UPPER EXTREMITIES

Axilla

 Pyramidal in shape
 Boundaries of the axilla:
 Anterior (Pectoral)
 Pectoralis major
 Pectoralis minor
 Subclavius
 Posterior (Scapular)
 Subscapular
 Latissimus dorsi
 Teres major
 Medial (Costal)
 2nd and 3rd rib, and intercostal muscles
 Serratus ant. Muscle
 Lateral (Humeral)
 Humerus
 Long head of biceps brachii
 Short head of biceps brachii
 Coracobrachialis
 Apex
 Bounded by 3 bones:
1. Clavicle (Anterior)
2. Scapula (Posterior)
3. 1st rib (medially)
 Base
 Skin
 Subcutaneous fascia
 Axillary fascia

 Contents of the Axilla (** these structures are covered by the Axilla fascia).
 Axilla vein
 Axillary artery
 Bracial plexus

The neurovascular bundle is enclosed in connective tissue sheath, called Axillary Sheath.

ROTATOR CUFF MUSCLES SSTI

 Stabilizes the shoulder joint- anterior, superior and posterior parts

 Weakest on inferior- inprotected by muscles
 Supraspinatus- above
 Infraspinatus - posterior
 Teres minor - posterior
 Subscapularis - anterior

Intrinsic muscles of the shoulder

Muscles Nerve supply Action
Supraspinatus Suprascapular Abductor
Infraspinatus Suprascapular Lateral rotator
Teres Minor Axillary Lateral Rotator
Subscapularis Upper subscapular Medial Rotator
Deltoid axillary ABductor
Teres Major Lower subscapular Medial rotator

Dislocations of the shoulder Joint

 Anterior inferior Dislocation - sudden violence applied to the humerus with the joint fully
abducted tilts the humeral head downward into the inferior weak part
 Posterior dislocation - rare, caused by direct violence to the front joint

Inflammation of the rotator cuff

 Inflammation of the rotator cuff - tendons may become torn or inflamed

 Most commonly affected is the tendon of supraspinatus muscle
 Patients experiences pain anterior of superior to the shoulder joint during abduction

Shoulder Dislocation

 Displacement of the bones of the glenohumeral joint

Shoulder separation
 Clavicle is torn away from the end of the acromion
 Occurs at acromioclavicular joint

Dorsal Scapular spaces

1. Quadrangular space
 Boundaries:
 Above - Teres Minor
 Below - Teres Major
 Medial - Long head of Triceps bracahii
 Lateral - surgical neck of humerus
 Contents:
 AXILLARY nerve (CIRCUMPLEX nerve)
 Posterior circumflex humeral vessels
2. Triangular Space
 Boundaries:
 Above - Teres Minor
 Below- teres Major
 Laterally - Long head of Triceps Brachii
 Content: Circumflex scapular vessels

ARM

Muscles of the arm

1. Anterior compartment = flexor
a) Innervated by Musculocutaneous nerve
b) CORACOBRACHIALIS - adducts/flexes arm
c) BRACHIALIS - main flexor of forearm
d) BICEPS BRACHII - flexes the main supinator of forarm

FOREARM

FLEXOR muscles of the forearm

 Innervated by the MEDIAN NERVE except Flexor Carpi Ulnaris (FCU) and Flexor Digitorum
Profundus (FDP).
 Superficial group
 Pronator ters
 Flexor carpi radialis (FCR)
  Plamaris longus
 FLexor Carpi Ulnaris (FCU) - ulnar nerve
 Intermediate group
 Flexor digitorum superficialis (FDS)

 Deep Group
 FLexor pollicis longus (FPL)
 Flexor Digitorum profundus (FDP) medial - ulnar nerve
 Pronator quadratus

 Medial Epicondyle of Humerus

 Common FLEXOR tendon
 Common origin of:
 Pronator teres -humeral head
 FCR
 Palmaris longus
 FCU - humeral head
 FDS - hemeroulnar head

