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GENERAL ANATOMY | DGA1 21

Upper Extremities
Ture Mr. Raigel Kent Alcera
First Semester

UPPER LIMB REGIONS

The upper limb is divided into the shoulder, arm,
elbow, forearm, wrist, and hand. The shoulder is a
complex region connecting the trunk with the upper
limb and can be considered as three parts: pectoral
region, scapular region, and axilla. The arm (upper arm,
brachium) is the proximal segment of the upper limb
from the shoulder to the elbow. In contrast, in the
lower limb, the leg is the more distal segment from the
knee to the ankle. Remember, spelling does matter
because sometimes one or two letters can make a
major difference in the location you are describing
(e.g., “brachial” vs. “bronchial” vs. “branchial”). The
elbow is the area connecting the arm with the forearm.
The cubital fossa is a depression across the front of the
elbow. The forearm (lower arm, antebrachium) is the
segment of the upper limb from the elbow to the wrist.
The wrist (carpus) is a complex of small bones
connecting the forearm and hand. The hand (manus),
a very important organ, is located at the distal end of
the upper limb.
Pectoral Region
The pectoral region is the anterior aspect of the
shoulder. Although this area may be considered part of
the anterior thoracic wall, several structures here (e.g.,
pectoral muscles) connect with and function as part of
the upper limb, thus uniting these areas. The pectoral
region also houses the breasts.

Breasts
Strictly speaking, the breasts are not anatomically part
of the upper limb. However, they are situated in the
pectoral region, and their blood supply and lymphatic
drainage are largely related to the armpit. The clinical
importance of the breasts cannot be overemphasized.
Location and Description
The breasts are specialized accessory glands of the
skin that secrete milk. They are present in both sexes
and share similar structure in males and immature
females. The nipples are small and surrounded by a
colored area of skin called the areola (Fig. 3.14). The
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breast tissue consists of a system of ducts embedded ducts, and the connective tissue becomes filled with
in connective tissue that does not extend beyond the expanding and budding secretory alveoli. The
margin of the areola. vascularity of the connective tissue also increases to
Puberty provide adequate nourishment for the developing
gland. The nipple enlarges, and the areola becomes
darker and more extensive as a result of increased
deposits of melanin pigment in the epidermis. The
areolar glands enlarge and become more active.

At puberty in females, the breasts gradually enlarge

and assume their hemispherical shape under the
influence of ovarian hormones. The ducts elongate,
but the increased size of the glands is mainly from the Late
deposition of fat. The base of the breast extends from During the second half of pregnancy, the growth
the second to sixth rib and from the lateral margin of process slows. However, the breasts continue to
the sternum to the midaxillary line. The greater part of enlarge, mostly because of the distention of the
the gland lies in the superficial fascia. An extension of secretory alveoli with the fluid secretion called
the gland called the axillary tail (see Fig. 3.14C) colostrum.
continues upward and laterally, pierces the deep Postweaning
fascia at the lower border of the pectoralis major The breasts return to their inactive state once the baby
muscle, and enters the axilla. has been weaned. The remaining milk is absorbed; the
Each breast consists of 15 to 20 lobes, which radiate secretory alveoli shrink, and most of them disappear.
out from the nipple (see Fig. 3.14A). The main duct The interlobular connective tissue thickens. The
from each lobe opens separately on the summit of the breasts and the nipples shrink and return nearly to their
nipple and possesses a dilated ampulla just before its original size. The pigmentation of the areola fades, but
termination. The base of the nipple is surrounded by the area never lightens to its original color.
the areola. The underlying areolar glands produce tiny
Post menopause
tubercles on the areola. The lobes of the gland are The breast atrophies after the menopause (see Fig.
separated by fibrous septa that serve as suspensory 3.15). Most of the secretory alveoli disappear, leaving
ligaments (see Fig. 3.14B). A space filled by loose behind the ducts. The amount of adipose tissue may
connective tissue called the retromammary space lies increase or decrease. The breasts tend to shrink in size
deep to the breast and superficial to the underlying and become more pendulous. The atrophy after
pectoral muscles. menopause is caused by the absence of ovarian
Young Women estrogens and progesterone.
In young women, the breasts tend to protrude forward Blood Supply
from a circular base. The arterial supply to the breasts includes the
Pregnancy perforating branches of the internal thoracic artery and
Early the intercostal arteries. The axillary artery also
In the early months of pregnancy, the duct system supplies the gland via its lateral thoracic and
rapidly increases in length and branching (Fig. 3.15). thoracoacromial branches. The veins correspond to
The secretory alveoli develop at the ends of the smaller the arteries.
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Lymph Drainage up again and raise both arms above her head. With this
The lymph drainage of the mammary gland is of great maneuver, a carcinoma tethered to the skin, the
clinical importance because of the frequent suspensory ligaments, or the lactiferous ducts
development of cancer in the gland and the produces dimpling of the skin or retraction of the nipple
subsequent dissemination of the malignant cells along Mammography
the lymph vessels to the lymph nodes. The lateral Mammography is a radiographic examination of the
quadrants of the breast drain into the anterior axillary breast (Fig. 3.17). This technique is extensively used
or pectoral group of nodes (Fig. 3.16) (situated just for screening the breasts for benign and malignant
posterior to the lower border of the pectoralis major tumors and cysts. Extremely low doses of x-rays are
muscle). The medial quadrants drain by means of used so that the dangers are minimal, and the
vessels that pierce the intercostal spaces and enter examination can be repeated often. Its success is
the internal thoracic group of nodes (situated within based on the fact that a lesion measuring only a few
the thoracic cavity along the course of the internal millimeters in diameter can be detected long before it
thoracic artery). A few lymph vessels follow the is felt by clinical examination
posterior intercostal arteries and drain posteriorly into
Upper Extremities : Shoulder Region
the posterior intercostal nodes (situated along the
course of the posterior intercostal arteries); some Scapular Region
vessels communicate with the lymph vessels of the The scapular region is the posterior aspect of the
opposite breast and with those of the anterior shoulder. Although this area may be considered part of
abdominal wall. the back and/or posterior thoracic wall, several
structures here (e.g., trapezius and latissimus dorsi
muscles) connect with and function as part of the
upper limb, thus uniting these areas.

