CUBITAL FOSSA

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• The cubital fossa is an important area of
transition between the arm and the forearm.
• It is located anterior to the elbow joint and is a
triangular depression formed between two
forearm muscles:
• The brachioradialis muscle originating from
the lateral supraepicondylar ridge of the
humerus;
• The pronator teres muscle originating from
the medial epicondyle of the humerus
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• The boundaries of the cubital fossa are:
• Superiorly--an imaginary line connecting the
medial and lateral epicondyles.
• Medially--the pronator teres.
• Laterally--the brachioradialis.
The base of the triangle is an imaginary
horizontal line between the medial and lateral
epicondyles.
The bed or floor of the fossa is formed mainly
by the brachialis muscle medially and supinator
muscle laterally.
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 Cubital fossa showing boundaries

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 CONTENTS OF CUBITAL FOSSA
• The major contents of the cubital
fossa, from lateral to medial, are:
• The tendon of the biceps brachii
muscle;
• The terminal part of brachial artery;
• The median nerve.
• The superficial branch of radial nerve

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• The brachial artery normally bifurcates
into the radial and ulnar arteries in the
apex of the fossa, although this
bifurcation may occur much higher in the
arm, even in the axilla.
• When taking a blood pressure reading
from a patient, the clinician places the
stethoscope over the brachial artery in
the cubital fossa.
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• The median nerve lies immediately medial to the
brachial artery and leaves the fossa by passing
between the ulnar and humeral heads of the
pronator teres muscle.
• The brachial artery and the median nerve are
covered and protected anteriorly in the distal part
of the cubital fossa by the bicipital aponeurosis.
• This flat connective tissue membrane passes
between the medial side of the tendon of the
biceps brachii muscle and deep fascia of the
forearm.
• The sharp medial margin of the bicipital
aponeurosis can often be felt.
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• The radial nerve lies just under the lip of the
brachioradialis muscle, which forms the lateral
margin of the fossa.
• In this position, the radial nerve divides into
superficial and deep branches: the superficial
branch continues into the forearm just deep
to the brachioradialis muscle;
• the deep branch passes between the two
heads of the supinator muscle to access the
posterior compartment of the forearm.

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• The roof of the cubital fossa is formed by superficial
fascia and skin.
• The most important structure within the roof is the
median cubital vein, which passes diagonally across
the roof and connects the cephalic vein on the lateral
side of the upper limb with the basilic vein on the
medial side.
• The bicipital aponeurosis separates the median cubital
vein from the brachial artery and median nerve.
• Other structures within the roof are cutaneous nerves-
the medial cutaneous and lateral cutaneous nerves of
the forearm.

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 FOREARM

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• The forearm is the part of the upper limb that
extends between the elbow joint and the wrist
joint.
• Proximally, most major structures pass
between the arm and forearm through, or in
relation to, the cubital fossa, which is anterior
to the elbow joint.
• The exception is the ulnar nerve, which passes
posterior to the medial epicondyle of the
humerus.

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• Distally, structures pass between the forearm
and the hand through, or anterior to, the
carpal tunnel.
• The major exception is the radial artery, which
passes dorsally around the wrist to enter the
hand posteriorly.

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• The bony framework of the forearm consists
of two parallel bones, the radius and the ulna.
• The radius is lateral in position and is small
proximally, where it articulates with the
humerus, and large distally, where it forms the
wrist joint with the carpal bones of the hand.

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• The ulna is medial in the forearm, and its
proximal and distal dimensions are the reverse
of those for the radius: the ulna is large
proximally and small distally.
• Proximal and distal joints between the radius
and the ulna allow the distal end of the radius
to swing over the adjacent end of the ulna,
resulting in pronation and supination of the
hand.
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 FOREARM BONES

• The two forearm bones include:

• The laterally placed radius and
• The medially placed stabilizing bone called
ulna

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 ANTERIOR
COMPARTMENT OF THE
FOREARM

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• Muscles in the anterior (flexor) compartment
of the forearm occur in three layers:
superficial, intermediate, and deep.
• Generally, these muscles are associated with:
• movements of the wrist joint;
• flexion of the fingers including the thumb;
• pronation.

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• All muscles in the anterior compartment of
the forearm are innervated by the median
nerve, except for the flexor carpi ulnaris
muscle and the medial half of the flexor
digitorum profundus muscle, which are
innervated by the ulnar nerve.

