THE UPPER LIMB

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Outline
• Introduction
• Bones of the upper limb
• Superficial structures of upper limb
• Axioappendicular Muscles
• Axilla
• Brachial plexus
• Arm
• Cubital fossa
• Forearm
• Hand
• Surface anatomy upper limb
• Joints of upper limb
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INTRODUCTION
• Upper limb consists of 4
segments
– Shoulder:
• pectoral girdle
– Arm:
• humerus
– Forearm:
• ulna and radius
– Hand:
• carpus,
• metacarpus and
• phalanges
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 BONES OF THE UPPER LIMB

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Introduction
• The superior appendicular skeleton
– Composed of
• pectoral girdle
• bones of the free part of the upper limb
– Articulates with the axial skeleton only at the
sternoclavicular joint
• allows great mobility

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 Pectoral (Shoulder) Girdle
• Consists of two bones:
clavicle and scapula
• Loosely attached, held in
place largely by
musculature
• Frees girdle to move over
the thorax

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Clavicle (collar bone)
Double curved bones extending along the superior
thorax
The medial two thirds of the shaft of the clavicle are
convex anteriorly, whereas the lateral third is flattened
and concave anteriorly
curvatures increase the resilience of the clavicle
sternal end: articulates with manubrium of the sternum
at the sternoclavicular (SC) joint
acromial end:
 articulates with
acromion of scapula
at the acromioclavicular (AC)
joint
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CLAVICLE: FUNCTION
• Connects the upper limb to the trunk
• Attachment site for muscles of the thorax and shoulder
• Position scapula away from thorax so that the arm has
maximum freedom of motion
• Enables elevation of the ribs for deep inspiration
• Afford protection to the neurovascular bundle supplying
the upper limb
• Transmits shocks (traumatic impacts) from the upper
limb to the axial skeleton

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 FRACTURE OF CLAVICLE
• Commonly caused by an indirect force
transmitted from an outstretched hand
during a fall
• The weakest part is at the junction of its
middle and lateral thirds
• After fracture
– sternocleidomastoid (SCM) muscle
elevates the medial fragment of bone
– trapezius muscle is unable to hold up
the lateral fragment owing to the
weight of the upper limb
– thus the shoulder drops

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 SCAPULA (SHOULDER BLADE)
• Triangular flat bone
• Lies on the posterolateral
aspect of the thorax,
overlying the 2nd-7th ribs.
• It has
– 3 angles (lateral, superior, and
inferior);
– 3 borders (superior, lateral, and
medial);
– 2 surfaces (costal and
posterior); and
– 3 processes (acromion, spine,
and coracoid process
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 LATERAL ANGLE

• is marked by a shallow,
somewhat comma-shaped
glenoid cavity, which
articulates with the head of the
humerus to form the
glenohumeral joint.
• A large triangular-shaped
roughening (the infraglenoid
tubercle) inferior to the glenoid
cavity is the site of attachment
for the long head of the triceps
brachii muscle.
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 Cont… LATERAL
• A less distinct
supraglenoid tubercle is
located superior to the
glenoid cavity and is the
site of attachment for the
long head of the biceps
brachii muscle.

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 POSTERIOR SURFACE
• convex
• divided by spine into
supraspinous and
infraspinous fossa
• spine continues laterally as
flat expanded acromion
which articulates with the
acromial end of the
clavicle

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 Cont… POSTERIOR
• The region
between the
lateral angle of
the scapula and
the attachment of
the spine to the
posterior surface
of the scapula is
the greater
scapular notch
(spinoglenoid
notch).
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 ANTERIOR SURFACE
• Is characterized by a shallow
concave subscapular fossa
over much of its extent.
• The costal surface and
margins provide for muscle
attachment, and the costal
surface, together with its
related muscle
(subscapularis), move freely
over the underlying thoracic
wall.

