2

1. . AXILLARY ARTERY
• COMMENCEMENT – upper border of first rib, continuation of subclavian artery
• COURSE – in axilla, runs along lateral wall nearer to anterior wall.
• In axilla – crossed superficially by pectoralis minor muscle

PARTS OF AXILLARY ARTERY:

• Pectoralis minor divides it into 3 parts
1. FIRST PART – superior to muscle
2. SECOND PART- posterior to muscle
3. THIRD PART – inferior to muscle

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RELATIONS OF AXILLARY ARTERY:

PART ANTERIOR POSTERIOR MEDIAL LATERAL

FIRST ● Skin, Superficial ● Medial cord of ● Axillary ● Brachial plexus

fascia, Deep fascia
PART ● Pectoralis major brachial plexus vein – lateral &
(clavicular part) ● Serratus anterior posterior cords
● Clavicular fascia (1st & 2nd div.)
● Loop of
communication ● Nerve to serratus
b/w lateral & anterior
medial pectoral
nerves

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PART ANTERIOR POSTERIOR MEDIAL LATERAL

SECOND ● Skin, ● Brachial ● Brachial plexus ● Brachial plexus –

PART superficial plexus – – medial cord lateral cord
fascia, deep posterior cord ● Medial pectoral ● coracobrachialis
fascia ● Subscapularis nerve
● Pectoralis ● Axillary vein
major
● Pectoralis
minor

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PART ANTERIOR POSTERIOR MEDIAL LATERAL

THIRD ● Skin, ● Radial nerve ● Axillary vein ● Coracobrachialis
PART superficial ● Axillary nerve ● Medial ● Musculocutaneous
fascia, deep (in upper part) cutaneous nerve (in upper part)
fascia ● Subscapularis nerve of ● Lateral root of
● Pectoralis (in upper part) forearm & median nerve (in
major (in ● Tendons of ulnar nerve upper part)
upper part) Latissimus ● Medial ● Trunk of median
● Medial root dorsi & Teres cutaneous nerve (in lower part)
of median major (in lower nerve of arm
nerve (in part)
upper part)

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BRANCHES OF AXILLARY ARTERY:

• Six branches: one – from 1st part, two – from 2nd part, three – from 3rd part

1ST PART:

1.SUPERIOR THORACIC ARTERY (from first part)

• Arises near subclavius

• Passes b/w pectoral muscles
• Ends by supplying pectoral muscles

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2ND PART:

2.THORACOACROMIAL ARTERY 3. LATERAL THORACIC ARTERY

• Arises & runs along pectoralis minor

• Arises near pectoralis minor (upper
(lower border)
border)
• Closely related to ant. group of axillary
• Pierces clavipectoral fascia
lymph nodes
• Gives 4 terminal branches –
• In females, it gives lateral mammary
pectoral br., deltoid br., acromial
branches to breast.
br., clavicular br.

3RD PART:

4.SUBSCAPULAR ARTERY 5. ANTERIOR CIRCUMFLEX 6. POSTERIOR CIRCUMFLEX

HUMERAL ARTERY HUMERAL ARTERY
• Largest branch
• Runs along • Arises at subscapularis • Arise at subscapularis
subscapularis (lower (lower border) (lower border)
border) • Anastomoses with • Supplies – shoulder joint,
• Ends near inferior angle posterior circumflex deltoid, muscles bounding
of scapula humeral quadrangular space
• Supplies – latissimus • Gives an ascending • Gives off descending
dorsi & serratus branch supplying head branch (anastomose with
anterior of humerus & shoulder ascending branch of
• Large branch- joint profunda brachii)
circumflex scapular

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ANASTOMOSES AND COLLATERAL CIRCULATION:

• Branches of axillary artery

anastomose with branches
from – internal thoracic,
intercostal, subscapular, deep
branch of transverse cervical,
profunda brachii arteries.

APPLIED ANATOMY:
• Axillary arterial pulsations
• Collateral circulation in
blockage of proximal part of
axillary artery.

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3. SHOULDER JOINT:
TYPE OF JOINT:
• Ball and socket type of synovial joint.

ARTICULAR SURFACES:

1. Head of humerus (1/3) - Rounded; Faces medially

2. Glenoid cavity of humerus: Shallow depression, faces laterally.

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LIGAMENTS:

1. CAPSULAR LIGAMENT
• Encloses articular surfaces
• Extends between anatomical neck of humerus and glenoid cavity margins
• Encloses long head of biceps brachii tendon
• Joint cavity communicates with subscapular bursa and infraspinatus bursa
2. GLENOHUMERAL LIGAMENT
• Anterior thickening of fibrous capsule
• Defect causes anterior dislocation of shoulder joint.

3. CORACOHUMERAL LIGAMENT
• Extends between coracoid process of scapula and greater tubercle of humerus
• Degenerated part of pectoris minor

4. TRANSVERSE HUMERAL LIGAMENT

• Bridges bicipital groove
• Encloses biceps brachii tendon

5. CORACO ACROMIAL LIGAMENT

• Extends between coracoid process and acromial process of scapula
• Coracoid process + Coraco acromial ligament+ acromial process = Coraco
acromial arch
• Prevents superior dislocation of shoulder joint

6. GLENOID LABRUM
• Fibrocartilage - Surrounds the margin of glenoid cavity
• Deepens glenoid cavity.

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BURSAE:

1. SUBSCAPULAR BURSA:
• Lies below subscapular tendon.
• Communicates with joint cavity.
2. SUBACROMIAL BURSA:
• Lies between Coraco-acromial ligament above and supraspinatus below.
• Largest bursa and continues below deltoid as sub-deltoidal bursa.
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3. INFRASPINATUS BURSA:
• Lies below infraspinatus tendon.
• Communicates with joint cavity.