EXTENSOR MUSCLES OF THE FOREARM

 Innervated by the RADIAL NERVE
 Superficial group
 Brachioradialis - flexor
 Extensor carpi radialis longus (ECRL)
 Extensor carpi radialis brevis (ECRB)
 Extensor Digitorum (ED)
 Extensor digiti minimi (EDM)
 Extensor carpi ulnaris (ECU)
 Anconeus

 Deep group
 Supinator
 Extensor indicis
 Abductor pollicis longus (APL)
 Extensor pollicis longus (EPL)
 Extensor pollicis brevis (EPB)

 Lateral epicondyle of humerus

 Common EXTENSOR tendon
 Common origin of:
 ECRB
 ED
 EDM
 ECU
 Anconeus
 Supinator

EPICONDYLITIS
 Golfer’s elbow (medial epicondylitis)
 Inflammation of the common flexor tendon - medial epicondyle
 Repetitive flexion and pronation of the forearm at the elbow

 Tennis elbow (lateral epicondylitis)

 Inflammation of the common extensor tendon - lateral epicondyle
 Results from forced extensor and flexion of the forearm at the elbow
CUBITAL FOSSA
 Contents (from medial to lateral)
 Median nerve
 Brachial artery
 Biceps brachii tendon
 Radial nerve
 Boundaries
 Lateral - Brachioradialis
 Medial - pronator teres
 Upper -horizontal line connecting the epicondyles of humerus
 Floor -brachialis and supinator

THENAR MUSCLES
 Abductor pollicis brevis
 Flexor pollicis brevis
 Opponens pollicis
 Supplied by the MEDIAN NERVE

INTRINSIC MUSCLES OF HAND

Ulnar nerve
Plamar interossei (3) - ADduct fingers
Dorsal interossei (4) - ABducy fingers

ULNAR nerve - medial Median nerve - lateral

Lumbricales (4) - flex MCP joints

RADIAL nerve
Extensor digitorum

EXTRINSIC MUSCLES OF HAND

 Flexor digitorum superficialis - flexes the PROXIMAL IP joints = MEDIAN NERVE
 Flexor digitorum profundus - DISTAL IP joints = MEDIAN and ULNAR NERVES

HYPOTHENAR MUSCLES
 Abductor digiti minimi
 Flexor digiti minimi
 Opponens digiti minimi
 supplied by ULNAR NERVE

BRACHIAL PLEXUS

 Muscles in the ANTERIOR arm, anterior forearm and hand that act mainly as FLEXORS are
innervated by nerves that contain ANTERIOR DIVISION FIBERS.
 MUSCULOCUTANEOUS, ULNAR, MEDIAN, Lateral and medial pectoral nerves

 Muscles in the POSTERIOR arm and posterior forearm that act mainly as EXTENSORS are
innervated by nerves that contain POSTERIOR DIVISION FIBERS
 AXILLARY, RADIAL, Upper, Middle and Lower Subscapular nerves
 ROOTS:
 Dorsal Scapular (C5) - Rhomboids
 Long Thoracic (C5-C7) - Serratus Anterior

 UPPER TRUNK:
 Nerve to Subclavius (C5-C6)
 Suprascapular (C5 and C6) Supraspinatus, Infraspinaatus

 CORDS:
 Lateral Cord:
 Lateral Pectoral (C5-C7) - Pect. Major
 Musculocutaneous (C5-C7)
 Coracobrachialis
 Biceps brachii
 Brachialis
 Lateral root of MEDIAN (C5, C6, C7)

 Medial Cord:
 Medial Pectoral (C8-T1) - Pect. Major
 Medial cutaneous nerve of arm (C8-T10
 Medial cutaneous nerve of forearm (C8-T1)
 ULNAR (C8 -T1)
 Medial root of MEDIAN (C8 and T1)