Breast Examination
The breast is one of the common sites of cancer in
women. It is also the site of different types of benign
tumors and may be subject to acute inflammation and
abscess formation. For these reasons, clinical
personnel must be familiar with the development,
structure, and lymph drainage of this organ. With the
patient undressed to the waist and sitting upright, first
inspect the breasts for symmetry. Some degree of
asymmetry is common and is the result of unequal
breast development. Any swelling should be noted. An
underlying tumor, a cyst, or abscess formation can
cause a swelling. Carefully examine the nipples for
evidence of retraction. A carcinoma within the breast
substance can cause retraction of the nipple by pulling
on the lactiferous ducts. Next, ask the patient to lie
down so that the breasts can be palpated against the
underlying thoracic wall. Finally, ask the patient to sit
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 The superior border is the short, thin, superior edge of
the scapula. A notch (the scapular notch) is located
on the lateral aspect of the superior border, near the
base of the coracoid process. The superior transverse
scapular ligament bridges the notch. Normally, the
suprascapular artery passes superior to this ligament,
whereas the suprascapular nerve passes inferior to it
(remember: the Army goes over the bridge; the Navy
goes under the bridge). The medial (vertebral) border
is the long, medial edge of the scapula, located closest
to the vertebral column. The lateral (axillary) border
is the thickened, lateral edge of the scapula, located
closest to the axilla. The junction of the superior and
medial borders forms the superior angle of the
scapula. The junction of the medial and lateral borders
forms the inferior angle. The inferior angle of the
scapula can be palpated easily in the living subject and
marks the level of the seventh rib and the spine of the
seventh thoracic vertebra. The junction of the superior
and lateral borders forms the lateral angle.
The lateral angle of the scapula is the thickest and
most complex part of the scapula. It is composed
mainly of a broadened process (the head of the
scapula) that is connected to the rest of the bone by a
Scapula slight constriction (the neck of the scapula). The
Also known as the “shoulder bone,” the scapula lateral surface of the head forms a shallow articular
(scapul- is Latin for “shoulder blade”) is a large, flat, surface, the glenoid cavity or fossa (glen- is Greek for
triangular bone that lies on the posterior chest wall “pit” or “socket”), for the head of the humerus. A
between the second and seventh ribs. It articulates fibrocartilage ring (glenoid labrum) rims the margin of
with the acromial extremity of the clavicle and the the glenoid cavity and serves to broaden and deepen
head of the humerus. The major defining features of the joint cavity. A small elevation (supraglenoid
the scapula are its three borders (superior, medial, tubercle) is located at the apex of the glenoid cavity,
lateral), three angles (superior, inferior, lateral), two near the base of the coracoid process. A roughened
surfaces (dorsal, costal), and three large bony area (infraglenoid tubercle) is located immediately
processes (spine, acromion, coracoid). inferior to the glenoid cavity.
The dorsal (posterior) surface of the scapula is
subdivided into two unequal-sized regions by the spine
of the scapula. The smaller, troughlike area superior to
the spine is the supraspinous fossa. The much larger
area inferior to the spine is the infraspinous fossa. The
spine is the large, triangular ridge that runs laterally
from the medial border of the scapula to merge into the
acromion process. The lateral border of the spine
blends into the neck of the scapula and forms a
notchlike passageway (spinoglenoid, or greater
scapular, notch) that connects the supraspinous
fossa with the infraspinous fossa. This allows the
suprascapular nerve and vessels to pass between
these fossae. The acromion (acromi- is Greek for
“point of the shoulder”) is the broad, flat lateral
extension of the spine of the scapula. This forms the
easily palpable tip of the shoulder. It partly roofs over