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 LATERAL BORDER
• Is strong and thick for
muscle attachment,
whereas the medial
border and much of the
superior border is thin
and sharp.
• It includes head of the
scapula where the
glenoid cavity is located
• Neck
– just inferior to the head
• Coracoid process
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 SUPERIOR BORDER

• Is marked on its lateral

end by:
– the coracoid process, a hook-
like structure that projects
anterolaterally and is
positioned directly inferior to
the lateral part of the clavicle;
and
– the small but distinct
suprascapular notch, which
lies immediately medial to the
root of the coracoid process.

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 THE FREE UPPER LIMB
• Arm
– Humerus
• Forearm
– Ulna
– Radius
• Hand
– Wrist (8 carpal bones)
– Palm (5 metacarpal bones)
– Fingers (14 phalanges)
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 HUMERUS
• The longest bone of
upper extremity
• Consist of head, shaft
(body), anatomical &
surgical necks,
tubercles (greater &
lesser)
• Head
– ball-shaped
– proximally articulate
with the glenoid
cavity of the scapula
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 TUBERCLES
• lesser and greater tubercle
• intertubercular groove
(bicipital groove)
separates the two
tubercles.
• Anatomical neck
– just distal to the humeral
head
– separates the head from
the tubercles
• Surgical neck
– narrow part just distal to
the tubercles
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SHAFT (BODY)
• two prominent features:
– deltoid tuberosity
laterally for
attachment of deltoid
muscle
– radial (spiral) groove
posteriorly for radial
nerve and deep artery
of the arm
• inferior end
– widens as sharp
medial and lateral
supracondylar ridges
– ends distally as medial
and lateral epicondyle

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 CONDYLES OF THE HUMERUS

• distal end of the humerus

• include trochlea, capitulum,
olecranon, coronoid, and
radial fossae
• has two articular surfaces
– capitulum: for articulation
with
the head of the
radius
– trochlea: for articulation with
the trochlear notch of the ulna

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• Coronoid fossa
– superior to the trochlea anteriorly
– receives the coronoid process of
the ulna during full flexion of the
elbow
• Radial fossa
– superior to the capitulum
anteriorly
– accommodates the edge of the
head of the radius when the elbow
is fully flexed
• Olecranon fossa
– posteriorly
– accommodates the olecranon of
the ulna during extension of the
elbow
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 FRACTURE OF THE HUMERUS
• Fractures of the surgical
neck of the humerus
– common in elderly people
– usually result from a fall on
the hand
• Transverse fractures of the
shaft of humerus
• Supracondylar fracture

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• Because nerves are in
contact with the humerus,
they may be injured when
the associated part of the
humerus is fractured
– Surgical neck – axillary nerve
– Radial groove – radial nerve
– Distal humerus – median nerve
– Medial epicondyle – ulnar nerve

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 ULNA
• The medial and longer of
the two forearm bones
• Its proximal end has two
prominent projections
– olecranon posteriorly
– coronoid process
anteriorly - form the
walls of the trochlear
notch

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• Trochlear notch
– articulates with the trochlea of
the humerus
• Radial notch
– on the lateral side of the
coronoid process
– articulates with the head of
radius
• Shaft (body)
– proximally it is thick, but it
tapers distally
• Head
– narrow distal end
– rounded with small, conical
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ulnar styloid process
 RADIUS
• The lateral and shorter of
the two forearm bones
• Its proximal end consists
of a cylindrical head, a
short neck, a projection
from the medial surface
(radial tuberosity)

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• Head
– superior surface is concave for
articulation with capitulum of
humerus
– medially articulate with radial
notch of ulna
• Neck
– narrow part between head and
radial tuberosity
• Shaft (body)
– gradually enlarges distally
• Distal end
– medially - ulnar notch for head of
ulna
– laterally - radial styloid process
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FRACTURE OF ULNA AND RADIUS
• A direct injury usually produces
transverse fractures at the same
level, often in the middle third of
the bones
• Colles fracture
– A complete fracture of the distal end
of the radius
– The most common fracture of the
forearm
– Results from forced dorsiflexion of
the hand
– The distal fragment of the radius is
displaced dorsally and often broken
into pieces
– Often, the ulnar styloid process is
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 CARPALS BONES
• 8 bones, form the
wrist (carpus)
• Arranged in two
transverse rows of 4
bones
• Carpus is convex
from side to side
posteriorly and
concave anteriorly

