Our upper limbs are complex structures.

 
They've got bones, muscles, fascia, nerves and blood vessels, and everything in
between. 
And, much like every other part of the body, are prone to various forms of injuries or
ailments, and learning the anatomy of the upper limbs can help us understand their
mechanisms and consequences. 
Ok, now, let’s start from the top, and have a look at the pectoral (or shoulder) girdle,
starting with the clavicle. 
It’s right below the skin, and because of its subcutaneous position, it’s prone to
fractures, which are usually the result of direct or indirect trauma. 
An example of direct trauma is falling directly on the shoulder. 
Indirect trauma, on the other hand, may occur when falling on an outstretched hand,
and the force of impact is transmitted through the bones of the forearm and the arm
to the shoulder, which can result in a clavicular fracture. 
Most of these fractures occur in the middle third of the clavicle, particularly where the
middle third meets the lateral third, which is the weakest point of the clavicle. 
So with clavicular fractures, the medial fragment is usually pulled up by
the sternocleidomastoid muscles, which can be apparent to the naked eye and
palpable. 
At the same time, the trapezius muscle is having trouble holding the lateral fragment
up, because of the weight of the limb, so the shoulder drops. 
And since the two fragments may glide under each other, the clavicle is also
shortened. 
Additional features may signal complications of a clavicle fracture. 
For example, if the skin above the fracture seems to be tenting, meaning it looks like
a tent, that suggests the fracture may become an open fracture in the future, and
warrants surgical stabilization. 
Alright, now, another thing that can happen in this region is an acromioclavicular
dislocation, also called a “shoulder separation”. 
Just like the name says, the clavicle and acromion process separate, usually
because of a direct blow to the shoulder, or a fall landing directly on
the shoulder joint. 
And this may be seen in contact sports, like football, soccer or hockey. 
In most cases, the dislocation is mild if the acromioclavicular ligament is just
stretched or partially torn. 
In severe cases, both the acromioclavicular ligament and the coracoclavicular
ligaments are torn. 
If the coracoclavicular ligament tears, the shoulder can completely separate and
drop due to the weight of the upper limb. 
If the joint capsule also tears, the acromion process may slip under the clavicle. 
Clinically, there is swelling of the acromioclavicular joint, and pain that worsens with
overhead arm movement and lying on the affected side. 
Okay then! 
Now, right below the acromioclavicular joint, there’s the glenohumeral,
or shoulder joint, which is a ball and socket joint, where the ball is the humeral head,
and the scapular glenoid cavity is the socket. 
The joint is supported by ligaments, and surrounded by the rotator cuff muscles,
commonly remembered with the SITS mnemonic: supraspinatus, infraspinatus, teres
minor, and subscapularis. 
The glenohumeral joint is freely movable, which lets us make complex movements
like throwing a baseball, but this also means that the joint is highly unstable. 
So, one thing that can happen is a glenohumeral joint dislocation, which can be
anterior, meaning the humeral head is dislocated towards the front, or posterior,
when the humeral head is dislocated towards the back. 
Anterior dislocations are more common in young people, and they occur because of
a direct blow, or a fall on an outstretched arm. 
Think of a soccer goalkeeper jumping to catch the football, arms outstretched, and
landing on his side. 
This usually happens when the arm is externally rotated and abducted, and when
there is a hard blow to the humerus, the humeral head gets pushed down towards
the weaker inferior part of the joint capsule. 
If it tears, the humeral head goes inferiorly, and the strong flexors and adductors pull
it forward. 
Clinically, the shoulder is visibly displaced and may appear “squared off” since
the curvature from the deltoid muscle is lost. 
One possible complication to be aware of is damage to the axillary nerve, which is
located inferior to the glenohumeral joint. 
Axillary nerve damage causes a loss of sensation over the lateral part of the
proximal arm and atrophy of the deltoid muscle. 
Posterior dislocations, on the other hand, are rare, and they usually happen because
of forceful muscle contraction during an electric shock or seizure. 
