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Upper extremity
 Surface anatomy
 Clavicle
 Manubrium
 Jugular notch (suprasternal notch)
 Deltoids
 Scapula, Acromion, spine, coracoid process, fossa,
borders
 Humerus, tubercle, body
 Ulna, head, olecranon process, ulnar nerve
 Radius, radial nerve, styloid process
 Carpals, pisiform, scaphoid and trapezium, anatomical
snuff box
Brachial Plexus
 Brachial plexus formation….

 The brachial plexus starts from the five ventral

rami of the spinal nerves, after they have given
off their segmental supply to the muscles of the
neck. These are the five roots.
 These roots merge to form three trunks:
"superior" or "upper" C5-C6, "middle" C7, and
"inferior" or "lower" C8-T1.
 Each trunk then splits to form an anterior and a
posterior division.
 Brachial plexus formation….

 The six divisions will regroup to become the

cords. The cords are named by their position in
respect to the axillary artery.
 The posterior cord is formed from the three
posterior divisions of the trunks.
 The lateral cord is the anterior divisions from the
upper and middle trunks.
 The medial cord is simply a continuation of the
lower trunk.
 Brachial plexus formation…

 Branches of the brachial plexus

 3 branches from the roots
 Dorsal scapular nerve
 arises from C5 root, supplies the rhomboid muscles and
levator scapulae.
 Nerve to subclavius
 arises from C5 and C6 roots, supplies the subclavius muscle
 Long thoracic nerve
 arises from C5, C6 and C7 roots, supplies
serratus anterior
 Brachial plexus formation…
 1 branch from the trunks
 Suprascapular nerve
 arises from the superior trunk, supplies supraspinatus and
infraspinatus muscles
 3 branches from the lateral cord
 Lateral pectoral nerve
 supplies pectoralis major and pectoralis minor( by communicating
with the medial pectoral nerve) from C5, C6, C7.
 Musculocutaneous nerve
 from C5 and C6 it supplies coracobrachialis, brachialis and
biceps brachii. It then becomes the
lateral cutaneous nerve of the forearm.
 Lateral root of the median nerve
 supplies C5, C6 and C7 fibres to the median nerve.
 Brachial plexus formation…
 5 branches from the posterior cord
 Upper subscapular nerve
 supplies subscapularis (upper part) from C5 and C6
 Thoracodorsal nerve
 supplies latissimus dorsi with nerve fibres from C6, C7 and C8
 Lower subscapular nerve
 supplies the lower part of subscapularis and teres major from C5 and
C6.
 Axillary nerve
 from C5 and C6, it supplies deltoid and a small area of overlying skin by
its anterior branch.
 Its posterior branch supplies teres minor and deltoid muscles then
becomes the upper lateral cutaneous nerve of the arm
 Radial nerve
 nerve fibres from all 5 roots (C5-T1)
 largest nerve of the plexus
 supplies triceps brachii, the skin of the posterior arm as the
posterior cutaneous nerve of the arm, anconeus, and the
extensor muscles of the forearm.
 Brachial plexus formation…

 5 branches from the medial cord

 medial pectoral nerve
 from C8 and T1, it supplies pectoralis major and pectoralis minor
 medial root of the median nerve
 supplies C8 and T1 fibres to the median nerve.
 medial cutaneous nerve of the arm
 supplies the front and medial skin of the arm from C8 and T1
 medial cutaneous nerve of the forearm
 supplies medial skin of the forearm from C8 and T1
 ulnar nerve
 C7, C8 and T1 fibres
 supplies flexor carpi ulnaris , the medial 2 bellies of
flexor digitorum profundus , most of the small muscles of the hand and
the skin of the medial side of the hand and medial one and a half
fingers
 Anesthesia of the Brachial Plexus

