UpperLimbExam Nur

GENERAL ANATOMY &
ANATOMY OF UPPER LIMB
Compiled by NUR KM ‫יוני‬

Table of Contents
1. General features and classification of bones. Types of ossification. ................................................................ 3
2.Connections between bones. Classification and general description of joints. ................................................ 9
3.General features of skeletal muscles and fasciae. Types of muscles. Innervation and regeneration
of muscles. ............................................................................................................................................................. 14
4.Biomechanics of the muscle lever functions. Structural and functional features of myo- and
osteotendinous junctions, tendon sheaths. ......................................................................................................... 23
5. The bones, joints and movements of the shoulder girdle. Radiological anatomy of the shoulder
girdle. ..................................................................................................................................................................... 26
6.The gross and radiological anatomy and movements of the shoulder joint and the participating
muscles. The morphological features and biomechanics of the rotator cuff. .................................................... 30
7. The gross and radiological anatomy and movements of the elbow joint and the participating
muscles .................................................................................................................................................................. 37
8. Pronation and supination in the forearm: participating joints and muscles. ................................................. 40
8.The gross and radiological anatomy and movements of the wrist joint and the participating
muscles .................................................................................................................................................................. 46
10. Joints and movements of the hand. Radiological anatomy of the hand. ..................................................... 50
11. The anatomy, innervation and function of the spinohumeral and thoracohumeral muscles. .................... 54
12. Classification (types) and innervation of medium and large blood vessels. Types of vascular
anastomoses.......................................................................................................................................................... 59
13. Capillaries: structure, function, type .............................................................................................................. 62
14. The systemic circulation: the large branches of the aorta and the great veins. ........................................... 64
15. The branches and anastomoses of the axillary artery ................................................................................... 68
16. The branches of the brachial artery; collateral circulation of the elbow...................................................... 71
17. Palmar arterial arches: topography and branches......................................................................................... 74
19.The organization of spinal cord segments and spinal nerves. The general organization and
features of the cranial nerves. .............................................................................................................................. 81
20. Organization and supply areas of the brachial plexus ................................................................................... 86
21. Branches of the median nerve, functional loss of the median nerve. .......................................................... 94
22. Branches of the ulnar nerve, functional loss of the ulnar nerve. .................................................................. 98
23. Branches of the radial nerve, functional loss of the radial nerve. .............................................................. 101
24. Skin innervation of the upper limb. .............................................................................................................. 104
Anatomy First Semester Exam: Upper Limb

Compiled by
Nur KM
25. Axillary fossa, triangular and quadrangular axillary space .......................................................................... 109
26. Sectional anatomy of the arm: fascial (osteofibrous) compartments, muscle groups, vessels and
nerves. The cubital fossa..................................................................................................................................... 112
27. Sectional anatomy of the forearm: fascial (osteofibrous) compartments, muscle groups, vessels
and nerves. Supinator canal. .............................................................................................................................. 116
29. Dorsum of the hand. The anatomical snuffbox (Foveola radialis). ............................................................. 132
30. Palm of the hand: muscles, fasciae, compartments, vessels and nerves. .................................................. 136

Compiled by
Nur KM
1. General features and classification of bones. Types of ossification.
General features and classification of bones

Tissue types
• Compact bone tissue forms the outer shell of bones. It consists of a very hard mass of
bony tissue arranged in concentric layers (Haversian systems).
• Cancellous (also known as 'spongy') bone tissue is located beneath the compact bone
and consists of a meshwork of bony bars (trabeculae) with many interconnecting spaces
containing bone marrow.
• There are axial and appendicular bones, the appendages are the arms and legs, which
contain approx. 30 bones each.
• There are typically 22 bones in the head.
• There are 33 bones in the spine.
• These include:
o 7 cervix (neck)
• 12 thorax
• 5 lumbar
• 5 sacral
• 4 coccyx.
• The thorax (chest) consists of 12 pairs of ribs:
o 7 pairs 'true' ribs - joined directly to the
sternum ("breast-bone"),
o 3 pairs 'false' ribs - joined to the
sternum ("breast-bone") by cartilage, o
o 2 pairs 'floating' ribs (not connected to
the sternum ("breast-bone") at all, connected
to the diaphragm.
• The shoulder girdle consists of the scapula (shoulder blade) and the clavicle ("collar
bone").
Bones Types
1. Long bones have greater length than width and consist of a shaft and a variable number
of endings (extremities). They are usually curved for strength. Examples include femur,
tibia, fibula, humerus, ulna and radius.

Compiled by
Nur KM
2. Short bones are roughly cube-shaped and have
approximately equal length and width.
Examples include ankle and wrist bones.
3. Flat bones have a thin shape / structure and provide
considerable mechanical protection and extensive
surfaces for muscle attachments.
Examples include cranial bones (protecting the brain), the
sternum and ribs (protecting the organs in the thorax), and
the scapulae (shoulder blades).
4. Irregular bones have complicated shapes. Their shapes are
due to the functions they fulfill within the body e.g.
providing major mechanical support for the body, also
protecting the spinal cord (in the case of the vertebrae).
Examples include the vertebrae and some facial bones.
5. Sesamoid bones develop in some tendons in locations
where there is considerable friction, tension, and physical stress. They may therefore form in
the palms of the hands and the soles of the feet.
Examples common to everyone include the patellae (kneecaps).
6. Sutural bones are classified by their location rather than by their shape. They are very small
bones located within the sutural joints between the cranial bones. The number of sutural
bones varies considerably from person to person, therefore these are un-named bones.
7. Pneumatized bones contain air-filled cavities lined by mucous membrane Example mastoid
process
Parts of bone
・ diaphysis (shaft): a tubular shape made of compact bone, hard and rigid
・ medullary cavity: a cavity inside the diaphysis, filled with yellow bone marrow
・ epiphyses: the ends (head/foot) of the bone, made of spongy bone
・ periosteum: a strong fibrous membrane covering the entire bone with the exception of the joint surfaces
・ endosteum: a fibrous membrane that lines the medullary cavity

Compiled by
Nur KM
Long bone contents

Compiled by
Nur KM
Types of ossification
➢ Ossification is the process by which bone is formed.
There are two types of ossification:
➢ Intramembranous ossification
→ direct bone formation
・ development of bone from connective tissue
・ mesenchymal cells develop via osteoblasts into

osteocytes
・ osteoclasts develop and collagen fibres
appear
・ membranous bone is remodeled into lamellar bone
Example: skull, facial bones and clavicles develop as

intramembranous bones

Compiled by
Nur KM
➢ Endochondral ossification
→ indirect bone formation
・ requires preformed parts of skeletal cartilage which will be replaced by bone later
・ depends on the presence of chondroclasts (differentiated connective tissue cells that

degrade cartilage)
・ endochondral ossification begins inside the cartilage, and occurs in epiphysis
・ perichondral ossification originates in perichondrium and confined to diaphysis

Compiled by
Nur KM
Bone regeneration
Bone regeneration by bone fracture bone matrix is destroyed,
adjacent osteocytes are damaged and vessels form blood clot
→ damaged tissue (dead osteocytes, clot) is removed by macrophages
・ endosteum and periosteum start intense proliferation
→ produced tissue surrounds fracture
・ primary bone tissue (bone callus) is formed by intramembranous and endochondral

ossification (healing of fracture)
・ primary bone is gradually replaced by secondary bone tissue
・ there is no scar formation

Compiled by
Nur KM
2.Connections between bones. Classification and general description of
joints.
Connections between bones
The human skeleton is made up of 206 bones.

The places where bones are joined together are called joints.
There are three types of joints:
1. Fibrous
2. Cartilaginous
3. 3. synovial.
Fibrous joints
Fibrous - synarthrodial - immovable: This type of joint is held together by only a ligament.
Examples are where the teeth are held to their bony sockets and at both the radioulnar and
tibiofibular joints.
Cartilaginous
1. synchondroses: almost immovable

2. symphyses - immovable
These joints occur where the connection between the articulating bones is made up of
cartilage example between vertebrae in the spine.
Synovial Joints
Synovial (diarthrosis), are highly moveable and all have:
1. a synovial capsule (collagenous structure) surrounding the entire joint,
Compiled by
Nur KM
2. a synovial membrane (the inner layer of the capsule) which secretes synovial fluid (a
lubricating liquid)
3. cartilage known as hyaline cartilage which pads the ends of the articulating bones.
**There are 6 types of synovial joints which are classified by the shape of the joint and the
movement available. **

Compiled by
Nur KM
Joint Type Movement at joint Examples Structure
Hinge Flexion/Extension
Elbow/Knee Hinge joint
Pivot Rotation of one bone around

another
Top of the neck

(atlas and axis bones) Pivot Joint

Compiled by
Nur KM
Ball and Flexion/Extension/Adduction/
Socket Abduction/Internal &
External Rotation
Shoulder/Hip Ball and socket joint

Compiled by
Nur KM
Saddle Flexion/Extension/Adduction/
Abduction/Circumduction
CMC joint of the thumb Saddle joint
Condyloid Flexion/Extension/Adduction/
Abduction/Circumduction
Wrist/MCP & MTP joints Condyloid joint
Gliding Gliding movements
Gliding joint
Intercarpal joints

Compiled by
Nur KM
3.General features of skeletal muscles and fasciae. Types of muscles.
Innervation and regeneration of muscles.
Types of muscles
➢ Muscle tissue is one of the principle tissues of the human body,It has the ability to
contract,
which generates force and enables movement.
➢ Muscle functions are enabled by conversion of chemical energy stored in ATP
into mechanical energy.
➢ The elementary unit of muscle tissue is the myofibril, which contains
contractile proteins.
Characteristics Skeletal muscle Cardiac muscle Smooth muscle

features striated, multinuclear striated, 1 or 2 nuclei non-striated, 1 nucleus
connective tissue endomysium endomysium perimysium endomysium

perimysium
epimysium
innervation innervated by innervated by autonomic innervated by

somatomotor neuron nervous system, but autonomic nervous
contracts spontaneously system (involuntary)
(voluntary)
without any nerve supply
(involuntary)

Compiled by
Nur KM
contraction ACh released by ACh and NE released by ACh and NE released
regulated by: somatic motor autonomic motor neurons by autonomic motor
neurons neurons, several
hormones, local
chemical changes,
stretching
There are three Types of Muscle Tissue:
1. Smooth muscle
• composed of elongated spindle-shaped cells with centrally positioned nuclei
• derived from the splanchnic mesoderm
• orms the walls of hollow organs (such as the stomach,intestines, ureter and uterus)
and blood vessels
• found in the dermis of the skin
• maintains a degree of tension at rest, as it never completely relaxes
• contracts and relaxes slowly, so is not subjected to fatigue
• innervated by autonomic nerves and so is not under voluntary control

Compiled by
Nur KM
2.Cardiac muscle
• consists of individual muscle cells called cardiomyocytes
• under the control of the cardiac conduction system, which is influenced by autonomic
nerves (not under voluntary control)
• derived from the cardiogenic mesoderm of splanchnopleura
2.1 Intercalated discs (disci intercalares)

• connections between cardiomyocytes
• allow fast transmission of impulses
2.2 Functional syncytium
• a functional network of cells that are connected by intercalated discs
2.3. Conducting system of the heart (complexus stimulans cordis)
• formed by specialised cardiomyocytes capable of generating electrical impulses
(cardiac automaticity)
3.Skeletal muscle
• composed of striated muscle fibres, which contain myofibrils
• derived from the somites of the paraxial mesoderm
• striated muscle fibre is a syncytium, made up of individual muscle cells that fuse
during development
• contraction is mainly under voluntary control and is usually fast
• Fat gable
• innervated by spinal and cranial nerves (somatic motor fibres)
• almost all striated muscles are attached to bones (except for some muscles of the
tongue, the striated muscle of the oesophagus and the facial muscles)

Compiled by
Nur KM
General features of skeletal muscles and fascia
1.Structure
• Muscle: is Name of the structural unit of skeletal muscle
• Fascia: a layer of fibrous connective tissue surrounding the muscle
• Epimysium - a thinner layer of connective tissue between the muscle and the fascia
2. Bundles of muscle fibers

• Perimysium - a layer of connective tissue that covers muscle bundles which:
2.1. consists of septa that arise from the epimysium, run through the muscle and contain
vessels and nerves
2. 2.the continuation of tendons inside the muscle, transmits tension through the muscle
3. Muscle fibre (myofibril) - the functional unit of skeletal muscle

• Several muscle fibers form a muscle bundle fascicle
3.1. Endomysium a layer ensheathing individual muscle fibres
• contains numerous capillaries
Muscles are separated by fascia
・Superficial fascia
: under the skin everywhere (except the face). Their name is fascia superficialis .
・Deep fascia
: covering and separating muscle groups (e.g.: fascia lata).
・Subserous fascia
: related to body cavities inside (e.g.: endothoracic fascia).

Compiled by
Nur KM
Regeneration of muscles
• Definition
• Muscle regeneration is the process by which damaged skeletal, smooth or cardiac

muscle undergoes biological repair and formation of new muscle in response to death
(necrosis) of muscle cells.
• The success of the regenerative process depends upon the extent of the initial
damage and many intrinsic and environmental factors.
• events required for regeneration
1.Necrosis required for muscle regeneration.
2.Inflammation essential to remove necrotic tissue and initiate myogenesis.
3.re vascularisation New blood vessel formation is required after major injury of muscles.
4.Innervation essential for functional recovery of skeletal muscle.
5.myogenesis where new muscle is formed
General Definitions:
1. The source of the myogenic precursor cells (myoblasts) varies between conventional
tissue regeneration and epimorphic regeneration (where mature cells dedifferentiate).
2. The microenvironment, including the extracellular matrix, affects all aspects of
regeneration, for example, the muscle precursors and their capacity for new muscle
formation (and fibrosis impairs myogenesis).
• Skeletal muscle contains numerous 'satellite cells' underneath the basal lamina, these are
mononucleated quiescent cells.
• When the muscle is damaged, these cells are stimulated to divide.
• After dividing, the cells fuse with existing muscle fibres, to regenerate and repair the
damaged fibres.
Compiled by
Nur KM
• The skeletal muscle fibres themselves, cannot divide. However, muscle fibres can lay
down new protein and enlarge (hypertrophy).
Cardiac muscle
can also hypertrophy. However, there are no equivalent to cells to the satellite cells found in
skeletal muscle. Thus when cardiac muscle cells die, they are not replaced.
3. Smooth cells

Compiled by
Nur KM
have the greatest capacity to regenerate of all the muscle cell types. The smooth muscle cells
themselves retain the ability to divide, and can increase in number this way.
As well as this, new cells can be produced by the division of cells called pericytes that lie along
some small blood vessels.
Smooth muscle can also hypertrophy.