RELATIONS:

1. SUPERIOR:
• Coraco acromial arch
• Supraspinatus tendon
• Subacromial bursa
• Deltoid
2. INFERIOR:
• Long head of triceps brachii
• Axillary nerve
• Posterior circumflex humeral vessels
3. ANTERIOR:
• Subscapularis
• Coracobrachialis
• Short head of biceps brachii
• Deltoid
4. POSTERIOR:
• Infraspinatus
• Teres minor
• Deltoid

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ROTATOR CUFF/ MUSCULOTENDINOUS CUFF:

FORMATION:

• Formed by tendons of muscles surrounding shoulder joint

a. Superior – Supraspinatus
b. Posterior - Infraspinatus; Teres minor
c. Interior - Subscapularis
• Most important factor providing support to shoulder joint.
• Deficient inferiorly (Inferior dislocation of joint is more common).

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MOVEMENTS:
• Multiaxial joint
• Most Mobile and least stable joint
• More prone to dislocation

MOVEMENTS MUSCLES INVOLVED

• Pectoralis Major
FLEXION
• Deltoid (Anterior fibres)
[Arm moves forwards; medially]
• Biceps brachii
EXTENSION • Latissimus dorsi
[Arm moves backwards; laterally] • Deltoid (Posterior fibres)
• Pectoralis major
ADDUCTION
• Latissimus dorsi
[arm moves backwards; medially]
• Teres major
• 0 - 15° Supraspinatus
ABDUCTION • 15 - 90° Deltoid (Lateral fibres)
[arm moves forwards; laterally] • 90 - 180° Serratus anterior,
Trapezius
MEDIAL ROTATION • Subscapularis
[arm moves medially in semi-flexed • Deltoid (Anterior fibres)
position]
LATERAL ROTATION • Infraspinatus
[arm moves laterally in semi-flexed • Teres minor
position] • Deltoid (Posterior fibres)

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NOTE*
• Deltoid muscle forms all relations for shoulder joint except inferiorly
• Deltoid causes all movements at shoulder joint except adduction

CIRCUMDUCTION - Combination of all movements of shoulder joint

SCAPULOHUMERAL RHYTHM –
• Abduction of shoulder joint is accompanied by lateral rotation of scapula
• Scapula and humerus move in ratio 1:2
• For every 15° abduction, scapular movement is 5° and humeral movement is 10°

CLINICAL ANATOMY:

DISLOCATION OF SHOULDER JOINT

• More common - Inferior dislocation
• Rotator cuff deficit inferiorly
• Causes injury of axillary nerve - Deltoid and teres minor palsy

PAINFUL ARC SYNDROME / IMPINGEMENT SYNDROME

• Most common cause - Supraspinatus injury; Subacromial bursitis
• Painful abduction

FROZEN SHOULDER
• Inflammation of rotator cuff tendons
• Painful movements

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4. ELBOW JOINT:
INTRODUCTION:
• It’s a hinge variety of synovial joint between the lower end of humerus and the upper
end of ulna and radius bones.
• The elbow joint complex includes the humeroulnar, humeroradial and upper
radioulnar joint.

ARTICULATION:

1. UPPER:
• Formed by the capitulum and the trochlea of the humerus.
• Radial fossa lies above the capitulum which articulates with the radial head during
extreme flexion.
• Coronoid fossa lies above the trochlea which articulates with the coronoid
process of the ulna during extreme flexion.
2. LOWER:
• Upper surface of the head of the radius articulates with the capitulum.
• Trochlear notch of the ulna articulates with the trochlea of the humerus.

LIGAMENTS:

1. CAPSULAR LIGAMENT:
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• Superiorly its attached to the lower end of humerus in such a way that the
capitulum, trochlea, the radial fossa, the coronoid fossa and the olecranon fossa
lies within it.
• lnferomedially, it is attached to the margin of the trochlear notch of the ulna
except laterally
• Inferolaterally, it is attached to the annular ligament of the superior radioulnar
joint.

2. THE ULNAR COLLATERAL LIGAMENT:

● It is triangular in shape.
● Its apex is attached to the medial epicondyle of the humerus, and its base to the
ulna.
● The ligament has thick anterior and posterior bands.
● These are attached below to the coronoid process and the olecranon process
respectively.
● Their lower ends are joined to each other by an oblique band which gives
attachment to the thinner intermediate fibres of the ligament.
● The ligament is crossed by the ulnar nerve and it gives origin to the flexor
digitorum.

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3. THE RADIAL COLLATERAL LIGAMENT:

● It is a fan-shaped band extending from the lateral epicondyle to the annular
ligament.
● It gives origin to the supinator and to the extensor carpi radialis brevis

RELATIONS:
1. ANTERIORLY:
• Brachialis, median nerve, brachial artery and tendon of biceps brachii.
(Contents of cubital fossa)
2. POSTERIORLY:
• Triceps brachii and anconeus.
3. MEDIALLY:
• Ulnar nerve, flexor carpi ulnaris and common flexors.
4. LATERALLY:
• Supinator, extensor carpi radialis brevis and other common extensors

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BLOOD SUPPLY:
• From anastomoses around the elbow joint

NERVE SUPPLY:
• The joint receives branches from the following nerves.
a. Ulnar nerve.
b. Median nerve.
c. Radial nerve through branch to anconeus.
d. Musculocutaneous nerve through its branch to the brachialis.

MOVEMENTS:
FLEXION:

a. Brachialis.
b. Biceps brachii.
c. Brachioradialis.

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EXTENSION:

a. Triceps brachii.
b. Anconeus.

BURSAE OF ELBOW JOINT:

1. SUB TENDINOUS OLECRANON BURSA between the tendon of triceps and capsular
ligament.
2. SUBCUTANEOUS OLECRANON BURSA behind the posterior attachment of the
capsular ligament
3. A bursa between biceps brachii and the radial tuberosity.