One issue that’s commonly associated with a shoulder dislocation is a rotator
cuff injury. 
But rotator cuff injuries may also occur on their own. 
Degenerative injuries of the rotator cuff occur in the context of repetitive stress, such
as in sports like baseball or tennis, or occupations that require repetitive overhead
movements. 
This causes a lot of inflammation and an accumulation of small tears in
the tendons overtime. 
Also, the supraspinatus tendon can become impinged as it passes between
the acromion process and the humeral head during abduction. 
This space is already very small, so if there is anything that makes this space
smaller, like inflammation or bone spurs, which are bony overgrowths on the inferior
part of the acromion, the tendon can get repetitively impinged and irritated. 
On the other hand, acute injuries can occur when falling on an outstretched arm, or
when lifting something heavy with a jerking motion, which can tear an already
degenerated rotator cuff. 
Clinically, rotator cuff injuries can cause pain during overhead movement, when lying
on the affected side, or even at rest. 
Weakness with abduction and external rotation can also be present, and there may
also be crepitus, or a crackling sensation with movement. 
The “empty can” and “full can” tests can help assess for supraspinatus tendinopathy,
where the patient has their arm raised parallel to the ground in the scapular plane,
either in internal rotation for the “empty can” or in external rotation for the “full can”
test. 
The examiner then pushes down at the elbow or wrist while the patient resists. The
test is positive if there is weakness and/or pain. 
Next, there’s adhesive capsulitis, or “frozen shoulder”, which is when connective
tissue, like tendons, around the glenohumeral joint, gradually becomes inflamed and
stiff, usually in people between the ages of 40 and 60. 
This process may be initiated by injuries like glenohumeral dislocations, or rotator
cuff injuries, as well as many others. 
Clinically, there are usually three stages. 
In the first stage there is disabling pain and increasing stiffness for up to 9 months. 
The second phase is characterized by progressive range of motion limitation, to the
point where both passive and active movement is nearly impossible, but the pain is
less pronounced. 
This phase can last up to 12 months. 
And lastly, the third phase is the recovery phase where patients regain their mobility,
which can take up to 2 years. 
Okay, now, let’s delve into some clinically relevant details regarding the axilla! 
Remember that the axilla is like a train station, where a number of vascular, nervous
and lymphatic structures pass between the trunk and the upper limb. 
One very important structure is the brachial plexus, which can be divided into five
roots, three trunks, six divisions, the three anterior and three posterior cords, and
five terminal branches. 
The order can be remembered using the acronym “Remember To Drink Cold Beer.” 
But you may want to wait until the end of the video before you act on that! 
Now, an upper brachial plexus injury affects the superior roots, namely spinal
nerves C5 and C6, and a classic example of an upper brachial plexus injury is
Erb’s palsy, which can happen in adults as a shoulder trauma that results in an
increase in the angle between the neck and the shoulder, or in newborns, when
excessive stretching of the neck occurs during childbirth. 
The clinical consequences reflect the affected nerves, which are the ones that are
derived solely from C5 and C6 roots, namely, the musculocutaneous, axillary,
and suprascapular nerves. 
This causes paralysis of muscles like the biceps brachii, which normally
allows forearm flexion and supination, and the infraspinatus and teres minor,
so lateral rotation of the arm is affected, as well as
the deltoid and supraspinatus muscles, which cause arm abduction. 
So with superior brachial plexus injuries, the classic finding is a “waiter’s tip position”,
which reflects arm adduction and medial rotation,
and forearm extensionand pronation. 
Lower brachial plexus injuries are much more uncommon, and they affect the inferior
roots of the brachial plexus, namely C8 and T1. 
This can happen because of excessive abduction of the arm, aka an increased angle
between the trunk and the upper limb. 
This can happen to a person falling from a tree and grabbing on to a branch, or
during delivery, if the newborn is pulled out by the arm. 