 Posterior Cord:
 Upper Subscapular (C5 and C6) - Subscapularis
 Thoracodorsal (C6, C7 and C8) -Latissimus dorsi
 Lower SUbscapular (C5 and C6)- Teres major
 Axillary (C5 and C6) - Deltoid and Teres Minor
 Radial (C5, C6, C7, C8 and T1)

 BRANCHES:
 AXILLARY nerve - Deltoid and Teres minor
 Musculocutaneous nerve - Anterior/Flexor compartment of arm
 Radial nerve - Posterior/ Extensor compartment of arm and forearm
 Median nerve - anterior/ Flexor compartment of forarm except (FCU and FDP are ulnar
nerve)
 ULNAR nerve- intrinsic muscles of hands

Ape hand Median nerve

Carpal tunnel syndrome
Pope’s benediction/papal blessing
Wrist drop Radial nerve
Injury after using ill-fitting crutches
Claw hand Ulnar nerve
Most common elbow dislocation Posterior dislocation
Pulled elbow Nursemaid’s elbow
Dispalced annular ligament
Golfer’s elbow Medial epicondylitis
Tennis elbow Lateral epicondylitis
BLOOD VESSELS - UPPER EXTREMITIES

AXILLARY ARTERY
 Continuation of subclavian artery
 From 1st rib to Teres Major
 Tendon of Pectoralis Minor divides the vessel into 3 parts:
 1st PART
 Superior thoracic artery (Highest Thoracic Artery)
 Supplies muscles of the first two intercostal spaces
 2nd PART
 Thoracoacromial
 Pectoral
 Acromial
 Deltoid
 Clavicular
 Lateral Thoracic
 3rd PART
 Subscapular srtery:
 Largest branch
 Supplies:
 Subscapularis
 Teres major
 Latissimus dorsi
 Branches:
 Thoracodorsal artery (along the thoracodorsal nerve and long
thoracic nerve)
- Supplies the anterior serratus muscle
 Circumflex Scapular Artery
 Ant. Circumflex Humeral
 Post. Circumflex humera
 Continues as:
 Brachial artery
 Radial/ulnar arteries
 Palmar arch

RADIAL ARTERY
 Smaller of the terminal branches of the Brachial artery
 Begins in the Cubital fossa at the level of the NECK OF RADIUS
 Passes downward and laterally beneath the Brachioradialis muscles and resting on the deep
muscles of the forearm
 In the DISTAL part lies on the anterior surface of the Radius and covered only by skin and fascia
 SITE for TAKING THE RADIAL PULSE - tendon of Brachioradialis on its LATERAL side and tendon of
FCR on its MEDIAL SIDE

PALPATION OF THE ARTERIES OF THE UPPER LIMB

 Subclavian Artery- can be palpated in the root of the posterior triangle of the neck as it CROSSES
the FIRST RIB
 Axillary Artery - THIRD PART - can be felt in the axilla as it lies IN FRONT of the Teres major
 Brachial Artery - can be palpated in the arm as IT LIES on the Brachialis and is overlapped from
the lateral side by the Biceps Brachii

VEINS
 Cephalic vein -> Axillary Vein
 Cephalic Vein - posterior to styloid process of radius -> ascends lateral side of Biceps brachii
-> reaches infraclavicular fossa -> drains into Axillary vein
 Basilic Vein +Brachial vein = Axillary Vein
 Choice for central venous catheterization
 Increase in diameter and is in direct line with Axillary vein

 Axillary Vein -> Subclavian -> Brachiocephalic

CLAVICLE
 First bone to begin ossification during fetal development
 Last one to complete ossification at about age 21
 Medial 2/3 convex forward; lateral 1/3 flattened
 JUNCTION- WEAKEST POINT

FRACTURE OF THE CLAVICLE

 Fall on the shoulder or outstretched hand; most commonly fractured bone
 MEDIAL segment displaced downward by gravity and pill of deltoid and pectoralis major
 Cause BRACHIAL PLEXUS INJURY/LOWER TRUNK
 Hemorrhage from SUBCLAVIAN VEIN/ART

