This is not all, there are many more clinical anatomy in terms of condition such as Popeye Deformity with are not included here and Special Test such as Neer's Impingement and Hawkins Kennedy etc... with touches on the upper limb muscles and joints. Also not forgotten Long tendon test and so forth. In general, this is just a simplified slides. Tq

1. Clinical Anatomy of Upper
Limb Joints and Muscles
By : Gan Quan Fu, PT,
MSc Human Anatomy (Batch 3)

2. Contents
 Bones and Joints
 Important Muscles of Upper Limb
 Clinical Anatomy of Upper Limb Joints
 Clinical Anatomy of Upper Limb
Muscles
 Clinical Anatomy of Nerve affect
Upper Limb Muscles
 Special Diagnostic Test
 References

3. Nerves
Relationship
of Structures
in Upper
Limb
Muscles
Joints &
Ligaments
Bone
 No structures in the Upper Limb act by it’s own, they are
all related and integrated hence, diseases or disorder
involving one structure will directly or indirectly affect the
others.

4. Bones and Joints of Upper
Limb
Regions Bones Joints
Shoulder Girdle Clavicle
Scapula
Sternoclavicular Joint
Acromioclavicular Joint
Bone of Arm Humerus Upper End: Glenohumeral Joint
Lower End: See below
Bones of
Forearm
Radius
Ulnar
Humeroradial Joint
Humeroulnar Joint
Proximal Radioulnar Joint
Distal Radioulnar Joint
Bones of Wrist
and Hand
8 Carpal
Bones
5 Metacarpal
14 Phalanges
Intercarpal Joint
Carpometacarpal Joint
Metacarpophalangeal Joint
Interphalangeal Joint

5. Important Muscles of Upper Limb
Muscles Description
Trapezius Attach scapula to trunk.
Important in raising of arm high (over 90
degrees).
Serratus Anterior Attach scapula to trunk.
Important in forward punching.
Deltoid Covering shoulder.
Important in raising arm from the side (30
degrees – 90 degrees).
Pectoralis Major Large muscle from front of chest to humerus.
Important in bringing raised arm towards chest
and moving arm forwards.
Latissimus Dorsi Large muscle from middle of back to humerus.
Important in bringing raised arm towards chest
and moving arm backwards.

6. Important Muscles of Upper Limb
Muscles Description
Biceps Prominent muscle on the front of arm.
Important in bending elbow and supinate
forearm.
Triceps Only muscles of the back of arm.
Important in straightening the elbow.
Brachioradialis Passing from lower end of humerus to lower
end of radius.
Important for holding elbow at desired angle.
Flexor carpi
radialis
A landmark at front of wrist.
Interossei &
lumbricals
For fine movement of fingers.
Thenar muscles Small muscles of thumb
Important for movement of opposition of thumb,

8. Shoulder Joint Dislocation
 Most commonly dislocated major joint in
body.
◦ Ball & Socket; Synovial Joint
◦ Large head of humerus to shallow glenoid cavity
◦ Capsule is lax (Wide ROM at cost of stability)
◦ Stability depends almost entirely on the strength
of surrounding muscles (Rotator Cuff).
 Commonly dislocated inferiorly.
◦ Anteriorly shoulder joint protected by
subscapularis.
◦ Superiorly shoulder joint protected by
supraspinatus.
◦ Posteriorly shoulder joint protected by teres
minor and infraspinatus.
◦ Inferior aspect of shoulder joint completely
unprotected.

10. Subacromial Bursitis
 Shoulder joint in adducted position = No pain;
Shoulder joint in abducted position = Pain
◦ Subacromial bursa is located inferior to
acromion, above supraspinatus tendon.
◦ Pain occur when abduction because
supraspinatus tendon comes in contact with
inferior surface of acromion, inflammed bursa
slips up underneath coraco-acromial arch and
gets impinged between supraspinatus tendon
and acromion.
 Dawbarn’s Sign
◦ Pain when deltoid is pressed just below acromion
process when arm is adducted.
◦ When arm abducted to 90 degrees pain cannot
be elicited by pressure on the point because
bursa slips up underneath acromion process.

