1

ASSIGNMENT OF MANUAL THERAPY

SUBMITTED BY

HAFIZ M HAMZA MUHAMMAD IQBAL

SUBMITTED TO

DR KIRAN ARSHAD

DATED

7-MAY-2021
 2

QUESTION#1

WRITE DOWN GLENOHUMERAL JOINT MOBILIZATION WITH PROPER

PROCEDURE?

INTRODUCTION

The glenohumeral joint is structurally a ball-and-socket joint and functionally is

considered a diarthrodial, multiaxial, joint. The glenohumeral articulation involves
the humeral head with the glenoid cavity of the scapula, and it represents the
major articulation of the shoulder girdle. The latter also includes minor
articulations of the sternoclavicular (SC), acromioclavicular (AC), and
scapulothoracic joints. The glenohumeral joint ranks as the most mobile joint of
the human body. The static and dynamic stabilizing structures allow for
extreme degrees of motion in multiple planes of the body that predisposes the
joint to instability events.

STRUCTURE AND FUNCTION

The glenohumeral joint is a ball and socket joint that includes a complex, dynamic,
articulation between the glenoid of the scapula and the proximal humerus.
Specifically, it is the head of the humerus that contacts the glenoid cavity (or
fossa) of the scapula. The articulating surfaces of both have a lining of articular
cartilage. The glenoid cavity is a shallow osseous element that is structurally
deepened by a fibrocartilagenous rim, the glenoid labrum, that spans the osseous
periphery of the vault. The labrum is continuous with the tendon of the biceps
brachii at its superior aspect.

Due to the loose joint capsule, and the relative size of the humeral head
compared to the shallow glenoid fossa (4:1 ratio in surface area), it is one of the
most mobile joints in the human body. This increased mobility contributes to it
being the most commonly dislocated joint.

The glenohumeral joint is enclosed by a joint capsule that encapsulates the

structures of the joint in a fibrous sheath. Structurally the joint capsule wraps
around the anatomic neck of the humerus to the rim of the glenoid fossa.  While
 3

the joint capsule itself is a contiguous supportive structure surrounding the

articulating elements, the capsulolabral complexes include important
characteristic thickened bands that constitute the glenohumeral ligaments. First
described in 1829, the glenohumeral ligaments do not act as traditional ligaments
that carry a pure tensile force along their length, but rather, the glenohumeral
ligaments become taut at varying positions of abduction and humeral rotation. A
synovial membrane forms the lining of the inner surface of the joint capsule. This
membrane produces synovial fluid to reduce friction between the articular
surfaces.

In addition to the synovial fluid reducing friction within the joint, there are
multiple synovial bursae present as well. These bursae functionally act as a
cushion between joint structures, such as tendons. The most clinically significant
are the subacromial and subscapular bursae. There are numerous, including:

 SUBACROMIAL/SUBDELTOID BURSA - This structure lies between the

deltoid muscle and joint capsule in the superolateral aspect of the joint. It is
superficial to the supraspinatus tendon. This bursa reduces friction
underneath the deltoid muscle, allowing an increased range of motion. This
bursa, excluding anatomic variants, does not usually communicate with the
shoulder joint itself.

 SUBCORACOID BURSA - This bursa is between the coracoid process and the
subscapularis.

 SUBSCAPULAR BURSA - is located between the tendon of the subscapularis

muscle and the capsule. It functions to reduces frictional damage to the
subscapularis muscle during movement of the glenohumeral joint,
particularly during internal rotation.  

STATIC stabilizing structures include the osseous articular anatomy and joint
congruity, the glenoid labrum, the glenohumeral ligaments, joint capsule, and
negative intraarticular pressure:
 4

 GLENOHUMERAL LIGAMENTS- Composed of a superior, middle, and

inferior ligament, these three ligaments combine to form the glenohumeral
joint capsule connecting the glenoid fossa to the humerus. Due to their
location, they protect the shoulder and prevent it from dislocating
anteriorly — this group of ligaments functions as the primary stabilizers of
the joint.

 CORACOCLAVICULAR LIGAMENT – This ligament is composed of the conoid

and trapezoid ligaments and spans from the coracoid process to the
clavicle. It functions to maintain the position of the clavicle in
conjunction with the acromioclavicular ligament. Strong forces can rupture
these ligaments during acromioclavicular joint injuries.

