillary artery
SubA - subclavian artery
SA
SM
SP
56

Brachial plexus injury
Common cause as obstetric complication
1. Upper trunk (C5 & C6) – Erb’s paralysis
2. Lower trunk (C8, T1) – Klumpke’s paralysis
57

Upper trunk (C5 & C6) – Erb’s paralysis
Waiter’s tip position – where
the UL is adducted. Medially
rotated, extend & pronation of
forearm due to paralysis of the
opposite muscle (abductor, lat
rotator, flexor and supinator)
Shoulder dystocia is when, after delivery of the head,
the baby’s anterior shoulder gets caught above the
mother’s pubic bone
58

Lower trunk (C8, T1) – Klumpke’s paralysis
claw hand deformity due to ulnar and median nerve
paralysis – affecting muscles of the hand
hand weakness and sensory changes involve most of
the palmar hand and ulnar aspect of the dorsal hand
59

Nerves of upper limb – Axillary nerve
Axillary nerve
• Branch of posterior cord of BP
• Pass around the surgical neck of
humerus;
• accompanied by post circumflex
humeral vessels
• Closely related to shoulder joint
• Deltoid muscle & teres minor
• Intramuscular injection to deltoid
should be given in lower part to
avoid injury to axillary nerve
60

Nerves of upper limb – Musculocutaneous
nerve
• Branch of lateral cord
• Pierces coracobrachialis
• Supplies:- Biceps brachii,
coracobrachialis & brachialis
muscles
• End as - Lateral cutaneous of
forearm
61

Nerves of upper limb – Median nerve
• Branch of medial & lateral cord
• Passes on the lateral aspect of brachial artery
then crosses in front of brachial artery at mid-
arm, to runs on its medial aspect
• Enter cubital fossa medial to brachial artery
(in front of brachialis & behind bicipital
aponeurosis)
• It enters forearm by passing between the 2
heads of pronator teres:- ulnar head of PT m.
in between median nerve (in front PT) and
ulnar artery (behind PT)
• it descend in the middle of forearm between
FDS and FDP
• It passes deep to flexor retinaculum through
carpal tunnel
PT undercover bicipital aponeurosis
PT (cut)
FDS
62

• Innervates muscles of anterior compartment
of forearm & thenar muscles of hand
• Passes through carpal tunnel
• Injury results in – ‘Ape’-like deformity & loss
of sensation (as indicated by area blue)
63

Nerves of upper limb – ulnar nerve
• Branch from medial cord of BP
• Runs medially to brachial artery on the post
axillary wall and long head of triceps
• At mid-arm (the point of coracobrachialis
insertion) it pierces the medial
intermuscular septum to enter posterior
compartment of arm to run on the medial
head of triceps
• Then it passes behind medial epicondyle of
humerus
• It descend between the 2 heads of FCU to
run on ulnar side of forearm between the
FDP and FCU accompanied by ulnar artery
• It enters the hand by passing superficial to
Flexor Retinaculum
• Innervates muscles of anterior compartment
of forearm (ulnar half) & all muscles of the
hand (except thenar muscles)
• Passes superficial to flexor retinaculum
• Injury results in – ‘Claw’-like deformity &
loss of sensation (as indicated by area blue)
64

Nerves of upper limb – radial nerve
• Largest branch of posterior cord
• Passed behind axillary artery infront of
the posterior axillary wall (subsca., Tma
& LatDorsi
• Passed backward between long head &
medial head of triceps, then
• Passes behind shaft of humerus (on
radial/spiral groove) from medial to
lateral
• Then pierces the lateral intermuscular
septum of arm
• it runs in the groove between brachialis
and brachioradialis muscle
• To enter cubital fossa on the lateral
epicondyle
• Innervates muscles of posterior
compartment of arm & forearm
(extensor muscles)
• Injury results in inability to extend
elbow, wrist or fingers (elbow
drop/wrist drop/ finger drop)
PIN pierces S
Supplies surrounding muscles
Main stem run on APL, EPB and
passes underneath ER
Superficial radial nerve
emerges from anterior aspect
(undercover of brachioradialis)
& passes superficial to tendon
of Anat.snuffbox – and
superficial to ER
An
B
EC
RL
EC
RB
EC
U
S
A
P
L
E
P
B
E
I
n
E
P
L
Deep branch of radial nerve
(Posterior interosseous nerve)
Superficial radial nerve emerges from radial
nerve & passes anterior to brachioradialis (B)
ER
65

B
brachioradialis
Superficial
radial nerve
Radial artery
S
Bi
Bi
Superficial radial nerve
accompanied by radial
artery
66

Blood supply of upper limb
1. Arterial supply – axillary artery, brachial artery, radial artery, ulnar
artery, superficial & deep palmar arch
2. Venous drainage – superficial & deep veins of UL
67

Axillary Artery
• Begins:
• lateral border of the 1st rib;
• continuation of the subclavian
• Ends:
• lower border of the teres major muscle
• continues as the brachial artery
• closely related to the cords of the brachial plexus and their branches
• enclosed in a connective tissue sheath called the axillary sheath
• pectoralis minor muscle crosses in front of the axillary artery and
divides it into three parts:-
1. First Part - the lateral border of the 1st rib to the upper border of the
pectoralis minor
2. Second Part - behind the pectoralis minor muscle
3. Third Part - from the lower border of the pectoralis minor to the
lower border of the teres major
68

