Anatomy of upper extremity

1. Dr. Sunil Pahari, 3rd year resident , department of orthopaedic
surgery, yangtze university , hubei , China

2. Boundaries of upperlimbs
 Superior clavical—acrimoin—
spinous process of C7
 Anterior anterior border of the
deltoid—anterior axillary fold
 Posterior posterior border of the
deltoid—posterior axillary fold

3. Bony structures of upperlimbs
 Clavical
 Scapula
 Humerus
 Radius
 Ulna
 Carpal bones
 Matacarpal bones
 Phalanges

4. Clavicle
 Only one bone that lie horizontally
,subcutaneous through out , first bone to
start ossify , 2 primary center of
ossification , membranous ossification,
S- shaped ,
 1 shaft and 2 end ,, medial part articulates
with sternum and lateral part with
acromian process of scapula …
 m/c fracture site - junction between
middle and outer -third .
 Most common fracture bone in body
 also called Collar bone or beauty bone ..

5. scapula
 2nd to 7th rib
 Flat and triangular
 Anterior surface(costal surface) & dorsal
or posterior surface(spine of scapula).
 Superior, medial and lateral border.
 Superior, inferior angle.
 Acromian articulates with clavicle .
 glenoid cavity articulates with head of
humerus.
 Coracoid process projects upward provides
attachment for muscles and ligaments.

6. humerus
 Longest and largest bone of upper
limb
 Body and two ends
 Head, greater and lesser tubercle/
intertubecular sulcus or bicipital
groove.
 Anatomical neck
 Surgical neck=head meets the shaft
 Lower end is flat and two articular
surfaces
 Capitulum for head of radius
 Trochlea for articulation with
trochlear notch of ulna.
 Lateral and medial epicondyles for
muscles and ligament attachment
 Radial fossa for radial head when
elbow is flexed
 Coronoid fossa for coronoid process
of ulna during same movement.
 Olecranon fossa posteriorly for
olecranon process of ulna during
extension.

7. Humerus fractures and
nerve injury
 surgical neck fracture - axillary nerve
injury .
 shaft #- radial nerve injury
 supracondylar # - median nerve injury
 .
Supracondylar fracture

8. Radius and ulna

9. Radius
 Fracture of the distal end (Colle’s
fracture):
 It is due to a fall on the outstretched
hand in patients over (50) years.
 The distal fragment of the radius is
pulled posteriorly and superiorly
 The distal articular surface is directed
posteriorly.
 The posterior displacement produces
a posterior bump.
 The deformity is referred to as,
‘dinner-fork deformity’ because the
forearm and wrist resemble the shape
of a dinner fork.
 Smith’s fracture is a reversed Cole’s
as the distal segment is displaced
anteriorly

10. Carpal bones
8 in numbers
 proximal row (lateral to medial )
Scaphoid ( boat shaped )
Lunate( half –moon )
Triquetrum ( three cornered
Pisiform ( pea Shaped )
Distal row
Trapezium ( four sided )
Trapezoid ( babys shoes
shaped )
Capitate ( head ,,, biggest )
Hamate ( hook)
Scaphoid fracture is most common .

11. Fracture of the Scaphoid Bone
 Common in young adults
 Fracture line passes through the
narrowest part of the bone
 If the fragments will not unite properly,
there will be permanent pain and
weakness at the wrist
 Deep tenderness in the anatomical snuff
box after a fall on an outstretched hand
in a young adult is an indication of
fracture of scaphoid bone

12. Elbow Joint
 Dislocations are common and
most are posterior. Are more
common in children, due to a
fall on outstretched hand. The
distal end of humerus is pushed
anteriorly through weak part of
the capsule
 Pulled Elbow: occurs in
children, when the child is
lifted by the upper limb. The
radial head is pulled out of the
annular ligament