12. Frozen Shoulder
 Pain and uniform limitation off all
movements of shoulder joint, though
there is NO evidence of radiological
changes in joint.
 Occurs due to shrinkage of capsule of
shoulder joint (adhesive capsulitis).
 Causes:
◦ When nor moving the shoulder joint for a
period of time because of:
 Pain
 Injury
 Chronic health condition

14. Painful Arc Syndrome
 Pain in shoulder region and arm during
abduction in mid-range (i.e. between 60-
120 degrees).
 Complete freedom from pain during
initial and terminal stages.
 Causes:
1. Tear, inflammatory degeneration, or
calcified deposits in supraspinatus tendon.
2. Subacromial bursitis.
3. Contusion and undisplaced fracture of
greater tubercle of humerus.

16. Shoulder Separation
(Acromioclavicular Subluxation)
 Tearing of coracoclavicular and
coracoacromial ligaments caused by
downward blow on tip of shoulder.
 Coracoclavicular and coracoacromial
joint spaces become 50% wider than in
normal contralateral shoulder.
 Presenting features:
1. Injured arm hangs lower than normal
(contralateral arm)
2. Noticeable bulge at tip of shoulder as a
result of upward displacement of clavicle.

18. Carrying Angle
 Extended forearm makes an angle with the arm,
being deviated slightly laterally.
 Anatomical factors responsible:
◦ Medial flange of trochlea is 6mm below than the
lateral flange.
◦ Superior articular surface of coronoid process of ulnar
is placed obliquely to long axis of Ulnar.
 Varies from 5 to 15 degrees
 Axis of elbow joint is transverse between radius
& humerus, oblique between ulnar and humerus.
 Diminishes or disappears when forearm pronated
or flexed.
 More pronounce in females than males due to
wider pelvis.

20. Student’s Elbow or Miners’
Elbow
 Inflammation of subcutaneous olecranon
bursa (lying over the subcutaneous triangular
area on dorsal surface of olecranon process
of Ulna).
 Causes a round fluctuating painful swelling of
1” or so in circumference over olecranon.
 Occurs due to:
1. Repeated friction as occurs in students who
read for long hours with head supported by
hand and elbow resting on table.
2. Trauma during falls on elbow
3. Infection from abrasions of skin covering
olecranon process.

22. Tennis Elbow
 Repeated or violent extension of the
wrist with forearm pronated (i.e.
movements required during backhand
strokes in lawn tennis), leads to
tenderness over lateral epicondyle of
humerus.
 Possibly due to:
◦ Sprain of radial collateral ligament.
◦ Tearing of fibers of extensor carpi radialis
brevis muscle.
◦ Inflammation of the bursa underneath
extensor carpi radialis brevis
◦ Strain or tear of common extensor origin.

24. Pulled Elbow
 Also known as radial subluxation.
 Vulnerable for preschool children (1-3
years old).
 Annular ligament is funnel-shaped in
adults, but its sides are vertical in young
children. (When child is suddenly
lifted/pulled up when forearm is in
pronated position, head or radius may
slips out partially from annular ligament).
 Pain and limitation of supination.

26. Aspiration of Elbow Joint
 Locate the head of radius and capitulum of
humerus. (flex elbow to 90 degrees, pronate
and supinate forearm and feel with the thumb
its rotation).
 Insert needle in the palpable depression
between proximal part of radial head and
capitulum in a direction directly forwards, the
joint being flexed to right angle and forearm
semi pronated.
 Safest and most direct approach. When
elbow is distended with pus, the capsule
bulges to either side of triceps and hence the
pus can easily and effiviently be drained.