 CORACOHUMERAL LIGAMENT – This ligament supports the superior aspect

of the joint capsule. It is a dense fibrous structure connecting the base of
the coracoid process to the greater and lesser tuberosities. At its origin, the
ligament is thin and broad, measuring about 2 cm in diameter at the base
of the coracoid. Laterally, the CHL separates into two distinct bands that
envelope the Long Head Biceps tendon at the proximal extent of the
bicipital groove.

DYNAMIC stabilizing structures include the Long head biceps tendon,

rotator cuff muscles, the rotator interval, and the periscapular muscles.

Soft tissue pulley system and Long head of the biceps tendon (LHBT)

 The subscapularis has superficial and deep fibers that envelope the bicipital
groove, creating the “roof” and “floor,” respectively. These fibers also
coalesce with those from the supraspinatus and superior glenohumeral
ligament/coracohumeral ligament complex.  These structures attach
intimately at the lesser tuberosity to create the proximal and medial aspect
of the pulley system, with soft tissue extensions serving to further envelope
the LHBT in the bicipital groove. Once the LHBT exits the groove, it takes a
30- to 40-degree turn as it heads toward the supraglenoid tubercle and
 5

glenoid labrum. Thus, the proximal soft tissue elements of the groove are
especially critical for the overall stability of the entire biceps complex.

The glenohumeral joint possesses the capability of allowing an extreme

range of motion in multiple planes.

 FLEXION – Defined as bringing the upper limb anterior in the sagittal plane.

The usual range of motion is 180 degrees. The main flexors of the shoulder
are the anterior deltoid, coracobrachialis, and pectoralis major. Biceps
brachii also weakly assists in this action.

 EXTENSION—Defined as bringing the upper limb posterior in a sagittal

plane. The normal range of motion is 45 to 60 degrees. The main extensors
of the shoulder are the posterior deltoid, latissimus dorsi, and teres major.

 INTERNAL ROTATION—Defined as rotation toward the midline along a

vertical axis. The normal range of motion is 70 to 90 degrees. The internal
rotation muscles are the subscapularis, pectoralis major, latissimus dorsi,
teres major, and the anterior aspect of the deltoid.

 EXTERNAL ROTATION - Defined as rotation away from the midline along a

vertical axis. The normal range of motion is 90 degrees. Primarily
infraspinatus and teres minor are responsible for the motion.

 ADDUCTION – Defined as bringing the upper limb towards the midline in

the coronal plane. Pectoralis major, latissimus dorsi, and teres major are
the muscles primarily responsible for shoulder adduction.

 ABDUCTION- Defined as bringing the upper limb away from the midline in
the coronal plane. The normal range of motion is 150 degrees. Due to the
ability to differentiate several pathologies by the range of motion of the
glenohumeral joint in this plane of motion, it is essential to understand how
different muscles contribute to this action.

I. The supraspinatus is responsible for the first 0 to 15 degrees of

abduction.
 6

II. The middle fibers of the deltoid are responsible for approximately 15 to
90 degrees of abduction following.

III. Scapular rotation due to the actions of the trapezius and serratus
anterior allow for abduction beyond 90 degrees.

EMBRYOLOGY:

The development of the skeletal shoulder consists of both forms of

ossification processes. The clavicle undergoes intramembranous
ossification, which is the direct laying down of bone into the mesenchyme.
The rest of the bony structures of the shoulder form by endochondral
ossification. The mesoderm germ layer forms nearly all of the connective
tissues of the musculoskeletal system, including the glenohumeral joint.
Musculoskeletal and limb abnormalities, due to both environmental and
genetic contributions, are one of the largest groups of congenital
abnormalities.

BLOOD SUPPLY AND LYMPHATICS

The glenohumeral joint receives vascular supply via the posterior and
anterior circumflex humeral arteries, both of which are branches of the
axillary artery. The predominant arterial blood supply to the humeral head
is via the posterior humeral circumflex artery. The arcuate artery is the
extension/continuation of the ascending branch of the anterior humeral
circumflex. It enters the bicipital groove and supplies most of the humeral
head. A branch of the thyrocervical trunk, the subscapular arteries, and its
branches, also contribute to the blood supply of the shoulder.