The result is what’s clinically known as Klumpke palsy, which has serious effects on
nerves derived from the C8 and T1 roots, like the median and ulnar nerves, and
causes loss of sensation along the medial side of the arm, and paralysis of the
intrinsic hand muscles. 
The classic finding is a claw hand, which is due to flexion of the interphalangeal
joints, and extension of the metacarpophalangeal, or MCP, joints. 
This is mainly due to paralysis of the lumbricals, which normally act to flex the MCP
joints and extend the interphalangeal joints, as if you’re waving “bye-bye”. 
Lower brachial plexus injuries can also occur due to compression of the
lower trunk and subclavian vessels, for example, by an extra (or cervical) rib, or by
a apicallung tumor, called a Pancoast tumor. 
This is called thoracic outlet syndrome, and results in the same deficits as seen
in Klumpke palsy, and patients may also have symptoms of ischemia, like pain,
or edema due to compression of the subclavian vessels. 
Finally, the axilla is also home to the axillary lymph nodes, which are
often dissected and sent for pathologic analysis in the evaluation of breast cancer. 
Axillary nerve dissection, however, comes with a risk of long thoracic nerve injury,
which clinically translates as a winged scapula. 
A winged scapula is more apparent when a person tries to push against a wall: the
medial border and inferior angle of the scapula pull away from the posterior thoracic
wall, making the scapula look like a wing. 
Besides protracting the scapula against the posterior thoracic wall, the serratus
anterior also helps abduct the arm above the horizontal plane, so patients may have
trouble doing overhead movements, like brushing their hair for example. 
Alright, now let’s travel further down the upper limb and look at humeral fractures. 
The most common kind are fractures of the surgical neck of the humerus, which
occur more frequently in elderly people with osteoporosis, who
have structurallyweaker bones. 
The cause is usually indirect trauma, like falling on the hand with an extended arm. 
Next, there are humeral shaft fractures, which are usually caused by direct trauma. 
Now, remember that the radial nerve passes through the radial, or spiral, groove on
the back of the humerus, so a common complication of midshaft humeralfractures
is radial nerve injury. 
Finally, distal humeral fractures are a result of trauma to the elbow region. 
In a supra-epicondylar fracture, which is a fracture above the epicondyles, a
displaced portion of the humerus could injury the median nerve, ulnar nerve, or the
brachial vessels.
Now, before we move to the elbow, let’s have a look at one important muscle of the
arm, namely, the biceps brachii. 
The tendon of the long head of the biceps lies in the intertubercular sulcus, or
the bicipital groove of the humerus. 
So repetitive actions that cause movement of the tendon in its groove, like in sports
that involve throwing or use of a racquet, may cause inflammation of this tendon,
or biceps tendinitis. 
Biceps tendinitis causes tenderness and crepitus, or a crackling sound, during
movements of the long head of the biceps brachii, and it may also lead to a rupture
of the tendon over time. 
Alternatively, the tendon may rupture in the context of a forceful contraction of the
muscle against excessive resistance, like during weightlifting. 
So… pace yourself at the gym, alright? 
Usually, the tendon is ruptured from its proximal attachment at the supraglenoid
tubercle of the scapula with an associated snapping or popping sound. 
It is often described as a “Popeye deformity” because the muscle belly forms a ball
at the distal part of the arm. 
Ok, now, let’s have a look at the elbow region, and discuss another kind of wear-
and-tear injury called epicondylitis. 
Epicondylitis is when there is inflammation and small tears of the tendons that attach
to the epicondyle. 
Lateral epicondylitis usually results from repetitive use of forearm extensor muscles,
which is commonly seen in tennis players, and results in pain around their muscle
origin on the lateral epicondyle that radiates down the posterior forearm. 
The same thing can happen with the medial epicondyle, which results in medial
epicondylitis, or, and here’s another sports injury, “golfer’s elbow”. 
Medial epicondylitis occurs because of excessive force used to bend the wrist
anteriorl, or flexion, like when trying to make that far-away golf shot; hence,
golfer’s elbow. 