28. Prolonged Immobilisation of
Hand
 Performed in an optimum position of hand
where ligaments are at their maximum length.
 If joints are immobilized in any other position
for a prolonged period (i.e. 3-6 weeks),
ligaments will be shorten and may never
regain their normal length, leading to
permanent joint stiffness.
 Optimum position of hand:
◦ Wrist dorsiflexed by 15-25 degrees
◦ Metacarpophalangeal joints are flexed by 60-90
degrees
◦ Interphalangeal joints are flexed by 5 degrees
◦ Thumb is held in opposition

31. Preferred site for Intramuscular
Injection
Deltoid Muscles
◦ Well-developed in most adults and easily
accessible.
◦ Injection given in the lower half to avoid
injury to axillary nerve.
◦ Exact site of injection: Needle should be
inserted in center of triangle.
◦ Place 4 fingers across deltoid muscle with
top finger kept along acromial process,
injection site is 3 fingers breadth below
acromial process.

33. Paralysis of Serratus Anterior
 Functions of Serratus Anterior
◦ Keeps medial border of scapula in contact with
chest wall.
◦ Important role in abduction of arm and elevation
of arm above horizontal.
◦ Pulls scapula forward as in throwing, pushing
and punching.
 Effects of paralysis of serratus anterior
◦ Medial border of scapula stands out from the
chest wall, particularly when patient is asked to
press against a wall in front of him (winged
scapula).
◦ Inability to raise arm above head.
◦ Inability to carry arm forward in breast stroke
swimming (Swimmer’s Palsy).

35. Ruptured Supraspinatus
 Active initiation of abduction is not
possible.
 Patient gradually develop a trick of tilting
his body towards injured side so that the
arm swings away from the body due to
gravity leading to 15 degrees initial
abduction. Later deltoid and scapular
rotators come into play to do the required
job.
 Sometimes may also lift arm on the side
of injury with opposite hand to cause
initial abduction

37. Golfer’s Elbow
 Repetitive use of superficial flexors of
forearm, strains their common flexor
origin with subsequent inflammation of
medial epicondyle (medial
epicondylitis).
 Characterised by pain on medial side
of elbow.

39. Supination and Pronation
(Screwing & Unscrewing
movements)
 Supination is more powerful than
pronation because it is an antigravity
movement.
 Supination is achieved by powerful
muscles such as biceps brachii and
supinator.
 Pronation is achieve by less powerful
muscles like pronator teres and
quadratus. Gravity also helps
movements of pronation.

41. Touching Live Electrical Wire
 In normal position, fingers are partially flexed
because flexor muscles in hand are stronger
than extensor.
 On touching a live electrical wire, the hand
closes tightly (flexed and fixed) and holds on
to the wire.
◦ On touching live wire, body gets strong stimulus,
making all muscles contract.
◦ Since flexor muscles in hand are stronger than
extensors, there is a preponderance of flexion of
the hand.
◦ Consequently, the hand gets close tightly and
holds on the electrical wire.

44. Suprascapular Nerve
Entrapment
 Entrapment may occur as it passes
through suprascapular notch or in
spinoglenoid notch.
 Effects:
◦ Typical dull posterior and lateral shoulder
pain.
◦ Tenderness, 2.5cm lateral to midpoint of
spine of scapular
◦ Weakness of shoulder abduction and
external rotation due to involvement of
supraspinatus and infraspinatus muscles.

46. Axillary Nerve damage
 Axillary nerve usually damaged by fractures
of surgical neck of humerus or due to an
inferior dislocation of shoulder joint.
 Effects:
◦ Loss or weakness of abduction of shoulder
(between 15 degrees to 90 degrees) due to
paralysis of Deltoid.
◦ Rounded contour/profile of shoulder is loss due
to paralysis of deltoid
◦ Sensory loss over lower half of the outer aspect
of shoulder ‘regimental badge area’.
Paralysis of teres minor is not easily
demonstrated clinically.

48. Lesion of Musculocutaneous
Nerve
 Sometimes damaged in fracture of
humerus.
 Effects:
◦ Weakness of elbow flexion due to
paralysis of biceps brachii, and medial
two-third of brachialis.
◦ Weak supination of forearm with the
elbow flexed at 90 degrees in mid-prone
due to paralysis of biceps brachii.
◦ Sensory loss over lateral half of anterior
surface of forearm due to involvement of
lateral cutaneous nerve of forearm.