The majority of the lymph nodes in the upper extremity are located within
the axilla. These can be divided based on location into five main groups:
pectoral, subscapular, humeral, central, and apical. Efferent vessels coming
from the apical axillary nodes travel through the cervico-axillary canal and
then converge to form the subclavian lymphatic trunk. This trunk will either
 7

continue to enter the right venous angle or drain directly into the thoracic
duct on the right and left, respectively. Removal and analysis of axillary
lymph nodes is often an essential tool in the staging of breast cancers. The
interruption of lymphatic drainage from the upper limb can, however,
result in lymphoedema, a condition where accumulated lymph in the
subcutaneous tissue leads to painful swelling of the upper limb.

NERVES

Innervation of the glenohumeral joint is a function of the suprascapular,

lateral pectoral, and axillary nerves. All of the nerves supplying the
glenohumeral joint originate from the brachial plexus, which is a network of
nerves formed by the ventral rami of the lower four cervical nerves and the
first thoracic nerve (C5, C6, C7, C8, and T1). The anatomy of the axillary
nerve is critical as it is close to the glenohumeral joint. The axillary nerve
arises from the posterior cord of the brachial plexus, courses along the
subscapularis to its inferior edge, and then passes closely along the inferior
glenohumeral joint capsule. It then courses posterior to the humerus,
wraps around the surgical neck of the humerus with the posterior
circumflex artery, running in the deep deltoid fascia.

MUSCLES

The four muscles that constitute the rotator cuff are the supraspinatus,
infraspinatus, subscapularis, and teres minor.  The primary biomechanical
role of the rotator cuff is stabilizing the glenohumeral joint by compressing
the humeral head against the glenoid. The rotator cuff muscles thus act as
dynamic stabilizers of the glenohumeral joint. In addition to the rotator
cuff, the LHBT has a controversial contribution and overall role in
glenohumeral joint stability. The current consensus agreement is
that the stabilizing role of the LHBT in regards to the glenohumeral
joint becomes more important and/or relevant in the setting of rotator
cuff dysfunction.
 8

The supraspinatus primarily abducts the shoulder and is responsible for the
initial 15 degrees of abduction. The infraspinatus and teres minor aid in
external rotation of the shoulder. The subscapularis muscle aids in internal
rotation of the shoulder. The supraspinatus and infraspinatus muscles are
innervated by the suprascapular nerve. The teres minor is innervated by
the axillary nerve and subscapularis by the subscapular nerve.

CLINICAL SIGNIFICANCE

SHOULDER DISLOCATIONS

The glenohumeral joint is by far the most commonly dislocated joint of the
body, accounting for up to 45% of dislocations. Anterior dislocation
accounts for 96% of cases and is often the result of a force directed to the
shoulder joint while the arm is in abduction and external rotation. Posterior
dislocation is the second most common direction of dislocation, accounting
for 2% to 4% of cases. Posterior dislocations are usually due to indirect
mechanisms such as electric shock or convulsions, causing contraction of
the relatively stronger internal rotators of the shoulder (latissimus dorsi,
pectoralis major, and subscapularis muscles).

Glenohumeral joint dislocation has an incidence of approximately 17 per

100,000 a year, with a peak incidence among males in the 21 to 30 year age
range and females in the 61 to 80 year age range. Treatment typically
involves analgesics and closed reduction, with some patients requiring
subsequent surgical correction, especially those with concurrent soft tissue
injuries resulting in recurrent shoulder dislocations. The axillary nerve
courses within close proximity of the glenohumeral joint and wrap around
the neck of the humerus, and can incur damage during dislocation or
subsequent attempts at reduction of the dislocated joint. Injury to the
axillary nerves causes a loss of sensation over the lateral shoulder and
paralysis of the deltoid. Hill-Sachs lesions (impaction fracture of the
posterolateral humeral head against anteroinferior glenoid) and Bankart
lesions (detachment of anteroinferior labrum with or without an avulsion
fracture) can also occur following anterior dislocation. The recurrence rate
 9

of glenohumeral joint dislocation is approximately 50% on average;

however, there is a significant increase in the risk of reoccurrence with a
younger age of initial dislocation.