Compiled by
Nur KM
Compiled by
Nur KM
Innervation of muscles

Compiled by
Nur KM
4.Biomechanics of the muscle lever functions. Structural and functional
features of myo- and osteotendinous junctions, tendon sheaths.
Biomechanics of the muscle lever functions
Definition
1. lever: Muscles and bones act together to form levers. A lever is a rigid rod; usually
a length of bone, that turns about a pivot; usually a joint
2. mechanical advantage: Levers can be used so that a small force can move a much
bigger force. This is called mechanical advantage.
3. efficiency of the lever: the greater the mechanical advantage, the less effort
required.
Components of the Lever
1. bones act as lever arms
2. joints act as pivots
3. muscles provide the effort forces to move loads
4. load forces are often the weights of the body parts that are moved or forces needed
to lift, push or pull things outside our bodies.
• The location of these 4 components determines the mechanical advantage and the lever
class.
• Levers can also be used to magnify movement
• Levers are able to give us a strength advantage or a movement advantage but not both
together.
Tendon sheaths
Tendon sheath
1. A tendon sheath is a membrane that wraps around a tendon
2. allows the tendon to stretch and prevents it from adhering to the overlying fascia.
3. This sheath also produces a fluid, the synovial fluid, which keeps the tendon moist and
lubricated.
4. Tendon sheaths consist of two layers:
1. fibrous layer, made of tight collagenous tissue
2. synovial layer which consists of a visceral and parietal layer separated by synovial
fluid.
Compiled by
Nur KM
5. There are also fibrous bands, known as retinacula, which make a tunnel around the
tendons. The tendon sheaths are located between these two structures and thus
prevent friction between them.
Myo and osteotendinous junction
• Axial tendons connect the muscles that are located along the spinal column to
vertebrae.
• • Axial ligaments connect vertebrae to each other, contributing to the stability of the
spine.
• Axial ligaments attach to and support the intervertebral disc, preventing its herniation.
The osteotendinous junction - enthesis - tendon insertion site
1. is the site of connection between tendon and bone

2. provides a gradual transition from tendinous to bone
tissue.
3. The enthesis is divided into four zones:
1. zone one, starting at the tendon side, consists of aligned collagen I fibers and
decorin, and exhibits tendon properties only.
2. The second zone contains collagen types II and III, aggrecan and decorin,
resembling fibrocartilage composition.
Compiled by
Nur KM
3. Zone three is defined as mineralized fibrocartilage and is comprised of collagen
types II and X and aggrecan.
4. zone four is composed of mineralized collagen type I and is considered to be a
bone protrusion, providing a dedicated connection point.
Myotendinous junction
1. is the site of connection between tendon and muscle.
2. the force generated by muscle contraction is transmitted from intracellular
contractile muscle proteins to the extracellular connective tissue proteins of the
tendon.
3. At the site of connection, tendon collagen fibrils are set within deep processes that
are formed on the surface of the muscle cells.
4. The main components of the myotendinous junction:
1. Laminin
2. Integrin
3. Vinculin
4. Fibronectin
5. talin, which enable a strong connection between the muscle actin filaments and
the tendon collagen fibers.
5. myotendinous junction is the weakest element of the muscle-tendon complex,
making it susceptible for injury.

Compiled by
Nur KM
5. The bones, joints and movements of the shoulder girdle. Radiological
anatomy of the shoulder girdle.
• The shoulder girdle is composed of two bones: clavicle & scapula.
scapula

Compiled by
Nur KM
Clavicle
Joints and movements of the shoulder girdle
• Joints of the shoulder girdle:

 Sternoclavicular joint:
a) Type: (double) plane synovial joint / restricted ball and socket.
b) Articular facets+cartilage: sternal end of clavicle and clavicular notch of
sternum.
 Facets are covered by fibrocartilage and the joint is completely divided by
an articular disc.
c) Ligaments:
1. Interclavicular ligament.
2. Anterior & posterior sternoclavicular ligament.
3. Costoclavicular ligament.
d) Movements:
1. Elevation-depression.(Frontal plane, saggital axis)
2. Protraction-retraction.(transverse plane, vertical axis)
3. Rotation.(axis of clavicle) 4. Circumduction.
e) Accessories:
1. Articular disc between the facets of the joint.

Compiled by
Nur KM
 Acromioclavicular joint:
a) Type: plane synovial joint.
b) Articular facets+cartilage: acromial end of clavicle and flat articular surface of
acromion.
 Facets are covered by fibrocartilage, articular disc is often found.
c) Ligaments:
1. Acromioclavicular ligament.
2. Coracoclavicular ligaments (trapezoid lig. & conoid lig.) 3. Coracoacromial
ligament (forms “shoulder vault”).
d) Movements: associated with the scapula movements which are usually
accompanied by movements of humerus and shoulder joint. 1. Elevation-
depression.(Frontal plane, saggital axis)
2. Protraction-retraction.(transverse plane, vertical
axis)
3. Rotation.(axis of clavicle) 4. Circumduction.
e) Accessories:
1. Articular disc is often found.

Compiled by
Nur KM
Radiological anatomy of the shoulder girdle

Compiled by
Nur KM
6.The gross and radiological anatomy and movements of the shoulder joint and the
participating muscles. The morphological features and biomechanics of the rotator
cuff.
Shoulder joint
 Glenohumeral joint (shoulder joint):

a) Type: ball and socket synovial joint (multiaxial joint).
b) Articular facets+cartilage: glenoid cavity of scapula and head of humerus.
 Fibrocartilage rim is attached to the margin of the glenoid cavity, the glenoid
labrum deepens this cavity.
c) Ligaments:
1. Coracohumeral ligament.
2. Coracoacromial ligament.
3. Glenohumeral ligament.
d) Movements:
1. Flexion-extension.(transverse plane, vertical axis).
2. Abduction-adduction.(coronal plane, sagittal axis).
3. Rotation.(around the axis of the arm from humeral head to capitulum).
4. Circumduction.
e) Accessories:
1. Fibrous capsule: envelops the joint from the glenoid labrum to the
anatomical neck. It includes the origin of long head of biceps muscle.
2. Bursae: connective tissue sacs with a slippery inner surface, are filled with
synovial fluid.
- Subdeltoid bursa.
- Subacromial bursa.
3. Glenoid labrum: a cartilaginous margin that enlarges that articular cavity.
 The capsule forms a sheath around the tendon of long biceps head into the
intertubercular groove as far as the surgical neck.

Compiled by
Nur KM
Compiled by
Nur KM
Rotator cuff
❖ These individual muscles combine at the shoulder to form a thick "cuff" over this joint. The rotator
cuff has the important job of stabilizing the shoulder as well as elevating and rotating the arm. Since
the joint capsule and ligaments are weak.
❖ The ROTATOR CUFF muscle tendons are the primary stabilizers of the glenohumeral joint. Each
muscle originates on the scapula, and inserts on the humerus. They prevent the dislocation of the
humerus during movements (mainly abduction, which is very unstable position).

Compiled by
Nur KM
Summary of muscles of shoulder and scapula
Muscle Origin Insertion Innervation Function

① Supraspinatus* scapula: humerus: suprascapular n. initiates and assists
supraspinous fossa top of greater deltoid in abduction
tubercle of arm and acts with
rotator cuff muscles
② Infraspinatus* scapula: humerus: behind suprascapular n. lateral rotator of the

infraspinous fossa the arm
supraspinatus /
greater tubercle
③ Teres Minor* scapula: lateral humerus: back axillary n. lateral rotator of the
border / upper of greater arm
2/3 tubercle
④ Teres Major scapula: lateral humerus: lesser lower Adductor / extensor /

border / lower tubercular crest subscapular n. medial rotator of the
1/3 arm
⑤ Subscapularis* scapula: humerus: lesser upper and lower medial rotator of the
subscapular fossa tubercle subscapular n. arm
⑥ Deltoid clavicle: humerus: lateral axillary n. abductor of the arm:

lateral 1/3 surface of the ant. fibres → flex
scapula: shaft (deltoid and medially rotate
spine and tuberosity) post. fibres →
acromion extend, adduct and
laterally rotate

Compiled by
Nur KM
Compiled by
Nur KM
Summary of muscles of arm

① Coracobrachialis scapula: humerus: - weak
coracoid process medial surface adductor /
of the shaft flexor of the
arm
② Biceps brachii ➢ long head radius: flexor of the

scapula: -tuberosity elbow /
supinator of
supraglenoid musculocutaneous
the forearm
tubercle n.
➢ short head
scapula:
coracoid process
③ Brachialis humerus: ulna: - flexor of the
lower half coronoid elbow
process
④ Triceps brachii ➢ long head ulna: extensor of the

scapula: -olecranon elbow
infraglenoid
tubercle
➢ lateral head
humerus:
upper half of the
posterior surface radial n.
➢ medial head
humerus:
lower half of the
posterior surface
⑤ Anoconeus Humerus: ulna: extensor of the

-lateral epicondyle -olecranon elbow

Compiled by
Nur KM
Compiled by
Nur KM
7. The gross and radiological anatomy and movements of the elbow joint
and the participating muscles
Cubital or elbow joint
Bones of the elbow joint: Humerus, Radius, Ulna

The elbow joint consists of 3 joints:
1. humeroulnar joint
 Type of joint: hinge synovial joint
 Articular surfaces: trochlea of the humerus and the trochlear notch of ulna
 Movements: (uniaxial) flexion - extension
2. humeroradial joint
 Type of joint: ball and socket synovial joint
 Articular surfaces: capitulum of humerus and art. facet of head of radius
3. proximal radioulnar joint
 Type of joint: pivot synovial joint
 Articular surfaces: articular circumference of head of radius and notch of ulna

Movements: supination - pronation (around construction axis of the forearm, it
connects the head of radius with the styloid process of the ulna)

Compiled by
Nur KM
Ligaments of elbow joint:
1. ulnar collateral ligament
2. radial collateral ligament
3. annular ligament of radius
Accessories:
1. capsule: broad anteriorly, thin dorsally and thick at both sides. It attaches to the
epicondyle above, enclosing the radial and coronoid fossa below to the neck of the
radius and to the rim of the olecranon fossa.
2. sacciform recess: tissue fold that provides a reserve capacity during pronation and
supination.

Compiled by
Nur KM
movements of the elbow joint and the participating muscles

Compiled by
Nur KM
8. Pronation and supination in the forearm: participating joints and
muscles.
Definition: Movements in which the upper end of the radius nearly rotates within the annular
ligaments.
Pronation: medial rotation, the shafts of the radius and ulna cross each other, palm face backward.
Supination: lateral rotation, the shafts of radius and ulna lie parallel to one another, palm face forward

Compiled by
Nur KM
Participating muscles:
1) supination: biceps brachii, brachioradialis, supinator.
2) pronation: brachioradialis, pronator quadratus, pronator teres
 Note: muscles of supination are stronger than the muscles of pronation.
Summary of muscles of forearm
ANTERIOR GROUP

First layer
① Pronator teres humeral head: radius: lateral pronator of the forearm
medial epicondyle surface of
shaft
ulnar head:
coronoid process of
ulna median n.
② Flexor carpi humerus: metacarpus: flexor and abductor of

radialis medial epicondyle bases of 2nd the wrist
and 3rd bones
③ Flexor carpi humerus: carpus: ulnar n. flexor and adductor of

ulnaris medial epicondyle pisiform and the wrist
hamate
ulna:
metacarpus:
medial side of basis of 5th
olecranon bone
④ Palmaris humerus: flexor median n. flexor of wrist

longus medial epicondyle retinaculum/
palmar
aponeurosis
Second layer

Compiled by
Nur KM
⑤ Flexor humerus: middle median n. flexor of the fingers
digitorum medial epicondyle phalanges of and wrist superficialis ulna:
fingers II-V
coronoid process radius: anterior
surface of shaft
Third layer
⑥ Flexor ulna: distal median and flexor of the fingers
digitorum anteromedial surface phalanges of ulnar nn. and wrist
profundus of the shaft fingers II-V
⑦ Flexor pollicis radius: anterior distal phalanx median n. flexor of the thumb
longus surface of the of the 1st
shaft finger
Fourth layer
⑧ Pronator ulna: radius: anterior median n. pronator of the forearm
quadratus anterior surface surface

Compiled by
Nur KM
Compiled by
Nur KM
POSTERIOR GROUP

Superficial layer
① Brachioradialis radius: flexor of the

styloid process elbow
humerus:
② Extensor carpi lateral supracondylar metacarpus: base extensor and
radialis longus ridge of the 2nd bone abductor of
the wrist
③ Extensor carpi metacarpus: base extensor and

radialis brevis of the 3rd bone abductor of
the wrist
④ Extensor middle and distal radial n. extensor of

digitorum phalanges of the fingers
fingers II-V and wrist
humerus:
⑤ Extensor digiti lateral epicondyle extensor extensor of
minimi expansion of the little finger
finger V
⑥ Extensor carpi metacarpus: base extensor and

ulnaris of the 5th bone adductor of
the wrist
Deep layer
⑦ Supinator humerus: radius: supination of

lateral epicondyle neck and shaft forearm
annular ligament ulna
⑧ Abductor radius & ulna: base of 1st abductor and

pollicis longus post. surface of their metacarpal bone extensor of
shafts the thumb
⑨ Extensor radius: base of the

pollicis brevis post. surface of the shaft proximal phalanx
radial n.

Compiled by
Nur KM
of the thumb extensor of
the thumb
⑩ Extensor ulna: base of the distal
pollicis longus post. surface of the shaft phalanx of the
thumb
⑪ Extensor indicis ulna: extensor radial nerve extensor of

post. surface of the shaft expansion of the the second
2nd finger finger (index)

Compiled by
Nur KM
8.The gross and radiological anatomy and movements of the wrist joint and the
participating muscles
Radio carpal or wrist joint
• The wrist joint (also known as the radiocarpal joint) is an ellipsoid type synovial joint.
The wrist joint is formed by:
• Distally – The proximal row of the carpal bones (except the pisiform).
• Proximally – The distal end of the radius, and the articular disk
• The ulna is not part of the wrist joint – it articulates with the radius, just proximal to the
wrist joint, at the distal radioulnar joint.
• Synovial Membrane Capsule: Synovial membrane is a thin connective tissue. Synovial
membrane produces viscous lubricating fluid. Synovium covers all three sections of wrist
joint. Lax synovial capsule allows following wrist joint movements.

Compiled by
Nur KM
Compiled by
Nur KM
There are four ligaments of note in the wrist joint:
• Palmar radiocarpal – It is found on the palmar (anterior) side of the hand. It passes from
the radius to both rows of carpal bones. Its function, apart from increasing stability, is to
ensure that the hand follows the forearm during supination.
• Dorsal radiocarpal – It is found on the dorsum (posterior) side of the hand. It passes from
the radius to both rows of carpal bones. It contributes to the stability of the wrist, but also
ensures that the hand follows the forearm during pronation.
• Ulnar collateral – Runs from the ulnar styloid process to the triquetrum and pisiform.
Works in union with the other collateral ligament to prevent excessive lateral joint
displacement.
• Radial collateral – Runs from the radial styloid process to the scaphoid and trapezium.
Works in union with the other collateral ligament to prevent excessive lateral joint
displacement
Wrist Joint Retinaculum:
• Flexor Retinaculum- Flexor retinaculum lies on palmer side in front of wrist joint.
• Extensor Retinaculum- Extensor retinaculum lies on back of wrist.
• Functions of Wrist Joint Retinaculum-
1. Retinaculum confines nerve, blood vessels and tendons against wrist joint.
2. Retinaculum prevents bending or sliding of the tendon, nerve or blood vessels.
3. Retinaculum prevents bowstring shape of tendon, blood vessels and nerve

Compiled by
Nur KM
movements of the wrist joint and the participating muscles
Neurovascolar Supply:
The wrist joint receives blood from branches of the dorsal and palmar carpal arches, which
are derived from the ulnar and radial arteries. Innervation to the wrist is delivered by
branches of three nerves:
• Median nerve – Anterior interosseous branch.
• Radial nerve – Posterior interosseous branch.
• Ulnar nerve – deep and dorsal branches.
Carpal Tunnel Syndrome
❖ Hypertrophy or thickening of flexor retinaculum causes pinch of median nerves

that results in symptoms like tingling, numbness, weakness in hand Carpal tunnel
narrowing may cause ischemic changes in hand because of partial obstruction of
blood flow to hand and fingers.