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 PROXIMAL ROW
• articulate with radius and
articular disc of wrist
joint proximally and distal
row of carpals distally
• Proximal row from lateral
to medial:
– Scaphoid: boat-shaped
with scaphoid tubercle
– Lunate: moon-shaped
– Triquetrum: pyramidal
– Pisiform: pea-shaped; lies
on palmar surface of
triquetrum

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 DISTAL ROW

• Articulate with proximal

row of carpals proximally
and metacarpals distally
• Distal row from lateral to
medial
– Trapezium: four sided
– Trapezoid: wedge-shaped
– Capitate: head like; largest
– Hamate: wedge-shaped,
has hooked process (hook
of hamate

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 METACARPALS
• Forms the skeleton of the
palm
• Composed of five
metacarpal bones
• Each metacarpal consists of
a base, shaft, and head
• The proximal bases
articulate with the carpal
bones
• The distal heads articulate
with the proximal phalanges
and form the knuckles
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 PHALANGES
• 14 bones; form the fingers
• Each digit has three
phalanges (proximal, middle,
and distal) except for the
first, which has only two
(proximal and distal)
• Each phalanx has a base
proximally, a shaft (body),
and a head distally
• The distal phalanges are
flattened and expanded at
their distal ends, which
underlie the nail beds
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SURFACE ANATOMY OF UPPER LIMB
BONES
• The following structures are palpable
– Jugular notch
– Acromion
– Coracoid process of scapula
– Spine of scapula
– Greater tubercle of humerus
– Medial and lateral epicondyles
– Olecranon
– Styloid processes of radius and ulna
– Pisiform
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SUPERFICIAL STRUCTURES
OF UPPER LIMB

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 FASCIA OF UPPER LIMB
• Pectoral fascia
– Invests the pectoralis
major
– Continuous inferiorly
with fascia of anterior
abdominal wall
– Leaves lateral border
of pectoralis major
and becomes axillary
fascia

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• Clavipectoral fascia
– Deep to pectoralis major
– Descends from the clavicle,
enclosing subclavius and then the
pectoralis minor
– Becoming continuous inferiorly
with the axillary fascia
– Costocoracoid membrane
• the part of clavipectoral fascia
between pectoralis minor and
subclavius
• pierced by lateral pectoral nerve
– Suspensory ligament of axilla
• the part of the clavipectoral fascia
inferior to pectoralis minor
• supports the axillary fascia and
pulls it upward and forms axillary
fossa
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• Deltoid fascia
– Invests deltoid muscle
• Brachial fascia
– encloses the arm
– continuous with deltoid,
pectoral, axillary, infraspinous
and antebrachial fasciae
– form two intermuscular septa
• medial and lateral
• extend from the deep surface of
the brachial fascia and attach to
the humerus
• divide the arm into anterior
(flexor) and posterior (extensor)
fascial compartments

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• Antebrachial fascia
– In the forearm
– Surrounds fascial compartments separated by
interosseous membrane
– Thickens posteriorly over the distal end to
form a transverse band, extensor retinaculum,
which holds the extensor tendons in position
– Anteriorly at distal end forms an anterior
thickenings, palmar carpal ligament and flexor
retinaculum

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• Palmar fascia
– Extension of deep fascia beyond retinacula
– Palmar aponeurosis
• Central part, thick, triangular
• Forms four thickenings that radiate to the base of
fingers
• Superficial transverse metacarpal ligament:
traverse bands distally and form the base of palmar
aponeuroses
• Ligaments extend from aponeurosis to skin, hold
the skin closer