ADHESIVE CAPSULITIS

Adhesive capsulitis is a disorder of unclear cause in which the glenohumeral

capsule becomes inflamed and stiff, significantly restricting motion and can
cause chronic pain. The pain is usually constant, worse at night. Incidence is
approximately 3% of the general population, with some controversy over
this number due to concerns of over-diagnosis of this disorder. It occurs
more commonly in women aged 40 to 70 years of age. Risk factors for
adhesive capsulitis include diabetes mellitus, connective tissue diseases,
thyroid disease, and heart disease. It has associations as an adverse effect
of specific highly active antiretroviral therapies as well. Management
consists of physical and occupational therapy, medication
(analgesics/NSAIDs), intraarticular steroid injection, and, in rare cases,
surgery. Manipulation under general anesthesia may also be an option,
which disrupts the scar tissue and adhesions within the joint. Over time,
most people regain approximately 90% of their shoulder range of motion.

ROTATOR CUFF INJURIES

The tendons of the rotator cuff are often under heavy strain as they
function in stabilizing the glenohumeral joint. Therefore, the pathology of
these rotator cuff tendons is relatively common. Rotator cuff conditions are
the most common source of shoulder pain for primary care office visits. A
wide spectrum of pathology exists, including sub-acromial bursitis, rotator
cuff tendinitis, shoulder impingement, and rotator cuff tears. Patients with
impingements/subacromial bursitis will often complain of pain with
overhead activity. Most patients will have a resolution of their symptoms
with properly designed and performed physical therapy programs. If
patients do not improve after a period of conservative management,
however, evaluation by an orthopedic surgeon and/or sports medicine
specialist is often necessary. Rotator cuff tendon tears can be chronic due
 10

to tendon degeneration or shoulder impingement, or it can be acute

following an injury. It could be partial thickness tear or full-thickness tear.

QUESTION#2

WRITE DOWN HUMEROULNAR JOINT MOBILIZATION WITH PROPER

PROCEDURE?

INTRODUCTION

The humeroulnar joint (ulnohumeral or trochlear joint), is part of the elbow-joint.

It is composed of two bones, the humerus and ulna, and is the junction between
the trochlear notch of ulna and the trochlea of humerus. It is classified as a
simple hinge-joint, which allows for movements of flexion, extension and
circumduction. Owing to the obliquity of the trochlea of the humerus, this
movement does not take place in the antero-posterior plane of the body of the
humerus.

When the forearm is extended and supinated, the axis of the arm and forearm are
not in the same line; the arm forms an obtuse angle with the forearm, known as
the carrying angle. During flexion, however, the forearm and the hand tend to
approach the middle line of the body, and thus enable the hand to be easily
carried to the face.

The accurate adaptation of the trochlea of the humerus, with its prominences and
depressions, to the trochlear notch of the ulna, prevents any lateral movement.

Flexion in the humeroulnar joint is produced by the action of the biceps brachii
and brachialis, assisted by the brachioradialis, with a tiny contribution from the
muscles arising from the medial epicondyle of the humerus.

Extension in the humeroulnar joint is produced by the triceps brachii and

anconeus muscle, with a tiny contribution from the muscles arising from the
lateral epicondyle of the humerus, such as the extensor digitorum muscle.

STRUCTURE
 11

The humeroulnar joint provides most of the structural stability to the elbow as a
whole. This stability is provided primarily by the jaw-like trochlear notch of the
ulna interlocking with the spool-shaped trochlea of the humerus. The elbow is a
hinged joint made up of three bones, the humerus, ulna, and radius. The ends of
the bones are covered with cartilage. Cartilage has a rubbery consistency that
allows the joints to slide easily against one another and absorb shock. The bones
are held together with ligaments that form the joint capsule.

FUNCTION

The humeroulnar joint, is part of the elbow-joint or the Olecron Joint, between
the ulna and humerus bones is the simple hinge-joint, which allows for
movements of flexion, extension and circumduction. The Humero-Ulnar Joint is
the junction of trochlear notch of the ulna and the trochlea of the humerus.

Key facts about the elbow joint

Type Hinge joint
Bones Humerus, radius, ulna
Mnemonics CRAzy TULips (Capitulum = RAdius, Trochlea = ULna)
Ligaments Ulnar collateral ligament, radial collateral ligament, annular
ligament, quadrate ligament
Blood Proximal to elbow joint - Ulnar collateral artery, radial
supply collateral artery, middle collateral artery
Distal to elbow joint - Radial recurrent artery, ulnar recurret
artery
Movements Flexion - Biceps brachii, Brachialis, Brachioradialis muscles
Mnemonic: 3 B's bend the elbow
Extension - Triceps brachii muscle
Clinical Fractures, epicondylitis, arthritis, venipunctures
 12

OSTEOLOGY 

Humerus

There are three bones that comprise the elbow joint:

 the humerus

 the radius

 the ulna.