The level of lower
border of teres major
• 1st & 2nd parts are deep
• The 3rd part is more superficial
and can be palpated in the axilla
• It ends at lower border of teres
major to continue as brachial
artery
A
SA
SubA
AxA
B
A
STA
TA
L
T
A
Sub
sca
pul
ar
arte
ry
Thoracodorsal artery
Axillary
artery
Branches
1st part Superior thoracic artery (STA)
2nd part 1. Thoracoacromial artery (TA)
2. Lateral thoracic artery (LTA)
3rd part 1. Anterior circumflex
2. Posterior circumflex
3. Subscapular artery → thoracodorsal
artery
Axillary artery
69

Arteries of upper limb
2. Brachial artery
i. Starts: at lower border of teres major as
continuation of axillary aa.
ii. End: at the neck of radius by becoming radial
and ulnar arteries (in cubital fossa)
iii. Relation to humerus: Initially passes medial to
humerus → As it pass down it lies anterior to
humerus
iv. Important branches – profunda brachii artery
Pass posteriorly on the radial/spiral groove with
radial nerve
v. Pulse point in cubital fossa and midarm
70

Arteries of upper limb
3. Radial artery
i. Starts: in cubital fossa
ii. Run in the lateral side of forearm on the deep muscles of
the forearm
iii. In the distal part of the forearm it lies on the anterior to
the radius and is covered only by skin and fascia (pulse
point)
iv. Another pulse point is anatomical snuffbox
v. Ends: as deep palmar arch
4. Ulnar artery
i. Starts: in cubital fossa
ii. It runs on the medial/ulnar side of forearm deep to
muscles of forearm
iii. Then pierces deep fascia & run superficial to flexor
retinaculum
iv. It can be palpated in the distal part of the forearm –
covered by skin & superficial fascia
v. Ends: as deep palmar arch
vi. Superficial & deep palmar arch anastomose with each
other 71

Anatomic Snuffbox
• skin depression that lies distal to the styloid process
of the radius
• bounded medially by the tendon of extensor pollicis
longus and laterally by the tendons of abductor
pollicis longus and extensor pollicis brevis
• Floor: styloid process of the radius, base of the first
metacarpal bone, scaphoid and the trapezium
• radial artery can be palpated within the snuffbox as
the artery winds around the lateral margin of the
wrist to reach the dorsum of the hand
• The cephalic vein can also sometimes be recognized
crossing the snuffbox as it ascends the forearm
Ext poll brevis and
Abd Poll longus
72

Points of pulse palpation in upper limb
Pulse/artery Location of pulse point
Axillary artery Axilla/armpit
Brachial artery Midarm/grooves between biceps brachii and triceps
Cubital fossa
Radial artery Wrist (distal forearm) – lateral/radial site, lateral to flexor
carpi radialis muscle
Anatomical snuffbox
Ulnar artery Wrist (distal forearm) – medial/ulnar side, proximal to
pisiform bone
73

1) Axillary pulse
2) Brachial pulse in mid-arm
3) Brachial pulse in cubital fossa
4) Radial pulse in distal fore-arm
6) Radial pulse in anatomical snuffbox
5) Ulnar pulse in distal forearm
Points of pulse palpation
in upper limb
74

Venous drainage of Upper limb
1. Superficial veins of UL – cephalic vein, basilic vein
2. Deep veins of UL – vena comitantes accompanying the arteries
(superficial & deep palmar arch, radial artery, ulnar artery, brachial
artery)
3. Axillary vein
75

Dorsal venous arch
Basilic vein
Cephalic vein
Superficial veins of UL – cephalic vein, basilic vein
Cephalic vein
• Arise as continuation of lateral
aspect of dorsal venous arch
• Runs on the lateral forearm then
on the lateral aspect of biceps -
until it reaches deltoid
• it then passess on the groove
between deltoid and pec major -
pierces deep fascia in the
deltopectoral groove
• It pierces the clavipectoral fascia
to joins the axillary vein
Basilic vein
• Arise as continuation of
medial aspect of dorsal
venous arch
• Runs on the medial forearm
then on the medial aspect of
biceps
• In mid-arm it pierces deep
fascia, to runs of medial
aspect of brachial artery
• Ends by continue as axillary
vein
Basilic vein
Basilic vein
76

Axillary vein
• Formed: lower border of the teres major
muscle by the union of the venae
comitantes of the brachial artery and the
basilic vein
• runs upward on the medial side of the
axillary artery
• Ends: outer border of the 1st rib by
becoming the subclavian vein
• receives tributaries, correspond to the
branches of the axillary artery, and the
cephalic vein
78

Contents of carpal tunnel
1. Flexor digitorum superficialis tendons and,
posterior to these, the tendons of the flexor
digitorum profundus; both groups of tendons
share a common synovial sheath
2. Median nerve – it passes beneath the flexor
retinaculum in a restricted space between the
flexor digitorum superficialis and the flexor
carpi radialis muscles
3. Flexor pollicis longus tendon surrounded by a
synovial sheath
4. Flexor carpi radialis tendon going through a
split in the flexor retinaculum. The tendon is
surrounded by a synovial sheath.
The contents are tightly packed
Carpal tunnel syndrome
4
3
2
1
79

X-ray of the shoulder region
Source: Dept of Bio Medical Imaging, UMMC (2013)
Netter image 80

X-Ray of THE Elbow joint
Department of Bio Medical Imaging (2013)
81

X-Ray Of the wrist & hand
Department of Bio Medical Imaging (2013)
82

References
1. Clinical Anatomy by Regions 9th Edition by Snell, Richard S.
2. Gray's Anatomy for Students 2nd Edition by Richard Drake A. Wayne
Vogl Adam Mitchell.
3. Atlas of Human Anatomy, 5th edition by Frank H. Netter.
83

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