Anatomy of the Upper Limb:

Sternoclavicular Joint:
- Articulation between the sternum and clavicle.
- Reinforced by the anterior and posterior sternoclavicular ligaments.
- Allows limited movements: elevation, depression, protraction, and retraction.

Acromioclavicular Joint:
- Connection between the acromion of the scapula and clavicle.
- Supported by the acromioclavicular and coracoclavicular ligaments.
- Permits limited gliding and rotational movements.

Shoulder Joint:
- Also known as the glenohumeral joint.
- Ball-and-socket joint formed by the head of the humerus and the glenoid cavity of the scapula.
- Reinforced by the rotator cuff muscles (supraspinatus, infraspinatus, teres minor,
subscapularis).
- Allows a wide range of motion, including flexion, extension, abduction, adduction, rotation, and
circumduction.

Muscles of the Shoulder:

- Deltoid muscle: Responsible for arm abduction.
- Pectoralis major: Involved in flexion, adduction, and medial rotation.
- Latissimus dorsi: Contributes to extension, adduction, and medial rotation.
- Rotator cuff muscles: Stabilize the shoulder joint.

Movements of the Upper Limb:

- Elevation, depression, protraction, and retraction occur at the sternoclavicular joint.
- Gliding and rotational movements take place at the acromioclavicular joint.
- The shoulder joint enables a wide range of motions.

Clinical Notes:
- Sternoclavicular and acromioclavicular joint injuries can result from trauma.
- Rotator cuff injuries are common, leading to pain and limited shoulder mobility.
- Dislocations of the shoulder joint may damage surrounding structures.
- A thorough understanding of shoulder anatomy is crucial for diagnosing and treating
shoulder-related conditions.

These condensed notes provide a concise overview of the anatomy and clinical significance of
the sternoclavicular joint, acromioclavicular joint, shoulder joint, associated muscles,
movements, and common clinical issues.
Dermatomes and Cutaneous Nerves:

- Dermatomes: C3 to T2.
- Dermatomes vary.
- Supraclavicular nerves supply the shoulder and may refer pain.
- Shoulder pain can be due to issues elsewhere (e.g., spinal cord or pleura).

Superficial Veins:

- Two groups: superficial and deep veins.

- Cephalic and basilic veins are superficial in the arm.
- Used for venipuncture, transfusion, and catheterization.
- Variations in vein paths exist.

Nerve Supply of the Veins:

- Vein walls have sympathetic postganglionic nerve fibers, like arteries.

Superficial Lymph Vessels:

- Drain superficial tissues of the upper arm toward the axilla.

- Follow cephalic and basilic veins.
- Deep lymphatic vessels drain muscles and deep structures to the lateral group of axillary
nodes.
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**Bones of the Forearm:**

- **Radius:** Lateral bone of the forearm, articulating with the humerus and ulna. It has a
bicipital tuberosity, interosseous border, and a styloid process.
- **Ulna:** Medial bone of the forearm, with an olecranon process, trochlear notch, coronoid
process, and a styloid process.

**Bones of the Hand:**

- **Carpal bones:** Eight carpal bones in two rows (proximal and distal).
- **Metacarpal bones:** Five metacarpal bones with bases, shafts, and heads.
- **Phalanges:** Three for each finger (proximal, middle, and distal), except the thumb which
has two.

**Common Fractures in the Hand and Forearm:**

- **Scaphoid bone:** Commonly fractured in young adults, especially after a fall on the
outstretched hand.
- **Lunate bone:** May dislocate in cases of hyperextension of the wrist.
- **Metacarpal fractures:** Can occur due to direct violence, leading to dorsal angulation, like
the "boxer's fracture."
- **Phalangeal fractures:** Often result from direct injury.

**Compartment Syndrome of the Forearm:**

- Deep fascia encloses the forearm, divided into compartments.
- Edema or soft tissue injury can cause pressure on nerves and blood vessels within
compartments, leading to symptoms like altered skin sensation, disproportionate pain, muscle
tenderness, and absent capillary refill.
- Surgical intervention is needed to relieve pressure.

**Interosseous Membrane:** Strong membrane uniting the radius and ulna, transmitting forces
from the radius to the ulna and onward.

**Flexor and Extensor Retinacula:** Bands of deep fascia at the wrist that hold tendons in
position.

**Flexor Retinaculum:** Forms the carpal tunnel, allowing passage of flexor tendons and the
median nerve.
Compression of the median nerve and flexor tendons in the forearm can lead to severe damage
if not promptly addressed.

Volkmann's ischemic contracture may result from compromised blood flow due to arterial spasm
or overtight casts.

Important Structures in the Forearm:

- Palmaris longus muscle

- Ulnar nerve and artery
- Flexor carpi ulnaris muscle
- Anterior interosseous nerve and artery
- Flexor digitorum profundus muscle (ulna)
- Extensor pollicis longus muscle
- Extensor carpi ulnaris muscle
- Extensor digiti minimi muscle
- Posterior interosseous nerve and artery
- Abductor pollicis longus muscle
- Supinator muscle
- Radius
- Extensor digitorum muscle
- Extensor carpi radialis brevis muscle
- Extensor carpi radialis longus muscle
- Brachioradialis muscle
- Flexor pollicis longus muscle
- Pronator teres muscle
- Superficial branch of radial nerve
- Radial artery
- Flexor carpi radialis muscle
- Median nerve
- Flexor digitorum superficialis muscle

The Carpal Tunnel:

- Describes the tunnel formed by the carpal bones and flexor retinaculum, through which long
flexor tendons of the fingers and the median nerve pass.