13. Tennis Elbow
 Caused by partial tear or
degeneration of the origin of
superficial extensor muscles
attached to the lateral
epicondyle
 It results due to excessive use
of these muscles as in tennis,
violinists and housewives.
 Results in pain and
tenderness over the lateral
epicondyle that radiates to the
lateral side of the forearm

14. Golfer’s Elbow (Medial Epicondylitis)
 Caused by partial tear or
degeneration of the
origin of superficial
flexor muscles attached
to the medial epicondyle
 It results due to excessive
use of these muscles as
in playing golf
 Results in pain and
tenderness over the
medial epicondyle that
radiates to the medial
side of the forearm

15. Bones of Hand
 Carpal bones
 Metacarpals
 Phalanges
From lateral to medial:
1- the proximal row : scaphoid
,lunate , triquetral & pisiform
.
2- the distal row : trapezium ,
trapezoid , capitate & hamate

16. Deltoid
origin – from lateral 1/3rd of clavicle , acromion process
and spine of scapula.
insertion – into the deltoid tuberosity of humerus .
Action- act as main muscle for abduction of shoulder
joint . Its anterior part is flexor and medial rotator of
humerus while posterior part is extensior and lateral
roatatior of humerus.
supraspinatus- deep to
trapezius, arises from supraspinatus
fossa of scapula. Fibers crosses above
the shoulder joint and is inserted into
greater tubercle of humerus. Stabilizes
shoulder joint and abducts the
humerus.
Muscles that abduct the upper arm

17. Muscles origin Insertion Actions Nerve supply
Deltiod Scapula and
clavical
Humerus Abduct the
upper arm
Axillary nerve
Supra
spinatous
Scapula Humerus Abduct the
upper arm
Suprascapular
nerve

18. Muscles that adduct the upper arm
 1) pectoralis major
 2) lattissimus dorsi
 3) teres major
 4) subscapularis

20.  Latissimus dorsi: very
broad, flat and triangular muscle in
lower back. It is overlapped by
lower part of trapezius. It originates
from lumbar fascia, spines of lower
six thoracic vertebrae, lower three
or four ribs and inferior angle of
scapula. .

24. Muscles origin Insertion Actions Nerve supply
Pectoralis major Clavical and
sternum
Humerus Adduct the
upper arm
Medial and
lateral
pectoral nerves
from
brachial plexus
Lattissimus
dorsi
Thoracic-
lumber
vertebrae
Humerus Adduct the
upper arm
Thoracodorsal
nerve
Teres major Scapula Humerus Adduct the
upper arm
Lower
subscapular
nerve
Subcapsularis scapula Humerus Rotate the upper
arm medially
Upper and lower
subscapular
nerves
Infraspinatus scapula Humerus Rotate the
upper arm
laterally
Suprascapular
nerve

25. Rotator cuff muscles
 The name given to the tendons
of the subscapularis, the
supraspinatus, the
infraspinatus, and the teres
minor muscles, which are
fused to the underlying capsule
of the shoulder joint.
 The cuff is important in
stabilizing the shoulder joint.

26. Mucles that move forearm
 Anterior flexor muscles
 1) bicep brachii
 2)brachilais
 3) coracobrachialis

29. coracobrachialis
 elongated muscle in
superiomedial aspect of
arm. Originates from
coracoid process of
scapula and inserts into
medial aspect of shaft of
humerus. It flexes the
arm
 musculocutaneous
nerve.