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the glenoid cavity and provides an articulation with the Glenohumeral Joint (Shoulder Joint)
clavicle at the acromioclavicular joint.  Articulation: This occurs between the rounded
The costal (ventral, anterior) surface of the scapula head of the humerus and the shallow, pear-
lies against the posterior aspect of the rib cage. A large shaped glenoid cavity of the scapula. The
part of this surface forms a shallow concavity, the articular surfaces are covered by hyaline
subscapular fossa. The coracoid process (coraco- is articular cartilage, and the glenoid cavity is
Greek for “like a crow’s beak”) is a thick, beaklike deepened by the presence of a fibrocartilaginous
structure that projects anterolaterally from the rim termed the glenoid labrum.
junction of the neck and lateral end of the superior  Type: Synovial ball-and-socket joint.
border of the scapula. It can be palpated via deep  Capsule: This surrounds the joint and is attached
pressure through the anterior part of the deltoid medially to the margin of the glenoid cavity
muscle, inferior to the lateral end of the clavicle. The outside the labrum; laterally, it is attached to the
main muscles and ligaments attached to the scapula. anatomic neck of the humerus. The capsule is
Scapular Fractures thin and lax, allowing a wide range of movement.
Fractures of the scapula are usually the result of Fibrous slips from the tendons of the
severe trauma, such as occurs in run-over accident subscapularis, supraspinatus, infraspinatus, and
victims or in occupants of automobiles involved in teres minor muscles (the rotator cuff muscles)
crashes. Injuries are usually associated with fractured strengthened the capsule.
ribs. Most fractures of the scapula require little direct  Ligaments: The glenohumeral ligaments are
treatment because the muscles on the anterior and three weak bands of fibrous tissue that
posterior surfaces adequately splint the fragments strengthen the front of the capsule. The
Sternoclavicular Joint transverse humeral ligament strengthens the
 Articulation: Occurs between the sternal end of capsule, bridges the gap between the two
the clavicle, the manubrium sterni, and the first tuberosities, and holds the tendon of the long
costal cartilage (Fig. 3.71A). head of the biceps muscle in place. The
 Type: Synovial double-plane joint. coracohumeral ligament strengthens the
 Capsule: Surrounds the joint and is attached to the capsule above and stretches from the root of the
margins of the articular surfaces. coracoid process to the greater tuberosity of the
 Ligaments: Capsule is reinforced in front of and humerus.
behind the joint by the strong sternoclavicular  Accessory ligaments: The coracoacromial
ligaments. ligament extends between the coracoid process
 Articular disc: A flat fibrocartilaginous disc lies and the acromion. Its function is to protect the
within the joint and divides the joint’s interior into superior aspect of the joint.
two compartments, medial and lateral (Fig.  Synovial membrane: This lines the capsule and
3.71A). Its circumference is attached to the is attached to the margins of the cartilage
interior of the joint capsule, but it is also strongly covering the articular surfaces. It forms a tubular
attached to the superior margin of the articular sheath around the tendon of the long head of the
surface of the clavicle above and to the first costal biceps brachii. It extends through the anterior
cartilage below. wall of the capsule to form the subscapularis
 Accessory ligament: The costoclavicular ligament bursa beneath the subscapularis muscle.
is a strong ligament that runs from the junction of  Nerve supply: Axillary and suprascapular
the first rib with the first costal cartilage to the nerves.
inferior surface of the sternal end of the clavicle
(Fig. 3.71A).
 Synovial membrane: Lines the joint capsule and is
attached to the margins of the cartilage covering
the articular surfaces.
 Nerve supply: Supraclavicular nerve and the nerve
to the subclavius muscle.

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 Acromioclavicular Joint
 Articulation: Occurs between the acromion of
the scapula and the lateral end of the clavicle
(see Fig. 3.71B).
 Type: Synovial plane joint.
 Capsule: Surrounds the joint and is attached to
the margins of the articular surfaces.
 Ligaments: Superior and inferior
acromioclavicular ligaments reinforce the
capsule. A wedge-shaped fibrocartilaginous disc
projects into the joint cavity from the capsule,
from above (see Fig. 3.71B).
 Accessory ligament: The very strong
coracoclavicular ligament extends from the
coracoid process to the undersurface of the
clavicle and is largely responsible for suspending
the weight of the scapula and the upper limb from
the clavicle (see Fig. 3.71B).
 Synovial membrane: Lines the capsule and is
attached to the margins of the cartilage covering
the articular surfaces.
 Nerve supply: Suprascapular nerve.

Humerus
The humerus (humer- is Latin for “shoulder”) is
located in the arm (brachium) and is the longest bone
of the upper limb. Proximally, the humerus articulates
with the glenoid cavity of the scapula, at the
glenohumeral (shoulder) joint. Distally, it articulates
with the head of the radius and the trochlear notch of
the ulna, at the elbow joint.
The humerus can be divided into three main regions:
(1) proximal extremity, (2) body or shaft, and (3) distal
extremity. The major muscles and ligaments attached
to the humerus.

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 defines the groove for the radial nerve. The groove
(sulcus) for the radial nerve (radial groove, spiral
groove) is the shallow depression that spirals around
the posterior and lateral aspects of the midshaft of the
humerus. The groove is most distinct where it lies
between the deltoid tuberosity and the upper end of
the lateral supracondylar ridge. It has important
relations with the radial nerve and the profunda brachii
vessels. Fractures of the midshaft humerus are
common, especially inferior to the deltoid tuberosity,
and may affect the radial groove and its contents. The
medial supracondylar ridge is the narrow ridge
running proximally from the medial epicondyle,
forming the lower medial border of the humerus. The
lateral supracondylar ridge is the narrow ridge
running proximally from the lateral epicondyle, forming
the lower lateral border of the humerus.
Proximal Extremity
The head is the round, smooth, proximal end of the
humerus. It forms about one third of a sphere and is
oriented medially, superiorly, and slightly posteriorly. It
articulates with the glenoid cavity of the scapula to
form the glenohumeral joint in the shoulder joint
complex. The greater tubercle is the large, roughened
elevation on the lateral proximal end of the humerus,
lateral to the head. The lesser tubercle is the small,
roughened elevation on the anterior proximal end of
the humerus, inferior to the head and medial to the
greater tubercle. The anatomical neck is the slightly
constricted region surrounding the articular surface of
the head. The articular capsule of the glenohumeral
joint attaches along the inferior edge of the anatomical
neck. Fractures here generally are rare but may be
Distal Extremity
more frequent in the elderly. The surgical neck is the
constricted area immediately inferior to the greater
and lesser tubercles. This forms the interface between
the proximal extremity and the shaft of the humerus.
The surgical neck has important relations with the
axillary nerve and the anterior and posterior circumflex
humeral vessels. Fractures here are common. The
intertubercular (bicipital) groove is the deep groove
on the anterior surface of the humerus that separates
the greater and lesser tubercles. It houses the tendon
of the long head of the biceps brachii muscle and
extends into the upper third of the shaft of the
humerus.
Body/Shaft
The deltoid tuberosity (delt as in the triangular Greek The lateral epicondyle is the small, roughened
letter “delta”) is the roughened triangular elevation on projection on the distal, lateral side of the humerus,
the anterolateral surface of the midshaft of the proximal to the capitulum. It is readily palpable. The
humerus. This serves as the attachment area for the common extensor tendon (tendon of origin for several
deltoid muscle. The posterior edge of the tuberosity superficial forearm extensor muscles) attaches here.