Compiled by
Nur KM
10. Joints and movements of the hand. Radiological anatomy of the hand.
1. Wrist Joint, Radiocarpal joint:

The wrist joint marking the area of transition between the forearm and the hand.
Ellipsoid synovial joint
Formed by:
1. Distally – The proximal row of the carpal bones: scaphoid and lunate
2. Proximally – The distal end of the radius, and the articular disk
Joint capsule:
1. The outer layer is fibrous attaches to the radius, ulna and the proximal row of
the carpal bones.
2. The internal layer is comprised of a synovial membrane, secreting synovial fluid
which lubricates the joint.
Movements:
1. Flexion – Produced mainly by the flexor carpi ulnaris, flexor carpi radialis, with
assistance from the flexor digitorum superficialis.
2. Extension – Produced mainly by the extensor carpi radialis longus and brevis, and
extensor carpi ulnaris, with assistance from the extensor digitorum.
3. Adduction – Produced by the extensor carpi ulnaris and flexor carpi ulnaris
4. Abduction – Produced by the abductor pollicis longus, flexor carpi radialis, extensor
carpi radialis longus and brevis.
Joints of the hand:

1. Intercarpal joints
• synovial joints formed
between:
1. the bones of the proximal row of the carpal bones which are the scaphoid,
lunate, triquetral and pisiform
2. between the individual bones of the distal row of carpal bones which are
the trapezium, trapezoid, capitate and hamate
3. between the proximal and distal rows

Compiled by
Nur KM
Movements:
These joints don’t have much movement, just a small amount of gliding between the
bones.
2. Carpometacarpal joint
• synovial joints
• Between the distal carpal bones and the metacarpals, and the intermetacarpal joints
are between the metacarpals
2.1 Carpometacarpal joint of the thumb

• saddle-shaped joint
• Formed between the trapezium and the base of the first metacarpal.
• The joints have a synovial membrane surrounded by fibrous joint capsules.
The joints have a synovial membrane surrounded by fibrous joint capsules. They’re supported
by anterior, posterior, and interosseous (between bone) ligaments. The thumb joint can
extend, flex, abduct, adduct, and circumduct. The fifth metacarpal joint is fairly mobile, but
the rest don’t have much movement.
Fingers:
Each finger has 2 joints:
1. Metacarpophalangeal (MCP) joints

• condyloid joints
• Formed by the articulation between metacarpal and proximal phalanx in each of
the
5 digits.

Compiled by
Nur KM
2. Interphalangeal Joints :
• Hinge joints “Ginglymus”
• Formed by the phalanges
• There are two in each digit. The
thumb is an exception, and has only
one interphalangeal joint.
The two joints are the:
2.1 Proximal interphalangeal (PIP) joints
• Formed by The articulation between the proximal phalanx and intermediate phalanx
in each of the 2nd to 5th digits.
2.2 Distal interphalangeal (DIP) joints
• Formed by The articulation between the intermediate phalanx and distal phalanx in
each of the 2nd to 5th digits.
Movements:
• Flexion of digits : can be performed at each MCPJ, PIPJ and DIPJ and brings the
hand into a fist.
• Extension of digits: can be performed at each MCPJ, PIPJ and DIPJ and stretches the
hand out straight.
• Abduction of digits : moving the digits away from the midline.
• Adduction of digits – moving the digits back toward the midline.
• Opposition of thumb and little finger: bringing the thumb and little finger
together.
• Reposition of thumb and little finger: moving the thumb and little finger away from
each other.

Compiled by
Nur KM
Compiled by
Nur KM
11. The anatomy, innervation and function of the spinohumeral and
thoracohumeral muscles.
Spinohumeral muscles
1. Levator scapulae
• Action:
1. Draws the scapula medially upward while moving the inferior angle medially
2. Bends the neck laterally
• Innervation
Dorsal scapular nerve C5
Cervical spinal nerve C3 - C4
2. Trapezious
• Action:
Upper Part:
1. Upward rotation of the scapula
2. elevation of the scapula Middle Part:
1. Retraction of the scapula
Lower Part:
1. Upper rotation of the scapula
2. depression of the scapula
• Innervation: Spinal Accessory Cranial XI , Ventral Rami C2-C4
3. Rhomboid minor
• Action
1. Steadies the scapula
2. Draws the scapula medially upward - elevate and adduct scapula
3. Rotate the scapula downward
• Innervation: Dorsal scapular nerve C4 - C5
4. Rhomboid major
• Action
1. Steadies the scapula
2. Draws the scapula medially upward - elevate and adduct scapula
3. Rotate the scapula downward
• Innervation: Dorsal scapular nerve C4 - C5
Compiled by
Nur KM
5. Latissimus dorsi
Type of Extent of Muscle Innervation Responsible

movement movement nerve segment
Extension 40 degrees Latissimus dorsi Thoraco dorsal C6 - C8
Adduction 20 - 40 degrees Latissimus dorsi Thoraco dorsal C6 - C8
Internal rotation 50 - 95 degrees Latissimus dorsi Thoraco dorsal C6 - C8
Thoracohumeral muscles
1. Pectoralis major
• Function
1. Flexion,
2. Adduction
3. internal rotation of arm
4. Assists in respiration when limbs fixed
• Innervation: pectoral nerves (medial and lateral)
2. Pectoralis minor
• Function
1. pulls the scapula anteriorly and inferiorly toward the ribs (abduction and
depression)
2. Rotates the glenoid inferiorly
3. Assists in respiration
• Innervation: medial and lateral pectoral nerves C8 - T1
3. Subclavius
• Function
1. depression of clavicle
2. Steadies the clavicle in the sternoclavicular joint
• Innervation: subclavian nerve C5 - C6
4. Serratus anterior
• Function 1. Entire muscle:
• Draws the scapula laterally forward
Compiled by
Nur KM
• Elevate the ribs
• Assist in respiration (when limb is fixed)
2. Inferior part:
• Rotate the scapula and draws its inferior angle laterally forward allowing the arm
to be elevated above 90 degrees
3. Superior part:
• Lowers the raised arm
• Innervation: long thoracic nerve C5 - C7
Summary: Superficial muscles of the trunk: Thoracohumeral muscles

Pectoralis anterior surface of the lateral lip of the medial & adduction / medial
major sternal half of the clavicle intertubercular sulcus lateral rotation of the arm
/ anterior surface of the on the humerus pectoral nn.
sternum / from the
cartilages of the true ribs
(except the 1st and 7th) /
aponeurosis of the
external abdominal
oblique muscle
Pectoralis outer surface of the coracoid process of medial protractor and

minor 3rd-5th ribs the scapula pectoral n. rotator of the
scapula / elevates
the ribs during
forced inspiration
Subclavius 1st rib and its cartilage inferior surface of the subclavian Depresses /
middle 3rd of the n. from the stabilises the
clavicle brachial plx. clavicle

Compiled by
Nur KM
Serratus outer surfaces and ventral surface of the long thoracic suspends and
anterior superior borders of the medial border of the n. fixes the scapula /
first 8 and 9 ribs and from scapula / anterior rotates the inferior
the fasciae covering the surface of the angle laterally
external intercostals jsuperior angle /
muscles anterior surface of the
inferior angle of the
scapula
Summary: Spinohumeral muscles

Superficial muscles
Trapezius ext. occipital lateral 1/3 of spinal part of rotates / elevates =

protuberance / nuchal lig. clavicle / accessory n. / depresses the
/ spinous processes / acromion / spine scapula
supraspinal lig. of the 7th cervical
of the scapula
cervical and all thoracic (C3-C4) nn.
vertebrae

Compiled by
Nur KM
Latissimus lower 6 thoracic, lumbar, intertubercular thoracodorsal extends / adducts /
dorsi and sacral vertebrae by groove of the n. medially rotates the
means of the humerus humerus / assists
thoracolumbar fascia / in forced expiration
post. part of the iliac
crest / lower 3-4 ribs

Compiled by
Nur KM
12. Classification (types) and innervation of medium and large blood vessels. Types
of vascular anastomoses.
There are three types of blood vessels:

1. Arteries
• carry blood from the heart to the organs.
1.1. Large arteries:
• elastic arteries
• the pulmonary trunk and the aorta with its major branches
• innominate, subclavian, common carotids, iliacs, and pulmonary arteries
1.2. Medium-sized and small arteries
• muscular arteries
• regulate blood pressure by changing the size of their diameter
• constitute the majority of arteries
• aortic branches,coronary and renal arteries
1.3. Arterioles (arteriolae)
• 0.1-0.2 mm in diameter
• found in the microcirculation that extends and branches out from an artery
and leads to capillaries.
• Arterioles have muscular walls (usually only one to two layers of smooth
muscle) and are the primary site of vascular resistance.
2. Veins
• drain blood from the organs and direct It Veins back to the heart.
2.1. Venules (venulae) - 0.2-1 mm in diameter
2.2. Small and medium - sized veins - 1 - 9 mm in diameter
• the most common type of vein, contain valves
2.3. Large veins - the superior and inferior vena cava and their major tributaries
3. Capillaries form a network of thin-walled vessels in which oxygen and nutrient

exchange between the blood and tissues takes place.
All these types of vessels are organised in the pulmonary and systemic circulation. Direct
connections between vessels of approximately the same calibre are called anastomoses.
In the one hand Capillaries don’t have smooth muscle and not innervated, in the other
hand Capillaries in the cat hypothalamus receive axon terminals which are comparable
to neurovascular junctions in cerebral and systemic arteries and arterioles. The
innervation of capillaries in the central nervous system may be derived from central
neurons
Compiled by
Nur KM
Classification (types) and innervation of blood vessels
1. Conducting vessels: aorta, pulmonary trunk.
2. Distributing vessels (subclavian a.,axillary a., brachial a.) 3. Resistance
vessels: small muscular arteries and arterioles.
4. Exchange vessels: capillaries, venules.
5. Reservoir vessels: veins.
Innervation of blood vessels
We find sensory and effector nerve endings in vessel wall.

・Sensory nerve endings
：receptors for pressure and the composition of blood (baroreceptors, chemoreceptors). Sensory
nerve endings belong to glossopharyngeal (IX) and vagus (X) nerves.
・Effector nerve endings

：are postganglionic sympathetic nerve endings which release norepinephrine as transmitter cause
smooth muscle contraction in vessel wall vasoconstriction
Types of vascular anastomoses
Anastomoses
1. Shunts (anastomoses) are direct connections between vessels.
2. They dilate to change the pattern of blood distribution in various tissues of the body.
Types
1. Arterio-venous (a-v) anastomoses - directly connect arterioles and venules
• located in the skin of the palms and fingertips and function to regulate body
temperature
• located in the kidneys, lungs and thyroid gland, where they participate in the
regulation of blood pressure
2. Arterio-arterial (a-a) anastomoses
• directly connect small and medium-sized arteries
• located in the gastrointestinal tract

Compiled by
Nur KM
• form the palmar and plantar arches in the hands and feet
• the circle of Willis is a special kind of arterio-arterial anastomosis
1. Arterial anastomoses : arch (arcade) anastomosis

2. Collateral anastomoses : around large joints
3. Venous anastomoses : connecting superficial and
deep veins
4. Arteriovenous anastomoses: in capillaries.

Compiled by
Nur KM
13. Capillaries: structure, function, type
Capillaries
• Capillaries are tiny blood containing structures that connect arterioles to venules.
They are the smallest and most abundant form of blood vessel in the body.
• Capillaries are small enough to penetrate body tissues, allowing oxygen, nutrients,
and waste products to be exchanged between tissues and the blood.
• This occurs via passive diffusion and pinocytosis (ingestion of fluid by cells).
• White blood cells also enter tissues via the capillaries, attacking infections and
repairing damage.
Capillary Structure
• Most capillaries are 3 to 4 µm (micrometers) in diameter, but some can be as

large as 40 µm. They are composed of a thin layer of epithelial cells and a
basal lamina, or basement membrane, known as the tunica intima.
• There is also an incomplete layer of cells, that partially encircles the epithelial cells,
known as pericytes.
Microvascular pericytes regulate blood pressure in the capillaries through contraction.
This improves the efficiency of exchange between the blood in the capillary and the
tissue surrounding it. Blood flow into the capillaries is controlled by precapillary
sphincters, smooth muscle bands that wrap around metarterioles.
Capillary Types
There are 3 types of capillary in the body; continuous, fenestrated, and sinusoidal.
1. Continuous
o As their name suggests, continuous capillaries have a continuous endothelial lining.
They have tight junctions between their endothelial cells along with intercellular clefts
through which small molecules, like ions, can pass.
Continuous capillaries are generally found in the nervous system, as well as in fat and
muscle tissue.
Within nervous tissue, the continuous endothelial cells form a blood brain barrier,
limiting the movement of cells and large molecules between the blood and the
interstitial fluid surrounding the brain.
2. Fenestrated
o These capillaries can be found in tissues where a large amount of molecular
exchange occurs, such as the kidneys, endocrine glands, and small intestine. They are

Compiled by
Nur KM
particularly important in the glomeruli of the kidneys, as they are involved in filtration
of the blood during the formation of urine.
o The capillaries have small openings in their endothelium known as fenestrate or
fenestra, which are 80 to 100 nm in diameter. Fenestra has a non-
membranous, permeable membrane, which is diaphragm-like and spanned
with fibrils. This arrangement allows quick movement of macromolecules in
and out of the capillary. The basement membrane of the epithelial cells in the
lining remains unbroken by the fenestrate.
3. Sinusoidal
o Sinusoidal capillaries, sometimes referred to as sinusoids, or discontinuous
capillaries, have endothelial linings with multiple fenestrations (openings), that are
around 30 to 40 nm in diameter. These have no diaphragm and either a
discontinuous or non-existent basal lamina. This allows blood cells and serum
proteins to pass through the capillary wall as if it were a colander.
o Sinusoidal capillaries are mainly found in the liver, between epithelial cells and
hepatocytes. They can also be found in the sinusoids of the spleen where they are
involved in the filtration of blood to remove antigens, defective red blood cells, and
microorganisms. Sinusoidal capillaries can also be found in the lymph nodes, bone
marrow and some of the glands of the endocrine system.