This results in pain on the medial epicondyle that radiates down the anterior forearm,
which worsens when trying to make a fist, like when squeezing a stress ball. 
One last clinical correlate in the elbow region is radial head subluxation and
dislocation. 
These injuries are common in children, especially when they’re suddenly lifted by
the upper limb while their forearm is pronated. 
Subluxation is also called partial dislocation, or a “pulled elbow”, and it’s when
the radial head pops out of the annular ligament. 
This happens more in children because the radial head has not completely formed,
so it’s small enough to slip out of the annular ligament. 
With a complete dislocation, the muscles also pull the radial head up. 
Clinically, the child may cry and refuse to use their arm, and there can be pain in
the elbow region. 
Alright, now, let’s make our way down to the wrist, and have a look at
distal forearm fractures. 
There’s two kinds: Colles fractures, which are a direct result of falling on an extended
wrist, and Smith fractures, which result from falling on a flexed wrist, or a direct blow
to the posterior forearm. 
With Colles fractures, the displaced distal fragment moves posteriorly, or dorsally,
and the ulnar styloid process is often broken off. 
Clinically, that’s called a “dinner fork deformity” because when viewed laterally, the
hand and wrist are slightly curved anteriorly making it look like a fork. 
With Smith fractures, on the other hand, the displaced fragment moves anteriorly, or
ventrally, which clinically translates as a “garden spade” deformity. 
Next, let’s look at carpal bone fractures, of which the most common
are scaphoid fractures. 
Scaphoid fractures occur as a result of falling on the lateral side of an outstretched
hand in abduction. 
Clinically, this results in pain and tenderness on the lateral side of the wrist and
hand, in a location called the anatomical snuffbox, which is where you
can palpatethe scaphoid bone between the tendons of extensor pollicis longus on
the medial side and extensor pollicis brevis and abductor pollicis longus on the
lateral side. 
The big problem with these fractures is that because the blood vessels supply the
distal part of the scaphoid first then come back and supply the proximal part, a
fracture in the middle of this bone disrupts the blood supply. 
This can cause avascular necrosis of the proximal fragment of the scaphoid, which is
basically when the bone dies off because of lack of blood, and degenerative wrist
joint disease. 
Initial X-rays often miss scaphoid fractures at first, so when there is tenderness on
palpation of the anatomical snuffbox in a patient who fell on an outstretched hand,
it’s important to still treat it as a fracture to avoid this complication. 
Now, looking at the bones of the hand, some of the most common injuries include
fractures of the 5th metacarpal, also called “boxer’s fractures”, and “mallet finger”,
also called “baseball” finger. 
Let’s look at them one by one. 
5th metacarpal fractures occur when throwing a punch with a closed
and abducted fist. 
Finally, the fingertips are the site of injury for a mallet, or baseball finger. 
This injury is caused by damage to the extensor tendon at the distal interphalangeal
joint, and it’s called a “baseball” finger because it’s often the result of a forceful
impact of an object, like a baseball, with the fingertips. 
Clinically, this results in drooping, and inability to extend the fingertip. 
Alright, now, we’re still in the hand region, so let’s talk about Dupuytren contracture,
which is when the palmar fascia and aponeurosis gradually thickens, shortens and
becomes fibrotic, until the 4th and 5th fingers are pulled into permanent partial
flexion. 
Some risk factors for developing Dupuytren contracture include family
history, alcohol dependence, smoking, liver or thyroid disease and diabetes. 
Finally, there’s tenosynovitis, which is the inflammation of the sheath surrounding
a tendon. 
One form is de Quervain's tenosynovitis, which affects the tendons of the abductor
pollicis longus and extensor pollicis brevis, which have the same
common tendon sheath, because of repetitive forceful movements of the hands
during gripping and wringing, like when squeezing water out of clothes. 