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Inflammation of this tendon is termed “lateral at its distal end. The major muscles and ligaments
epicondylitis” (“tennis elbow”). The medial attached to the radius are shown in Figure 3.7.
epicondyle is the large, knoblike projection on the
distal, medial side of the humerus, proximal to the
trochlea. It is easily palpable and forms an important
surface landmark in the arm. The ulnar nerve crosses
the posterior surface of this epicondyle in the shallow
ulnar sulcus and is susceptible to injury here (e.g., via
blunt trauma or bony fracture). The nerve can be
palpated and rolled against the epicondyle.
Stimulation of the nerve by contact against the
epicondyle elicits the characteristic “funny bone”
response of tingling sensations in the medial border of
the hand and fifth digit. (So, why is the funny bone
funny? Because it borders on the “humerus.”) The
capitulum (capit- is Latin for “head”—in this
grammatical case, “little head”) is the rounded, half-
spherical, articular process at the distal, lateral end of
the humerus. It lies immediately lateral to the trochlea.
The capitulum articulates with the head of the radius.
The shapes of these structures allow both
flexion/extension and rotation at the humeroradial
joint. The trochlea (trochle- is Greek for “pulley”) is the
pulley-shaped articular process at the distal, medial
end of the humerus. It lies immediately medial to the The head is the expanded, round, proximal end of the
capitulum. The trochlea articulates with the trochlear radius. Its proximal surface is a shallow concavity for
notch of the ulna. The shapes of the articulated articulation with the capitulum of the radius. Its
trochlea and trochlear notch (plus the presence of the periphery articulates with the radial notch of the ulna.
humeroradial joint) limit lateral movements of the ulna, The head is held in place against the ulna by the
resulting in essentially a hinge action at the encircling anular ligament. Note that the head of the
humeroulnar joint. The coronoid fossa is the radius is at its proximal end, whereas the head of the
depression on the distal, anterior end of the humerus, ulna is at its distal end. The neck is the constricted
immediately proximal to the trochlea. This receives area immediately distal to the head. The radial
the coronoid process of the ulna when the elbow is tuberosity is the raised, mostly roughened area on the
fully flexed. The radial fossa is the shallow depression anteromedial, proximal aspect of the radius, just distal
on the distal, anterior end of the humerus, immediately to the neck. This is the insertion site of the biceps
proximal to the capitulum. This receives the margin of brachii muscle. The body (shaft) is the elongated
the head of the radius when the elbow is fully flexed. midportion of the radius. It widens along its proximal to
The olecranon fossa is the deep depression on the distal extent. The medial border of the shaft forms a
distal, posterior end of the humerus, immediately sharp crest (the interosseous border) for the
proximal to the trochlea. This holds the apex of the attachment of the interosseous membrane that binds
olecranon process of the ulna when the elbow is together the radius and ulna. The ulnar notch is the
extended. shallow depression on the distal, medial aspect of the
Radius radius. This is the articular surface for the head of the
The radius (radi- is Latin for “spoke” or “ray”) is the ulna. The styloid process (styl- is Greek for “pointed
bone on the lateral side of the forearm (antebrachium). instrument”) is the distal projection from the lateral,
Proximally, it articulates with both the capitulum of the distal aspect of the radius. This extends lateral to the
humerus and the radial notch of the ulna, in the elbow proximal row of carpal bones. The carpal articular
joint. Distally, it articulates with the head of the ulna surface forms the distal surface of the radius. This
and the scaphoid and lunate bones, in the wrist. During area articulates with the scaphoid (laterally) and lunate
pronation and supination, the radius rotates about its (medially) bones.
long axis at its proximal end and circumducts the ulna
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Axilla The axilla contains the axillary artery and its
The axilla, or armpit, is a pyramid-shaped space branches, which supply blood to the upper limb; the
between the upper part of the arm and the side of the axillary vein and its tributaries, which drain blood
chest. It forms an important passage for nerves, blood from the upper limb; and lymph vessels and lymph
vessels, and lymph channels as they travel between nodes, which drain lymph from the upper limb, the
the root of the neck to the upper limb. The upper end of breast, and the skin of the trunk as far down as the
the axilla, or apex, is directed into the root of the neck level of the umbilicus. The brachial plexus, an
and is bounded in front by the clavicle, behind by the important nerve network that innervates the upper
upper border of the scapula, and medially by the outer limb, lies among these structures. The contents of
border of the first rib. The lower end, or base, is the axilla are embedded in fat.
bounded in front by the anterior axillary fold (formed Pectoralis Minor
by the lower border of the pectoralis major muscle), The pectoralis minor is a thin triangular muscle that
behind by the posterior axillary fold (formed by the lies deep to the pectoralis major (see Fig. 3.12). It
tendons of the latissimus dorsi and teres major arises from the third, fourth, and fifth ribs and runs
muscles), and medially by the chest wall. upward and laterally to insert into the coracoid
Axillary Walls process of the scapula. Thus, it crosses the axilla and
The four walls of the axilla are constructed as follows: divides the area into three subregions (proximal,
 Anterior wall: By the pectoralis major, deep, and distal to the muscle) that are useful in
subclavius, and pectoralis minor muscles describing the course of the axillary artery and the
 Posterior wall: By the subscapularis, latissimus lymph drainage of the area (see the descriptions of
dorsi, and teres major muscles the axillary artery and lymph drainage below).
 Medial wall: By the upper four or five ribs and the Clavipectoral Fascia
intercostal spaces covered by the serratus The clavipectoral fascia is a strong sheet of
anterior muscle connective tissue lying immediately deep to the
 Lateral wall: By the coracobrachialis and biceps pectoralis major muscle (see Figs. 3.12 and 3.22).
brachii muscles in the bicipital groove of the Superiorly, it attaches to the clavicle. Inferiorly, it
humerus. splits to enclose the subclavius and pectoralis minor
muscles and then continues downward as the
suspensory ligament of the axilla and joins the fascial
floor of the armpit. The lateral pectoral nerve,
cephalic vein, branches of the thoracoacromial
artery, and lymphatic channels from the
infraclavicular nodes pierce the clavipectoral fascia
in order to make their superficial–deep connections.
Muscles: Shoulder Region
Pectoral Region