 The fact that the nerves of the brachial plexus are

grouped together acts as a benefit as well.
Local anesthetics such as lidocaine or bupivacaine can
be injected in close proximity to these nerves, rendering
an entire arm insensate and immobile. The process of
injecting local anesthetic for this purpose is called
regional nerve blockade or more simply, a nerve block,
and it is a common procedure in anesthesia. After an
onset time of approximately 10 to 15 minutes, the
targeted arm will be fully anesthetized and ready for
surgery. The patient can remain awake during the
ensuing surgical procedure, or he can be sedated with
medications or fully anesthetized with general anesthesia
 Peripheral nerve blockade
 The use of peripheral nerve blockade (in this case, a "brachial plexus nerve
block") offers several advantages when compared to general anesthesia or
local anesthesia:
 The patient can remain awake and breathing on their own, thus protecting
themselves from aspiration of stomach contents into the lungs. By avoiding
general anesthesia, patients with adverse reactions to general anesthetics
(viz. malignant hyperthermia, severe post-operative nausea and vomiting,
known hypersensitivity to agents) can be successfully treated. Similarly,
patients who experience nuisance side effects from general anesthesia such
as nausea, vomiting, or excessive sleepiness can minimize these symptoms.
 There is no need to perform an endotracheal intubation, the procedure of
inserting a breathing tube into the trachea. Occasionally, such intubation is
unexpectedly difficult to perform, causing injury to the patient.
 The affected limb's sympathetic nerves are anesthetized, leading to
vasodilation. This improves blood flow to the affected limb and makes
microvascular surgical procedures technically simpler.
 The limb can remain numb for several hours after surgery, providing
excellent pain relief.
 Deep and superficial structures of the limb are similarly anesthetized,
allowing extensive surgical exploration and correction to occur. This is in
contrast to locally injected local anesthetics, which tend only to numb
superficial structures in the immediate vicinity of the injection.
 Brachial plexus blockade
 Brachial plexus blockade is the preferred anesthetic technique when:
 Surgery is expected to be limited either to a region between the midpoint of
the humerus and the fingers (in which case the brachial plexus block should be
either a supra-clavicular, infra-clavicular, subcoracoid, or axillary block), OR
surgery is expected to be limited to a region between the midpoint of the
humerus and the shoulder (in which case the brachial plexus block should be
an interscalene block). Because of the distribution of the local anesthetics on
the various portions of the brachial plexus, surgeries crossing the midpoint of
the humerus often reveal patchy, unanesthetized portions of the arm. Such
procedures probably should not be performed under regional nerve block
alone.
 AND
 There are no contra-indications to a block such as infection at the intended
injection site, significant anti-coagulation, allergy or hypersensitivity to local
anesthetic medications, or disproportionate risk in the event of a local
anesthetic toxic reaction (seizure) such as gastric aspiration in a patient who
has not adequately fasted,
 AND
 There will not be a need to perform a neurologic examination immediately
following the surgical procedure,
 AND
 Patient prefers this technique over other available and reasonable approaches.
 Injuries
 Two injuries types are recognised in brachial plexus
injuries: Traumautic and Obstetric.
 Traumatic injuries often are the result of high velocity
RTA's (Road Traffic Injuries). The most common form of
injury are the motorcycle drivers falling, with either the
head/neck pushed to the side (upper plexus lesions) or
with their arm abducted (stretched upwards) which
produces a lower plexus injury.
 The brachial plexus is susceptible to injuries that
produce abduction of the thoracic limb from the body
wall or a direct blow to the lateral surface of the scapula.
 The cardinal signs of brachial
plexus avulsion are:
 a weakness in the arm
 diminished reflexes
 corresponding sensory deficits
 The nerve roots are stretched or torn from their origin by this
trauma, since the meningeal coverings of the nerve roots are
thinner than those in the peripheral nerve. The epineurium of the
peripheral nerve is contiguous with the dural mater, providing extra
support to the peripheral nerves. In cases where the nerve roots
have been torn, recovery is unlikely without new experimental
surgical techniques.
 The diagnosis may be confirmed by an EMG examination in 5-7
days. The evidence of denervation will be evident. If there is no
nerve conduction 72 hours after the injury, then avulsion is most
likely.
 Brachial Plexus and Nerves of Upper limb
Origin Muscle distribution
Supraclavicular nerve