These bones give rise to two joints:

 Humeroulnar joint is the joint between the trochlea on the medial aspect
of the distal end of the humerus and the trochlear notch on the proximal
ulna.

 Humeroradial joint is the joint between the capitulum on the lateral aspect
of the distal end of the humerus with the head of the radius.

The humeroulnar and the humeroradial joints are the joints that give the elbow
its characteristic hinge like properties. The rounded surfaces of the trochlea and
capitulum of the humerus rotate against the concave surfaces of the trochlear
notch of the ulna and head of the radius. 

At the elbow joint, the proximal ends of the radius and ulna articulate with each
other at the proximal radioulnar joint. 
 13

This joint, however, is considered to be a separate articulation than those forming

the elbow joint itself. The proximal radioulnar joint is the articulation between the
circumferential head of the radius and a fibro-osseous ring formed by the radial
groove of the ulna and the annular ligament that hold the head of the radius in
this groove. The proximal radioulnar joint is functionally a pivot joint, allowing a
rotational movement of the radius on the ulna.

Mnemonic

Here are is a mnemonic that can help you remember the articulations involved in
the elbow joint.

CRAzy TULips

 Capitulum = RAdius (capitulum of the humerus articulates with the head of

radius)

 Trochlea = ULnar (the trochlea of the humerus articulates with the

trochlear notch of the ulna)
 14

LIGAMENTS OF THE ELBOW JOINT

There are a collection of ligaments that connect the bones forming the
elbow joint to each other, contributing to the stability of the joint. The
humeroulnar and the humeroradial joints each have a ligament connecting
the two bones involved at the articulation: the ulnar collateral and the
radial collateral ligaments.

The ulnar collateral ligament extends from the medial epicondyle of the
humerus to the coronoid process of the ulna. It is triangular in shape, and is
composed of three parts: an anterior, a posterior and an inferior band.

The radial collateral ligament has a low attachment to the lateral

epicondyle of the humerus. The distal fibres blend with the annular
ligament that encloses the head of the radius, as well as with the fibres of
the supinator and the extensor carpi radialis brevis muscles.

The annular ligament also reinforces the joint by holding the radius and
ulna together at their proximal articulation. The quadrate ligament is also
present at this joint, and maintains constant tension during pronation and
supination movements of the forearm.

BLOOD SUPPLY AND INNERVATION

 15

The blood supply to the elbow joint is derived from a number of

periarticular anastamoses that are formed by the collateral and recurrent
branches of the brachial, profunda brachii, radial and ulnar arteries.
Proximal to the elbow joint, the brachial artery, the largest in the arm, gives
off two branches, a superior and inferior ulnar collateral artery. The
profunda brachii gives off a radial collateral and a middle collateral artery.
These pass towards the joint contributing to the anastomotic loop
supplying the joint. 

Distal to the elbow joint, the radial artery gives off the radial recurrent
artery, and the ulnar artery gives off the anterior and posterior ulnar
recurrent arteries. These arteries ascend towards the elbow joint,
anastamosing with the branches from the brachial and profunda brachii
arteries in the arm. 

MOVEMENTS

As the elbow joint is a hinge joint, movement is in only one plane. The
movements at the elbow joint involve movement of the forearm at the
elbow joint. Flexion of the forearm at the elbow joint involves decreasing
the angle between the forearm and the arm at the elbow joint. Extension
involves increasing  the angle between the arm and forearm. These
movements are performed by two groups of muscles in the arm: the
anterior compartment and the posterior compartment of the arm.

FLEXION

Most of the muscles producing flexion are found in the anterior

compartment of the arm. There are two muscles in this compartment that
produce flexion at the elbow joint:

 Biceps Brachii originates as two heads. The tendon of the long head
originates from the supraglenoid tubercle of the scapula. It passes through
the joint capsule of the shoulder joint and through the bicipital groove on
the anterior surface of the humerus. The short head of the biceps brachii
muscle originates from the coracoid process of the scapula. These heads
 16

join together to form the biceps brachii muscle belly. The muscle inserts via
a single tendon onto the radial tuberosity distal to the elbow joint. In the
forearm, there is a continuation of this tendon as a flattened connective
tissue sheath, the bicipital aponeurosis. This aponeurosis blends with the
deep fascia in the anterior forearm. 