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 Superficial muscles of the forearm
MUSCLE ORIGIN INSERTION INNERVATION ACTION

Pronator Humeral head-

medial
teres epicondyle and
adjacent
Roughening on
lateral surface, Flexes and
supraepicondyla mid-shaft, of Median nerve abducts the
r ridge; radius [C6,C7] wrist
ulnar head-
medial side of
coronoid
process
Flexor Medial Base of Median nerve Pronation
carpi epicondyle of metacarpals II [C6,C7]
radialis humerus and III

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 Superficial muscles of the forearm
MUSCLE ORIGIN INSERTION INNERVATION ACTION
Flexes wrist
joint; because
Palmaris Medial
epicondyle of
Palmar
aponeurosis of
Median nerve
[C7,C8]
the palmar
aponeurosis
longus humerus hand anchors skin of
the hand,
contraction of
the muscle
resists shearing
forces when
gripping

Flexor Humeral head-

medial
Pisiform bone,
and then via
carpi epicondyle of pisohamate and Ulnar nerve Flexes and
ulnaris humerus;
ulnar head-
pisometacarpal [C7,C8, T1]
ligaments into
adducts the
wrist joint
olecranon and the hamate and
posterior border base of
of ulna metacarpal V
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 Intermediate layer
MUSCLE ORIGIN INSERTION INNERVATION ACTION
Humero-ulnar Flexes proximal
head-medial Four tendons, interphalangeal
epicondyle of which attach to joints of the
Flexor humerus and the palmar index, middle,
digitorum adjacent margin surfaces of the Median nerve ring, and little
of coronoid middle [C8,T1] fingers; can also
superficialis process; phalanges of the flex
radial head- index, middle, metacarpophala
oblique line of ring, and little ngeal joints of
radius fingers the same fingers
and the wrist
joint

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Notes

• In the distal forearm, flexor digitorum superficialis

forms four tendons, which pass through the carpal
tunnel of the wrist and into four fingers.
• The tendons for the ring and middle fingers are
superficial to the tendons for the index and little
fingers.
• In the forearm, carpal tunnel, and proximal regions
of the four fingers, the tendons of flexor digitorum
superficialis are anterior to the tendons of the
flexor digitorum profundus muscle.

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Deep layer muscles of the forearm
MUSCLES ORIGIN INSERTION INNERVATION ACTION

Flexor Anterior and

medial surfaces
Four tendons,
which attach to
Lateral half by
median nerve
Flexes distal
interphalangeal
digitorum of ulna and the palmar (anterior joints of the
profundus anterior medial
half of
surfaces of the
distal phalanges
interosseous
nerve); medial
index, middle,
ring, and little
interosseous of the index, half by ulnar fingers; can also
membrane middle, ring, nerve [C8,T1] flex
and little fingers metacarpophala
ngeal joints of
the same fingers
and the wrist
joint

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Deep layer muscles of the forearm
MUSCLES ORIGIN INSERTION INNERVATION ACTION

Flexor Anterior surface

of radius and
Palmar surface
of base of distal
Median nerve
(anterior
Flexes
interphalangeal
pollicis radial half of phalanx of interosseous joint of the
longus inter-osseous
membrane
thumb nerve) [C7,C8] thumb; can also
flex metacarpo-
phalangeal joint
of the thumb

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Deep layer muscles of the forearm
MUSCLES ORIGIN INSERTION INNERVATION ACTION

Pronator Linear ridge on

distal anterior
Distal anterior Median nerve
surface of radius (anterior
Pronation
quadratus surface of ulna interosseous
nerve) [C7,C8]

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 ARTERIES AND VEINS OF ANTERIOR
FOREARM

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• The largest arteries in the forearm are in the
anterior compartment, pass distally to supply
the hand, and give rise to vessels that supply
the posterior compartment.
• The brachial artery enters the forearm from
the arm by passing through the cubital fossa.
At the apex of the cubital fossa, it divides into
its two major branches, the radial and ulnar
arteries.