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 CUTANEOUS NERVES OF UPPER LIMB
• Developmentally the limbs grow as lateral protrusions of trunk, with
thumb located on cranial side
• Most cutaneous nerves of upper limb are derived from brachial
plexus
• Cutaneous nerves to shoulder are derived from cervical plexus
• C4: base of the neck, shoulder
• C5: arm laterally
• C6: forearm laterally and thumb
• C7: middle three fingers and middle of posterior surface
• C8: little finger, the medial side
• T1: middle of forearm to axilla
• T2: small part of arm and axilla

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SUPERFICIAL VESSELS OF UPPER LIMB
• Dorsal venous network
– On dorsum of the hand
– Give rise to cephalic and basilic veins
• Cephalic vein
– Ascends from lateral part of dorsal venous network
– Proceed along anterolateral surface of forearm and arm
– Anterior to elbow communicate with median cubital vein
– Superiorly passes between deltoid and pectoralis major
muscles and enters clavipectoral triangle
– Pierces clavipectoral fascia and joins axillary vein

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• Basilic vein
– Ascends from medial part of dorsal venous network
– Proceed along medial side of forearm and inferior part of arm
– Passes deeply near the junction of the middle and inferior
thirds of the arm, piercing the brachial fascia and running
superiorly parallel to the brachial artery
– Merges with the accompanying veins (venae comitantes) of the
axillary artery to form the axillary vein
• Median antebrachial vein (median vein of forearm)
– Ascends in the middle of anterior aspect of forearm between
cephalic and basilic veins

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 LYMPHATIC VESSELS OF UPPER
LIMB
• Superficial lymphatic vessels
– Arise from lymphatic plexuses in the skin of fingers,
palm, and dorsum of the hand
– Ascend with superficial veins
– accompany the basilic vein cubital lymph nodes
– accompany the cephalic vein apical axillary
lymph nodes
• Deep lymphatic vessels
– Accompany major veins and terminate in humeral
axillary lymph nodes
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VENIPUNCTURE
• Puncture of a vein to draw blood or inject a
solution
• Because of the prominence and accessibility of
the superficial veins, they are commonly used for
venipuncture
• The median cubital vein is commonly used for
venipuncture
• The veins forming dorsal venous network and
the cephalic and basilic veins arising from it are
commonly used for long-term introduction of
fluids
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 AXIOAPPENDICULAR
MUSCLES

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 ANTERIOR AXIOAPPENDICULAR
MUSCLES

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PARALYSIS OF SERRATUS ANTERIOR

• Due to injury of long

thoracic nerve
– Medial border of the scapula
moves laterally and posteriorly
away from thoracic wall
• winged scapula
– Arm cannot be abducted above
horizontal position

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 POSTERIOR AXIOAPPENDICULAR
MUSCLES
• Attach the superior appendicular skeleton to the
axial skeleton
• Divided into three groups
– Superficial (extrinsic shoulder) muscles : trapezius and
latissimus dorsi
– Deep (extrinsic shoulder) muscles : levator scapulae and
rhomboids
– Scapulohumeral (intrinsic shoulder) muscles: deltoid, teres
major, and the four rotator cuff muscles (supraspinatus,
infraspinatus, teres minor, and subscapularis)

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SCAPULOHUMERAL MUSCLES
• Six muscles
– Deltoid
– Teres major
– Supraspinatus
– Infraspinatus
– Subscapularis
– Teres minor
• Short muscles that pass from scapula to humerus
• Act on glenohumeral joint

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Injury to axillary nerve
• Occur when surgical neck of humerus is
fractured
• Results in atrophy of deltoid
• Rounded contour of shoulder disappears
• To test deltoid (function of axillary nerve) the
arm is abducted against resistance
Rotator cuff injuries
• Produce instability of glenohumeral joint
• Rapture of supraspinous tendon is the most
common injury
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 SURFACE ANATOMY
• Triangle of auscultation
– The area formed by the superior
border of latissimus dorsi, the
medial border of the scapula, and
the inferolateral border of the
trapezius
– This gap in the thick back
musculature is a good place to
examine posterior segments of the
lungs with a stethoscope
– When the scapulae are drawn
anteriorly by folding the arms
across the thorax and the trunk is
flexed, the auscultatory triangle
enlarges
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