CARRYING ANGLE:
• Carrying angle is the angle between the long axis of arm and forearm when the arm
is in fully extended position. The carrying angle prevents forearm hitting the hips
while walking.
• Carrying angle is wider in females as compared to males due to wider pelvis of
females.

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CLINICAL ANATOMY:
● Distension of the elbow joint by an effusion occurs posteriorly because here the
capsule is weak and the covering deep fascia is thin. ASPIRATION is done
posteriorly on any side of the olecranon.
● Dislocation of the elbow is usually posterior, and is often associated with fracture
of the coronoid process. The triangular relationship between the olecranon and
the two humeral epicondyles is lost
● Subluxation of the head of the radius (pulled elbow) occurs in children when the
forearm is suddenly pulled in pronation. The head of the radius slips out from the
annular ligament.
● TENNIS ELBOW: Occurs in tennis players. Abrupt pronation with fully extended
elbow may lead to pain and tenderness over the lateral epicondyle which gives
attachment to common extensor origin. This is possibly due to:

1. Sprain of radial collateral ligament.

2. Tearing of fibres of the extensor carpi radialis brevis.

● STUDENT'S (MINER'S) ELBOW is characterized by effusion into the bursa over the
subcutaneous posterior surface of the olecranon process. The bursa on the
olecranon process gets inflamed
● GOLFER'S ELBOW is the microtrauma of medial epicondyle of humerus, occurs
commonly in golf players, the common flexor origin undergoes repetitive strain
and results in a painful condition on the medial side of the elbow.
● If carrying angle (normal is 13') is more, the condition is cubitus valgus, ulnar nerve
may get stretched leading to weakness of intrinsic muscles of hand. If the angle
is less it is called CUBITUS VARUS.

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5. BRACHIAL ARTERY:

INTRODUCTION:
• Main arterial supply of upper limb
• Present in the anterior compartment of the arm

COURSE:
• Continuation of the axillary artery from the lower border of teres major
• Terminates at the level of neck of the radius by dividing into two terminal
branches, radial and ulnar arteries
• The artery is superficial throughout its course, so it is easily accessible.

RELATIONS:

UPPER PART - Medial cutaneous nerve of forearm lies in front of it.

ANTERIOR MIDDLE PART - Median nerve crosses it from lateral to medial side.
LOWER PART - Bicipital aponeurosis crosses it.
FROM ABOVE DOWN- long head of triceps, medial head of triceps,
POSTERIOR
coracobrachialis, brachialis.
UPPER PART- Ulnar nerve and basilic vein.
MEDIAL
LOWER PART- Median nerve.
UPPER PART- Median nerve, Coracobrachialis, Biceps.
LATERAL
LOWER PART- Tendon of biceps.

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DISTRIBUTION/BRANCHES:

1. PROFUNDA BRACHII ARTERY: It is the largest and the first branch. After arising
from the posteromedial aspect of the brachial artery, it descends along with the
radial nerve  lower triangular intermuscular space spiral groove.
2. SUPERIOR ULNAR COLLATERAL ARTERY: It arises near the middle of the arm.
It accompanies the ulnar nerve.
3. INFERIOR ULNAR COLLATERAL ARTERY: It arises near the lower end of the
humerus. It will further divide into anterior and posterior branches.
4. MUSCULAR BRANCHES: To supply the muscles of the anterior compartment of
the arm.
5. NUTRIENT ARTERY: It runs through the nutrient canal of the humerus. This is one
of the events that occur at the level of insertion of the coracobrachialis.
6. TERMINAL BRANCHES: Ulnar artery and Radial artery. Of these, ulnar is larger
and radial is smaller.

**Diagram showing the extent and branches of the brachial artery

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APPLIED ANATOMY:
1. BRACHIAL PULSE: Since the brachial artery is superficial for most of its course,
its pulse can be felt. In the cubital fossa, its pulsations can be felt medial to the
tendon of biceps. These pulsations are auscultated for Korotkoff sounds while
recording blood pressure.
2. COMPRESSION OF BRACHIAL ARTERY: To stop hemorrhages in the upper limb,
the brachial artery is compressed against the shaft of the humerus at the level of
insertion of the coracobrachialis.
3. SUPRACONDYLAR FRACTURES OF THE HUMERAL SHAFT: These are common in
children after a fall on the elbow or on an extended hand and may cause posterior
displacement of the distal fragment. This proximal bone fragment may injure the
brachial artery. This may lead to Volkmann’s ischemic contracture, where the
flexors of the forearm are paralyzed due to ischemia.

SURFACE ANATOMY:
● Abduct the arm at right angles
● Mark a point A on the lower end of the lateral wall of the axilla, in front of the
posterior axillary fold (lower end of the axillary artery).
● Mark a point B in the anterior midline of the forearm at the level of neck of the
radius, medial to the tendon of biceps brachii.
● Join all the points. This is the surface marking of the brachial artery.

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6. MEDIAN NERVE
LATERAL ROOT:C5 C6 C7
FORMATION
MEDIAL ROOT:C8 T1 of brachial plexus
• Lies medial to brachial artery
• Enters cubital fossa
• Enters forearm
• Lie between flexor digitorium superficialis and flexor digitorum
COURSE profundus
• Reaches the wrist
• Lies deep and lateral to palmaris longus tendon
• Passes deep to flexor retinaculum
• Enters palm
CUBITAL FOSSA
● Medial-brachial artery
● Behind -bicipital aponeurosis
● Front - brachialis
FOREARM
● between 2 head pronator teres
• Crosses ulnar artery
RELATIONS • Passes beneath fibrous arch of flexor digitorum superficialis
• Runs deep to this muscle on surface of flexor digitorium profundus
• Accompanied by medial artery
• Lies between tendons of flexor carpi radialis and flexor digitorum
superficialis
• Overlapped by tendon of palmaris longus
• Passes through flexor retinaculum
CARPEL TUNNEL = then enters the palm
• Muscular branches
• Anterior interosseous branch
• Palmar cutaneous branch
BRANCHES
• Articular branch
• Vascular branch
• Communicating branch
• Carpel tunnel syndrome- positive Tinel and Phalen sign
CLINICAL
• TINEL SIGN (percussion over the nerve elicits tingling sensations)
ASPECTS • PHALEN SIGN (flexing both wrists at 90 degree for 60 seconds)