Dorsal scapular Ventral rami of C4, C5 Rhomboids & Lev. scapulae

Long thoracic Ventral rami of C4- C7 Serratus anterior

Nerve to subclavius Superior trunk, C4- C6 Subclavius, sternoclavicular joint

Suprascapular Superior trunk, C4-C6 Supraspinatus, infraspinatus,

glenohumeral (shldr) joint
Infraclavicular Origin Muscle distribution
nerves

Lateral pectoral Lateral cord, C5-C7 Pectoralis major, pectoralis minor

Musculocutane Lateral cord, C5-C7 Coracobrachialis, biceps brachii,

ous brachialis,

Median Lateral cord, C6-C7 Flexor carpi ulnaris, flexor

digitorum profundus

Medial pectoral Medial cord, C8-T1 Pectoralis major/minor

Medial brachial Medial cord C8-T1 Skin on medial side of arm.

cutaneous

Medial Medial cord, C8-T1 Skin over medial side of forearm

antebrachial
cutaneous
Infraclavicular Origin Muscle distribution
nerve
Ulnar Terminal of medial cord, Half of flexor forearm muscles,
C7, C8- T1 small muscles of hand, skin on
medial of hand to ring finger
Upper subscapular Posterior cord, C5-C6 Superior subscapularis
Thoracodorsal Posterior cord, C6-C8 Latissimus dorsi
Lower Posterior cord, C5-C6 Inferior subscapularis and teres
subscapular major
Axillary Terminal posterior cord, Teres minor, deltoids, shoulder
C5- C6 joints, skin over inferior
deltoids.
Radial Terminal posterior cord, Triceps brachii, anconeus,
C5- C6 brachioradialis, extensor
muscles of forearm, skin over
post. Aspect of arm and
forearm.
Muscle Origin Insertion Nerve Action
Biceps brachii Coracoid Radial Musculocutane Supinates
process, tuberosity, ous forearm, flexes
supraglenoid biciptal C5 – C6 forearm
tubercle aponeurosis
Brachialis Anterior surface Coronoid Musculocutane Flex and
of distal process, ulna ous adducts arms
humerus tuberosity C5 – C6
Cracobrachialis Coronoid Mid3rd medial Musculocutane Flex and
process of surface humerus ous adducts arm
scapula C5 – C7
Triceps brachii LH:Infraglenoid Olecranon of Radial nerve C6 Extend forearm,
tubercle ulna and fascia – C8 long head
Lat hd: post of forearm steadies head of
humerus sup. humerus
To radial
groove
Medial Hd:
post. Humerus
inf. To radial
groove
Anconeus Lateral Lat. Surface Radial nerve C7 Assist triceps to
epicondyle olecranon sup – T1 extend forearm,
Humerus of ulna stabilize elbow,
adducts ulna in
pronation
Break
 Axillary artery
 Boundaries = lateral border first rib to superior border of Teres minor muscle
 Division:
 1st division = from lateral border first rib to medial border of pectoralis minor
 Branch = supreme thoracic artery
 2nd division = from medial border of pectoralis muscle to lateral border of same
muscle
 Branch =
 Thoraco acromial artery
 Lateral thoracic artery
 3rd division = from lateral border of pectoralis minor to superior border of the Teres
minor muscle
 Branch =
 Subscapular artery
 Anterior circumflex humeral artery
 Posterior circumflex humeral artery
 Brachial artery
 Boundaries = distal edge of Teres major muscle to Cubital
 fossa.
 Branches = 1. Deep brachial or Profunda brachii artery = to
posterior compartment of the arm
 Recurrent branch anastomose with the posterior circumflex humeral
artery
 Lateral branch anastomose with the Radial recurrent artery.
 Posterior branch anastomose with Recurrent interosseous artery.
 Collateral branches
 Superior ulnar artery anastomose with posterior recurrent ulnar artery.
 Inferior ulnar artery anastomose with anterior recurrent ulnar artery.
 Venous return
 Deep veins = 2 to 3 joins to form the venae
comitantes brachiales freely anastomose about the
brachial artery.
 superficial veins
 Cephalic veins to the anterior of the lateral epicondyle to the
deltopectoral triangle, pierces the clavipectoral fascia to join
the axillary vein distal to first rib..
 Basilic vein = medial epicondyle along the deep medial
antebrachial joins the brachial vein near the teres major
muscle to form the axillary veins.
 Median cubital veins = the connecting veins between
the cephalic and the basilica veins at the cubital
 Fossa, it lies at the bicipital aponeurosis..
 Lymphatic drainage
 Deep lymphatics accompany brachial veins
into the axillary lymph nodes.
 Superficial lymphatics along the superficial
veins into the:
 supratrochlear lymph nodes near the medial
epicondyle
 superficial drainage bypass most axillary
nodes into the subclavian vein.
Ligaments of the Glenohumeral
Joint.
 There are several important ligaments in the
shoulder. Ligaments are soft tissue structures that
connect bones to bones. A joint capsule is a
watertight sac that surrounds a joint. In the
shoulder, the joint capsule is formed by a group of
ligaments that connect the humerus to the glenoid.
These ligaments are the main source of stability for
the shoulder. They help hold the shoulder in place
and keep it from dislocating. These are the
glenohumeral ligaments (GHL)
 Another ligament links the coracoid to the acromion
- coracoacromial ligament (CAL). This ligament can
thicken and cause Impingement Syndrome
 Ligaments attach the clavicle to the acromion in the
AC joint.
 Two ligaments connect the clavicle to the scapula
by attaching to the coracoid process, a bony ridge
on the scapula - coracoclavicular ligaments (CCL)
 Ligaments of the Shoulder Complex:
 CCL - coracoclavicular ligaments
 CAL - coracoacromial ligaments
 SGHL - Superior GlenoHumeral Ligament
 MGHL - Muperior GlenoHumeral Ligament
 IGHL - Inferior GlenoHumeral Ligament
 Ligaments of the Rotator Cuff