50. Erb-Duchenne Paralysis
 Brachial plexus injury at Erb’s point (C5,
C6).
 Maybe injured during childbirth, due to
forcible downward traction of shoulder
with lateral displacement of head to other
side (Usually during forceps delivery).
 Upper limb assumes typical policeman
receiving a tip position or waiter’s tip
position:
◦ Shoulder adducted and medially rotated.
◦ Elbow extended
◦ Forearm pronated

51. Erb’s Palsy (Muscle Affected)
Muscle
Paralysis
Loss of
Function
Effects
Deltoid Loss of
abduction of
shoulder
Arm is adducted
Supraspinatus,
Infraspinatus &
Teres Minor
Loss of lateral
rotation of
shoulder
Arm is medially
rotated
Biceps brachii &
Brachialis
Elbow is
extended
Loss of flexion
of elbow
Biceps brachii &
Supinator
Loss of
supination
Forearm is
pronated

53. Klumpke’s Paralysis (Claw
Hand)
 Lower Trunk Injury of Brachial Plexus
involving C8 and T1.
 Maybe injured due to upward traction
(i.e. force abduction in forcible breech
delivery).
 The lowest root of brachial plexus (T1) is
the chief segment concerned with supply
of intrinsic muscles of hand.
 Effects:
◦ Fingers hyperextended at
metacarpophalangeal joint and flexed at
interphalangeal joints
◦ Adduction of Fingers is lost.
◦ Sensory loss occurs over medial side of
forearm and hand.

55. Effects of Radial Nerve Injury
Depends on site of
lesion

56. Radial Nerve Injury (Axilla)
 Causes:
◦ Prolonged use of crutches (Crutch Paralysis)
 Effects:
◦ Loss of extension of elbow due to paralysis
of triceps.
◦ Loss of extension of wrist due to paralysis of
extensor muscles of forearm (Wrist Drop).
◦ Supination of forearm in elbow extension not
possible (paralysis of supinator)
◦ Loss of sensation over:
 Posterior surface of lower part of arm and narrow
strip over back of forearm
 Over lateral side of dorsum of hand and lateral 3½
fingers
◦ Loss of triceps and supinator reflexes.

57. Radial Nerve Injury (Radial
Groove)
 Causes:
◦ Fracture of shaft of humerus
◦ Improper intramuscular injection
◦ Prolonged pressure (Saturday night
paralysis)
 Effects:
◦ Triceps brachii is spared (extension of
elbow is possible)
◦ Other effects are similar as those of a
lesion of radial nerve in axilla

58. * Wrist drop is most outstanding feature of radial nerve
injury.

59. Ulnar Nerve Injury
 Usually injured at following sites:
◦ Elbow
◦ Cubital tunnel
◦ Wrist
◦ Hand
 Effects depending on site of lesion

60. Ulnar Nerve

61. Ulnar Nerve Injury at Elbow
 Easily damage (lies in ulnar groove behind
medial epicondyle of humerus)
 Causes:
◦ Fracture of medial epicondyle
 Effects:
◦ Loss of flexion of terminal phalanges of ring and little
finger due to paralysis of flexor digitorum profundus
(medial half)
◦ Weakness of flexion and adduction of wrist due to
paralysis of flexor carpi ulnaris
◦ Ulnar Claw Hand
◦ Loss of adduction and abduction of fingers due to
paralysis of Palmar (adductors) and dorsal
(abductors) interossei
◦ Loss of adduction of thumb due to paralysis of
adductor pollicis.
◦ Flattening of hypothenar eminence and depression of
interosseous space due to atrophy of hypothenar and
interosseous muscles

62. Ulnar Nerve Injury at Cubital Tunnel
(Cubital Tunnel Syndrome)
 Cubital Tunnel – Formed by tendinous
arch connecting 2 heads of flexor
carpi ulnaris (arise from humerus and
ulna)
 Causes:
◦ Entrapment of ulnar nerve in this cubital
tunnel (osseofibrous tunnel).
 Effects same as ulnar nerve lesion in
elbow

63. Ulnar Nerve Injury at Wrist
 Ulnar Nerve at wrist lies immediately
medial to ulnar artery and after giving
dorsal branch to dorsum of hand, it
enters the palm superficial to flexor
retinaculum along with artery.
 Often injured by penetrating wounds.
 Effects similar as ulnar nerve injury at
elbow except the flexor carpi ulnaris
and flexor digitorum profundus (medial
half) are not paralysed.