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7. RADIAL NERVE:
• Continuation of posterior cord of brachial plexus in the axilla
• It is the largest nerve of the brachial plexus

FORMATION/ROOT VALUE: C5, C6, C7, C8, and T1 of brachial plexus

COURSE AND RELATIONS:

A. IN THE AXILLA
• ANTERIOR: Third part of axillary artery
• POSTERIOR: Muscles forming posterior wall of axilla

B. IN THE ARM
• It enters the arm at the lower border of the teres major.
• It passes between the long and medial heads of triceps to enter the lower
triangular space, through which it reaches the spiral groove along with profunda
brachii artery.

C. IN THE SPIRAL GROOVE

• The radial nerve in the spiral groove lies in direct contact with the humerus.
• At the lower end of the spiral groove, the radial nerve pierces the lateral muscular
septum of the arm and enters the anterior compartment of the arm.
• It first descends between the brachialis and brachioradialis, and then between
brachialis and extensor carpi radialis longus.
• At the level of lateral epicondyle of humerus, it terminates by dividing into
superficial and deep branches in the lateral part of the cubital fossa
a. The deep branch; posterior interosseous nerve, in the cubital fossa
b. The superficial branch (superficial radial nerve) is sensory.
• It runs downwards over the supinator, pronator teres, and flexor digitorum
superficialis deep to brachioradialis.
• About one-third of the way down the forearm (at about 7 cm above wrist), it passes
posteriorly, emerging from under the tendon of brachioradialis, proximal to the
styloid process of radius and then passes over the tendons of anatomical snuff-
box.

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D. IN THE HAND
• It terminates as cutaneous branches in the anatomical snuff box which provide
sensory innervation to skin over the lateral part of the dorsum of hand and dorsal
surfaces of lateral 3½ digits proximal to the nail beds.

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BRANCHES:
A. IN THE AXILLA
1. Posterior cutaneous nerve of arm (which provides sensory innervation to skin on
the back of the arm up to the elbow).
2. Nerve to the long head of triceps.
3. Nerve to the medial head of triceps.

B. IN THE SPIRAL GROOVE

1. LOWER LATERAL CUTANEOUS NERVE OF THE ARM, which provides sensory
innervation to the skin on the lateral surface of the arm up to the elbow.
2. POSTERIOR CUTANEOUS NERVE OF THE FOREARM, which provides sensory
innervation to the skin down the middle of the back of the forearm up to the wrist.
3. NERVE TO LATERAL HEAD OF TRICEPS.
4. NERVE TO MEDIAL HEAD OF TRICEPS.
5. NERVE TO ANCONEUS; it runs through the substance of medial head of triceps to
reach the anconeus.

C. IN THE ANTERIOR COMPARTMENT OF ARM

Above the lateral epicondyle, it gives off the following three branches:
1. NERVE TO BRACHIALIS (small lateral part).
2. NERVE TO BRACHIORADIALIS.
3. NERVE TO EXTENSOR CARPI RADIALIS LONGUS (ECRL)

D. AT THE LEVEL OF LATERAL EPICONDYLE OF HUMERUS:

• Terminal superficial and deep branches in the lateral part of the cubital fossa.
• The DEEP BRANCH (posterior interosseous nerve) supplies 2 muscles in cubital
fossa
1. Extensor carpi radialis brevis
2. Supinator
• After supplying these two muscles, it passes through the substance of supinator and
enters the posterior compartment of the forearm and supplies all the extensor
muscles of the forearm.
• Articular branches to the distal radio-ulnar, wrist, and carpal joints.
• The SUPERFICIAL BRANCH (superficial radial nerve) is sensory.
➢ Terminates as cutaneous branches in anatomical snuff box

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➢ Provide sensory innervation to skin over the lateral part of the dorsum of hand and
dorsal surfaces of lateral 3½ digits proximal to the nail beds.
INJURIES TO THE RADIAL NERVE:
• The radial nerve may be injured at three sites:
A. In the axilla
B. In the spiral groove
C. At the elbow

A. INJURY OF RADIAL NERVE IN THE AXILLA:

• In the axilla the radial nerve may be injured by the pressure of the upper end of crutch
(crutch palsy)

CHARACTERISTIC CLINICAL FEATURES:

MOTOR LOSS:

• Loss of extension of elbow—due to paralysis of triceps.

• Loss of extension of wrist—due to paralysis of wrist extensors. This causes
wrist drop due to unopposed action of flexor muscles of the forearm
• Loss of extension of digits—due to paralysis of extensor digitorum, extensor
indicis, extensor digiti minimi, and extensor pollicis longus.
• Loss of supination in extended elbow because supinator and brachioradialis
are paralyzed but supination becomes possible in flexed elbow by the action of
biceps brachii.

SENSORY LOSS:

• Sensory loss on small area of skin over the posterior surface of the lower part
of the arm.
• Sensory loss along narrow strip on the back of forearm.
• Sensory loss on the lateral part of dorsum of hand at the base of thumb and
dorsal surface of lateral 3½ digits.

(there is an isolated sensory loss on the dorsum of hand at the base of the thumb)

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B. INJURY OF RADIAL NERVE IN THE RADIAL/SPIRAL GROOVE:

• In radial groove, the radial nerve may be injured due to:
1. midshaft fracture of humerus
2. inadvertently wrongly placed intramuscular injection
3. direct pressure on radial nerve by a drunkard falling asleep with his one arm
over the back of the chair SATURDAY NIGHT PARALYSIS.
• Injury to radial nerve occurs most commonly in the distal part of the groove
beyond the origin of nerve to triceps and cutaneous nerves.