 The tendons of the rotator cuff are the next layer in

the shoulder joint. Tendons are much like
ligaments, except that tendons attach muscles to
bone. Muscles move the bones by pulling on the
tendons. One important tendon that travels through
the shoulder joint is the biceps tendon . The
biceps tendon actually begins at the top of the
shoulder socket (the glenoid) and then passes
across the front of the shoulder to connect to the
biceps muscle. (The biceps is the muscle that
weightlifters are always showing off).
 The rotator cuff tendons are a group of four
tendons that connect the deepest layer of muscles
to the humerus.  They are the tendons of the
rotator cuff muscles (left)
 Tendons of the shoulder:
 From front to back:
 Subscapularis
 Biceps Tendon
 Supraspinatus
 Infraspinatus
 Teres Minor
 Muscles of the shoulder
 There are 30 muscles providing
movement and support for the
shoulder complex. 15 muscles move
and stabilize the scapula; 9 muscles
provide for glenohumeral joint motion;
and 6 support the scapula on the
thorax
 There are three important groups of
muscles around the shoulder:
 1. Surface muscles (Extrinsic):
 The large deltoid muscle forms the
outer layer of muscle. This is the
largest, strongest muscle of the
shoulder. The deltoid muscle takes
over lifting the arm once the arm is
away from the side.
 Pectoralis Major provides movement
and support in the front of the
shoulder
 Deep ( Intrinsic) muscles
 . Deep muscles (Intrinsic):
 The rotator cuff tendons attach to the deep rotator cuff muscles.
These 4 muscles are involved in raising the arm from the side and
rotating the shoulder in the many directions. The rotator cuff
mechanism also helps keep the shoulder joint stable by holding the
humeral head in the glenoid socket. These muscles are:
subscapularis, supraspinatus, infraspinatus and teres minor.
 3. Back Muscles (Posterior):
 These muscles are at the back of the shoulder that stabilise and
move the scapula on the trunk of the body. This group includes the
trapezius, rhomboids, levator scapulae, and the serratus anterior
muscles; and are concerned with stabilisation and rotation of the
scapula.
Bursas of the Shoulder
 Sandwiched between the rotator cuff
muscles and the outer layer of large bulky
muscles is a structure known as a bursa.
Bursae are everywhere in the body. They
are found wherever two body parts move
against one another and there is no joint to
reduce the friction. A bursa is simply a sac
between two moving surfaces that contains
a small amount of lubricating fluid.
 Think of a bursa like this: If you press your
hands together and slide them against one
another, you produce some friction. In fact,
when your hands are cold you may rub
them together briskly to create heat from
the friction. Now imagine that you hold in
your hands a small plastic sack that contains
a few drops of salad oil. This sack would let
your hands glide freely against each other
without a great deal of friction.
Muscles of the Back
 Superficial muscles
Muscle Origin Insertion Action Nerve
Trapezius Occiput, Clavicle, Rotator, Spinal
nuchal line acromion, adductor, accessory
spine of lowers the nerve
scapula scapula.