64. Ulnar Nerve Injury at Hand
(Ulnar Tunnel Syndrome)
 Ulnar nerve is compressed in the
region where it passes deeply into the
muscles of hypothenar eminence
through Guyon’s Tunnel (Ulnar Carpal
Tunnel). * Formed by pisiform medially,
hook of hamate laterally and pisohamate
ligament between these 2 bones.
 Effects:
◦ Same as those observed in case of ulnar
nerve injury at wrist except no loss of
cutaneous sensation on ulnar side of
hand.

66. Median Nerve Injury
 Usually injured at following sites:
◦ Axilla
◦ Wrist
◦ Carpal Tunnel
 Effects depending on site of lesion

67. Medial Nerve

68. Median Nerve Injury at Axilla
 Motor Effects:
◦ Weakness of pronation of forearm due to
paralysis of pronators.
◦ Deviation of wrist to Ulnar side on wrist flexion
due to unopposed action of flexor carpi ulnaris.
◦ Weakness of flexion of distal phalanx of thumb
and index finger.
◦ Wasting of thenar muscles due to paralysis.
◦ Loss of opposition of thumb due to paralysis of
opponens pollicis.
◦ Loss of flexion and weakness of abduction of
thumb.
◦ Ape-hand deformity
 Sensory Effects:
◦ Loss of cutaneous sensations over palmar
surface of lateral 3½ digits and radial two-thirds
of palm

69. Ape-hand Deformity
 Paralysis of thenar muscles:
◦ Opponens Pollicis
◦ Abductor Pollicis
◦ Flexor Pollicis
 Presenting Features
◦ Thumb laterally rotated and adducted
◦ Loss of thenar eminence
◦ Loss of opposition of thumb

71. Median Nerve Injury at Wrist
 Effects:
◦ Ape-hand Deformity
◦ Loss of cutaneous sensations over palmar
surface of lateral 3½ digits and radial two-thirds
of palm

72. Medial Nerve Injury at Carpal Tunnel
(Carpal Tunnel Syndrome)
 Compression of medial nerve in carpal tunnel.
 More common in women than man.
 Causes
◦ Tendosynovitis
◦ Bony encroachment (osteoarthritis/injury)
◦ Myxoedema, pregnancy, hypothyroidism etc
conditions resulting in fluid accumulation.
◦ Weight gain.
 Symptoms
◦ Painful paraesthesia and numbness affecting radial
3½ digits of hand.
◦ Wasting and weakness of thenar muscles.
◦ Loss of sensation or hypoaesthesia to light touch and
pin prick over palmar aspect of radial 3½ digits and
corresponding part of hand except skin over thenar
eminence

75. Yergason Test
 To determine if biceps tendon is stable in
bicipital groove.
 Steps:
◦ Instruct patient to fully flex elbow.
◦ Clinician grasp the flexed elbow in one hand
while holding his wrist with other hand.
◦ External rotate patient’s arm as he resists, at the
same time pull downward his elbow.
 If biceps tendon is unstable in bicipital
groove, it will pop out the groove and patient
will experience pain; If stable, it remains
secure and patient have no experience of
discomfort.

77. Drop Arm Test
 To detects any tears in the rotator cuff.
 Steps:
◦ Instruct patient to fully abduct his arm.
◦ Asked patient slowly lower it to his side.
 Of there are tears in rotator cuff (especially
supraspinatus), arm will drop to side from a
position of about 90° abduction.
 Patient still will not be able to lower his arm
smoothly and slowly no matter how many
times he tries.
 If he is able to hold his arm in abduction,
gentle tap on forearm will cause arm to fall to
his side.