CLINICAL FEATURES:
MOTOR LOSS:

• Loss of extension of the wrist and fingers.

• WRIST DROP.
• Loss of supination
➢ Extension of the elbow is possible but may have a little weakness because
nerves to long and lateral heads of triceps arises in the axilla i.e., before the
site of lesion.

C. INJURY OF RADIAL NERVE AT ELBOW: RADIAL TUNNEL SYNDROME:

• Entrapment neuropathy of the deep branch of radial nerve at elbow.
• Caused by compression of radial nerve by:
a. Fibrous bands, which can tether the radial nerve to the radio-humeral joint.
b. Sharp tendinous margin of extensor carpi radialis brevis.
c. Leash of vessels from the radial recurrent artery.
d. Arcade of Frohse, a fibro-aponeurotic proximal edge of the superficial part
of the supinator muscle.

CHARACTERISTIC CLINICAL FEATURES:

• Loss of extension of the wrist and fingers but no wrist drop.
• Pain over the extensor aspect of the forearm.

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8. ULNAR NERVE:
FORMATION:
• Arises from medial cord of brachial plexus C8 and T1 at the level of axilla
• Receives a contribution from ventral ramus of C7 which supplies flexor carpi ulnaris.

COURSE & RELATIONS:

• In axilla lies medial to 3rd part of axillary artery and lateral to axillary vein
• Enters arm as part of main neurovascular bundle & runs distally along medial side of
brachial artery up to level of insertion of Coraco-brachialis
• Here pierces medial intermuscular septum and enters posterior compartment of arm
and runs downwards to back of medial epicondyle, here it is lodged in a groove and
easily palpated.
• NO BRANCHES IN AXILLA & ARM.
• Enters forearm by passing between two heads of (FCU) flexor carpi ulnaris, upper 1/
3rd - vertically downwards under FCU, in lower 2/3rd superficial and lateral to FCU,
here ulnar nerve and artery descend together where artery is in lateral side

● Enters palm by passing superficial to flexor retinaculum lying just lateral to pisiform,
here it is covered by a fascial band (volar carpal ligament), the cavity formed by it is
known as ulnar tunnel

BRANCHES:

IN FOREARM:
• In proximal forearm, muscular branches to:
a. FCU
b. Medial half of flexor digitorum profundus (FDP)
• In mid fore- arm gives palmar cutaneous branch which enters palm superficial to
flexor retinaculum and provides sensory supply to skin above hypothenar eminence
• In distal forearm, gives dorsal cutaneous branch that provides sensory innervation to
skin over medial half of dorsum of hand and digital branches to medial 1½ finger.

IN PALM:
Just distal to pisiform, ulnar nerve divides to form superficial and deep terminal
branches:

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A. SUPERFICIAL TERMINAL BRANCH:

➢ Muscular branch to Palmaris brevis
➢ Digital branches to medial one and half digits including nail beds
B. DEEP TERMINAL BRANCH:
➢ Muscular branch to muscles of hypothenar eminence, medial two lumbricals,
eight interossei, terminates by supplying adductor pollicis and occasionally
deep head of flexor pollicis brevis.

EFFECTS OF INJURY:

A. INJURY AT ELBOW:
• It may be due to:
a. Fracture dislocation of medial epicondyle
b. Thickening of fibrous root of cubital tunnel
c. Compression between FCU muscle
d. Valgus deformity of elbow (tardy or late ulnar nerve palsy)

CLINICAL FEATURES:

• Atrophy and flattening of hypothenar eminence

• Claw hand deformity affecting ring and little fingers; first phalanges are
extended and middle & distal phalanges are flexed
• NOT TRUE CLAW HAND
• Loss of abduction and adduction of fingers
• Depression of interosseous spaces on dorsum of hand due to atrophy of
interosseous muscles
• Loss of abduction in thumb
• Foment's sign is positive (patient asked to grasp a card between thumb and
index finger on affected side and when examining doctor pulls the card; flexion
of distal phalanx of thumb occurs due to paralysis of adductor pollicis
B. INJURY AT WRIST:
• It may be due to:
a. Superficial position of ulnar nerve at this site makes its vulnerable to cuts
and wounds
b. Compression in GUYON'S CANAL/ PISOHAMTE’S TUNNEL

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CHARACTERISTIC CLINICAL FEATURES:

• Claw hand deformity affecting ring and little fingers but here FDP is not
paralyzed, therefore marked flexion of distal interphalangeal joints
• This is also known as ulnar paradox since FDP is not paralyzed
• Loss of abduction and adduction in fingers
• Atrophy and flattening of hypothenar eminence
• FOMENT'S SIGN IS POSITIVE

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9. BOUNDARIES OF AXILLA:

APEX or ANTERIOR: posterior surface of clavicle

POSTERIOR: superior border of the scapula and medial
CERVICOAXILLARY aspect of coracoid process
CANAL MEDIAL: outer border of first rib
BASE or FLOOR Skin, superficial fascia and axillary fascia
Pectoralis major
ANTERIOR WALL Clavipectoral fascia
Pectoralis minor
Subscapularis
POSTERIOR WALL Teres major
Latissimus dorsi
Upper 4 ribs with their intercostal muscles
MEDIAL WALL Upper part of serratus anterior
Upper part of shaft of humerus in the region of bicipital
groove
LATERAL WALL Coracobrachialis
Short head of biceps

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CONTENTS OF AXILLA:
1. Axillary artery and its branches
2. Axillary vein and its tributaries
3. Infraclavicular part of brachial plexus
4. Axillary lymph nodes
5. Axillary fat
6. Long thoracic and intercostobrachial nerves