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 Radial artery
• The radial artery originates from the brachial artery at
approximately the neck of the radius and passes along the
lateral aspect of the forearm .
• It is:
 just deep to the brachioradialis muscle in the proximal half
of the forearm;
 related on its lateral side to the superficial branch of the
radial nerve in the middle third of the forearm;
 medial to the tendon of the brachioradialis muscle and
covered only by deep fascia, superficial fascia, and skin in
the distal forearm.
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• The radial artery leaves the forearm, passes
around the lateral side of the wrist, and
penetrates the dorsolateral aspect of the hand
(floor of anatomical snuff box) between the
bases of metacarpals I and II.
• Branches of the radial artery in the hand
often provide the major blood supply to the
thumb and lateral side of the index finger.

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Branches of radial artery in the forearm
• a radial recurrent artery,
• a small palmar carpal branch contributes to
an anastomotic network of vessels that
supplies the carpal bones and joints;
• a somewhat larger branch, the superficial
palmar branch

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 Ulnar artery
• The ulnar artery is larger than the radial artery
and passes down the medial side of the
forearm.
• It leaves the cubital fossa by passing deep to
the pronator teres muscle, and then passes
through the forearm in the fascial plane
between flexor carpi ulnaris and flexor
digitorum profundus muscles.

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• In the distal forearm, the ulnar artery often
remains tucked under the anterolateral lip of the
flexor carpi ulnaris tendon, and is therefore not
easily palpable.
• It is also medial to the ulnar nerve.
• The ulnar artery leaves the forearm, enters the
hand by passing lateral to the pisiform bone and
superficial to the flexor retinaculum of the wrist,
and arches over the palm.
• It is often the major blood supply to the medial
three and one-half digits.
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 Branches of ulna artery in the forearm
• the ulnar recurrent artery with anterior and
posterior branches, which contribute to an
anastomotic network of vessels around the elbow
joint;
• numerous muscular arteries, which supply
surrounding muscles;
• the common interosseous artery, which divides into
anterior and posterior interosseous arteries;
• two small carpal arteries (dorsal carpal branch and
palmar carpal branch), which supply the wrist.
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 Veins of the Forearm

Superficial Veins
• The main superficial veins of the forearm are
the cephalic, basilic, median cubital, and
antebrachial veins and their tributaries.

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• Deep veins
• Many deep veins accompany the arteries in the
forearm.
• These accompanying veins arise from a deep venous
arcade.
• From the lateral side of the arcade, paired radial vein
accompany the radial artery while on the medial
side paired ulnar vein accompany the ulnar artery.
• These veins anastomose with each other freely.

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POSTERIOR COMPARTMENT
OF FOREARM

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• Muscles in the posterior compartment of the
forearm occur in two layers: a superficial and a
deep layer.
• These muscles are associated with:
movement of the wrist joint;
extension of the fingers and thumb;
supination.

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 Superficial group of muscles
• The seven muscles in the superficial layer are:
the brachioradialis,
extensor carpi radialis longus,
extensor carpi radialis brevis,
extensor digitorum,
extensor digiti minimi,
extensor carpi ulnaris,
and anconeus
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• They all have a common origin from the
supraepicondylar ridge and lateral epicondyle
of the humerus and, except for the
brachioradialis and anconeus, extend as
tendons into the dorsum of the hand.

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MUSCLE ORIGIN INSERTION INNERVATION ACTION

Brachiora Proximal part Lateral surface Radial nerve Accessory

of lateral of distal end of [C5,C6] before flexor of elbow
dialis supraepicondy radius division into joint when
lar ridge of superficial and forearm is
humerus and deep branches mid-pronated
adjacent inter-
muscular
septum

Extensor Distal part of Dorsal surface Radial nerve Extends and

carpi lateral of base of [C6,C7] before abducts the
supraepicondy metacarpal II division into wrist
radialis lar ridge of superficial and
longus humerus and deep branches
adjacent
intermuscular
septum

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 Extensor carpi
Brachioradialis radialis longus

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MUSCLE ORIGIN INSERTION INNERVATION ACTION
Extensor Lateral Dorsal surface Deep branch Extends and
carpi epicondyle of of base of of radial nerve abducts the
humerus and metacarpals II [C7,C8] before wrist
radialis adjacent and III penetrating
brevis intermuscular supinator
septum muscle

Extensor Lateral Four tendons, Posterior Extends the

epicondyle of which insert interosseous index, middle,
digitorum humerus and via 'extensor nerve [C7,C8] ring, and little
adjacent hoods' into fingers; can
intermuscular the dorsal also extend
septum and aspects of the the wrist
deep fascia bases of the
middle and
distal
phalanges of
the index,
middle, ring,
and little
fingers
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 Extensor Carpi
radialis brevis