The skin stretching between the anterior and

posterior walls forms the base of the axilla (see Fig.
3.22). Details of the muscles forming the walls of the
axilla are summarized later in this chapter in Tables
3.3 through 3.5.

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Back Region
Scapula Region

The muscles of the scapular region connect the

shoulder girdle with the upper part of the humerus and
are largely concerned with abduction and rotation of
the arm.
Scapular Region Muscles

 Extrinsic Muscles
1. Superficial
o Trapezius
o Latissimus Dorsi
2. Deep
o Levator Scapulae
o Rhomboids

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VASCULATURE
Arteries
The subclavian artery, located in the root of the neck,
continues as the axillary artery, which supplies the
upper limb.

First Part of Axillary Artery

 This extends from the lateral border of the first rib
to the upper border of the pectoralis minor
Relations
 Anteriorly: Pectoralis major and the skin; cephalic
vein crosses the artery
 Posteriorly: Long thoracic nerve (nerve to the
serratus anterior;
 Laterally: Three cords of the brachial plexus
 Medially: Axillary vein
Second Part of Axillary Artery
 This lies deep to the pectoralis minor muscle
Relations
 Anteriorly: Pectoralis minor, pectoralis major, and
the skin.
 Posteriorly: Posterior cord of the brachial plexus,
the subscapularis muscle, and the shoulder joint
 Laterally: Lateral cord of the brachial plexus
Axillary Artery  Medially: Medial cord of the brachial plexus and
The axillary artery begins at the lateral border of the the axillary vein
first rib and ends at the lower border of the teres major Third Part of Axillary Artery
muscle, where it continues as the brachial artery.  This extends from the lower border of the
Throughout its course, the artery is closely related to pectoralis minor to the lower border of the teres
the cords of the brachial plexus and their branches and major
is enclosed with them in a connective tissue sheath
Relations
called the axillary sheath. This sheath is continuous
 Anteriorly: Pectoralis major for a short distance;
with the prevertebral fascia in the root of the neck. The
more distally, the medial root of the median nerve
pectoralis minor muscle crosses in front of the axillary
crosses the artery
artery and divides it into three parts
 Posteriorly: Subscapularis, latissimus dorsi, and
teres major; axillary and radial nerves also lie
behind the artery

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 Laterally: Coracobrachialis, biceps, and humerus; supracondylar ridges of the humerus, respectively. In
lateral root of the median nerve and the this way, the upper arm is divided into an anterior and
musculocutaneous nerve also lie on the lateral a posterior osseofascial compartment, each having a
side set of muscles, nerves, and arteries. Also, these and
 Medially: Ulnar nerve, axillary vein, and medial additional structures pass through each compartment
cutaneous nerve of the arm on route to more distal areas.
Axillary Artery Branches
Typically, the axillary artery has six branches.
Conveniently for memory, one branch comes from the
first part of the artery, two branches from the second
part, and three branches from the third part. However,
the branching pattern is subject to much variation, and
recognizing the target territories of the branches in
order to verify the identities of the branches is
important.
Branch from First Part
The highest thoracic artery is small and extremely
variable. It runs along the upper border of the
pectoralis minor to reach the area of the first two ribs.
Branches from Second Part
The thoracoacromial artery is a short trunk that
immediately divides into four terminal branches that
supply the pectoral muscles and the Anterior View of the Upper Arm
acromioclavicular region. The lateral thoracic artery
runs along the lower (lateral) border of the pectoralis
minor along the lateral chest wall.
Branches from Third Part
The subscapular artery is a large vessel that descends
along the lower (axillary) border of the scapula. It
divides into the circumflex scapular and thoracodorsal
arteries. The circumflex scapular artery curls around
the axillary border of the scapula to reach the
infraspinous fossa. The thoracodorsal artery descends
along the latissimus dorsi muscle to reach the lateral
thoracic wall. The anterior and posterior circumflex
humeral arteries wind around the front and the back of
the surgical neck of the humerus, respectively, and
form an anastomosing circle. The posterior artery is the
larger of the two and passes through the quadrangular
space with the axillary nerve to reach the scapular
region.
Arm
The arm (upper arm; brachium) is the proximal
segment of the upper limb from the shoulder to the
elbow.
Osseofascial Compartments
The arm is enclosed in a sheath of deep fascia. Two
fascial intermuscular septa, one on the medial side
and one on the lateral side, extend inward from this
sheath and are attached to the medial and lateral