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• The long head originates from the infraglenoid tubercle of the scapula.
• The medial head originates from the extensive area on the posterior surface of the shaft of
the humerus inferior to the radial groove.
• The lateral head originates from a linear roughening superior to the radial groove of the
humerus.
The three heads converge to form a large tendon, which inserts on the superior surface of
the olecranon of the ulna.
The triceps brachii muscle extends the forearm at the elbow joint.
The basilic vein passes vertically in the distal half of the arm, penetrates deep fascia to
assume a position medial to the brachial artery, and then becomes the axillary vein at
the lower border of the teres major muscle. The brachial veins join the basilic, or axillary,
vein.
The cephalic vein passes superiorly on the anterolateral aspect of the arm and through
the anterior wall of the axilla to reach the axillary vein.
The musculocutaneous nerve leaves the axilla and enters the arm by passing through the
coracobrachialis muscle. It passes diagonally down the arm in the plane between the
biceps brachii and brachialis muscles. After giving rise to motor branches in the arm, it
emerges laterally to the tendon of the biceps brachii muscle at the elbow,
penetrates deep fascia, and continues as the lateral cutaneous nerve of the forearm.
The musculocutaneous nerve provides:

• motor innervation to all muscles in the anterior com

partment of the arm, and
• sensory innervation to skin on the lateral surface of the
forearm
• Muscular branches include those to the triceps brachii,
brachioradialis, and extensor carpi radialis longus muscles. In addition, the radial nerve
contributes to the innervation of the lateral part of the brachialis muscle. One of the
branches to the medial head of the triceps brachii muscle arises before the radial nerve's
entrance into the posterior compartment and passes vertically down the arm in
association with the ulnar nerve. • Cutaneous branches of the radial nerve that originate
in the posterior compartment of the arm are the inferior lateral cutaneous nerve of the arm
and the posterior cutaneous nerve of the forearm, both of which penetrate through the
lateral head of the triceps brachii muscle and the overlying deep fascia to become
subcutaneous.
 75

13. WRIST JOINT [RADIO CARPAL JOINT]:

TYPE: Ellipsoid Joint

ARTICULAR SURFACES:
PROXIMAL SURFACE DISTAL SURFACE
• Inferior surface of lower end of radius • Proximal surfaces of scaphoid,
• Inferior surface of articular radio-ulnar lunate & triquetral
joint disc of inferior

LIGAMENTS:
• There are 6 ligaments around wrist joint.

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CAPSULAR LIGAMENT:
• Fibrous covering of joint

• ATTACHMENT:

a. ABOVE- to the distal ends of radius, ulna

b. BELOW- to the proximal row of carpal bones

• Synovial membrane lines the inner surface of capsule
PALMAR RADIO-CARPAL LIGAMENT:
• It is formed by thickening of lateral part of fibrous capsule
• It extends from anterior margin of lower end of radius to anterior surface of
scaphoid, lunate, triquetral
PALMAR ULNO-CARPAL LIGAMENT:
• It is formed by thickening of medial part of fibrous capsule.
• It extends from styloid process of ulna and adjoining articular disc to anterior surface
os lunate and triquetral.
DORSAL RADIO CARPAL LIGAMENT:
• It extends from posterior margin of lower end of radius to dorsal surface of scaphoid,
lunate, triquetral.

RADIAL COLLATERAL LIGAMENT:

• It extends from styloid process of radius to lateral aspect of scaphoid &trapezium

ULNAR COLLATERAL LIGAMENT:

• It extends from styloid process of radius to lateral aspect of scaphoid &trapezium

ULNAR COLLATERAL LIGAMENT:

It extends from styloid process of ulna to medial aspect of triquetral & pisiform bones

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RELATIONS:

ANTERIOR:
• Tendon of flexor digitorum superficialis [FDS] and tendon of flexor digitorum
profundus [FDP] associated with ulnar bursa.

• Tendon of flexor pollicis longus [FPL]

• Tendon of flexor carpi radialis

• Median nerve

• Ulnar nerve & vessels.

POSTERIOR:
• Extensor tendon of wrist and fingers

• Anterior interosseous artery

• Posterior interosseous nerve

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LATERAL:
• Tendon of abductor pollicis longus [APL]

• Tendon of extensor pollicis brevis [EPB]

• Radial artery

MEDIAL:
• Dorsal cutaneous branch of ulnar nerve

MOVEMENTS:
• It is a biaxial joint

• It permits the following movements

a. FLEXION

b. EXTENSION

c. ABDUCTION

d. ADDUCTION

e. CIRCUMDUCTION.

CLINICAL ANATOMY:

• GANGLION: It is a non-tender cystic swelling due to mucoid degeneration of

synovial sheath around the tendon.

• ASPIRATION OF THE WRIST: It is done by introducing needle posteriorly

below the styloid process of radius.

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14. FLEXOR RETINACULUM [TRANSVERSE CARPAL LIGAMENT]

SHAPE: Rectangular

FORMED BY: Thickening of deep fascia

• Bridges the carpal bones and forms an Osseo-fibrous tunnel called CARPAL
TUNNEL.

• On either side it gives a slip.

SUPERFICIAL SLIP DEEP SLIP

• On medial side • On lateral side

• Ulnar nerve & vessels passes • Tendon of flexor carpi

through it radialis passes through it

ATTACHMENT:

• MEDIALLY: attached to pisiform & hook of hamate

• LATERALLY: attached to scaphoid & crest of trapezium.

RELATIONS:

STRUCTURES PASSING SUPERFICIALLY:

a. Ulnar nerve
b. Ulnar artery
c. Palmar cutaneous branch of ulnar nerve
d. Palmar cutaneous branch of median nerve
e. Superficial palmar branch of radial artery
f. Tendon of palmaris longus

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STRUCTURES PASSING DEEPLY [THROUGH CARPAL TUNNEL]:

a. Tendon of flexor digitorum superficialis [FDS]
b. Tendon of flexor digitorum profundus [FDP]
c. Tendon of flexor pollicis longus [FPL]
d. Median nerve

CLINICAL ANATOMY:

CARPAL TUNNEL SYNDROME:

• Compression of median nerve in
carpal tunnel.