Clinically, this causes sharp pain on the lateral side of the wrist, which can be elicited
using Finkelstein's test, where the examiner grasps and ulnar deviates the hand
when the person has their thumb held within their fist. 
Another form of tenosynovitis is known as “trigger finger”, or stenosing tenosynovitis,
which commonly affects the ring finger or the thumb, making it hard to extend these
fingers. 
Ok, now, before we wrap up, let’s go over how injuries of the median, ulnar and
radial nerves manifest clinically. 
For the median nerve, the clinical manifestations depend on whether the lesion has
occur distally, as in carpal tunnel syndrome, or proximally, as in a supra-epicondylar
fracture of the humerus. 
The most common cause of median nerve injury is carpal tunnel syndrome, which is
when the tunnel in the wrist through which the median nerve passes becomes
narrower and compresses the median nerve. 
This can happen due to repetitive use, like typing on a keyboard, injuries like
a lunate dislocation, or associated with conditions such as hypothyroidism or in
pregnancy. 
The sensory branches of the median nerve innervate the palmar side of the lateral
three and a half digits and the thenar eminence, so with median nerve injuries,
there’s typically a tingling sensation, or loss of sensation altogether in these areas. 
The median nerve also provides motor innervation to most of the thenar muscles of
the hand, which control thumb movement, so with injuries, people may have issues
opposing the thumb, and it may be difficult to perform actions like buttoning up
a shirt. 
Atrophy of the thumb and inability to oppose the thumb is called an “ape hand”. 
Finally, patients manifest clinically with a “median claw”. 
Let’s break this down quickly. 
So, the lumbricals normally flex the MCPs and extend the DIP and PIP. 
So at rest or when the patient tries to extend their hand, the index and middle fingers
stay extended at the MCP, and the DIP and PIP stay flexed, especially since
the finger flexors are unopposed.
Now, in a proximal lesion to the median nerve, as in a supra-epicondylar fracture, we
have all of the same deficits as in a distal lesion. 
But now, there is the additional problem that we have now lost all of the finger flexors
for the lateral fingers, like flexor digitorum superficialis and the lateral half of flexor
digitorum profundus. 
So, when an individual is asked to make a fist, they can only close their medial two
fingers, and this is called a “Pope’s blessing”. 
Ok, next, there’s ulnar nerve injuries, which can occur anywhere between its origin
from the brachial plexus and the ulnar canal, or Guyon canal, in the wrist, but it’s
most commonly associated with elbow injuries, such as a fracture of the medial
epicondyle of the humerus, aka the funny bone. 
For a distal injury, like a fracture to the hook of the hamate bone, or when
cyclists compress the hook of the hamate bone when holding onto handlebars, this
manifests clinically with the “ulnar claw”. 
This is the exact opposite of the “median claw”, where this time we have paralysis of
the medial two lumbricals. 
So at rest or when the patient tries to extend their hand, the ring and pinky fingers
stay extended at the MCP, and the DIP and PIP stay flexed, and the fingerflexors are
once again unopposed. 
The ulnar nerve also innervates the interossei, so they cannot abduct or adduct the
fingers. 
The sensory branches of the ulnar nerve innervate the medial 1.5 fingers including
the hypothenar eminence, so we also have tingling or a complete loss of sensation in
these areas.
Ok, so in a proximal lesion to the ulnar nerve, as in a medial epicondyle fracture, we
have all of the same deficits as in a distal lesion. 
But now, there is the additional problem that we have now lost the function of flexor
digitorum profundus on the medial side. 
So, when a patient is asked to make a fist, they can only close their lateral two
fingers, and this is called a “Ok gesture”, since that’s what it looks like. 
Another thing is that there is a loss of flexor carpi ulnaris, so when they try
to flex their wrist, it deviates radially. 
Finally, radial nerve injury can happen a few different ways. 
First off, it can occur by repetitive pronation and supination of the forearm, for
example, when using a screwdriver.
In this case, it manifests clinically by “finger drop” due to weakness of
the finger extensors and unopposed action of the finger flexors. 