Extensor digitorum

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MUSCLE ORIGIN INSERTION INNERVATION ACTION

Extensor Lateral
epicondyle of
digiti humerus and
adjacent Dorsal hood of
Posterior
interosseous Extends the
minimi intermuscular
septum
the little finger nerve [C7,C8] little finger

together with
extensor
digitorum

Extensor Lateral
epicondyle of
Tubercle on the Posterior
base of the interosseous
Extends and
adducts the
carpi humerus and
posterior border
medial side of
metacarpal V
nerve [C7,C8] wrist

ulnaris of ulna

Lateral Olecranon and Radial nerve [C6 Abduction of

epicondyle of proximal to C8] (via the ulna in
Anconeus humerus posterior branch to pronation;
surface of ulna medial head of accessory
triceps brachii) extensor of the
elbow joint
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 Anconeus

Extensor Carpi Ulnaris

Extensor Digiti Minimi

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 Deep layer
• The deep layer of the posterior compartment
of the forearm consists of five muscles:
Supinator,
Abductor pollicis longus,
Extensor pollicis brevis,
 Extensor pollicis longus,
And extensor indicis

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 A

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MUSCLE ORIGIN INSERTION INNERVATION ACTION
Superficial part- Lateral surface
lateral of radius
epicondyle of superior to the Posterior
Supinator humerus, radial
collateral and
anterior oblique interosseous
line nerve [C6,C7] Supination
anular
ligaments;
deep part-
supinator crest
of the ulna
Posterior Abducts
surfaces of ulna Lateral side of Posterior carpometacarpa
Abductor and radius base of interosseous l joint of thumb;
pollicis (distal to the
attachments of
metacarpal I nerve [C7,C8] accessory
extensor of the
longus supinator and thumb
anconeus), and
intervening
interosseous
membrane

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 A

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MUSCLE ORIGIN INSERTION INNERVATION ACTION
Posterior Extends
surface of Dorsal surface metacarpopha
Extensor radius (distal of base of Posterior langeal joint of
pollicis to abductor proximal interosseous the thumb;
brevis pollicis longus) phalanx of the nerve [C7,C8] can also
and the thumb extend the
adjacent carpometacar
interosseous pal joint of the
membrane thumb
Posterior Extends
surface of ulna Dorsal surface Posterior interphalange
Extensor (distal to the of base of interosseous al joint of the
abductor distal phalanx nerve [C7,C8] thumb; can
pollicis pollicis longus) of thumb also extend
longus and the
adjacent
carpometacar
pal and
interosseous metacarpopha
membrane langeal joints
of the thumb

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MUSCLE ORIGIN INSERTION INNERVATION ACTION

Extensor Posterior
suface of
indicis ulna (distal Extensor Posterior Extends
to extensor hood of interosseous index
pollicis index nerve [C7,C8] finger
longus) and finger
adjacent
interosseous
membrane

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 Nerve of the posterior compartment
• The nerve of the posterior compartment of
the forearm is the radial nerve.
• In the lateral wall of the cubital fossa, and
before dividing into superficial and deep
branches, the radial nerve innervates the
brachioradialis and extensor carpi radialis
longus muscles.

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• The deep branch innervates the extensor carpi
radialis brevis, then passes between the two
heads of the supinator muscle and follows the
plane of separation between the two heads
dorsally and laterally around the proximal
shaft of the radius to the posterior aspect of
the forearm.
• It supplies the supinator muscle and then
emerges, as the posterior interosseous nerve,
from the muscle to lie between the superficial
and deep layers of muscles.
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 Arteries of the posterior compartment
Posterior interosseous artery;
• The posterior interosseous artery
originates in the anterior
compartment from the common
interosseous branch of the ulnar
artery and passes dorsally over the
proximal margin of the interosseous
membrane and into the posterior
compartment of the forearm.
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 Anterior interosseous artery
• The anterior interosseous artery, also a branch
of the common interosseous branch of the
ulnar artery, is situated in the anterior
compartment of the forearm on the
interosseous membrane.
• It has numerous perforating branches, which
pass directly through the interosseous
membrane to supply deep muscles of the
posterior compartment.
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 GOODMORNING
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