Compiled by
Nur KM
14. The systemic circulation: the large branches of the aorta and the great
veins.
Systemic Circulation is the system of blood vessels and associated tissues that supplies blood, and
hence oxygen, to all parts of the body.
The aorta is the largest artery in the body, initially being an inch wide in diameter. It receives the
cardiac output from the left ventricle and supplies the body with oxygenated blood via the systemic
circulation.
The aorta can be divided into four sections: the ascending aorta, the aortic arch, the thoracic
(descending) aorta and the abdominal aorta. It terminates at the level of L4 by bifurcating into the left
and right common iliac arteries. The aorta classified as a large elastic artery
The ascending aorta arises from the aortic orifice from the left ventricle and ascends to become the
aortic arch. It is 2 inches long in length and travels with the pulmonary trunk in the pericardial sheath.
Branches
The left and right aortic sinuses are dilations in the ascending aorta, located at the level of the aortic
valve. They give rise to the left and right coronary arteries that supply the myocardium.
The aortic arch
is a continuation of the ascending aorta and begins at the level of the second sternocostal joint. It
arches superiorly, posteriorly and to the left before moving inferiorly.
The aortic arch ends at the level of the T4 vertebra. The arch is still connected to the pulmonary trunk
by the ligamentum arteriosum (remnant of the foetal ductus arteriosus).
Branches
There are three major branches arising from the aortic arch. Proximal to distal:
• Brachiocephalic trunk: The first and largest branch that ascends laterally to split into the right
common carotid and right subclavian arteries. These arteries supply the right side of the head and
neck, and the right upper limb.
• Left common carotid artery: Supplies the left side of the head and neck.
• Left subclavian artery: Supplies the left upper limb.
Thoracic Aorta
The thoracic (descending) aorta spans from the level of T4 to T12. Continuing from the aortic arch, it
initially begins to the left of the vertebral column but approaches the midline as it descends. It leaves
the thorax via the aortic hiatus in the diaphragm, and becomes the abdominal aorta.
Branches
In descending order:

Compiled by
Nur KM
• Bronchial arteries: Paired visceral branches arising laterally to supply bronchial and peribronchial
tissue and visceral pleura. However, most commonly, only the paired left bronchial artery arises
directly from the aorta whilst the right branches off usually from the third posterior intercostal
artery.
• Mediastinal arteries: Small arteries that supply the lymph glands and loose areolar tissue in the
posterior mediastinum.
• Oesophageal arteries: Unpaired visceral branches arising anteriorly to supply the oesophagus.
• Pericardial arteries: Small unpaired arteries that arise anteriorly to supply the dorsal portion of the
pericardium.
• Superior phrenic arteries: Paired parietal branches that supply the superior portion of the
diaphragm.
• Intercostal and subcostal arteries: Small paired arteries that branch off throughout the length of
the posterior thoracic aorta. The 9 pairs of intercostal arteries supply the intercostal spaces, with
the exception of the first and second (they are supplied by a branch from the subclavian artery).
The subcostal arteries supply the flat abdominal wall muscles.
The abdominal aorta is a continuation of the thoracic aorta beginning at the level of the T12 vertebrae.
It is approximately 13cm long and ends at the level of the L4 vertebra. At this level, the aorta terminates
by bifurcating into the right and left common iliac arteries that supply the lower body.
Branches
In descending order:
• Inferior phrenic arteries: Paired parietal arteries arising posteriorly at the level of T12. They supply
the diaphragm.
• Coeliac artery: A large, unpaired visceral artery arising anteriorly at the level of T12. It is also
known as the celiac trunk and supplies the liver, stomach, abdominal oesophagus, spleen, the
superior duodenum and the superior pancreas.
• Superior mesenteric artery: A large, unpaired visceral artery arising anteriorly, just below the celiac
artery. It supplies the distal duodenum, jejuno-ileum, ascending colon and part of the transverse
colon. It arises at the lower level of L1.
• Middle suprarenal arteries: Small paired visceral arteries that arise either side posteriorly at the
level of L1 to supply the adrenal glands.
• Renal arteries: Paired visceral arteries that arise laterally at the level between L1 and L2. They
supply the kidneys.
• Gonadal arteries: Paired visceral arteries that arise laterally at the level of L2. Note that the male
gonadal artery is referred to as the testicular artery and in females, the ovarian artery.
• Inferior mesenteric artery: A large, unpaired visceral artery that arises anteriorly at the level of L3.
It supplies the large intestine from the splenic flexure to the upper part of the rectum.
• Median sacral artery: An unpaired parietal artery that arises posteriorly at the level of L4to supply
the coccyx, lumbar vertebrae and the sacrum.
• Lumbar arteries: There are four pairs of parietal lumbar arteries that arise posterolaterally
between the levels of L1 and L4 to supply the abdominal wall and spinal cord.

Compiled by
Nur KM
• Blood is deoxygenated when it leaves the tissues and organs it has supplied with oxygen and other
nutrients, to return back to the pulmonary circulatory system.
This can also be summarised for the upper-body and lower-body separately:
• Return of Blood from the Upper-Body:
Blood returns from the head via the jugular veins, and from the arms via the subclavian veins. All
of the blood in the major veins of the upper body flows into the superior vena cava, which
returns the blood to the right ventricle of the heart.
• Return of Blood from the Lower-Body:
Blood returns from the small intestines by passing through the hepatic portal vein to the
liver. Blood returns from the liver via the hepatic vein, from the kidneys via the renal veins,
and from the legs via the iliac veins. All of the blood in the major veins of the lower body
flows into the inferior vena cava, which returns the blood to the right ventricle of the heart.
• After re-entering the (right atrium of the) heart via the superior vena cava and the inferior vena
cava, deoxygenated blood is pumped into the right ventricle of the heart and then out of the heart
to the lungs via the pulmonary artery.
・Subclavian vein runs together with artery.
・Axillary vein is continuation of the basilica

vein (which forms uniting basilic and
brachial veins).
・Subclavian and internal jugular veins form

the brachiocephalic vein. The angle of
the two veins is called venous angle.
Venous angle is the site of junction of
large lymphatic trunks (thoracic duct and
right lymphatic duct).

Compiled by
Nur KM
・Subclavian vein runs together with artery.
・Axillary vein is continuation of the basilica

vein (which forms uniting basilic and
brachial veins).
・Subclavian and internal jugular veins form

the brachiocephalic vein. The angle of
the two veins is called venous angle.
Venous angle is the site of junction of
large lymphatic trunks (thoracic duct and
right lymphatic duct).

Compiled by
Nur KM
15. The branches and anastomoses of the axillary artery
❖ The axillary artery is a continuation of the subclavian artery that begins at the outer
border of the first rib. It then courses through the axilla while being bordered by the lateral
(superiorly), posterior (posteriorly), medial (inferiorly) cords of the brachial plexus and the ansa
pectoralis (anteriorly).
❖ As it passes through the axilla, the artery is divided into three parts by pectoralis minor,
one branch leaves the first segment above, two branches from the second segment beneath and
three branches leave the third segment below. While exiting the axilla, the axillary artery changes
its name at the lower border of teres major and continues in the arm as the brachial artery.
Branches:
Hotel Spa
Thoracoacromial a.の branch

・acromial branch
・pectoral branch
・clavicle branch
・deltoid branch
1. Superior Thoracic Artery
The superior (highest) thoracic artery is the first branch of the axillary artery. It is given off
proximal to the outer border of the anterior scalene muscle. It forms part of the arterial
supply to the pectoral muscles.
2. Thoracoacromial Artery
The second part of the axillary artery gives rise to two vessels. The thoracoacromial
(acromiothoracic) artery is a primary trunk that gives rise to four other arteries. By way of its
branches, the thoracoacromial artery pierces the clavipectoral fascia to supply regions of the
upper limb and trunk for which they are named.

Compiled by
Nur KM
• The clavicular branch courses superomedially towards the sternoclavicular jointwhere it
supplies the joint and subclavius muscle.
• The pectoral branch travels inferomedially toward the pectorales muscles where it
provides oxygenated blood to the muscles and the mammaries.
• The acromial branch crosses the medial border of the coracoid process, deep to the
deltoid muscle. After supplying this muscle, it pierces it to reach the acromion, where it
joins the acromial anastomosis.
• Finally, the deltoid (humeral) branch courses over the tendon over pectoralis minor, then
through the deltopectoral groove (with the cephalic vein). Along this course, it supplies
both pectoralis major and the deltoid muscle.
3. Lateral Thoracic Artery

The other branch of the second part of the axillary artery is the lateral thoracic artery. It
travels inferomedially along the inferior margin of pectoralis minor. It carries oxygenated
blood for the:
• serratus anterior
• pectorales muscles
• subscapularis muscle
• mammaries
4. Subscapular Artery
The third part of the axillary artery first gives off the subscapular artery, which is the largest
branch of the axillary artery. The subscapular artery travels caudally, shortly after which it
bifurcates to give the circumflex scapular arteryand the thoracodorsal artery.
The circumflex scapular artery courses around the lateral border of the scapulathrough the
(upper) triangular space to enter the infraspinatus fossa. Here it joins the scapular
anastomosis. The thoracodorsal artery continues inferiorly alongside the thoracodorsal
nerve to supply the latissimus dorsi muscle. The thoracodorsal branch of the subscapular
artery forms an anastomosis with the pectoral branch of the thoracoacromial artery, the
internal intercostal and the internal mammary arteries.

Compiled by
Nur KM
5. Circumflex Humeral Arteries
Finally, the third part of the axillary artery gives off an anterior and a posterior circumflex
humeral artery (ACHA & PCHA, respectively). The ACHA is the smaller of the two arteries. It
travels in a horizontal manner towards the surgical neck of the humerus, deep to the short
head of biceps brachii and coracobrachialis. At the intertubecular groove, it gives a branch
that travels superiorly in the sulcus to supply the glenohumeral joint.

Compiled by
Nur KM
16. The branches of the brachial artery; collateral circulation of the elbow.
brachial artery:
● origin: continuation of the axillary artery distal to teres major
● location: medial upper arm
● supply: muscles of the arm, forearm and hand
The proximal brachial artery is the continuation of the axillary artery at the inferior border of teres
major.
After it emerges from the below teres major, it initially lies medial to the humerus where it is
accompanied by the basilic vein and the median nerve.
It sits medial to the biceps brachii muscle and anterior to the medial head of triceps.
The median nerve is medial to the brachial artery for most of its course.
Compiled by
Nur KM
Branches:
1. Muscular branches: It supplies all the muscles of arm directly or through its branches.
2. Nutrient artery to the humerus
3. Deep artery of the arm (Profunda brachii artery): Profunda brachii artery arises from
medial and posterior part of brachial artery as a large branch just below the lower
border of teres major muscle. It closely follows the radial nerve and passes between
the lateral and medial heads of triceps muscle. After passing through the radial grove
of humerus along the radial nerve, it pierces the lateral intermuscular septum and
reaches the front of lateral epicondyle of humerus. It ends by anastomosing with the
radial recurrent artery.
Profunda brachii artery supplies the deltoid muscle (which is primarily supplied by the
posterior circumflex humeral artery) and occasionally also gives an unusual nutrient artery to
the humerus. At its end, it takes part in the formation of anastomoses around elbow joint.
4. Superior ulnar collateral artery: It is a small sized artery arising from the brachial
artery just below the middle of the arm. It pierces the medial intermuscular septum of
the arm and reaches behind the medial epicondyle of humerus. It ends by taking part
in anastomoses around the elbow joint.
5. Inferior ulnar collateral artery: It arises from brachial artery about two and half inches
above the elbow joint. Near its origin it pierces the medial intermuscular septum and
reaches behind the medial epicondyle of humerus. It ends by taking part in
anastomoses around the elbow joint.
6. Radial artery
7. Ulnar artery

Compiled by
Nur KM
Compiled by
Nur KM
17. Palmar arterial arches: topography and branches.
Anatomical layers on the palm:

1. Skin
2. palmar aponeurosis
3. superficial palmar arch and common digital nerves
4. flexor tendons and lumbrical muscles
5. deep palmar arch, deep branch of the ulnar nerve
6. interosseus muscles and adductor pollicis muscle
Superficial palmar arch

• formed predominantly by:
o ulnar artery o superficial palmar branch of the radial artery. o in some individuals the
contribution from the radial artery might be absent, and instead anastomoses with either
the princeps pollicis artery, the radialis indicis artery, or the median artery, the former
two of which are branches from the radial artery.
• Is Covered by the palmar aponeurosis
• The superficial arch gives the arteries supplying four fingers (II-V)
• Common palmar digital arteries (3)
• Proper palmar digital arteries (6)
• A. digitalis propria (1) for the small finger
• the superficial palmar arch is completely formed only in 27 % of cases. It is unclosed in a
majority of cases.

Compiled by
Nur KM
Deep palmar arch
• located Beneath the long flexor tendons
(deepest layer of the palm)
• Radial artery (end-branch)
• Deep palmar branch of the ulnar artery
Branches:
• Palmar metacarpal arteries (4)

• Perforant branches to the superficial arch
Important branches of the radial artery before it
joins to the deep arch:
• Princeps pollicis artery: supplies the thumb

(2 digital arteries)
• Radial indicis artery: supplies the radial side
of the index finger
Anastomosis:
Arcus palmaris superficialis & profundus.
Arcus dorsalis: dorsal carpal arch (weak) on the back of the wrist and hand.

Compiled by
Nur KM
Compiled by
Nur KM
18. The venous and lymphatic drainage of the upper limb.
The veins of the upper limb form two systems.
1. The superficial system lies superficially to the fascia of the muscles and lacks corresponding
arteries.
2. The veins of the deep system follow the course of the arteries; two veins accompany each
artery up to the armpit.
Deep veins:
• accompany all of the major arteries of the arm, and drain blood from the dorsal and plantar
arches to the vessels accompanying the radial and ulnar arteries. These continue to the cubital
fossa, where they unite to form vena comitantes of the brachial vein. These vena comitantes
merge with the basilic vein in the axilla to form the axillary vein.
The major superficial veins of the upper limb are the cephalic and basilic veins., they are located
within the subcutaneous tissue of the upper limb.
The basilic vein originates from the dorsal venous network of the hand. It ascends the medial aspect of
the upper limb. At the border of the teres major, the vein moves deep into the arm. Here, it combines
with the brachial veins to form the axillary vein.
The cephalic vein arises from the dorsal venous network of the hand. It ascends the antero-lateral
aspect of the upper limb, passing anteriorly at the elbow. At the shoulder, the cephalic vein travels
between the deltoid and pectoralis major muscles (known as the deltopectoral groove), and enters
the axilla region via the clavipectoral triangle. Within the axilla, the cephalic vein terminates by
joining the axillary vein.

Compiled by
Nur KM
At the elbow, the cephalic and basilic veins are connected by the median cubital vein.
Superficial Lymphatic Vessels

The superficial lymphatic vessels of the upper limb initially arise from lymphatic plexuses in
the skin of the hand (networks of lymphatic capillaries beginning in the extracellular spaces).
They then ascend up the arm, in close proximity to the major superficial veins:
• The vessels shadowing the basilic vein go on to enter the cubital lymph nodes. These are
found medially to the vein, and proximally to the medial epicondyle of the humerus. Vessels
carrying on from these nodes then continue up the arm, terminating in the lateral axillary
lymph nodes.
• The vessels shadowing the cephalic vein generally cross the proximal part of the arm and
shoulder to enter the apical axillary lymph nodes, though some exceptions instead enter the
more superficial deltopectoral lymph nodes.
Deep Lymphatic Vessels
The deep lymphatic vessels of the upper limb follow the major deep veins (i.e. radial, ulnar
and brachial veins), terminating in the humeral axillary lymph nodes. They function to drain
lymph from joint capsules, periosteum, tendons and muscles. Some additional lymph nodes
may be found along the ascending path of the deep vessels. Lymph Nodes
The majority of the upper lymph nodes are located in the axilla.