• Compression may due to wrist

fracture, swelling or
inflammation due to arthritis.

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15.EXTENSOR RETINACULUM (DORSAL CARPAL LIGAMENT):

• Thickening of deep fascia to form strong fibrous band to retain tendon of long
muscles in position.
• Prevents bow stringing during their action.
• Directed obliquely, medially and downwards.

ATTACHMENTS:
a. LATERALLY - Anterior border of radius
b. MEDIALLY- Triquetral, pisiform and styloid process of ulna

COMPARTMENTS OF EXTENSOR RETINACULUM:

• From lateral to medial numbered as 1 to 6.
• Tendons enclosed within synovial sheaths traverse in their compartments
accordingly.

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TRANSVERSE SECTION OF WRIST:

1.
ABDUCTOR POLLICIS LONGUS (APL) Thumb abduction
1 EXTENSOR POLLICIS BREVIS (EPB) Radial border of anatomical snuff box

2. EXTENSOR CARPI RADIALIS LONGUS Extension of wrist

EXTENSOR CARPI RADIALIS BREVIS

3. EXTENSOR POLLICIS LONGUS(EPL) ULNAR border of anatomical snuff box

4. EXTENSOR DIGITORUM (ED) Extension of medial 4 digits

3 EXTENSOR INDICIS (EI)
POSTERIOR INTEROSSEOUS NERVE
ANTERIOR INTEROSSEOUS ARTERY
5. EXTENSOR DIGITI MINIMI (EDM) Extension of little finger

6. EXTENSOR CARPI ULNARIS (ECU) Extension and adduction of wrist

5

IMPORTANT SPOTTER: ATTACHMENTS & COMPARTMENTS MAYBE SUB QUESTIONS.

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17. WINGING OF SCAPULA:

• Paralysis of serratus anterior produce winging of scapula (Wings of Heaven).
• Inferior angle and medial border of scapula more prominent.
• Paralysis of this muscle −serratus anterior due to injury to long thoracic nerve. (C5, C6,
C7).
• This leads to protraction of scapula becomes weaken, arm cannot abduct beyond 90
degree.
• CAUSES:
A. Axillary node dissection after mastectomy
B. Stab wounds

SERRATUS ANTERIOR

NERVE
ORIGIN INSERTION CLINICALS
SUPPLY
• Muscle insert into costal
surface of scapula
Paralysis of
8 digitations • Superior angle of scapula Long this muscle
from upper 8 ➢ medial border of scapula Thoracic lead to
ribs (Ribs 1-9) Nerve winging of
➢ Inferior border of scapula
scapula

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20. CARRYING ANGLE:

• It is an angle between the longitudinal axes of the arm and forearm

• Average angle:
a. For FEMALES:20 (The wider carrying angle in females avoids rubbing of
forearms with the wider female pelvis while carrying loads., for example
buckets filled with water from one place to another.)
b. For MALES :15 degrees.

IMPORTANCE:
• It increases progressively from childhood until 16 years.
• Epicondylar disease
• Surgical planning for elbow reconstruction.
• For Carrying objects.

FACTORS INFLUENCING CARRYING ANGLE:

• Elbow musculature/ligaments
• Forearm rotation
• Elbow flexion
• Anatomical Factors
➢ Superior articular surface of the coronoid process
of the ulna is placed obliquely to the long axis of
the ulna.

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21. ULNAR CLAW HAND:

• Injury of Ulnar nerve at wrist causes Ulnar Claw Hand.
• The ulnar nerve supplies all the interossei, the 3rd and 4th lumbrical muscles, the
hypothenar muscles, and the adductor pollicis.
• Atrophy of the interossei in chronic ulnar nerve palsy causes guttering of the
intermetacarpal spaces and the 1st webbed space.
• The 4th and 5th joints are hyperextended at the MCP and flexed at the IP joints,
resulting in an ulnar claw hand, which is caused by a paralysis of the 3rd and 4th
lumbricals.

CAUSES:
• Ulnar nerve at wrist is
superficial which makes it
vulnerable to cuts and
wounds.
• Compression in Guyon's
canal.

CLINICAL FEATURES OF ULNAR CLAW HAND:

• Hyperextension at metacarpophalangeal joints, flexion at the interphalangeal joints,
involving ring and little finger more than middle and index finger.
• Claw hand deformity is more obvious in wrist lesions as Flexor Digitorum Profundus
is not paralyzed, hence there is marked flexion at terminal phalanges.
• Atrophy and flattening of hypothenar eminence.
• Loss of adduction (2, 4, 5 digits).
• Loss of abduction (2, 3, 4 digits).
• Gutters seen in palm.
• Forment's sign positive.
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• Sensory loss over medial 1 ½ digits in both palmar and dorsal aspect. [Injury of both
ulnar and median nerve causes complete or true ulnar claw hand

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22. ANATOMICAL SNUFF BOX:

• Triangular depression at the base of thumb.
• Best seen in extended thumb.
BOUNDARIES:
ANTEROLATERALLY:
• Tendon of Abductor pollicis longus.

• Tendon of Extensor pollicis brevis.

POSTEROMEDIALLY:
• Tendon of Extensor pollicis longus.

STRUCTURES CROSSING THE

ROOF:
• Cephalic vein (medial to lateral)
• Terminal branch of superficial radial nerve (lateral to medial)

CONTENT:
• Radial Artery.

APPLIED ASPECTS:
• Cephalic vein at roof of Anatomical snuffbox often used for giving intravenous fluids.

• Tenderness in anatomical snuff box indicates fracture of Scaphoid bone.

• Pulsations of radial artery can be felt in the anatomical snuff box.