30. Muscles origin Insertion Actions Nerve supply
Baicep brachii Scapula Radius Flexes the
forearm and
supinates the
hand
Musculocutane
ous
nerve
Coracobrachial
is
scapula humerus Flex the
forearm
Musculocutane
ous
nerve
Barchialis Humerus Ulna Flex the
forearm
Musculocutane
ous
nerve

31. Posterior extenser muscle of arm
Triceps Brachii:
 Arises by three heads, from which it
takes its name.
 Origin of each of the three heads is
1. Long Head: originates from infraglenoid tubercle
of scapula
2. Lateral Head: upper half of posterior surface of
shaft of humerus
3. Medial Head: Lower half of posterior surface of
shaft of humerus
 All the fibers inserts into olecranon
process of ulna.
 It is an extensor of elbow joint
 nerve supply - radial nerve

32. Muscles that move the hand
 Anterior flexor pronator group
1) Flexor carpi radialis (flexes and
abduct the hand )
2) Palmaris longus (flexes the
hand)
3) Flexor carpi ulnaris (flexes and
adduct the hand)
4) Proneter teres (pronates the
hand)
5) Brachioradialis
6) Flexor digitorium superficialis
7) Flexor pollicis longus
8) Pronator quadratus

36.  Posterior extensor group muscles :-
1) Extensor carpi radialis
- Extends and abduct the hand
2) Extensor carpi ulnaris
- Extends and adduct the hand
3) Extensor digitorium
- Extends the phalanges

41. Volkmann’s Ischaemic Contracture
 It is the contractures of
the muscles of the
forearm that follows
fractures of the distal
end of the humerus or
fractures of the radius
and ulna.
 Spasm of a localized
segment of the brachial
artery reduces the blood
flow to the flexors and
extensor muscles so that
they under go ischemic
necrosis.
 The flexor muscles are
mostly affected

42. Intrinsic muscles of the hand
 1) palmer flexors :- thernar group
 hypothernar
 intermidiate group
 2) dorsal extensor :-
 thenar extensor
 hypothernar extensor
 intermidiate extensor

43. Dupuytren’s Contracture
 It is a localized thickening and
contracture of the palmar
aponeurosis.
 It commonly starts near the root of
the ring finger pulling it to the palm
and flexing it at the metacarpo-
phalngeal joint. Later the little finger
is involved.
 Dupuytren's disease is familial, and
may be associated with cigarette
smoking, vascular disease, epilepsy,
and diabetes.

44. Pulp-Space Infection (Felon)
 This is the commonest hand
infection. Pus more often gathers
in the finger tips than anywhere
else in the hand.
 It is more common in the thumb
and index fingers.

45. ARTERIES OF THE UPPER LIMB:
THE AXILLARY ARTERY :It begins at the outer border of
the 1st rib as a continuation of the Subclavian A. & ends
at the lower border of the teres major M. by becoming
the Brachial A.

46. ARTERIES OF THE UPPER LIMB:
The pectoralis minor M . divided it to 3 parts
The 1st part : lies above the pectoralis minor & give one branch
(superior thoracic A.) . It lies very deeply with the axillary vein
on its medial side .

47. The 2nd part : lies behind the pectoralis minor M. & gives 2 branches ( acromio thoracic
A.& lateral thoracic A. ).
The 3rd part : lies below the pectoralis minor M. & gives 3 branches :( subscapular A.,
post. circumflex humeral A. & ant . Circumflex humeral A.).

48. Anastamosis around the scapula
The branches of the third part of axillary A.
* the sub scapular A. which go down along the lateral border of
the scapula.
*the circumflex scapular A. which arise from the sub scapular
A.& go to the infraspinous fossa.

49. THE BRACHIAL ARTERY :
It begins at the lower border of the Teres major M. as a continuation
of the Axillary A. & ends at the level of the neck of the Radius by
dividing to Radial & Ulnar Aa.
It is a superficial A. lies
immediately below the deep
fascia.
The basilic vein lies on its medial
side.

50. The branches of the brachial A.: It supplies all the Mm. of the
arm & gives 3 branches
1- the profunda brachii A.
2- the superior ulnar collateral A.
3- the inferior ulnar collateral A.