Compiled by
Nur KM
They can be divided anatomically into 3 levels:
Level I ( lateral to pectoralis minor)
• Pectoral (anterior) – 3-5 nodes, located in the medial wall of the axilla. They receive lymph
primarily from the anterior thoracic wall, including most of the breast.
• Subscapular (posterior) – 6-7 nodes, located along the posterior axillary fold and subscapular
blood vessels. They receive lymph from the posterior thoracic wall and scapular region.
• Humeral (lateral) – 4-6 nodes, located in the lateral wall of the axilla, posterior to the axillary
vein. They receive the majority of lymph drained from the upper limb.
• Para mammary
Level 2 (along pectoralis minor)
• Central – 3-4 large nodes, located near the base of the axilla (deep to pectoralis minor, close
to the 2nd part of the axillary artery). They receive lymph via efferent vessels from the
pectoral, subscapular and humeral axillary lymph node groups.
• Interpectoral
Level 3 (medial to pectoralis minor)
• Apical – Located in the apex of the axilla, close to the axillary vein and 1st part of the axillary
artery. They receive lymph from efferent vessels of the central axillary lymph nodes, therefore
from all axillary lymph node groups. The apical axillary nodes also receive lymph from those
lymphatic vessels accompanying the cephalic vein.
Efferent vessels from the apical axillary nodes travel through the cervico-axillary canal, before
converging to form the subclavian lymphatic trunk. The right subclavian trunk continues to
form the right lymphatic duct, and enters the right venous angle (junction of internal jugular
and subclavian veins) directly. The left subclavian trunk drains directly into the thoracic duct.
> superficial lymph vessels pass to the regional lymph nodes in parallel with the
subcutaneous veins
> deep lymphatic vessels follow the arteries

Compiled by
Nur KM
Compiled by
Nur KM
19.The organization of spinal cord segments and spinal nerves. The general
organization and features of the cranial nerves.
Central nervous system (CNS)
o Brain
o spinal cord
- Peripheral nervous system (PNS) o All the nerves outside of the CNS
• 12 pairs of cranial nerves
• 31 pairs of spinal nerves
o Connect the CNS to the limbs and organs
The organization of spinal cord segments and spinal nerves:
The spinal cord: The spinal cord is a long, thin, tubular bundle of nervous tissue and
support cells that extends from the medulla oblongata in the brainstem to the lumbar
region of the vertebral column.
In humans, the spinal cord begins at the occipital bone where it passes through the foramen
magnum, and meets and enters the spinal canal at the beginning of the cervical vertebrae.
The spinal cord extends down to between the first and second lumbar vertebrae where it
ends, and keep runs as a cauda equina .
The cauda equina (Latin for "horse's tail") is a bundle of spinal nerves and spinal nerve
rootlets, consisting of:
• the second through fifth lumbar nerve pairs

• the first through fifth sacral nerve pairs
• the coccygeal nerve all from above arise from the lumbar enlargement and
the conus medullaris of the spinal cord.
The conus medullaris (Latin for "medullary cone") or conus terminalis is the tapered, lower
end of the spinal cord.
The spinal cord can divide to 5 different bones at the next order (from superior to inferior):
1. Cervical region - 7 vertebras ,8 segments because the first cervical have also above
the bone segment and also beneath, all the other the segment are beneath,
lordosis
2. Thoracic region - 12 vertebras, 12 segments, kyphosis
3. Lumbar region - 5 vertebras, 5 segments ,lordosis
4. Sacral region – 5 bones ossified to 1, 5 segments, kyphosis
5. Coccygeal region - 3 bones , 1 segment Total 31 segments , 32 vertebras

Compiled by
Nur KM
Spinal cord
- Encased in bone - in spinal column

- Protected by bone and three meninges:
o Dura mater – outer layer, thick dense fibrous tissue, tightly
connected to the surrounding bone.
o Arachnoid mater – middle, thin layer, provides cushioning effect for the
CNS.
o Pia mater – inner most, thin, tightly associated with the brain and spinal
cord.
- Cushioned by cerebrospinal fluid (CSF)
- Has a central canal, containing CSF
- The gray matter is inside and the white mater is outside - Transmits impulses to
and from the brain:
o Ascending tracts
 Transmit information to the brain ‘afferent’ - sensation ,ascends to
the spinal cord by dorsal root
o Descending tracts
 Transmit information from the brain ‘efferent’ - motor ,descends to
the muscle by ventral root
Spinal ganglion – a group of cell bodies, next to the spinal cord.

Dorsal root – a bunch of sensory axons entering the spinal cord from the back. (afferent
nerves)
Ventral root – a bunch of axons caring motoric messages. (efferent nerves)

Compiled by
Nur KM
The Internal Anatomy of the Spinal Cord
The arrangement of gray and white matter in the spinal cord is relatively simple: The interior
of the cord is formed by gray matter, which is surrounded by white matter.In transverse
sections, the gray matter is conventionally divided into dorsal (posterior) lateral and ventral
(anterior) “horns.” The neurons of the dorsal horns receive sensory information that
enters the spinal cord via the dorsal roots of the spinal nerves. The lateral horns are present
primarily in the thoracic region, and contain the preganglionic visceral motor neurons that
project to the sympathetic ganglia. The ventral horns contains the cell bodies of motor
neurons that send axons via the ventral roots of the spinal nerves to terminate on striated
muscles. The white matter of the spinal cord is subdivided into dorsal (or posterior), lateral,
and ventral (or anterior) columns, each of which contains axon tracts related to specific
functions. The dorsal columns carry ascending sensory information from somatic
mechanoreceptors. The lateral columns include axons that travel from the cerebral cortex to
contact spinal motor neurons.
These pathways are also referred to as the cortico-spinal tracts. The ventral
(and ventrolateral or anterolateral) columns carry both ascending information about pain
and temperature, and descending motor information. Some general rules of spinal cord
organization are (1) that neurons and axons that process and relay sensory information are
found dorsally; (2) that preganglionic visceral motor neurons are found in an
intermediate/lateral region; and (3) that somatic motor neurons and axons are found in the
ventral portion of the cord

Compiled by
Nur KM
The general organization and features of the cranial nerves:
Cranial nerves: The nerves of the brain, which emerge from or enter the skull (the cranium),
as opposed to the spinal nerves, which emerge from the vertebral column. There are 12
cranial nerves, each of which is accorded a Roman numeral and a name
Cranial nerve I: the olfactory nerve which permits the sense of smell
Cranial nerve II: the optic nerve, the nerve that connects the eye to the brain and carries the
impulses formed by the retina -- the nerve layer that lines the back of the eye, senses light
and
creates the impulses -- to the brain which interprets them as images

Compiled by
Nur KM
Cranial nerve III: the oculomotor nerve. The oculomotor nerve is responsible for the nerve
supply to muscles about the eye:
• The upper eyelid muscle which raises the eyelid;

• The extraocular muscle which moves the eye inward; and
• The pupillary muscle which constricts the pupil.
Cranial nerve IV: the trochlear nerve, is the nerve supply to the superior oblique muscle of
the eye, one of the muscles that moves the eye. Paralysis of the trochlear nerve results in
rotation of the eyeball upward and outward
Cranial nerve V: the trigeminal nerve. The trigeminal nerve is quite complex. It functions
both as the chief nerve of sensation for the face and the motor nerve controlling the muscles
of mastication (chewing).
Cranial nerve VI: is the abducens nerve. It is a small motor nerve that has one task: to supply
a muscle called the lateral rectus muscle that moves the eye outward.
Cranial nerve VII: The facial nerve is the seventh cranial nerve.The facial nerve supplies the
muscles of facial expression.
Cranial nerve VIII: the vestibulocochlear nerve. The vestibulocochlear nerve is responsible
for the sense of hearing and it is also pertinent to balance, to the body position sense.
Cranial nerve IX: the glossopharyngeal nerve. The glossopharyngeal nerve supplies the
tongue, throat, and one of the salivary glands (the parotid gland). Problems with the
glossopharyngeal nerve result in trouble with taste and swallowing.
Cranial nerve X: The vagus nerve originates in the medulla oblongata, a part of the brain
stem. The vagus nerve is a remarkable nerve that relates to the function of numerous
structures in the body. The vagus nerve supplies nerve fibers to the pharynx (throat), larynx
(voice box), trachea (windpipe), lungs, heart, esophagus and most of the intestinal tract. And
the vagus nerve brings sensory information back from the ear, tongue, pharynx and larynx
Cranial nerve XI: the accessory nerve.. The accessory is so-called because, although it arises
in the brain, it receives an additional (accessory) root from the upper part of the spinal cord.
The
accessory nerve supplies the sternocleidomastoid and trapezius muscles
Cranial nerve XII: the hypoglossal nerve .The hypoglossal nerve supplies the muscles of the
tongue. (The Greek "hypo-", under and "-glossal" from "glossa", the tongue = under the
tongue).

Compiled by
Nur KM
20. Organization and supply areas of the brachial plexus
Organization and supply areas of the brachial plexus:
The brachial plexus is a network of nerves that supplies innervation to the skin and
musculature of the upper limb. It is subdivided into roots, trunks, divisions and branches and
the order in which these division occur can be remembered using the mnemonic
‘Remember To Drink Cold Beer’:
• Roots
• Trunks
• Divisions
• Cords
• Branches

Compiled by
Nur KM
There are typically 5 roots, 3 trunks, 6 divisions, 3 cords and 5 terminal branches
Supraclavicular nerves: above the clavicle also the trunks are classified as Supraclavicular
nerves.
1. Dorsal scapular nerve C4-C5
1. Rhomboid major muscle
2. Rhomboid minor muscle
3. levator scapulae muscle
2. Subclavian nerve (trunk) C5-C6
1. Subclavius muscle
3. Suprascapular nerve (trunk) C4-C6
1. Infraspinatus muscle
2. Supraspinatus muscle
4. Long thoracic nerve C5-C7

Compiled by
Nur KM
1. Serratus anterior muscle
The lateral cord: C5-C7 lateral to axillary artery, anterior divisions

1. Musculocutaneous nerve C5-C7
2. Lateral pectoral nerve C5-T1
3. The lateral part of median nerve C5-T1
The medial cord: C8+T1 medial to axillary artery, anterior divisions (tip to remember 4M and
U)
1. Medial brachial cutaneous nerve T1
2. Medial pectoral nerve C5-T1
3. The medial part of median nerve C5-T1
4. Medial antebrachial cutaneous nerve C8-T1
5. Ulnar nerve C8,T1
The posterior cord: C5-T1 posterior to axillary artery, posterior divisions (tip to remember
STARS)
1. Subscapular superior nerve C5-C6
2. Thoracodorsal nerve C6-C8
3. Axillary nerve C5-C6
4. Radial nerve C5-T1
5. Subscapular inferior nerve C5-C6
The nerves of the lateral cord :

1. Musculocutaneous nerve C5-C7 –
Pathway: leaves the axilla, and pierces the coracobrachialis muscle, near its point of
insertion on the humerus .It then passes down the arm, anterior to the brachialis muscle
but deep to the biceps brachii, innervating them both.The musculocutaneous nerve
emerges laterally to the biceps tendon, and continues into the forearm as the lateral
antebrachial cutaneous nerve.
Motor innervation: all the flexor of the arm
1. Coracobrachialis
2. biceps brachii
3. brachialis sensory function:
1. lateral antebrachial cutaneous nerve
2. Lateral pectoral nerve C5-T1
Pathway: The lateral pectoral nerves showed a constant course, parallel to the
thoraco-acromial vessels. They coursed inferomedially on the deep surface of
pectoralis major, under its fascia Motor innervation:

Compiled by
Nur KM
1. pectoralis major
2. pectoralis minor
The nerves of the medial cord :

1. median nerve C5-T1
Pathway:
After originating from the brachial plexus in the axilla, the median nerve descends down
the arm, initially lateral to the brachial artery. Halfway down the arm, the nerve crosses
over the brachial artery, and becomes situated medially. The median nerve enters the
anterior compartment of the forearm via the cubital fossa.
In the forearm, the nerve travels between the flexor digitorum profundus and flexor
digitorum superficialis muscles. The median nerve gives rise to two major branches in
the forearm:
1. Anterior interosseous nerve – Supplies the deep muscles in the anterior

forearm.
2. Palmar cutaneous nerve – Innervates the skin of the lateral palm.

The median nerve enters the hand via the carpal tunnel, where it terminates by
dividing into two branches:
1. Recurrent branch – Innervates the thenar muscles.
2. Palmar digital branch – Innervates the palmar surface and fingertips of the
lateral three and half digits. Also innervates the lateral two lumbrical
muscles.
Motor innervation:
Flexor antibrachi superficialis (except flexor carpi ulnaris)
1. Pronator teres
2. Flexor carpi radialis
3. Palmaris longus
4. Flexor digitorum
Flexor antibrachi profundus (except 4th 5th digit)

1. Pronator qudratus
2. Flexor pollicis longus
3. Flexor digitorum profundus -2nd 3rd digit
Thenar muscles (except adductor pollicis)

1. Abductor pollicis brevis
2. Flexor pollicis brevis – superficial head
Compiled by
Nur KM
3. Opponens pollicis
1st 2nd lumbricals

Sensory function:
1. Palmar branch of median nerve
2. Common and proper palmar digital nerve
2. Medial pectoral nerve C5 T1
Pathway: It passes behind the first part of the axillary artery, curves forward
between the axillary artery and vein, and unites in front of the artery with a
filament from the lateral nerve.
Motor innervation:
1. pectoralis major
2. pectoralis minor
3. Medial brachial cutaneous nerve T1
Pathway: Initially it runs with the ulnar nerve with which it is sometimes confused.
The nerve then pierces the deep fascia at approximately the mid-arm, alongside the
basilic vein to enter the subcutaneous tissues of the forearm. sensory function:
medial brachial cutaneous
4. Medial antebrachial cutaneous nerve, C8 and T1

Pathway: It gives off, near the axilla, a filament, which pierces the fascia and supplies the
integument covering the Biceps brachii, nearly as far as the elbow.
The nerve then runs down the ulnar side of the arm medial to the brachial artery, pierces the
deep fascia with the basilic vein, about the middle of the arm, and divides into a volar and an
ulnar branch..
sensory function: Medial antebrachial cutaneous
5.Ulnar nerve C8,T1
Pathway:
After arising from the brachial plexus, the ulnar nerve descends down the medial side of the
upper arm. At the elbow, it passes posterior to the medial epicondyle of the humerus, entering
the forearm. At the medial epicondyle, the nerve is easily palpable and vulnerable to injury. In
the forearm, the ulnar nerve pierces the two heads of the flexor carpi ulnaris, and travels

Compiled by
Nur KM
alongside the ulna. Three branches arise in the forearm: o Muscular branch: innervates some
muscles in the anterior compartment of the forearm.
o Palmar cutaneous branch: innervates the skin of the medial half of the palm.
o Dorsal cutaneous branch: innervates the skin of the medial 1 and 1/2 fingers,
and the associated palm area
At the wrist, the ulnar nerve travels superficially to the flexor retinaculum. It enters the hand
via the ulnar canal (or Guyon’s canal). In the hand the nerve terminates by giving rise
to superficial and deep branches.
Motor innervation:
Complementary for median nerve
1. flexor carpi ulnaris
2. adductor pollicis
3. Flexor pollicis brevis deep head
4. Flexor digitorum profundus -4th 5th digit
5. 3rd 4th lumbricals
Mesothenar muscles:
1. dorsal interosseous
2. palmar interosseous
Hypothenar muscles
1. palmaris brevis
2. opponens digiti minimi
3. flexor digiti minimi
4. abductor digiti minimi
Sensory function:
1. Palmar cutaneous branch
2. Common proper palmar digital nerve
3. Dorsal cutaneous branch
4. Dorsal digital nerves

Compiled by
Nur KM
The nerves of the posterior cord :
1. subscapular nerve – superior C5, C6
Pathway:
The upper subscapular nerve has a short course from the posterior cord of the
brachial plexus to the upper part of the subscapularis muscle
Motor innervation:
1. the higher part of the subscapularis muscle
2. teres major muscle Sensory function
2. thoracodorsal nerve c6-c8 Pathway:
After branching from the posterior cord between the upper and lower subscapular
nerves, the thoracodorsal nerve runs down the posterior axillary wall. At its origin
it is posterior to the subscapular artery. However, as it descends along the
posterior wall of the axilla it comes to lie anterior to the artery, then called the
thoracodorsal artery. The thoracodorsal nerve crosses the lower border of the
teres major muscle and enters the deep surface of the latissimus dorsi with
terminal branches of the nerve extending to the inferior border of the muscle
Motor innervation:
1. latissimus dorsi
3. axillary nerve C5 - C6 Pathway:
Immediately after its formation, the axillary nerve lies posteriorly to the axillary
artery and anteriorly to the subscapularis muscle. It descends to the inferior
border of the subscapularis muscle, and then exits the axilla posteriorly via the
quadrangular space. It is accompanied by the posterior circumflex humeral artery
Motor innervation:
1. teres minor muscle
2. the deltoid Sensory function
4. radial nerve C5-T1.

