UPPER LIMB

By :

Khadija Abouslima
 Bones of the upper limb
The pectoral girdle
Consists of scapula & clavicle

The clavicle:
- curved long bone
- starts ossification (membranous).
- starts at 5th week of development
- junction between ul & trunk
- lies horizontally in the root of the neck & covers 1st rip
- transmit forces from upper limb to the sternum
- acts as a strut holding arm free from trunk
- medial end is quadrilateral in shape, articulate with sternum forming sterno-clavicular joint
- lateral end is articulate with the acromial process of The scapula forming the acromio clavicular joint
- Body (shaft): - Its medial 2/3 convex forward, but its lateral 1/3 concave forward. - Its undersurface is
rough due to costoclavicular ligament, subclavius muscle and coraco-clavicular ligament. But its upper surface
is smooth

.the freepart of upper consists of 30 bones

Khadija Abouslima
 The scapula:
- Flat bone, triangular in shape.
- has 2 surfaces, 3 borders, 3 angles, 3 processes.
- Superior angle: level with 2nd rib.
- Inferior angle: thick, level with 7th rib
- Lateral angle (head = glenoid cavity or fossa)
lateral angle has supraglenoid and infraglenoid tubercles
- Anterior (costal) surface: subscapular fossa.
- Posterior surface: divided by spine of scapula into suprasinous fossa and infraspinous fossa.
- Lateral (axillary) border: thick.
- Medial (vertebral) border
- Superior border: suprascapular notch, coracoid process
- Spine (spinous process): triangular bony shelf, on the dorsal surface; level with 3rd rib, continues laterally
as acromion.
- Acromion: continuation of spine, forms tip of shoulder.
- Coracoid process: bent like finger, thick and very strong.

The Humerus:
- Long bone, tubular, Consists of: = Upper end = Body (shaft) = Lower end.
-Upper end: Consists of: - Head - 2 necks (anatomical & surgical) - 2 tuberosities (greater & lesser) -
Intertubercular (bicipital) groove. which has medial lip, lateral lip and floor
-Body (shaft): has: - Intertubercular (bicipital) groove - Deltoid tuberosity, Spiral groove, Lateral and
medial supracondylar ridges.
-Lower end: consists of: - Trochlea, Capitulum, Medial epicondyle, Lateral epicondyle, 3 fossae (coronoid,
radial, and olecranon).

Nerves related to the humerus

1- The circumflex (axillary) N. may be injured in fracture of surgical neck.
2- The Radial N. (which lies in the spiral groove) may be injured in fracture of the middle of the shaft.
3- The Ulnar N. may be injured in fracture of the lower end (the medial epicondyle)

Khadija Abouslima
The Ulna:
- The medial bone of forearm. Long bone, tubular.
Consists of: - Upper end (epiphysis), - Body (shaft) -Lower end (epiphysis).
-Body (shaft):
= Upper ¾: Triangular (in cross section):
3 surfces (anterior, posterior, medial).
3 borders (anterior, posterior, interosseous)
= Lower ¼: cylindrical.
-Upper end: presents;
2 curved processes: olecranon and the coronoid
2 concave, articular cavities, the tochlear and radial notches.
-Lower end: Has: - Head - Styloid process.

The Radius:
- The Lateral bone of forearm, Long bone, tubular
-Consists of: - Upper end - Body (shaft) - Lower end.
-Upper end: Consists of: Head, Neck, Radial tuberosity.
-Body (shaft): Triangular has
3 surfaces: anterior, posterior, lateral.
3 borders: anterior, posterior, interosseous
-Lower end: Has 5 surfaces: 1- anterior surface. 2- lateral surface. 3- posterior surface.
4- medial surface. 5- inferior surface.

Khadija Abouslima
Khadija Abouslima

Bones of the hand:

They consist of: carpus, metacarpus & phalanges bones

THE CARPUS BONES

- they are 8 short bones arranged in 2 rows (proximal & distal).

From lateral to medial:
1- the proximal row: scaphoid, lunate, triquetral & pisiform.
2- the distal row: trapezium, trapezoid, capitate & hamate.

METACARPAL BONES

- 5 long bones (one for each finger)

- Long bone, tubular.
Each Consists of: A base (directed proximally), Body (shaft), A head (directed distally)..