HUMERAL FRACTURES
 SURGICAL NECK - Axillary nerve may be affected and the posterior Circumflex artery may be
lacerated
 MidSHAFT/SPIRAL - RADIAL nerve may be affected and the profunda brachial artery may be
lacerated
 SUPRACONDYLAR fracture - MEDIAN nerve may be affected; contractions of Triceps and
Brachialis may shorten the arm
 MEDIAN EPICONDYLE - ULNAR nerve may be affected

Surgical neck of humerus = Axillary nerve

Supracondylar ridge = Median nerve
Radial/Spiral groove = Rdial nerve
Medial epicondyle = Ulnar nerve

FRACTURE LOWER END OF RADIUS

 COLLE/DINNER/SILVER FORK DEFORMITY

 Displacement:
 The distal segment POSTERIORLY and SUPERIORLY
 Distal radial fracture, fragment dorsally placed
 Mechanism of Injury:
 Fall on the outstretched hand

 SMITH FRACTURE
 Displacement:
 ANTERIORLY;
 Distal radial fracture, fragment ventrally placed
 Mechanism of Injury:
 Fall on the back of hand

M. CARPALS (lateral to medial)

 Proximal Row
 Scaphoid/Navicular
 Lunate
 Triquetral
 Pisiform
 Distal row
 Trapezium
 Trapezoid
  Capitate
 Hamate

ANATOMICAL SNUFF BOX

 Lateral-Tendons of EPB and Abd PL
 Medial - tendon of EPL
 Floor- Scaphoid
 Trapezium

** Radial artery; Styloid process of radius; base of 1st metacarpal bone can be palpated

DISLOCATIONS, FRACTURES, ETC.

SCAPHOID FRACTURE
 Common in young adults
 Exhibit pain and tenderness localized over the anatomical snuffbox after a fall on the
outstretched hand

LUNATE DISLOCATION
 LUNATE- most commonly dislocated carpal bone
 Typically dislocated anteriorly
 May cause carpal tunnel syndrome

CARPAL TUNNEL SYNDROME

 Burning pain / “pins and needles” along the distribution of MEDIAN NERVE
 Thickening of the synovial sheaths of the Flexor tendons or arthritic changes of carpal bones

DUPUYTREN CONTRACTURE
 Localized thickening and contracture of the palmar aponeurosis
 Starts- ring finger draws into the palm then little finger; flexion of proximal interphalangeal joint

BENNETT FRACTURE
 A fracture of the base of the first metacarpal bone;
 Thumb is forcefully abducted

BOXER’S FRACTURE
 Oblique fracture of the necks of the fourth or fifth metacarpals;
 Distal segment displaced proximally- shortening of the finger posterorly

DERMATOMES
 Area of the skin supplied by the somatosensory fibers from a single spinal nerve
 Useful in localizing the levels of lesions
 C2 -back of head
 C5- tip of shoulder
 C6-thumb
 C7-middle finger
 C8-small finger
 T4-T5 - nipple
 T10 - umbilicus
 L1 -inguinal
 L4 - knee, medial leg
 L5 - lateral leg ; big toe
 S1 - small toe
 S5 - perineum
TENDON REFLEXES
 BICEPS BRACHII TENDON REFLEX
 C5 AND C6
 Flexion of the elbow joint by tapping the biceps tendon
 TRICEPS TENDON REFLEX
 C6, C7 AND C8
 Extension of the elbow joint by tapping the triceps tendon
 BRACHIORADIALI TENDON REFLEX
 C5, C6 AND C7
 Supination of the radioulnar joints by tapping the insertion of the brachioradialis
tendon

LYMPHATIC DRAINAGE
 Anterior / Pectora LN
 Posterior/Scapular
 Lateral/ Humeral LN
 Central LN
 Apical LN -Thoracic / Right Lymphatic duct