Pathway:
arises in the axilla region, where it is situated posteriorly to the axillary artery. It
exits the axilla inferiorly (via the triangular interval), and supplies branches to the
long and medial heads of the triceps brachii.
The radial nerve then descends down the arm, travelling in a shallow depression
within the surface of the humerus – known as the radial groove.
As it descends, the radial nerve wraps around the humerus laterally, and supplies a
branch to the lateral head of the triceps brachii. During much of its course within
the upper arm, it is accompanied by the deep branch of the brachial artery.
To enter the forearm, the radial nerve moves anteriorly over the lateral epicondyle
of the humerus, through the cubital fossa. The nerve then terminates by dividing
into two branches:
Compiled by
Nur KM
1. Deep branch (motor) – innervates most of the muscles in the
posterior compartment of the forearm.
2. Superficial branch (sensory) – contributes to the cutaneous
innervation of the hand and fingers
Motor innervation: all the extensors!!
Extensor of the arm:
1. Triceps Brachii
2. Anconeus
Extensor of the forearm superficial:

1. Brachioradialis
2. Extensor carpi radialis longus
3. Extensor carpi radialis brevis
4. Extensor digitorum
5. Extensor digiti minimi
6. Extensor carpi ulnaris
Extensor of the deep:

1. Supinator
2. Abductor pollicis longus
3. Extensor pollicis brevis
4. Extensor pollicis longus
5. Extensor indicis
Sensory function
1. Posterior antebrachial cutaneous nerve
2. Inferior lateral brachial cutaneous nerve
3. Posterior brachial cutaneous nerve
4. Superficial branch of the radial nerve
5. subscapular nerve – inferior C5, C6

Pathway:
The lower subscapular nerve travels inferiorly from the brachial plexus to supply
the lower part of the subscapularis muscle. It donates a branch to the teres major
muscle which courses in the angle between the subscapular and circumflex
scapular arteries Motor innervation:
1. the lower part of the subscapularis muscle
2. teres major muscle

Compiled by
Nur KM
21. Branches of the median nerve, functional loss of the median nerve.
• Origin (C5-Th1):
➢ Lateral cord (lateral root)
➢ Medial cord (medial root)
• The roots surround the axillary artery
• runs through the Medial bicipital groove
• Forearm: between the flexors
• Wrist: carpal tunnel
The Median nerve functions as both sensory and motor nerve. Hence, it gives sensory nerves
and motor nerves.
arm
• Formed on the anterolateral aspect of the axillary a. by the union of lateral and medial
cords.
• Descends in the medial bicipital groove
• Runs downward on the axillary a. then further on the brachial a.
• Gradually crosses the brachial a. anteriorly to lie medial to the artery at the elbow •
Gives no branches to structures of the arm
forearm
・Enters the forearm on the front of the brachialis m. medial to the brachial artery.
Branches ( in the forearm):

Compiled by
Nur KM
Compiled by
Nur KM
1. The first group of motor branches is the muscular branches that originate directly from the
median nerve.
These branches innervate (4): M. pronator teres
M. flexor carpi radialis
M. palmaris longus
M.flexor digitorum superficialis
Course and other branches:

Distil to the union of Its brachial plexus roots, the median nerve runs in the medial
bicipital groove above the brachial artery to the elbow and passes under the bicipital
aponeurosis and between the two heads (humeral and ulnar) of pronator teres to the
forearm. After giving off THE ANTERIOR ANTEBRACHIAL INTEROSSEOUS NERVE DISTAL TO
PRONATOR TERES
2.ANTERIOR ANTEBRACHIAL INTEROSSEOUS NERVE is a motor branch, which innervate the

DEEP FLEXORS of the arm ( except radial half of M. flexor digitorum profundus )
M. flexor pollicis longus,

M.pronator quadratus,
M. flexor digitorum profundus (radial half)
Course: It accompanies the anterior interosseous artery along the anterior of the
interosseous membrane of the forearm, and ending below in the pronator quadratus and
wrist joint. After giving off the ANTERIOR ANTEBRACHIAL INTEROSSEOUS NERVE distal to
pronator tenes, the median nerve runs between the flexor digitorum superficialis and
profundus to the wrist and passes beneath the flexor retinaculum (transverse carpal
ligament) In the carpal tunnel to the palm of the hand, where It divides Into Its terminal
branches (a motor branch for the thenar muscles and sensory branches for the skin on the
palmar side of the palmar side of the radial
3.5 digits)
3. Palmar cutaneous branch (sensory),innervates:

Thenar and radial palmar skin
4. common palmar digital nerves (motor,3 in number), which is motor branches innervating :
Mm. lumbricales I-II.
M. abductor pollicis brevis
M. opponens pollicis
M. flexor pollicis brevis (superficialis)

Compiled by
Nur KM
5. Proper palmar digital nerves (7)- sensory , innervates:
7 radial finger sides + dorsally the distal skin of the fingers 2-5 + distal
skin of the first finger.
functional loss of the median nerve.

*** In general, when asked about the loss function of certain nerve , it depends where the
injury occurs. In this case, the functional loss could be just in the palmar (sensory and motor) ,
if the injury happened in the carpal tunnel, or it could include the rest of the muscles
innervated proximal to the carpal tunnel.
Signs and symptoms:
Medical check up: the patient can’t do the OK sign
**median nerve also gives articular branches (sensory) to the elbow and wrist joints.

Compiled by
Nur KM
22. Branches of the ulnar nerve, functional loss of the ulnar nerve.
• Arises from the medial cord

• Descends in the medial bicipital groove toward the medial epicondyle(groove for the ulnar n.
on the humerus)
• Enters the forearm by passing behind the medial epicondyle between the two heads of the
flexor carpi ulnaris.
• It runs downwards between the flexor carpi ulnaris and flexor digitorum profundus muscles.
• Emerges with the ulnar artery from behind the flexor carpi ulnaris above the wrist.
・Crosses the anterior surface of the flexor retinaculum with ulnar artery on its lateral side.
• Then divides into superficial and deep branches:
1. Superficial branch:
Gives rise to common and proper palmar digital branches providing the sensory innervation of
3 ulnar borders of the digits on the palmar side.
2. Deep branch:
supplies the hypothenar mm. & the adductor pollicis m. & deep head of the flexor pollicis brevis
m. & the mesothenar mm. except the 2 radial lumbricals

Compiled by
Nur KM
It gives off the dorsal branch above the wrist, which in turn gives rise to dorsal digital branches
providing cutaneous innervation for 5 ulnar borders of the digits on the dorsal side (except: distal
phalanges).
Functional loss of the ulnar nerve.

It depends where the injury occurs
1.proximal ulnar nerve lesion →clinical features: claw hand and sensory disturbance.
2. midlevel ulnar nerve lesion →clinical features: claw hand and sensory disturbance, that
spare the hypothenar region (palmar branch is intact)
3. distal ulnar nerve lesion →clinical features: claw hand and without sensory disturbance (
superficial branch is intact)
Medical check up:

Compiled by
Nur KM
Compiled by
Nur KM
23. Branches of the radial nerve, functional loss of the radial nerve.
• Arises from the posterior cord of the brachial plexus.

• After leaving the axilla it spirals posteriorly around the humerus and joins the deep brachial
a.
• After piercing the intermuscular septum it re-enters the anterior compartment to pass
downward and forward between the brachialis m. and brachioradialis m.
Then it gives rise to the deep and superficial ramuses.

Superficial ramus / branch:
• Descends alongside the ulnar border of brachioradialis m.
• In the middle-third of the forearm it runs together with the radial artery.

Compiled by
Nur KM
Deep branch (in the forearm)

Compiled by
Nur KM
functional loss of the radial nerve.
Wrist drop due to proximal and midlevel radial nerve lesions
When the radial nerve is damaged, the patient can no longer actively extend the hand at the
wrist, and wrist drop (drop hand) is said to be present. Besides the dropped position of the
wrist, clinical examination reveals areas of sensory loss on the radial surface of the dorsum
and on the extensor surface of the thumb, index finger, and the radial half of the middle
finger extending to the proximal interphalangeal joint. The sensory deficits are often confined
to the area of the hand that receives sensory innervation exclusively from the radial nerve
(the interosseous space between the thumb and index finger).
Additional sign: weakness of thumb finger extension

Compiled by
Nur KM
24. Skin innervation of the upper limb.

Compiled by
Nur KM
-> Superior lateral brachial cutaneous nerve:
Continuation of the posterior cord of the axillary nerve, after it pierces the deep fascia
• Provides sensation to the superior lateral cutaneous aspect of the arm.

• Originated from roots C5, C6 and branches from the axillary nerve.
-> Sensory branches of the radial nerve (C5-T1)posterior side of the forearm, dorsal surface
of the lateral part of the palm, later 3 and half of digits.it gives into 4 sensory branches:

Compiled by
Nur KM
1. Superficial branch of the radial nerve:
Anterior lateral aspect of the forearm .It lies at first slightly lateral to the radial artery,
concealed beneath the Brachioradialis.
Within the hand the superficial branch passes over the anatomical snuff box and then
innervates the dorsal lateral surface of the lateral three and half digits.
2. Posterior brachial cutaneous nerve (arm):

Supply: the skin on the posterior surface of the upper arm (on the back of the arm, passes
through the axilla to the medial side of the area supplying the skin on its dorsal surface nearly
as far as the olecranon.
 Arm skin posterior and lateral-inferior surface
3. Posterior antebrachial cutaneous nerve (dorsal antebrachial cutaneous nerve): also

perforating through the lateral head of the triceps and passes posteriorly to innervate
elbow skin and posterior side of forearm skin.
4. Inferior lateral brachial cutaneous nerve:

Perforating through the lateral head of the triceps it innervates the skin of the lateral part of
the lower half of arm.
** deep branch of the radial nerve goes thrught the supinator canal and has both motor and
sensory functions **
Lateral antebrachial cutaneous nerve: branch of musculocutaneous nerve,
Divides into: anterior and posterior branches  innervates the lateral aspect of the forearm.
Medial brachial cutaneous nerve: (of the arm)
• Originated: from the medial cord (C8-T1). Just proximal to where the medial
antebrachial cutaneous nerve comes off (they course through the arm in close to each
other).
• Innervation: axillary skin, medial skin of the upper arm • Distributed to the skin on the
medial brachial side of the arm.
• It is the smallest branch of the brachial plexus.
• It passes through the axilla  medial to the axillary veincommunicates with the
intercostobrachial nerve.( accompany with the medial antebrachial cutaneous nerve.)

Compiled by
Nur KM
• It passes inferiorly and medially to the brachial artery to the middle region of the arm
and passes through the deep fascia.
Medial antebrachial cutaneous nerve: (of the forearm)
• Arises from the medial cord of the brachial plexus. (C8, T1)
• it descends on the ulnar side next to the biceps muscle(medial biciptal groove, and
runs down medial to the brachial artery
• anterior side  ulnar skin of the forearm posterior side ulnar skin of the forearm
Lateral cutaneous branches: (T1, T2):
• These are the cutaneous branches of the intercostal nerves 2 and 3 which accompany
the medial brachial cutaneous nerve.
• It innervates the skin on the side of the thoracic wall by dividing into anterior and
posterior branches.
Sensory branches of the median nerve:
• Palmar branch of median nerve:

- Passes over the flexor retinaculum, within the carpal tunnel.
- Innervates the skin of the lateral palm. (thenar, radial palmar skin)
• Common palmar digital nerves : - Divides into 3 - Supply: lumbricales I-II.
Abductor pollicis brevis muscle.
opponens pollicis
Flexor pollicis brevis (superficial head)
• Proper palmar digital nerves:
- Divides into 7( 2 into the sides of the 1st- 3rd fingers and 1 to the lateral side of the
4th finger.
- Dorsally: it supplies 2 and half fingers( 2nd, 3rd and half of the
Sensory branches of the ulnar nerve: (C8, T1)

Palmar branch of the ulnar nerve:
Compiled by
Nur KM
• It crosses the flexor retinaculum of the hand on the lateral side of the pisiform bone, medial
to and a little behind the ulnar artery.
• Provides sensation to the medial/ulnar palmar aspect of the hand.
Superficial branch of the ulnar nerve (terminal branch) divides into → common and proper
palmar digital nerve
Dorsal branch of the ulnar nerve→ two dorsal digital branches, supplies→ - ulnar side of the little finger.
- Adjacent sides of the little and ring fingers

Compiled by
Nur KM
25. Axillary fossa, triangular and quadrangular axillary space
➢ With the arm abducted, the axilla (axillary fossa) resembles a four-sided pyramid whose apex
is approximately at the center of the clavicle and whose base is represented by the axillary
fascia.
➢ The walls of the axilla are formed by various muscles and their fascia:
Anterior wall of the axilla consists of the pectoralis major and minor and the clavipectoral
fascia.
Posterior wall: this consists of the subscapularis, teres major and latissimus dorsi muscles.
Lateral wall: this is narrow and formed by the intertubercular groove of the humerus.
Medial wall: this is formed by the lateral thoracic wall (ribs 1-4 and associated intercostal
muscles) and the serratus anterior.

Compiled by
Nur KM
The triangular and quadrangular spaces of the axilla and the triceps hiatus
provide important passageway that transmit neurovascular structures from the
anterior to the posterior scapular region:
passageways Structures Borders:
transmitted
Triangular Circumflex scapular • Inferior: the superior border of the teres major;
space artery • Lateral: the long head of the triceps;
• Superior: Teres minor
Quadrangular Posterior circumflex • above/superior: the teres minor (inferior margin).[2]
space humeral artery, • below/inferior: the teres major (superior margin)
axillary nerve • medially: the long head of the triceps brachii (lateral
margin)
• laterally: the surgical neck of the humerus
• anteriorly: the subscapularis
Triceps hiatus Profunda brachii • teres major - superior
artery , radial nerve • long head of the triceps brachii - medial

Compiled by
Nur KM
Compiled by
Nur KM
26. Sectional anatomy of the arm: fascial (osteofibrous) compartments,
muscle groups, vessels and nerves. The cubital fossa
The fascial compartments of arm refers to the specific anatomical term of the compartments
within the upper segment of the upper limb(the arm) of the body. The upper limb is divided
into two segments, the arm and the forearm. Each of these segments is further divided into
two compartments which are formed by deep fascia – tough connective tissue septa
(walls). Each compartment encloses specific muscles and nerves.
The compartments of the arm are the anterior compartment of the arm and the posterior
compartment of the arm, divided by the lateral and the medial intermuscular septa. The
compartments of the forearm are the anterior compartment of the forearm and posterior
compartment of the forearm.
The lateral intermuscular septum extends from the lower part of the crest of the greater
tubercle of the humerus, along the lateral supracondylar ridge, to the lateral epicondyle; it is
blended with the tendon of the deltoid muscle, gives attachment to the triceps brachii behind,
and to the brachialis, brachioradialis, and extensor carpi radialis longus muscles in front. It is
perforated by the radial nerve and profunda branch of the brachial artery.
The medial intermuscular septum, is thicker than the lateral intermuscular septum. It
extends from the lower part of the crest of the lesser tubercle of the humerus below the
teres major, and passes along the medial supracondylar ridge to the medial epicondyle; it is
blended with the tendon of the coracobrachialis, and gives attachment to the triceps brachii
behind and the brachialis in front.
It is perforated by the ulnar nerve, the superior ulnar collateral artery, and the posterior
branch of the inferior ulnar collateral artery.
The anterior compartment of the arm is also known as the flexor compartment of the arm as
its main action is that of flexion. The anterior compartment is one of the two anatomic
compartments of the upper arm, the other being the posterior compartment.
The anterior compartment contains three muscles; the biceps brachii, the brachialis and
the coracobrachialis. These muscles are all innervated by the musculocutaneous nerve
which arises from the fifth, sixth and seventh cervical spinal nerves. The blood supply is
from the brachial artery.
The posterior compartment of the arm is also known as the "extensor compartment", as its
main action is extension.