 Brachialis originates from the distal half of the anterior surface of the
humerus, as well as from the intermuscular septa on either side of the
anterior compartment. It is located deep to the biceps brachii muscle. It
forms a singular tendon that inserts onto the tuberosity of the ulna. 

Both the biceps brachii and brachialis muscles are innervated by the
Musculocutaneous nerve.

While the biceps brachii and the brachialis muscles are the main flexors of
the elbow joint, the brachioradialis muscle is also involved in flexion of the
forearm at this joint. Brachioradialis originates for the lateral aspect of the
distal humerus above the lateral epicondyle. It inserts onto the lateral
aspect of the distal radius. Although this muscle is primarily in the forearm,
it crosses the elbow joint so therefore it acts on the elbow joint. It is
innervated by the radial nerve. 

Mnemonic
 17

Learning the muscles that bend the elbow becomes child's play if you
anchor them to a mnemonic like the one below.

3 B's bend the elbow:

 Biceps.

 Brachialis.

 Brachioradialis.

EXTENSION

Extension of the forearm at the elbow joint is the increase of the angle at the
elbow to bring the forearm back to the anatomical position from a flexed
position. There is one muscle involved in extension, the triceps brachii muscle. It
is the only muscle in the posterior compartment of the arm.

Triceps Brachii originates as three heads. The long head originates from the
infraglenoid tubercle of the scapula, the lateral head originates from the lateral
aspect of the humerus above the radial groove, and the medial head originates
from the medial aspect of the humerus below the level of the radial groove. The
three heads converge on a single tendon that inserts onto the olecranon of the
ulna. It is supplied by the radial nerve, which passes down through the arm in the
radial groove between the lateral and medial heads of the muscle.

While flexion and extension are the only movements that can occur at the elbow
joint itself, movement is also afforded at the proximal radioulnar joint, which
contributes to the elbow joint. Movements at this joint are called pronation and
supination. These are rotational movements that occur when the distal end of the
radius moves over the distal end of the ulna by rotating the radius in the pivot
joint formed by the circular head of the radius, the radial groove of the ulna and
the annular ligament.

Pronation and supination are easily visualised when the elbow is flexed at 90°.
Supination is where the palm of the hand is facing upwards; pronation is rotation
of the forearm so that the palm is facing downwards. In the anatomical position,
the forearm is in the supine position. Pronation in the anatomical position is
movement of the forearm so that the palm is facing posteriorly.
 18

CLINICAL NOTES

FRACTURES

Common injuries to the elbow joint include fractures of the bony structures
contributing to the joint. Care must be taken when diagnosing a fracture of the
elbow joint with  respect to the age of the patient. This is because secondary
ossification centres in children and adolescents can easily be mistaken for a
fracture on a radiograph. Therefore, it is vital that a physician know the age of the
child when examining their radiograph. Some of the areas of secondary
ossification are as follows:

 Capitulum (1 year)

 Radial head and medial epicondyle (5 years)

 Trochlea (11 years)

 Olecranon (12 years)

A supracondylar fracture is a fracture to the humerus above the level of the

humeral condyles. This injury most commonly occurs in children. In such injuries,
the distal bone fragment can be pulled posteriorly by the triceps muscle. This can
cause bowstringing of the brachial arteries by stretching them, which can have
adverse effects.

Fracture of the head of the radius is a common fracture of the elbow joint. It is
often caused by a fall on an outstretched hand, and can have severe implications
including loss of full extension of the forearm at the elbow joint. 

EPICONDYLITIS AND ARTHRITIS

Epicondylitis is inflammation of the soft tissues surrounding the epicondyles of

the humerus. It typically occurs due to overuse of the flexor and extensor muscles
of the forearm. Pain is localised around the epicondylar region. Tennis players
typically get epicondylitis on the lateral epicondyle (common extensor origin),
whereas golfers usually have it on the medial epicondyle (common flexor origin).
 19

Arthritis can occur at the elbow joint, and is usually more severe in the dominant
limb of the patient.

VENIPUNCTURES

Anterior to the elbow joint is a transitional zone between the arm and the
forearm called the cubital fossa. Located in the subcutaneous tissue above the
cubital fossa is a very superficial vein: the median cubital vein. This is a short vein
connecting two longer superficial veins draining the upper limb, the cephalic and
basilic veins, together. The medial cubital vein is one of the most common sites
for venipuncture, which is collecting blood samples in the upper limb.