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24. DORSAL DIGITAL / EXTENSOR EXPANSION:

• It is a small triangular aponeurosis covering the dorsum of proximal phalanx.
• This aponeurosis is related to the tendons of extensor digitorum.
• Its base is proximal and covers the metacarpophalangeal (MP) joint.
• Main tendon of extensor digitorum occupies the central part and is separated from the
MP joint by a bursa.
• Tendons of interossei and lumbrical muscles join at posterolateral corners of extensor
expansion.
• Corners are attached to deep transverse metacarpal ligament.
• Wing tendons - The point of attachment of interossei and lumbrical is often called wing
tendon
• Near the proximal interphalangeal joint extensor tendon divides into a central slip and
2 collateral slips.
• Central slip is inserted into the dorsum of the base of the middle phalanx.
• Collateral slips along with thick margin of extensor expansion are inserted into the
dorsum of base of distal phalanx.
• Extensor expansion forms the dorsal part of fibrous capsule of metacarpophalangeal
and interphalangeal joints.

MUSCLES INSERTED INTO DORSAL DIGITAL EXPANSION:

• INDEX FINGER: 1stdorsal interosseous,2ndpalmar interosseous, 1stlumbrical, extensor

digitorum slip and extensor indicis.
• MIDDLE FINGER :2nd and 3rd dorsal interossei, 2ndlumbrical, extensor digitorum slip.
• RING FINGER: 4th dorsal interosseous, 3rd palmar interosseous, 3rd lumbrical and
extensor digitorum slip.
• LITTLE FINGER: 4th palmar interosseous, 4th lumbrical, extensor digitorum slip and
extensor digiti minimi.

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28. DELTOID:
ORIGIN:
1. Anterior border and adjoining
surface of lateral one third of
clavicle.
2. Lateral border of acromion where four
septa of origin are attached.
3. Lower lip of the crest of the spine of the
scapula.
INSERTION:
• Deltoid tuberosity of the humerus where
three septa of insertion are attached.
NERVE SUPPLY:
• Axillary nerve (C5, C6)
ACTIONS:
• Powerful abductors of arm at the shoulder joint from beginning to 90 degree.
• Anterior fibres are flexors and medial rotators of arm.
• Posterior fibres are extensors and
lateral rotators of arm.

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STRUCTURES UNDER COVER OF DELTOID:

BONES:
• Upper end of the humerus.
• Coracoid process.

MUSCLES INSERTION:
• Pectoralis minor on coracoid process.
• Supraspinatus, infraspinatus and teres minor on greater tubercle of the humerus.
• Subscapularis on lesser tubercle of humerus.
• Pectoralis major, teres major and latissimus dorsi on the
• Long head of triceps brachii from infraglenoid tubercle.
• Lateral head of triceps brachii from the upper part of posterior surface of humerus.
• intertubercular sulcus of humerus.

MUSCLES ORIGIN:
• Coracobrachialis and short head of biceps brachii from coracoid process
• Long head of biceps brachii from the supraglenoid tubercle.

VESSELS:
• Anterior circumflex humeral.
• Posterior circumflex humeral.

NERVE:
• Axillary nerve
JOINTS AND LIGAMENTS:
• Musculotendinous cuff of shoulder.
• Coracoacromial ligament.

BURSAE:
• Subacromial bursa and subdeltoid bursa.

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CLINICAL ANATOMY:
• Intramuscular injection is often given in the deltoid. It should be given in the middle of
the muscle to avoid injury to the axillary nerve.
• Axillary nerve may be damaged by dislocation of shoulder or by the fracture of surgical
neck of humerus

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29. MUSCLES CONTROLLING MOVEMENT OF THUMB:

• The muscles controlling the movements of thumb are
a. Three muscles of thenar eminence: abductor pollicis brevis, flexor pollicis
brevis, opponens pollicis
b. Adductor pollicis
c. First dorsal interossei

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 106

NERVE
MUSCLE ORIGIN INSERTION SUPPLY ACTION TEST

PEN /PENCIL
TEST: lay the
hand flat on
Tubercle of table with
ABDUCTOR scaphoid, Base of palm directed
crest of proximal Median Abduction upwards.
POLLICIS trapezium, phalanx of nerve of thumb The patient is
BREVIS flexor thumb unable to
retinaculum touch the
pen/pencil
held in front of
palm
flexor Flexes
FLEXOR retinaculu Base of metacarp
m, crest of proximal Median o
POLLICIS
trapezium, phalanx of nerve phalangea
BREVIS capitate thumb l joint of
bones thumb

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NERVE
MUSCLE ORIGIN INSERTION ACTION TEST
SUPPLY
Pulls
Lateral half thumb
of palmar medially
Flexor
surface of and Request the patient
OPPONENS retinaculum
shaft of Median forward to touch the proximal
POLLICIS , crest of
metacarpal nerve across phalanx of 2nd to 5th
trapezium
bone of palm with tip of thumb.
thumb (oppositi
on)

OBLIQUE FORMENT’S SIGN

HEAD: bases
OR BOOK TEST: Ask
of 2nd and
Base of the subject to grasp a
3rd
proximal book firmly between
metacarpals Deep Adduction
ADDUCTOR phalanx of thumbs and other
TRANS- branch of of fingers of both the
POLLICIS VERSE thumb on its ulnar nerve
thumb hands, the terminal
HEAD: medial
phalanx of the thumb
aspect
shaft of on paralyzed side
3rdmetacarpa becomes flexed at
l interphalangeal joint.
Flex
Via extensor metacarp
Ask the subject to
expansion o
FIRST Adjacent abduct the thumb
into dorsum Deep phalangea
DORSAL sides of shaft against resistance. As
of bases of branch of l joint and
of 1st and 2nd index finger is
INTEROSSEI metacarpal distal ulnar nerve extend
abducted one feels 1st
phalanx of interphala
dorsal interossei
2nd digit ngeal joint
abduction

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