Compiled by
Nur KM
The muscles of this compartment are the triceps brachii and anconeus muscle and these are
innervated by the radial nerve. Their blood supply is from the profunda brachii.
The triceps brachii is a large muscle containing three heads a lateral, medial, and middle.
The anconeus is a small muscle that stabilizes the elbow joint during movement.
The cubital fossa:

triangular area on the anterior view of the elbow. It’s superior boundary is an imaginary
line extending from the medial to the lateral epicondyle, medial boundary is the
lateral border of the teres major muscle, lateral boundary is the medial border of
brachioradialis muscle. superficial boundary (roof)- skin, superficial fascia containing the
median cubital vein, the lateral cutaneous nerve of the forearm and the medial cutaneous
nerve of the forearm, deep fascia reinforced by the bicipital aponeurosis (a sheet of tendon-
like material that arises from the tendon of the biceps brachii).
Deep boundary (floor)- brachialis and supinator muscles.
Contents:
1-Radial nerve – located between brachioradialis and brachialis.
2-The biceps brachii tendon.
3-The brachial artery, which later bifurcates to the ulnar and radial arteries.

Compiled by
Nur KM
4-The median nerve.
* there are other veins in the area (median cubital vein, basilic and cephalic veins) but these
are usually considered superficial to the cubital fossa and not part of its contents. Nerves of
the upper arm: radial nerve(posterior cutaneous nerve of the arm), ulnar nerve, axillary
nerve(superior lateral cutaneous nerve), musculocutaneous nerve, median nerve, medial
brachial cutaneous nerve, posterior brachial cutaneous nerve, inferior lateral cutaneous
nerve
Arteries: brachial artery, deep brachial artery, superior and inferior ulnar collateral artery,
anterior & posterior circumflex humeral artery, radial collateral a., middle collateral a.
Veins: basilica vein, cephalic vein, brachial veins(2) which become the ulnar and radial veins.

Compiled by
Nur KM
Muscle Origin Insertion Nerve Function
Biceps brachii Short head: coracoid Radial tuberosity Musculocutaneous Flexes arm &
process of radius forearm, supinates
long head: supraglenoid arm
tubercle
Coracobrachialis Coracoid process Medial surface of Musculocutaneous Flexes & adducts arm
humerus
Brachialis Lower anterior surface of Coronoid Musculocutaneous Flexes forearm
humerus process, ulnar
tuberosity
Triceps brachii Long head: infraglenoid Olecranon Radial nerve Extends forearm
tubercle process of ulna
Lateral head: superior to
radial groove
medial head: inferior to
radial groove
Anconeus Lateral epicondyle of Olecranon, Radial nerve Extends forearm
humerus upper posterior
surface of ulna

Compiled by
Nur KM
27. Sectional anatomy of the forearm: fascial (osteofibrous)
compartments, muscle groups, vessels and nerves. Supinator canal.
Anterior compartment:
Fascia: bicipital aponeurosis – common tendons(extensor, flexor) – antebrachial fascia

*didn’t find too much info on the fascial compartment of the forearm other than that^
Muscles:
Level Muscle Nerve
Superficial Pronator teres Median
Superficial Flexor carpi radialis Median
Superficial Palmaris longus Median
Superficial\intermediate Flexor digitorum Median

superficialis
Superficial Flexor carpi ulnaris Ulnar
Deep Flexor digitorum Median(as anterioir interosseus

profundus nerve)-ulnar
Deep Flexor pollicis longus Median(as anterioir interosseus nerve)
Deep Pronator quadratus Median (as anterioir interosseus nerve)
Posterior compartment:
Level Muscle Nerve
Superficial Brachioradialis* Radial

Superficial Extensor carpi radialis longus Radial
Superficial Extensor carpi radialis brevis Radial(deep branch)
Superficial/intermediate Extensor digitorum Radial(as posterior
interrosseus nerve)

Compiled by
Nur KM
Superficial Extensor carpi ulnaris Radial(as posterior
interrosseus nerve)
Superficial/intermediate Extensor digiti minimi Radial(as posterior
interrosseus nerve)
Deep Abductor pollicis longus Radial(as posterior
interrosseus nerve)
Deep Extensor pollicis brevis Radial(as posterior
interrosseus nerve)
Deep Extensor pollicis longus Radial(as posterior
interrosseus nerve)
Deep Extensor indicis Radial(as posterior
interrosseus nerve)
Deep Supinator Radial(deep branch)
*brachioradialis belongs to the extensor group but it’s job is to flex the arm*
Vessels in the forearm:
Nerves: median-> anterior interosseus nerve, radial-> superficial branch, deep branch that
becomes the posterior interosseus nerve, ulnar, lateral cutaneous branch of the
forearm(continuation of musculocutaneous nerve), medial cutaneous branch of the
forearm(from medial cord), posterior cut. branch of the forearm(from radial nerve).
Arteries: Brachial artery , radial artery(+radial recurrent artery) , ulnar artery(+anterior and
posterior ulnar collateral arteries, common interosseus artery-> anterior & posterior
interosseus arteries) .
Veins: Cephalic , basilic, medial cubital vein, radial vein, ulnar vein.
Supinator canal: *didn’t find anything about it other than deep branch(motor and
sensory) of radial nerve goes through there.
Muscle Origin Insertion Nerve Function
Pronator teres Medial epicondyle, Middle of lateral side Median Pronates forearm
coronoid process(ulna) of radius
Flexor carpi radialis Medial epicondyle Base of 2nd & 3rd Median Flexes forearm, flexes and
metacarpals abducts hand

Compiled by
Nur KM
Palmaris longus Medial epicondyle Palmar aponeurosis, Median Flexes forearm,hand
flexor retinaculum
Flexor digitorum Medial condyle, coronoid Middle phalanges of Median Flexes proximal interphalangeal
superficialis process, oblique line of fingers joints and hand
radius
Flexor carpi ulnaris Medial epicondyle, Pisiform, hook of Ulnar Flexes foreaem, flexes and
medial olecranon& hamate & base of 5th adducts hand
posterior border of ulna metacarpal
Flexor digitorum Anteromedial surface of Bases of distal Median Flexes distal interphalangeal
profundus ulna, interosseus phalanges (2-5) joints & hand
& ulnar
membrane
Flexor pollicis Anterior surface of radius, Base of distal median Flexes thumb
longus interosseus membrane phalanx
Pronator quadratus Anterior surface of distal Anterior surface of median Pronates forearm
ulna distal radius
Brachioradialis Lateral supracondylar Styloid process of Radial Flexes forearm

ridge of humerus radius
Extensor carpi Lateral supracondylar Dorsum of base of Radial Extends & abducts hand
radialis longus ridge of humerus
2nd metacarpal
Extensor carpi Lateral epicondyle Dorsum of base of Radial Extends & abducts hand
radialis brevis 3rd metacarpal
Extensor digitorum Lateral epicondyle Extensor expansion Radial extends fingers 2-5 and hand
of fingers 2-5

Compiled by
Nur KM
Extensor digiti Common extensor Extensor expansion Radial Extends 5th digit
minimi tendon, interosseus
of 5th digit
membrane
Extensor carpi Lateral epicondyle, Base of 5th metacarpal Radial Extends & adducts hand
ulnaris posterior surface of ulna
Abductor pollicis Interosseus membrane, Base of 1st metacarpal Radial Abducts & extends thumb
longus posterior surfaces radius
and ulna
Extensor pollicis Inter. Memb., posterior Base of proximal Radial Extends proximal phalanx of
brevis surface of radius phalanx of thumb thumb
Extensor pollicis Inter. Memb., post. Surf. Base of distal phalax Radial Extends distal phalax of thumb
longus Of ulna of thumb
Extensor indicis Post. Surf. Of ulna, inter. Extensor expansion of Radial Extends index
2nd digit
Memb.
Supinator Lateral epicondyle, Anterior, lateral and Radial Supinates forearm

supinator crest(ulna) posterior surfaces of
radius

Compiled by
Nur KM
Compiled by
Nur KM
Compiled by
Nur KM
28.Topography of the volar and dorsal wrist regions: tendons, tendon sheaths,
osteofibrous compartments, vessels and nerves. The carpal tunnel
The anterior (volar) wrist region
・The main structure is the carpal tunnel.
・Tendons of the flexor muscles are covered by tendon sheaths.
・Median nerve: located in the tunnel.
・Ulnar nerve and ulnar artery run medially, NOT entering the carpal tunnel.
・Radial artery and nerve branches run laterally around the distal end of the radius and the
foveola radialis (anatomical snuff-box).
・Minor structure is the Guyon-tunnel, which is more superficial compared to the carpal tunnel.

Compiled by
Nur KM
Structures that pass through the Carpal tunnel:
1. Median nerve
2. Tendons of flexor digitorum profoundus (4)
3. Tendons of flexor digitorum superficialis (4)
4. Flexor policis longus
• Above carpal tunnel the ulnar nerve and palmaris longus pass to the hand though they DO
NOT PASS IN THE TUNNEL.
• Flexor carpi radials pass through the layers of flexor retinaculum and not in the tunnel
itself.
Carpal tunnel syndrome: is a medical condition that leads to the compression of the median
nerve as it travels through the wrist at the carpal tunnel. The main symptoms are pain,
numbness, and tingling, in the thumb, index finger, middle finger, and the thumb side of the
ring fingers ( these are the skin innervation done by the median nerve).
Treatment: surgical intervention to reduce the pressure – cutting the flexor
retinaculum.
Compiled by
Nur KM
The tendons in the ventral region are those of the deep and superficial flexor region :
1. Flexor carpi radialis

2. Palmaris longus
3. Flexor digitorum superficialis
4. Flexor carpi ulnaris
5. Flexor digitorum profundos
6. Flexor policis longus
Palmar aponeurosis :
The central portion occupies the middle of the palm, is triangular in shape, and of great strength
and thickness.
May be defines as the thickened, central portion of the deep palmar fascia
• Insertion/ extension of palmaris longus.

Dorsal wrist compartment:
osteofibrous compartments:
Extensor tendon compartments of the wrist are anatomical tunnels on the back of the
wrist that contain tendons of muscles that extend (as opposed to flex) the wrist and the
digits (fingers and thumb).
The extensor tendons are held in place by the extensor retinaculum. As the tendons travel
over the posterior (back) aspect of the wrist they are enclosed within synovial tendon
sheaths.
Compartment 1
Conducts the abductor pollicis longus and the extensor pollicis brevis tendons. These
tendons form the lateral (thumb side) border of the anatomical snuff box.
Compartment 2
Conducts the extensor carpi radialis longus and extensor extensor carpi radialis brevis
muscle tendons.
Compartment 3
Conducts the extensor pollicis longus tendon that acts to extend the thumb. It forms
the medial (little finger) side of the border of the anatomical snuff box.
Compartment 4
Conducts the extensor digitorum and extensor indicis tendons to the four fingers.
Compartment 5
The extensor digiti minimi tendon travels through this compartment to the little
finger.
Compartment 6
Compiled by
Nur KM
Conducts the extensor carpi ulnaris tendon. This muscle both extends and adducts
(hand flexes toward little finger side) the hand.
Extensor compartments
vessels and nerves:
Median nerve: It gives nerve supply to the thenar muscles and the first two lumbricals, plus it
sends sensory fibers to the skin on the lateral part of the palm and to the sides and distal
portions of the first three digits.
The palmar cutaneous branch of the median nerve branches off before the carpal tunnel. It
innervates the middle of the palm.
Ulnar nerve: The ulnar nerve comes from under the tendon of the flexor carpi ulnaris and
runs through the ulnar tunnel (or tunnel of Guyon), which is between the pisiform and the
hook of the hamate. The ulnar nerve and its dorsal cutaneous, palmar cutaneous, and
superficial branches innervate the medial portion of the wrist and hand and the medial one
and a half digits.
Radial nerve: The radial nerve has two branches in the forearm: The deep branch runs
through the posterior part of the forearm, supplying motor innervation to the extensor
muscles. The superficial branch is a cutaneous nerve that runs under the brachioradialis
muscle and passes through the anatomical snuff box, which is a visible depression formed
near the base of the thumb by the tendons of the extensor pollicis longus and extensor

Compiled by
Nur KM
pollicis brevis muscles. It doesn’t innervate any intrinsic hand muscles; instead, it
innervates the skin and fascia of the lateral portion of the back of the hand and lateral three
and half digits.
Arteries and veins :
Primary arterial supply are the branches of the radial and ulnar arteries :
• Anterior interosseous artery: This artery runs from the ulnar artery anterior to the
interosseous membrane. It pierces the membrane distally to join the dorsal carpal arch.
• Palmar carpal branch: This branch runs from the ulnar artery over the anterior part of the
wrist under the flexor digitorum profundus tendons.
• Dorsal carpal branch: This branch runs from the ulnar artery across the back of the wrist
under the extensor tendons.
• Palmar carpal branch: This branch runs from the radial artery across the anterior wrist
underneath the flexor tendons.
• Dorsal carpal branch: This branch runs from the radial artery across the wrist beneath the
pollicis and extensor radialis tendons.
• These carpal branches of the ulnar arteries join together with the carpal branches of the
radial arteries to form two arches in the wrist:
• Palmar carpal arch: The area where the palmar carpal branches of the radial and ulnar
arteries meet
• Dorsal carpal arch: Formed by the anastomoses of the dorsal carpal branches of the radial
and ulnar arteries.
• The superficial and deep palmar venous arches return blood to the heart and are located
near the arterial arches, They drain into the deep veins of the forearm.
• Dorsal digital veins drain into dorsal metacarpal veins, which form the dorsal venous
network. This blood drains into the cephalic and basilic veins.