P a g e 12 | 23
Posterior View of Upper Arm

Elbow and Cubital Fossa

The elbow is the area connecting the arm with the
forearm. The cubital fossa is a triangular depression
that lies in the anterior aspect of the elbow. This fossa
is important because it conveys several major
structures between the arm and forearm.

Arm Osseofascial Compartments

Structures Passing through Anterior

Osseofascial Compartment
The musculocutaneous nerve, median nerve, ulnar
nerve, brachial artery, and basilic vein pass through
this region. The radial nerve is present in the lower part
of the compartment. Cubital Fossa Boundaries
Structures Passing through Posterior  Laterally: Brachioradialis muscle
Osseofascial Compartment  Medially: Pronator teres muscle
 Base: Imaginary line drawn between the two
The radial nerve, ulnar nerve, and profunda brachii
epicondyles of the humerus forming the base of
vessels pass through this region.
the triangle
 Floor: Supinator muscle laterally; the brachialis
muscle medially
 Roof: Skin and fascia, reinforced by the bicipital
aponeurosis

P a g e 13 | 23
 Proximal
The proximal end of the ulna is large and is known as
the olecranon process; this forms the prominence of
the elbow. It has a notch on its anterior surface, the
trochlear notch, which articulates with the trochlea of
the humerus. Below the trochlear notch is the
triangular coronoid process, which has on its lateral
surface the radial notch for articulation with the head
of the radius.
Shaft
The shaft of the ulna tapers from above down. It has a
sharp interosseous border laterally for the
Cubital Fossa Contents attachment of the interosseous membrane. The
 The cubital fossa contains the following
posterior border is rounded and subcutaneous and can
structures, enumerated from the medial to the
be easily palpated throughout its length. Below the
lateral side: the median nerve, the bifurcation of
radial notch is the supinator crest that gives origin to
the brachial artery into the ulnar and radial arteries,
the supinator muscle.
the tendon of the biceps muscle, and the radial
nerve and its deep branch.
Distal
At the distal end of the ulna is the small, rounded
head, which has projecting from its medial aspect the
styloid process.

Radius
The radius is the lateral bone of the forearm. Its
proximal end articulates with the humerus at the elbow
joint and with the ulna at the proximal radioulnar joint.
Its distal end articulates with the scaphoid and lunate
bones of the hand at the wrist joint and with the ulna at
Ulna the distal radioulnar joint.

The ulna is the medial bone of the forearm. Its proximal

end articulates with the humerus at the elbow joint and
with the head of the radius at the proximal radioulnar
joint. Its distal end articulates with the radius at the
distal radioulnar joint, but it is excluded from the wrist
joint by the articular disc.

P a g e 14 | 23
Proximal Distal
At the proximal end of the radius is the small circular At the distal end of the radius is the styloid process;
head. The upper surface of the head is concave and this project distally from its lateral margin. On the
articulates with the convex capitulum of the humerus. medial surface is the ulnar notch, which articulates
The circumference of the head articulates with the with the round head of the ulna. The inferior articular
radial notch of the ulna. Below the head, the bone is surface articulates with the scaphoid and lunate
constricted to form the neck. Below the neck is the bones. On the posterior aspect of the distal end is a
bicipital tuberosity for the insertion of the biceps small tubercle, the dorsal tubercle, which is grooved
muscle on its medial side by the tendon of the extensor pollicis
longus.
Clinical

Muscles of the Forearm

 Anterior Compartment
o Superficial
▪ Flexor Carpi Radialis
▪ Flexor Carpi Ulnaris
▪ Palmaris Longus
▪ Pronator Teres
o Intermediate
▪ Flexor Digitorum Superficialis
o Deep
▪ Flexor Digitorum Profundus
▪ Flexor Pollicis Longus
▪ Pronator Quadratus

Contents of Forearm Osseofascial

Compartments

Shaft
The shaft of the radius, in contradistinction to that of
the ulna, is wider below than above. It has a sharp
interosseous border medially for the attachment of the
interosseous membrane that binds the radius and ulna
together. The pronator tubercle, for the insertion of the
pronator teres muscle, lies halfway down on its lateral
side.