51. Anastamosis around The Elbow Joint :
It is a rich anastamosis between small branches of
brachial ,ulnar & radial Aa.:

52. Anastamosis around medial
epicondyle :
The two branches of the brachial A .
(the superior ulnar collateral A. & the
inferior ulnar collateral A.)
with the branches of ulnar A. (the ant. &
post. Ulnar recurrent Aa.) .i.e.
the brachial & the ulnar Aa. only .
Anastamosis around lateral
epicondyle :
The 2 terminal branches of the profuda
brachii a. with recurrent branches of
ulnar & radial Aa.

53. Radial artery
 Begins: in the cubital fossa at the neck of the radius.
 Course: passes downward and laterally end with
deep palmer arch
 Branches
 Radial recurrent a.
 Superfical and deep palmar branch
 Principal artery of thumb
At the lower end of the
radius , it leaves the
front of the forearm &
turns backward round
the lateral border of the
wrist , below the styloid
process of the radius&
enter the anatomical
snuff-box where the
pulsation can be felt
then pass to the palm .

54. Ulnar artery
 Begins in the cubital fossa at the
opposite neck of the radius.
 Course: passes downward and
medially .
 Branches
 Ulnar recurrent a.
 Common interosseous artery
 Anterior interossous a.
 Posterior interosseous a.
 Deep palmar branch

55. THE SUPERFICIAL PALMER ARCH :
It is superficial because it lies
immediately next to the palmer
aponeurosis.
It is formed mainly by the ulnar A.
with the superficial palmer
branch of the radial A.
It gives 4 digital Aa. to supply the 4
medial fingers.

56. THE DEEP PALMER ARCH :
It is formed mainly by the
radial A. with the deep
palmer branch of the ulnar A.
It gives 3 palmer – metacarpal
Aa. To pass to the clefts of
the fingers.

57. Review
 The subclavian artery becomes the axillary artery after crossing the 1st
rib
 The axillary artery becomes the brachial artery after crossing the
posterior axillary fold
 The brachial artery divides just distal to the elbow into the radial and
ulnar arteries.
 The ulnar artery gives rise to the common interosseous artery, which
divides into anterior and posterior interosseous arteries.
 The hand is supplied on the palmar aspect by variable anastomoses
between branches of the radial and ulnar arteries.

58. THE VEINS OF THE UPPER LIMB
There are superficial & deep veins in the upper limb .
The deep veins are the veins which accompany the
main Aa. ( way & name ).
The superficial Vv. : start as superficial venous
network on the back of the hand. this network drains in
2 directions
laterally into Cephalic V &
medially to the basilic V.

59. Blood vessels of upper limbsSuperficial veins
 Dorsal venous network
 Cephalic vein
 Basilic vein
 Axillary vein( basilic+ brachial vein)
 Median cubital vein
 Median vein of forearm
Deep veins
 Named according to companian
arteries
 Radial vein
 Ulnar vein
 Brachial vein
 Axillary vein

60. Clinical importance of median cubital vein
 Often used for clinical
procedures
1. Blood sampling
2. Blood transfusion
3. Intravenous injection
4. Introduction of cardiac
catheters to secure
blood samples from
chambers of heart and
great vessels
5. Cardio-angiography

61. Brachial plexus

62. THE BRACHIAL PLEXUS
A plexus: it is a complex arrangement of the anterior
primary rami of certain spinal Nn. Which gives
branches to supply the Mm. & skin of a certain part
of a body.

63. It is formed by the anterior primary rami of C5,C6,C7,C8 &T1 Nn. these
are called ROOTS of the plexus.
It lies in the lower part of the neck behind the clavicle & in the axilla &
formed of 4 main parts : Roots , Trunks , Divisions & cords.