79. Apprehension Test for Shoulder
Dislocation
 To test for chronic shoulder
dislocation.
 Steps:
◦ Clinician abduct and externally rotate
patient's arm to a position where it might
easily dislocate
 If patient's shoulder is ready to
dislocate, the patient will have a
noticeable look of apprehension and
alarm on his face and will resist further
motion.

81. Elbow Stability Test
 To assess stability of medial and lateral
collateral ligaments of elbow.
 Steps:
◦ Clinician cup posterior aspect of patient's elbow
in one hand and hold patient's wrist with the
other.
◦ The hand on the elbow will act as fulcrum, other
hand will force the forearm during the test.
◦ Instruct patient to flex his elbow few degrees
while forcing his forearm laterally, producing
valgus stress on joint’s medial side.
◦ Then do it in reverse direction.
 Notice if any gapping collateral ligament with
the clinician hand that act as fulcrum.

83. Tennis Elbow Test
 To reproduce pain of tennis elbow.
 Steps:
◦ Stabilize patient's forearm and instruct him to
make a fist and to extend his wrist.
◦ Apply pressure with other hand to dorsum of
his fist in an attempt to force his wrist into
flexion.
 If patient has tennis elbow, he will
experience sudden severe pain at site of
wrist extensors’ common origin (lateral
epicondyle).

85. Bunnel-Littler Test
 To evaluates the tightness of intrinsic muscles of
hand (lumbricals and interossei). Also to
determine if flexion limitation in proximal
interphalangeal joint is due to tightness of
intrinsic or joint capsule contracture.
 Steps:
◦ Hold metacarpophalangeal joint in a few degrees of
extension.
◦ Try to move proximal interphalangeal joint into
flexion.
 If in this position, the proximal interphalangeal
joint can be flexed, the intrinsic are not tight and
are not limiting flexion; However, if the proximal
interphalangeal joint cannot be flexed, either the
intrinsic are tight or there are joint capsule
contracture.

87. Retinacular Test
 Verifies tightness of retinacular ligaments. To determine
if flexion limitation in distal interphalangeal joint is due to
tightness of retinacular ligaments or to joint capsule
contractures.
 Steps:
◦ Hold proximal interphalangeal joint in neutral position and
try to move distal interphalangeal joint into flexion.
◦ If joint does not flex, limitation is due either to joint capsule
contracture or retinacular tightness.
◦ To distinguish either joint capsule contracture or retinacular
tightness, flex proximal interphalangeal joint slightly to
relax the retinaculum.
 If distal interphalangeal joint flexes, the retinacular
ligaments are tight. However, if the joint still does not
flex, the distal interphalangeal joint capsule is probably
contracted.

89. References
 Ellis, H. (1997) Clinical Anatomy; A
revision and applied anatomy for clinical
student, 9th edn. Blackwell Science;
United Kingdom.
 Hoppenfeld, S. (1976) Physical
Examination of the Spine and
Extremities. Prentice-Hall; East Norwalk.
 Singh, V. (2007) Clinical & Surgical
Anatomy, 2nd edn. Elsevier; New Delhi.
 Snell, R.S. (2007) Clinical Anatomy: An
Illustrated Review with Questions and
Explanations, 3rd Edn. Lippincott
Williams & Wilkins; Philadelphia.

91. Acknowledgment
 Thanks to Prof Dr Menon for developing my
interest in Anatomy to continue my post
graduate, taught me anatomy during my
undergraduate and helping me to clear many of
my doubts during my undergraduate years.
 Thanks to Prof Dr Arulmoli (my post graduate
Anatomy HOD), Prof Dr Wai Wai, Dr Jegadeesh,
Dr Savinaya and all my post graduate anatomy
lecturers.
 Thanks to my undergraduate physiotherapist
lecturers Mr Pathiban, Mr Vera Perumal, Mr
Muthu, Mr Naga, Mdm Chan all my other
undergraduate lecturers.
 Thanks to my family and my darling Lim Yi Ting
for the support.