P a g e 15 | 23
Anterior Compartment

Superficial

Osseofascial Compartment

Intermediate

Deep
Muscles of Lateral Forearm Osseofascial
Compartment

P a g e 16 | 23
Muscles of Posterior Forearm Osseofascial Posterior View of Forearm
Compartment

Anterior View of Forearm

Posterior Osseofascial Compartment

Muscles
- extensor except brachioradialis
The muscles of the posterior Osseo fascial
compartment are arranged in two groups: superficial
and deep. The superficial group muscles possess a
common tendon of origin that is attached to the lateral
epicondyle of the humerus
Superficial group: Extensor carpi radialis brevis,
extensor digitorum, extensor digiti minimi, extensor
carpi ulnaris, and anconeus

P a g e 17 | 23
Deep group: Supinator, abductor pollicis longus, Brachial Artery
extensor pollicis brevis, extensor pollicis longus, and The brachial begins at the lower border of the teres
extensor indicis major muscle as a continuation of the axillary artery. It
travels through the anterior compartment of the arm.
However, its branches supply both the anterior and
posterior compartments of the arm, and thus, the
brachial artery supplies the entire arm. It terminates
opposite the neck of the radius by dividing into the
radial and ulnar arteries.
Ulnar Artery
The ulnar artery is the larger of the two terminal
branches of the brachial artery. It begins in the cubital
fossa at the level of the neck of the radius. It descends
through the medial (ulnar) aspect of the anterior
compartment of the forearm and enters the palm
superficial to the flexor retinaculum in company with
the ulnar nerve. It ends by forming the superficial
palmar arch, often anastomosing with the superficial
palmar branch of the radial artery.
Ulnar Artery in Forearm
In the proximal forearm, the ulnar artery lies deep to
most of the flexor muscles. More distally, it becomes
ARTERIES superficial and lies between the tendons of the flexor
carpi ulnaris and the tendons of the flexor digitorum
superficialis. As the artery crosses over the flexor
retinaculum, it lies just lateral to the pisiform bone and
is covered only by skin and fascia, making this a good
site for taking the ulnar pulse.
Forearm Branches
 Muscular branches to neighboring muscles.
 Anterior and posterior ulnar recurrent
branches that take part in the arterial
anastomoses around the elbow joint.
 Branches that take part in the arterial
anastomosis around the wrist joint.
 The common interosseous artery arises from
the upper part of the ulnar artery and, after a brief
course, divides into the anterior and posterior
interosseous arteries. The interosseous arteries
pass distally on the anterior and posterior
surfaces of the interosseous membrane,
respectively. They provide nutrient arteries to
the radius and ulna, supply adjacent muscles in
the anterior and posterior compartments, and
end by taking part in the anastomosis around the
wrist joint.
Ulnar Artery in Hand
The ulnar artery enters the hand superficial to the flexor
retinaculum on the lateral side of the ulnar nerve and
the pisiform bone. The artery gives off a deep palmar
branch and then continues into the palm as the
P a g e 18 | 23
superficial palmar arch. On entering the palm, the
superficial palmar arch curves laterally deep to the
palmar aponeurosis and superficial to the long flexor
tendons. The arch is completed on the lateral side by
anastomosing with the superficial palmar branch of
the radial artery. The curve of the arch lies across the
palm, level with the distal border of the fully extended
thumb. The superficial arch gives rise to three
common palmar digital arteries. Each common
artery divides into two proper palmar digital arteries
that supply adjacent sides of two digits. The deep
palmar branch of the ulnar artery arises superficial to
the flexor retinaculum, passes deep between the
abductor digiti minimi and the flexor digiti minimi, and
joins the radial artery to complete the deep palmar
arch.

Radial artery
The radial artery is the smaller of the two terminal
branches of the brachial artery. It begins in the cubital
fossa at the level of the neck of the radius and
descends through the lateral (radial) aspect of the
anterior compartment of the forearm. It ends by
forming the deep palmar arch in the hand, often

P a g e 19 | 23
anastomosing with the deep palmar branch of the dorsum of the hand. Branches of the dorsal carpal arch
ulnar artery. take part in anastomoses around the wrist joint and
Radial Artery in Forearm also supply the digits.
In the proximal forearm, the radial artery lies deep to
the brachioradialis muscle. In the middle third of its
course, it runs medial to the superficial branch of the
radial nerve. In the distal forearm, the radial artery lies
on the anterior surface of the radius, between the
tendons of the brachioradialis and flexor carpi radialis
muscles and is covered only by skin and fascia . This is
the ideal site for taking the radial pulse.
Forearm Branches
Muscular branches to neighboring muscles. The radial
recurrent artery takes part in the arterial anastomosis
around the elbow joint. The superficial palmar branch
arises just proximal to the wrist, enters the palm of the
hand, and joins the ulnar artery to complete the
superficial palmar arch.
Radial Artery in Hand
The radial artery leaves the forearm by winding around
the lateral aspect of the wrist to reach the
posterolateral surface of the hand. The artery enters
the floor of the anatomic snuffbox, lying on the lateral Veins
ligament of the wrist joint and passing deep to the The veins of the upper limb can be divided into two
tendons of the abductor pollicis longus and extensor groups: superficial and deep. The deep veins
pollicis brevis muscles. The vessel continues under comprise the venae comitantes and the axillary vein.
the tendon of the extensor pollicis longus to reach the The venae comitantes are usually paired and
interval between the two heads of the first dorsal accompany the large and medium-sized arteries
interosseous muscle. Here, the artery dives between
the muscle heads to enter the deep aspect of the palm
of the hand.
Upon entering the palm, the radial artery curves
medially between the oblique and transverse heads of
the adductor pollicis and continues as the deep palmar
arch. The deep palmar arch curves medially deep to
the long flexor tendons and superficial to the
metacarpal bones and the interosseous muscles. The
arch is completed on the medial side by the deep
palmar branch of the ulnar artery. The curve of the arch
lies at a level with the proximal border of the extended
thumb.
Immediately upon entering the palm, the radial artery
gives off the arteria radialis indicis, which supplies the
lateral side of the index finger, and the arteria princeps
pollicis, which divides into two and supplies the lateral Superficial veins
and medial sides of the thumb. The deep palmar arch - Dorsal Venous network
sends branches proximally, which take part in - Cephalic Vein
anastomoses around the wrist joint, and distally, to - Basilic Vein
join the digital branches of the superficial palmar arch. - Axillary Vein (Basilic + brachial vein)
Before it dives to form the deep palmar arch, the radial - Median Cubital Vein
artery gives rise to the dorsal carpal arch on the - Median Vein of Forearm
Deep Veins
P a g e 20 | 23
 - Named according to companion arteries venae comitantes of the brachial artery to form the
- Radial Vein axillary vein on the medial side of the biceps. In its
- Ulnar Vein course, the basilic vein receives the median cubital
- Brachial Vein vein and a variable number of tributaries from the
- Axillary Vein medial and posterior surfaces of the upper limb.