Compiled by
Nur KM
Compiled by
Nur KM
Extra Info/Summary
Tendon sheaths
Palmar aponeurosis
・ a triangular-shaped condensation of deep fascia that covers the palm
・ anchored to the skin in distal regions
・ the apex of the triangle is continuous with the palmaris longus tendon (when present)
→ otherwise, it is anchored to the flexor retinaculum
・ from this point, fibres radiate to extensions at the base of the digits that project into each of the index,
middle, ring, and little fingers and, to a lesser extent, the thumb
・ vessels, nerves, and long flexor tendons lie deep to the palmar aponeurosis in the palm

Compiled by
Nur KM
Fibrous digital sheaths
・ after exiting the carpal tunnel, the tendons of the flexor digitorum superficialis and profundus cross the
palm and enter fibrous sheaths on the palmar aspect of the digits
・ these fibrous sheaths:
➢ begin proximally, anterior to the metacarpophalangeal joints, and extend to the distal
phalanges
➢ are formed by fibrous arches and cruciate ligaments, which are attached posteriorly to the
margins of the phalanges and to the palmar ligaments
➢ hold the tendons to the bony plane and prevent the tendons from bowing when the digits are
flexed
・ within each tunnel, the tendons are surrounded by a synovial sheath
・ synovial sheaths of the thumb and little finger are continuous with the sheaths associated with the
tendons in the carpal tunnel
Synovial sheath
・ a layer of a tendon sheath containing:
➢ flexor carpi radialis tendon
➢ flexor pollicis longus tendon
➢ flexor digitorum superficialis and profundus tendons
Superficial fascia
・ superficial fascia of the palmar region is a tough and thick layer which is attached to the skin and to the
deep fascia by means of strong, vertical fibrous bands
・ the dorsal superficial fascia is separated from the deep fascia by distinct fascial cleft
Deep fascia
・ deep fascia of the palmar region is the continuation of the deep forearm fascia which becomes
condiserably stronger at the wrist ・ it splits into 3 layers:
① superficial, which forms: palmar aponeurosis
fasciae of the thenar and hypothenar muscles
② deep, which forms the flexor retinaculum
③ deepest (= palmar interosseous fascia)
Guyon’s tunnel
・ a tissue space between the palmar aponeurosis and the flexor retinaculum
Compiled by
Nur KM
・ contains the ulnar artery and the superficial branch of the ulnar nerve as they enter the palmar region
Osteofibrous compartment
Extensor compartement
・ the extensor tendons of the muscles of the back of the forearm that have insertions into the fingers and
metacarpal bones pass under the posterior annular ligament
・ there are 6 compartments for
these tendons
→ each compartment is lined
by a synovial sheath
① abductor pollicis
longus extensor pollicis
brevis
② extensor carpi radialis
longus extensor carpi
radialis brevis
③ extensor pollicis
longus
④ extensor digitorum extensor indicis
⑤ extensor digiti minimi
⑥ extensor carpi ulnaris
Compartment of palmar aponeurosis

・ palmar aponeurosis covers the whole central area of the palm and fans out to the fingers, too
・ at the thenar and hypothenar eminences the palmar aponeurosis fuses with the fasciae of the thenar and
hypothenar muscles
・ moreover, the aponeurosis turns to the deep and forms the thenar septum, which is attached to the first
metacarpal bone, and hypothenar septum, which is attached to the fifth metacarpus
・ these 2 septa divide the palmar space into 3 compartments:
① thenar-compartment
② central (or mesothenar)-compartment
③ hypothenar-compartment

Compiled by
Nur KM
Compiled by
Nur KM
29. Dorsum of the hand. The anatomical snuffbox (Foveola radialis).
Useful studying material for the hand section:
http://www.orthopaedicmedicineonline.com/downloads/pdf/B9780702031458000727_web.pdf
➢ The anatomical snuffbox (also known as the radial fossa), is a triangular depression
found on the lateral aspect of the dorsum of the hand.
➢ It is located at the level of the carpal bones, and best seen when the thumb is extended.

Compiled by
Nur KM
➢ In the past, this depression was used to hold snuff (ground tobacco) before inhaling via
the nose – hence it was given the name ‘snuffbox’.
➢ As the snuffbox is triangularly shaped, it has three borders, a floor, and a roof:
In supination position( palmar view)
➢ Ulnar (medial) border: Tendon of the extensor pollicis longus.

➢ Radial (lateral) border: Tendons of the abductor pollicis longus and extensor pollicis
brevis.
➢ Proximal border: Styloid process of the radius.
➢ Floor: Carpal bones; scaphoid and trapezium.
➢ Roof: Skin.
➢Deep to the tendons which form the borders of the anatomical snuff box lies the radial
artery, which passes through the anatomical snuffbox on its course from the normal radial
pulse detecting area, to the proximal space in between the first and second metacarpals to
contribute to the superficial and deep palmar arches.
➢ The vein arises within the anatomical snuffbox, while the dorsal cutaneous branch of the
radial nerve can be palpated by stroking along the extensor pollicis longus with the dorsal
aspect of a fingernail.
➢The radius and scaphoid articulate deep to the snuffbox to form the basis of the wrist
joint. In the event of a fall onto an outstretched hand (FOOSH), this is the area through
which the brunt of the force will focus. This results in these two bones being the most often
fractured of the wrist.
➢ In a case where there is localized tenderness within the snuffbox, knowledge of wrist
anatomy leads to the speedy conclusion that the fracture is likely to be of the scaphoid.
➢This is understandable as the scaphoid is a small, oddly shaped bone whose purpose is to
facilitate
mobility rather than confer
stability to the wrist joint.
Dorsum of hand
Skin innervation

Compiled by
Nur KM
Muscles of dorsum of hand:

Compiled by
Nur KM
Dorsal interrosei muscles: four muscles in the back of the hand that act to abduct (spread)
the index, middle, and ring fingers away from hand's midline (ray of middle finger) and assist
in flexion at the metacarpophalangeal joints and extension at the interphalangeal joints of
the
index, middle and ring fingers.
• each muscle arises by two heads from the adjacent sides of the metacarpal bones(
bipenate).
• are inserted into the bases of the proximal phalanges and into the extensor expansion
of the corresponding extensor digitorum tendon.
• the first dorsal interosseous muscle is larger than the others. Between its two heads,
the radial artery passes from the back of the hand into the palm.
• Between the heads of dorsal interossei two, three, and four, a perforating branch from
the deep palmar arch is transmitted.
Origin Insertion
on the radial side of the second metacarpal and on the radial side of the base of the second
first the proximal half of the ulnar side of the first proximal phalanx (index finger) and the extensor
metacarpal expansion
on the radial side of the third metacarpal and the on the radial side of the third proximal phalanx
second
ulnar side of the second metacarpal (the middle finger) and the extensor expansion
on the radial side of the fourth metacarpal and the on the ulnar side of the third proximal phalanx
third
ulnar side of the third metacarpal (the middle finger) and the extensor expansion
on the radial side of the fifth metacarpal and the on the ulnar side of the fourth proximal phalanx
fourth
ulnar side of the fourth metacarpal (the ring finger) and the extensor expansion

Compiled by
Nur KM
30. Palm of the hand: muscles, fasciae, compartments, vessels and nerves.
Muscles:
Called " The intrinsic muscles of hand":
• thenar (thumb):
Abductor pollicis brevis muscle: arises from the tubercles of the scaphoid and
trapezium, and from the flexor retinaculum. From there, its short tendon courses to
the base of the proximal phalanx and the dorsal aponeurosis of the thumb via the
radial sesamoid bone. The abductor pollicis brevis lies quite superficially, underneath
the skin.
The opponens pollicis and abductor pollicis brevis are normally innervated by the
median nerve. The flexor pollicis brevis has two heads a superficial and a deep. The
superficial is innervated by the median nerve and the deep is innervated by the ulnar
nerve. The adductor pollicis is typically innervated by the ulnar nerve.
Adductor pollicis muscle: has two origin surfaces.
1. The transverse head originates from the palmar base of the third metacarpal
bone.
2. The oblique head arises from the capitate bone and the palmar bases of the
second and third metacarpal bones.
The common tendon attaches distally to the proximal phalanx and the
dorsal aponeurosis of the thumb via the ulnar sesamoid bone. The
adductor pollicis is the deepest of all thenar muscles.
Flexor pollicis brevis muscle: has two heads separated by the tendon of the flexor
pollicis longus. The superficial head originates from the flexor retinaculum and the
deep head from both the capitate and trapezium bones. The tendon runs to the base
of the proximal phalanx of the thumb via the radial sesamoid bone.
Opponens pollicis muscle: courses from the tubercle of the trapezium bone and the
flexor retinaculum to the radial surface of the first metacarpal bone. It is mostly
covered by the abductor pollicis brevis
• hypothenar (little finger) muscles:

1. Abductor digiti minimi muscle: ranges from the pisiform bone to the ulnar side of the
proximal phalanx and the dorsal aponeurosis of the little finger.

Compiled by
Nur KM
2. Flexor digiti minimi muscle: has its origin surface at the flexor retinaculum and the
hook of the hamate bone. Distally it inserts at the base of the proximal phalanx of the
little finger. This muscle is often very small or even completely missing.
3. Opponens digiti minimi muscle: arises also from both the flexor retinaculum and the
hook of the hamate bone but inserts more proximally at the ulnar surface of the
fifth metacarpal bone. The opponens digiti minimi is the strongest and deepest of all
hypothenar muscles.
• All hypothenar muscles are supplied by the ulnar nerve (C8-Th1)
• the interossei muscles (four dorsally and three volarly) originating between the
metacarpal bones;
The palmar interossei adduct the fingers; The second, third and fourth palmar interossei
arise from the middle finger side of the metacarpal bone of the index, ring and little
fingers and are inserted into the same side of the extensor expansion and proximal
phalanx of each respective finger.
All the interossei are supplied by the deep branch of the ulnar nerve (T1), but an
occasional variant is for the first dorsal interosseous to be supplied by the median
nerve.
• the lumbrical muscles arising from the deep flexor (and are special because they have
no bony origin) to insert on the dorsal extensor hood mechanism.
They flex the metacarpophalangeal joints and extend the Interphalangeal joints.
It passes posteriorly along the

It originates from the radial side of the
radial side of the index finger to
most radial tendon of the flexor
First unipennate insert on the extensor
digitorum profundus (corresponding to
expansion near the
the index finger).
metacarpophalangeal joint.
It passes posteriorly along the

It originates from the radial side of the
radial side of the middle finger
second most radial tendon of the flexor
Second unipennate and inserts on the extensor
digitorum profundus (which corresponds
expansion near the
to the middle finger).
metacarpophalangeal joint.

Compiled by
Nur KM
One head originates on the radial side of
The muscle passes posteriorly
the flexor digitorum profundus tendon
along the radial side of the ring
Third bipennate corresponding to the ring finger, while
finger to insert on its extensor
the other originates on the ulnar side of
expansion.
the tendon for the middle finger.
One head originates on the radial side of

The muscle passes posteriorly
the flexor digitorum profundus tendon
along the radial side of the little
Fourth bipennate corresponding to the little finger, while
finger to insert on its extensor
the other originates on the ulnar side of
expansion.
the tendon for the ring finger.

Compiled by
Nur KM
lumbricals
Fasciae:
Palmar aponeurosis :
The central portion occupies the middle of the palm, is triangular in shape, and of great
strength and thickness.
Compiled by
Nur KM
May be defines as the thickened, central portion of the deep palmar fascia
• Insertion/ extension of palmaris longus.

Compiled by
Nur KM
Compartments:
• Thenar compartment Contains the thenar muscles.

• Central compartment Contains the flexor tendons and their sheaths, the lumbricals,
the superficial arterial palmar arch, and the digital vessels and nerves.
• Hypothenar compartment Contains the hypothenar muscles.
• Adductor compartment Contains only Adductor Pollicis .
• Interosseous compartments Contains the interossei muscles.
vessels and nerves:

blood supply:
the Ulnar and radial arteries forms two arches in the palm of the hand; the superficial palmar
arch and the deep palmar arch.
Superficial palmar arch:
The superficial palmar arch is formed predominantly by the ulnar artery, with a contribution
from the superficial palmar branch of the radial artery.
Three common palmar digital arteries arise from the arch, proceeding down on the second,
third, and fourth lumbrical muscles, respectively. They each receive a contribution from a
Compiled by
Nur KM
palmar metacarpal artery. Near the level of the metacarpophalangeal joints, each common
palmar digital artery divides into two proper palmar digital arteries.
The deep palmar arch :
The deep palmar arch (deep volar arch) is an arterial network found in the palm. It is usually
formed mainly from the terminal part of the radial artery, with the ulnar arterycontributing via
its deep palmar branch, by an anastomosis. This is in contrast to the superficial palmar arch,
which is formed predominantly by the ulnar artery.
Alongside of it, but running in the opposite direction—toward the radial side of the hand—
is the deep branch of the ulnar nerve.
From the deep palmar arch emerge palmar metacarpal arteries.

Compiled by
Nur KM
Compiled by
Nur KM
Nerves + skin innervation:
the hand is innervated by 3 nerves: the median, ulnar, and radial. Each has sensory and motor
components
The skin of the forearm is innervated medially by the medial antebrachial cutaneous nerve
and laterally by the lateral antebrachial cutaneous nerve
Median nerve:
the palmar cutaneous branch provides sensation at the thenar eminence. As the median nerve
passes through the carpal tunnel, the recurrent motor branch innervates the thenar muscles
(abductor pollicis brevis, opponens pollicis, and superficial head of flexor pollicis brevis). It also
innervates the index and long finger lumbrical muscles. Sensory digital branches provide
sensation to the thumb, index, long, and radial side of the ring finger.

Compiled by
Nur KM
Ulnar nerve:
the palmar cutaneous branch provides sensation at the hypothenar eminence. The dorsal
branch, which branches from the main trunk at the distal forearm, provides sensation to the
ulnar portion of the dorsum of the hand and small finger, and part of the ring finger. At the
hand, the superficial branch forms the digital nerves, which provide sensation at the small
finger and ulnar aspect of the ring finger. The deep motor branch passes through the Guyon
canal in company with the ulnar artery. It innervates the hypothenar muscles (abductor digiti
minimi, opponens digiti minimi, flexor digiti minimi, and palmaris brevis), all interossei, the 2
ulnar lumbricals, the adductor pollicis, and the deep head of the flexor pollicis brevis.

Compiled by
Nur KM
Compiled by
Nur KM

UpperLimbExam Nur

Uploaded by

Document Information

Original Title

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

UpperLimbExam Nur

Uploaded by

Copyright:

Available Formats

GENERAL ANATOMY &

ANATOMY OF UPPER LIMB

Compiled by NUR KM ‫יוני‬

Anatomy First Semester Exam: Upper Limb

Anatomy First Semester Exam: Upper Limb

General features and classification of bones

Anatomy First Semester Exam: Upper Limb

Anatomy First Semester Exam: Upper Limb

Anatomy First Semester Exam: Upper Limb

There are two types of ossification:

→ direct bone formation

・ development of bone from connective tissue

・ mesenchymal cells develop via osteoblasts into

・ osteoclasts develop and collagen fibres

・ membranous bone is remodeled into lamellar bone

Example: skull, facial bones and clavicles develop as

Anatomy First Semester Exam: Upper Limb

→ indirect bone formation

・ depends on the presence of chondroclasts (differentiated connective tissue cells that

・ endochondral ossification begins inside the cartilage, and occurs in epiphysis

・ perichondral ossification originates in perichondrium and confined to diaphysis

Anatomy First Semester Exam: Upper Limb

Bone regeneration by bone fracture bone matrix is destroyed,

adjacent osteocytes are damaged and vessels form blood clot

→ damaged tissue (dead osteocytes, clot) is removed by macrophages

・ endosteum and periosteum start intense proliferation

→ produced tissue surrounds fracture

・ primary bone tissue (bone callus) is formed by intramembranous and endochondral

・ primary bone is gradually replaced by secondary bone tissue

・ there is no scar formation

Anatomy First Semester Exam: Upper Limb

The human skeleton is made up of 206 bones.

1. synchondroses: almost immovable

Anatomy First Semester Exam: Upper Limb

Elbow/Knee Hinge joint

Pivot Rotation of one bone around

Top of the neck

Anatomy First Semester Exam: Upper Limb

Shoulder/Hip Ball and socket joint

Anatomy First Semester Exam: Upper Limb

CMC joint of the thumb Saddle joint

Wrist/MCP & MTP joints Condyloid joint

Gliding Gliding movements

Anatomy First Semester Exam: Upper Limb

Characteristics Skeletal muscle Cardiac muscle Smooth muscle

connective tissue endomysium endomysium perimysium endomysium

innervation innervated by innervated by autonomic innervated by

Anatomy First Semester Exam: Upper Limb

There are three Types of Muscle Tissue:

Anatomy First Semester Exam: Upper Limb

2.1 Intercalated discs (disci intercalares)

Anatomy First Semester Exam: Upper Limb

2. Bundles of muscle fibers

3. Muscle fibre (myofibril) - the functional unit of skeletal muscle

Muscles are separated by fascia

Anatomy First Semester Exam: Upper Limb

• Muscle regeneration is the process by which damaged skeletal, smooth or cardiac

• events required for regeneration

1.Necrosis required for muscle regeneration.

2.Inflammation essential to remove necrotic tissue and initiate myogenesis.

4.Innervation essential for functional recovery of skeletal muscle.

5.myogenesis where new muscle is formed

Anatomy First Semester Exam: Upper Limb