Carpal Tunnel Syndrome:

- Explains the syndrome caused by compression of the median nerve within the carpal tunnel,
leading to pain, tingling, and weakness in the hand.
1. Compression in the Carpal Tunnel:
○ Compression in the carpal tunnel can be caused by thickening of synovial sheaths or arthritic
changes in carpal bones.
○ Paresthesia does not occur over the thenar eminence due to the palmar cutaneous branch of
the median nerve.
○ Decompressing the tunnel through a longitudinal incision in the flexor retinaculum provides
relief.

2. Dupuytren's Contracture:
○ Thickening and contracture of the palmar aponeurosis, often starting in the ring and little
fingers.
○ Can result in flexion of the metacarpophalangeal and proximal interphalangeal joints.
○ Surgical division of fibrous bands followed by physiotherapy is a common treatment.
○ Collagenase injection can also reduce contractures.

3. Fibrous Flexor Sheaths:

○ Fibrous sheaths cover the anterior surface of fingers, forming tunnels for flexor tendons.
○ Thick over phalanges but thin over joints.

4. Synovial Flexor Sheaths:

○ Synovial sheaths surround flexor tendons, allowing smooth movement.
○ The flexor pollicis longus has its own synovial sheath.
○ The vincula longa and brevia connect tendons to phalanges.

5. Tenosynovitis of the Synovial Sheaths:

○ Infection of a synovial sheath, often due to bacterial introduction.
○ Results in swollen, painful fingers due to pus distention.
○ May lead to tendon rupture or scarring.

6. Insertion of the Long Flexor Tendons:

○ Flexor digitorum superficialis tendons divide, pass around flexor digitorum profundus tendons,
and unite.
○ Flexor digitorum profundus tendons insert into the base of the distal phalanx.
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1. Elbow dislocations, particularly posterior ones, commonly result from falling on an

outstretched hand.

2. Injuries to the ulnar nerve can result from dislocations, fractures, or scar tissue formation near
the elbow joint.

3. Radiological examination of the elbow considers the normal angulation of the lower end of the
humerus (45° forward) and the correct orientation of anatomical landmarks.

Fibrocartilage in the Forearm and Hand:

4. Fibrocartilage is specialized cartilage found in the forearm and hand joints.

5. It is attached by its apex to the lateral side of the base of the styloid process of the ulna and
by its base to the lower border of the ulnar notch of the radius.

6. It acts as a barrier separating the distal radioulnar joint from the wrist and providing a strong
union between the radius and ulna.

7. The synovial membrane lines the joint capsule between the two articular surfaces.

8. Nerve supply includes the anterior interosseous nerve and the deep branch of the radial
nerve.

Movements of Pronation and Supination:

9. Pronation and supination of the forearm involve rotary movement around a vertical axis at the
proximal and distal radioulnar joints.

10. The axis runs through the head of the radius above and the attachment of the apex of the
triangular articular disc below.

11. In pronation, the head of the radius rotates within the annular ligament, while the distal end
of the radius moves forward, and the ulnar notch of the radius moves around the circumference
of the head of the ulna.

12. The movement also involves lateral movement of the distal end of the ulna to keep the hand
in line with the upper limb.

13. Pronation results in the palm facing posteriorly, and the thumb lies on the medial side.
14. Supination is the reverse movement, bringing the hand back to the anatomical position with
the palm facing anteriorly.

15. Supination is more powerful due to the strength of the biceps muscle.

Radioulnar Joint Disease:

16. The proximal radioulnar joint communicates with the elbow joint, while the distal radioulnar
joint does not communicate with the wrist joint.

17. Infections in the elbow joint can involve the proximal radioulnar joint.

18. The strength of the proximal radioulnar joint depends on the integrity of the anular ligament,
which can rupture in cases of anterior dislocation of the head of the radius on the humerus
capitulum.

19. In young children, a sudden jerk on the arm can pull the radial head down through the
anular ligament.
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**Middle Finger Movement:**

- **Metacarpophalangeal Joint Movement:** Middle finger movement occurs at the
metacarpophalangeal joint.
- **Muscles:** Dorsal interossei muscles are responsible for movement.
- **Abduction:** The abductor digiti minimi abducts the little finger.
- **Adduction:** This movement brings the fingers toward the midline of the middle finger and
occurs at the metacarpophalangeal joint.
- **Muscles for Adduction:** Palmar interossei muscles are responsible for finger adduction.
- **Position for Abduction and Adduction:** These movements are possible only in the extended
position of the fingers.

**Flexed Finger Position:**

- In the flexed position, the base of the proximal phalanx contacts the flattened anterior surface
of the metacarpal bone.
- Collateral ligaments hold the bones closely together in this position.