64. The root of C7 alone form the middle trunk.
The roots of C8 & T1 unite to form the lower trunk.
Then each trunk divides into anterior & posterior division .
Then the 3 posterior divisions unite to form the posterior cord .
The anterior divisions of the upper & middle trunks form the lateral cord.
The anterior division of the lower trunk alone forms the medial cord .
THE TRUNKS formed by
The roots of C5 & C6 unite to form the upper trunk

65. So we have :5 roots , 3 trunks , 6 division , 3 cords & 5 terminal
branches .
No branches arise from the trunks nor from the divisions (
except the suprascapular N. which come from the erbs
point=at beginning of the upper trunk). .
The brachial plexus gives 16 branches , 11 small branches & 5
big branches : radial , ulnar , median , circumflex (axillary) &
musclocutaneous Nn.

66. Each cord gives rise to 2 branches one is big & consider the
continuation of the cord & one is small SO
The posterior cord continues as the radial N.
The medial cord continues as the ulnar N.
The lateral cord continues as the median N.
The 3 cords named according to their position to 2nd part of the
axillary A. (post. , medial & lateral.) while the name of the
main N. according to position in the forearm( ulnar , median
& radial ).

67. The 5 main Nn. Arise opposite the lower border of the
pectoralis minor M. near the coracoid process .
1- The circumflex (axillary ) N. supplies the
deltoid & teres minor Mm. then become the lateral
cutaneous N. of the arm.
2- The musculocutaneous N. supplies the
biceps , coracobrachialis & brachialis Mm. then
become the lateral cutaneous N. of the forearm .
3- The median N ( with its branch =ant.
Interosseous N.) supplies most of the Mm. of front
of the forearm with sensation of lateral 3 & ½
fingers anteriorly .

68. 4- The radial N.( with its branch=post. Interosseous
N.) supplies most of the mm. of the back of the forearm.
With sensation of lateral 3 & ½ fingers posteriorly.
5- The ulnar N. supplies Mm. on the medial side of the
forearm with sensation of medial 1 & ½ fingers
anteriorly & posteriorly .

70. Median nerve
Origin: arises from the medial and
lateral cord of the brachial
plexus.
Course:
 Descends on the lateral side of
brachial artery.
 Halfway down the arm, it
crosses the brachial artery to
reach its medial side.

71.  he median nerve travels through
a tunnel within the wrist called
the Carpal Tunnel. The median
nerve gives sensation to the
palm sides of the thumb, index
finger, long finger, and half of
the ring finger. It also sends a
nerve branch to control
the thenar muscles of the
thumb. The thenar muscles help
move the thumb and let you
touch the pad of the thumb to
the tips each of each finger on
the same hand, a motion
called opposition.

72. Ulnar nerve
Origin: arises from the medial cord of the
brachial plexus.
Course:
 Descends on the medial side of brachial
artery.
 At the middle of the arm, it pierces the
medial intermuscular septum and passes
down behind the medial epicondyle of the
humerus.

75. THE DERMATOMES OF THE UPPER LIMB
It is the cutaneous sensation of the upper limb.
C4 supplies the skin over the tip of the shoulder .
C5 supplies the lateral side of the arm &the upper lateral part of the forearm .
C6 supplies the lateral side of the lower part of the forearm & the lateral aspect of the hand
C7 supplies the middle aspect of the hand (ant.& post.) .
C8 supplies the medial side of the hand & the
medial lower part of the forearm.
T1 supplies the medial part of the upper part of the
forearm & the medial lower part of the arm.
T2 supplies the medial side of the upper part of the
arm & the floor of the axilla.

76. Cubital fossa
Boundaries
Superior: an imaginary line drawn
between the two epicondyles of the
humerus.
Lateral: brachioradialis;
Medial: pronator teres;
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cavity Pelvic cavity

77. Cubital fossa
Contents:
The median N.
The brachial A., radial A., ulnar A.
The superficial and deep branches of
the radial N.
Radial artery
Ulnar artery
Median nerve
Brachial artery
Radial nerve
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cavity Pelvic cavity

78. The blood pressure is universally
recorded by auscultating the
brachial artery in medial side of the
biceps’ tendon in the cubital fossa.
Applying
Cubital fossa
Brachial artery
Biceps
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81. Thank you !!!