And as we already mentioned, it can also occur due to a midshaft fracture of
the humerus. 
This manifests clinically as weakness of the supinator and extensor muscles of the
wrist and fingers. 
The classic clinical finding is wrist drop, which is when the wrist hangs in a
partly flexed position on account of unopposed wrist and finger flexors. 
Finally, it can occur due to compression of the brachial plexus, for example when
using crutches, or sleeping with your arm hanging over the chair, hence the term
“Saturday night palsy”. 
Since this injury occurs superior to the branches of the triceps brachii, this also
cases paralysis of the triceps leading to loss of elbow extension in addition to loss of
wrist and finger extension. 
There will also be loss of sensation over the dorsal hand, and depending on the level
of the injury, there could also be loss of sensation over the posterior forearmor arm. 

Summary
All right, as a quick recap… Clavicular fractures may result from direct or indirect
trauma. 
They often occur in the middle third of the clavicle, and result in shoulder drooping
and a shortened clavicle. 
Another injury of the shoulder girdle is acromioclavicular dislocation, which is usually
the consequence of a direct blow to the shoulder. 
And this may be seen in contact sports, like football, soccer or hockey. 
Then, there’s glenohumeral dislocation. 
Anterior glenohumeral dislocations occur because of a direct blow to the shoulder, or
falling on an outstretched arm. 
Clinically, the shoulder is visibly displaced and may appear “squared off” since
the curvature from the deltoid muscle is lost. 
Posterior dislocations are rare, and they usually happen because of forceful
muscle contraction during an electric shock or seizure. 
Acute rotator cuff injuries can be associated with shoulder dislocations, in which
case there’s pain during overhead movement, when lying on the affected side, or
even at rest. 
The axilla is where superior and inferior brachial plexus injuries may occur. 
Superior injuries cause Erb’s palsy, and the classic finding is a “waiter’s tip position”,
which reflects arm adduction and medial rotation,
and forearm extension and pronation. 
Inferior injuries cause Klumpke’s palsy, and the classic finding is a claw hand, due to
flexion of the interphalangeal joints, and extension of the metacarpophalangeal
joints. 
Finally, the axilla is also home to the axillary lymph nodes, and during axillary lymph
node dissection, damage to the long thoracic nerve may result in a winged scapula. 
In the arm, humeral fractures may be caused by direct or indirect trauma, and they
may occur proximally, often in elderly people with osteoporosis, or in
the humeral shaft or distal humerus. 
Humeral shaft fractures can result in radial nerve injury, whereas
distal humeral fractures can damage the ulnar nerve, median nerve, or the brachial
vessels. 
In the elbow region, radial head dislocations or subluxations may occur, and they’re
especially common in children who are suddenly lifted by the upper limb when
the forearm is pronated. 
Distal forearm fractures include Colles and Smith fractures. 
Colles fractures result from falling on an extended wrist, and this may result in a
“dinner fork deformity”, whereas Smith fractures usually result from falling on
a flexed wrist, causing a “garden spade” deformity. 
In the hand region, Dupuytren’s contracture may occur, which is when the
palmar fascia and aponeurosis gradually thickens, shortens and becomes fibrotic,
until the 4th and 5th fingers are pulled into permanent partial flexion. 
Finally, remember that median nerve injuries may be associated with atrophy of
the thumb and inability to oppose the thumb, called an “ape hand”, and a
“medianclaw”, which is when the index and middle fingers stay extended at
the metacarpophalangeal joints, while the distal and proximal interphalangeal
joints stay flexed. 
Proximal median nerve injuries may also result in a clinical finding called “Pope’s
blessing”, when an individual is asked to make a fist, and they can only close their
medial two fingers. 
Ulnar nerve injuries may result in an “ulnar claw”, which is the exact opposite of a
“median claw”. 
And radial nerve injuries may result in either “finger drop”, “wrist drop” or “Saturday
night palsy”, depending on the location and mechanism of the injury.