**Extended Finger Position:**

- In the extended position of the metacarpophalangeal joint, the base of the phalanx contacts
the rounded part of the metacarpal head.
- Collateral ligaments are slack in this position.

**Cupping the Hand:**

- Cupped hand formation involves thumb abduction, partial opposition, and slight flexion.
- Thenar eminence is drawn forward, and the hypothenar eminence is also drawn forward with
flexed 4th and 5th metacarpal bones.
- Palmaris brevis muscle contracts, puckering the skin and improving grip.
- Fingers are partially flexed and rotated slightly to enhance the concavity of the cupped hand.

**Making a Fist:**
- To make a fist, flex the metacarpophalangeal and interphalangeal joints of fingers and thumb.
- Long flexor muscles of the fingers and thumb contract.
- Synergic contraction of extensor carpi radialis longus and brevis and extensor carpi ulnaris
extends the wrist joint.

**Clinical Importance of the Hand:**

- The hand is crucial for daily functioning and livelihood.
- Preservation of the thumb is vital for effective hand function.
- Tactile sensation in opposing skin surfaces is crucial for hand function.
- Median nerve palsy is more disabling than ulnar nerve palsy.
- Immobilization of the hand in a functional position is important during treatment.

**Development of the Upper Limb:**

- Limb buds appear during the sixth week of development.
- Arm buds develop before leg buds.
- Limb buds elongate, and spinal nerves grow into them.
- Brachial plexus forms as nerves divide within the limb.

**Common Limb Developmental Anomalies:**

- Amelia: Absence of one or more limbs.
- Ectromelia: Partial absence of a limb.
- Syndactyly: Webbing of fingers.
- Brachydactyly: Shortening or absence of phalanges.
- Floating Thumb: Absent metacarpal with present phalanges.
- Polydactyly: Extra digits.
- Macrodactyly: Enlarged digits, usually diminishes with age.

**Radiographic Anatomy:**
- Radiologic examination focuses on bony structures.
- Magnetic resonance imaging can show soft tissues.
- Specific radiographic images of upper limb parts are mentioned.

**Surface Anatomy:**
- Anterior and posterior surface anatomy of the chest, scapula, axilla, and breast are described.
Radial Nerve:
- Cubital Fossa: Branches into deep and superficial branches.
- Deep Branch: Supplies extensor carpi radialis brevis and supinator in cubital fossa and all
extensor muscles in the posterior forearm.
- Superficial Branch: Sensory, supplies lateral dorsum of the hand and dorsal surface of lateral
3.5 fingers proximal to nail beds.
Injuries to Radial Nerve:
- In the Axilla: Can be injured by crutch pressure, drunkard falling asleep with arm over a chair,
or humeral fractures/dislocations.
- Clinical Findings: Triceps, anconeus, long extensors of wrist paralyzed; wristdrop occurs.
Sensory loss on posterior arm and dorsum of hand.
In the Spiral Groove:
- Injury Site: Common in distal part of groove during humeral shaft fracture or tourniquet
application in slender triceps.
- Clinical Findings: Inability to extend wrist and fingers; sensory loss on dorsum of hand and
fingers.
Deep Branch of Radial Nerve:
- Motor Nerve: Supplies extensor muscles in the posterior forearm.
- Injury: Can occur in radius fractures or radial head dislocation; no wristdrop, no sensory loss.
Superficial Radial Nerve:
- Division: Sensory nerve.
- Injury: Division leads to sensory loss over dorsum of hand and lateral 3.5 fingers.

Musculocutaneous Nerve:
- Protection: Rarely injured due to position beneath biceps brachii.
- High Injury: Paralyzes biceps, coracobrachialis; brachialis functions. Sensory loss on lateral
forearm.

Median Nerve:
- Branches: No branches in axilla or arm.
- Proximal Forearm: Supplies most forearm muscles except flexor carpi ulnaris and medial half
of flexor digitorum profundus.
- Distal Forearm: Gives palmar cutaneous branch (lateral palm) and thenar muscles.
- Clinical Injury: Supracondylar fractures or wounds at the elbow and wrist.
- Motor: Pronator muscles, wrist/finger flexors paralyzed; thumb opposition lost.
- Sensory: Loss on lateral palm and fingers.
- Trophic Changes: Dry skin, nail issues in long-standing cases.
Carpal Tunnel Syndrome:
- Cause: Median nerve compression in carpal tunnel.
- Symptoms: Burning pain, "pins and needles," thenar muscle weakness; relieved by surgery.

Ulnar Nerve:
- Branches: No branches in axilla or arm.
- Proximal Forearm: Supplies flexor carpi ulnaris and medial half of flexor digitorum profundus.
- Distal Forearm: Palmar/posterior cutaneous branches; enters palm, supplies muscles except
thenar and first two lumbricals.
- Clinical Injury: Elbow injuries (fractures), wrist injuries (cuts).
- Motor: Flexor carpi ulnaris, medial flexor profundus paralyzed; clawhand deformity.
- Sensory: Loss on medial hand and fingers.
- Trophic Changes: Dry skin, nail issues in long-standing cases.