Axillary Vein
The axillary vein is formed at the lower border of the
teres major muscle by the union of the venae
comitantes of the brachial artery and the basilic vein. It
runs upward on the medial side of the axillary artery
and ends at the lateral border of the first rib by
becoming the subclavian vein. The axillary vein
Cephalic Vein receives tributaries, which correspond to the branches
The cephalic vein arises from the lateral side of the of the axillary artery and the cephalic vein.
dorsal venous arch on the back of the hand and winds
around the lateral border of the forearm. It then
ascends into the cubital fossa and up the front of the
arm in the superficial fascia on the lateral side of the
biceps. It dives into the deltopectoral triangle, pierces
the clavipectoral fascia, and terminates by draining
into the axillary vein. As the cephalic vein passes up
the upper limb, it receives a variable number of
tributaries from the lateral and posterior surfaces of
the limb. The median cubital vein, a branch of the
cephalic vein in the cubital fossa, runs upward and
medially and joins the basilic vein. The median cubital
vein is normally present, but the form in which it
connects the cephalic and basilic veins is subject to
variation. In the cubital fossa, the median cubital vein
crosses over the brachial artery and the median nerve,
but it is separated from them by the bicipital
aponeurosis.
Basilic Vein
The basilic vein arises from the medial side of the
dorsal venous arch on the back of the hand and winds Lymphatic drainage of the upper limb
around the medial border of the forearm. It then  Superficial lymphatics
ascends into the cubital fossa and up the front of the - From the thumb, index finger, and lateral part
arm in the superficial fascia on the medial side of the of the hand follow the cephalic vein ->
biceps. Halfway up the arm, it pierces the deep fascia infraclavicular lymph nodes.
and at the lower border of the teres major joins the

P a g e 21 | 23
 - From the medial part of the hand follow the
basilic vein -> supratrochlear lymph node
which lies just above the medial epicondyle of
the humerus -> lateral group of axillary lymph
nodes
 Deep lymphatics: follow the arteries -> lateral
group of axillary lymph nodes.

Hands

Carpals
The carpal (carp- is Greek for wrist) bones are the eight
small bones comprising the wrist. These are arranged
in two rows (proximal and distal), with four bones in
each row. The arrangement of the bones forms a deep
concave groove on the ventral aspect of the wrist. This
groove is roofed over by a strong ligamentous band (the
flexor retinaculum), thus forming the osseofascial
carpal tunnel. The carpal tunnel conveys several flexor
tendons and the median nerve into the hand.
Compression of the tunnel space and/or trauma to its
contents results in carpal tunnel syndrome. The bones
of the hand are cartilaginous at birth. The capitate Metacarpal
begins to ossify during the 1st year, and the others The metacarpal bones are the five bones located
begin to ossify at intervals thereafter until the 12th between the carpal bones and the phalanges of the
year, when all the bones are ossified. hand. These comprise the body of the hand, whereas
the phalanges make up the fingers. The bones are
identified by number (1–5), starting with the most
lateral unit (i.e., metacarpal 1 aligns with the thumb).
Each bone has a base, a body, and a head. The base is
the expanded proximal end of the bone. It articulates
with the distal row of carpal bones. The body (shaft) is
the elongate, slender midportion of the bone. The shaft
of each metacarpal bone is slightly concave anteriorly
P a g e 22 | 23
and is triangular in transverse section. It has posterior,
lateral, and medial surfaces. The head is the rounded
distal end of the bone. It articulates with the proximal
phalanx of the corresponding digit and forms a knuckle
of the hand. The first metacarpal bone of the thumb is
the shortest and most mobile. It does not lie in the
same plane as the others but occupies a more anterior
position. It is also rotated medially through a right angle
so that its extensor surface is directed laterally rather
than posteriorly.

Phalanges
The phalanges (phalan- is Greek for “battle line”;
phalanx = singular; phalanges = plural) are the bones
that comprise the digits of the hand. As with the
metacarpals, each has a base, body (shaft), and head.
The thumb has 2 phalanges (proximal and distal),
whereas each other digit has 3 phalanges (proximal,
middle, distal). Thus, each hand has 14 phalanges in
total. The base of each proximal phalanx articulates
with the head of the corresponding metacarpal bone.
The base of the middle or distal phalanx articulates
with the head of the next most proximal phalanx. The
body of each distal phalanx is very short. The head of
each proximal and middle phalanx articulates with the
base of the next most distal phalanx

P a g e 23 | 23