Latissimus Thoraco- Intertuberc Extends, Thoraco

dorsi Lumbar ular groove adducts, dorsal ( long
fascia,spine or bicipital median subscapular
s of lumbar groove. rotator of )
& sacral, shoulder
iliac crest,
lower 4 ribs
 Superficial, rhomboid layer…
Muscle Origin Insertion Action Nerve
Levator Post, Medial Elevator and Dorsal
scapula tubercle and border rotator of scapular
transverse scapula, scapula nerve
process higher
C1-4
Rhomboid Nuchal lig. Medial Adduct Dorsal
minor Spine C7-T1 border scapula scapular
scapula, medially, nerve
lower depressor of
scapula
Rhomboid Spine T2 – Medial Adduct Dorsal
major T5, border lower scapula scapular
supraspinous medially, nerve
lig.
depressor
 Deep muscles of the back,
transverse- costal group
 Splenius capitis – from nuchal lig, spine of C7, T1-3 to occiput , mastoid
 Splenius cervicis – spines of T3-6 to transverse process C1-3
 Erector spinae – med crest of scarum to lower 6 ribs
 Iliocostalis lumborum – from spines T11 – L5, iliac crest to sacrum
 Iliocostalis thoracis- from lower 6 rib angle to rib 1-6/trnsvrs proc. C7
 Iliocostalis cervicis- angle rib 3-6 to trnsvrs poc. C4-6
 Longissimus thoracis- mid crest sacrum
 Longissimus cervicis- transvrs proc T1 - 5
 Longissimus capitis- transvrs proc. T1- 5, artic. Proc C5 - 7
 Spinalis thoracis- spines T11 – L2
 Spinalis cervicis- C7 to spine C2
 Deep layer, Transverse-spinal group

 Semispinalis thoracis – transvrs proc. T6 -10 to spines C6-T4

 Semispinalis cervicis – transvrs proc. T1-T6, to spines C2-C5
 Semispinalis capitis – Transvrs proc. C7-T7, to nuchal plane of occiput
 Spinalis capitis- transvrs proc. C7-T7, to nuchal plane occiput
 Multifidus
 Sacral – post sacrum to spines o C2 – L5
 Lumbar – mamillary proc.
 Thoracic – from transvrs process
 Cervical – from articular proc C4 – C7
 Rotatores
 Longi – transvrs proc of 1 vertebra to spine 2 vertebra above
 Breves – transvrs proc of 1 vertebra to next vertebra above
 Interspinalis – connects apices of spines of adjoining vertebra
 Intertransverse- interconnects anterior tubercle of transvrs process
 Suboccipital muscle

 Rectus capitis posterior major

 From spinous process of axis, to inf nuchal line. Extend and rotate
the head to same side
 Tubercle post arch of atlas, to inf nuchal line. Extends head.
• Rectus capitis posterior minor
 Tubercle on post arch atlas to inferior nuchal line.
 Extends head.
 Obliquus capitis inferior
 apex, and spine of atlasTrnsvrse proc. Atlas, turns head same side
• Obliquus capitis superior
 Transvrs proc. Atlas to occipital bone between nuchal lines.
 Extends head and bends it to same side.
 Actions, general….
 Nerve supply by all posterior primary divisions of spinal nerves.
 Splenius – draws head back, bends head laterally, rotates ace to
same side.
 Iliocostalis- bends vertebral column to side, lumborum depress ribs
 Longissimus thoracis and cervicis bends column to side, depress ribs
 Longissimus capitis extends head, bends head to side, rotates face to
same side
 Semispinalis thoracis & cervicis- rotates column to same side.
 Semispinalis capitis – extends head rotates head to opposite side.
 Multifidus rotates column to opposite side.
 Rotatores rotates column to opposite side.
 Intertransverse bends column to same side.
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