PHALANGES

- ALL fingers have 3 phalanges (proximal, middle, and distal) EXCEPT thumb (has 2 ONLY;
proximal and distal)
- Each phalanx (long bone) consists of: A base (directed proximally), Body (shaft), A head
(directed distally).
 Joints of the upper limb
SHOULDER (GLENOHUMERAL) JOINT :.
-Type: multiaxial ball and socket synovial joint.
-Bones that form it:

A- glenoid fossa of the scapula: it is shallow and contains the glenoid labrum which deepens it
and aids in its stability.
B- head of the humerus. due to the very limited interface of the humerus and scapula, it is
the most mobile joint of the human body

- Fibrous Capsule:

- shoulder joint has a loose capsule, which lax inferiorly( at risk of dislocation inferiorly).
A number of bursae related to the capsule aid its mobility, they are:
- Subdeltoid bursa (between the joint capsule and deltoid muscle),
- Subcoracoid bursa: between joint capsule and coracoid process.
- Coracobrachial bursa: between subscapularis muscle and tendon of coracobrachialis muscle.
- Subacromial bursa: between joint capsule and acromion of scapula.
- Subscapular bursa: between joint capsule and tendon of scapular neck
- Supraspinatus bursa: between joint capsule and tendon of supraspinatus muscle
- infraspinatus bursa: between joint capsule and tendon of infraspinatus muscle

- Ligaments:

The shoulder joint is a muscle dependent joint as it lacks strong ligaments. The primary
stabilizers of the shoulder include the biceps brachii and tendons of the rotator cuff.
1- Superior, middle and inferior glenohumeral ligaments: thickened parts of fibrous capsule.
2- Coracohumeral ligament: from root of coracoids to greater tuberosity of humerus.
3- Transverse humeral ligament: transverse ligament bridge over bicipital groove to hold biceps
long head tendon.
4- Coraco-acromial ligament.

- Shoulder joint is unstable joint due to:

A- little fitting between glenoid cavity and head of the humerus.
B-the capsule is lax and weak.
C- inferior aspect is not supported by muscles.
- intracapsular structures of shoulder joint are; synovial membrane, labrum glenoidale and long
tendon of biceps (intracapsular extrasynovial).
Elbow joint:
~ The elbow complex is comprised of three distinct articulations:
– The humeroulnar joint, The humeroradial joint, The proximal radioulnar joint

-Type: hinge uniaxial synovial joint.

-Bones that form it:

-Humeroulnar joint: trochlear notch of the ulna with trochlea of humerus.

-Humeroradial joint: head of the radius with capitulum of the humerus.

- Ligaments of the joint:

- Ulnar collateral ligament: triangular ligament on medial side of joint.

- Radial collateral ligament: triangular ligament on lateral side of joint.

- Movements and Muscles do it:

1-Flexion: by biceps, brachialis, and brachioradialis

2- Extension (145 - 150°).: by Triceps and anconeus muscles.

Carrying angle: When the arm is extended, the bones of the upper arm (humerus) and
forearm (radius and ulna) are not perfectly aligned. The deviation from a straight line
occurs in the direction of the thumb, and is referred to as the "carrying angle"
RADIO-ULNAR JOINTS :
1-Superior Radioulnar joint.
2-Middle Radioulnar articulation.
3-Distal Radioulnar joint

1-Superior Radioulnar joint.

-Type: pivot-joint
- Bones that form it: between the circumference of the head of the radius and the ring formed by
the radial notch of the ulna and the annular ligament.
NB: cavity of superior radioulnar joint is continuous with the cavity of elbow joint.
- Ligaments of the joint:
1- Annular ligament: -it is a strong band of fibers, which encircles the head of the radius, and
retains it in contact with the radial notch of the ulna.
2- Quadrate ligament: a thickened band which extends from the inferior border of the annular
ligament below the radial notch to the neck of the radius.
- Movements : supination and pronation.

2-Middle Radioulnar articulation

- The shafts of the radius and ulna are connected by the Oblique Cord and the Interosseous
Membrane.
-The Interosseous Membrane: it is a broad and thin sheet of fibrous tissue connect the radius and
ulna together and considered as fibrous joint (syndesmosis).
- Direction: descending obliquely downward and medially, from the interosseous crest of the radius
to that of the ulna.
- it is tense in midprone position, relaxed in complete pronation and slightly stretched in complete
supination.
-Function: connect ulna and radius together, increase the surface area for the attachment of the
deep muscles, transmission of the hand weight from radius to the ulna.

3-Distal Radioulnar joint

- Type: it is a pivot synovial joint.

-Bones that form it: head of the ulna and the ulnar notch on the lower end of the radius and the
triangular articular disc.
-Ligaments: The articular surfaces are connected together by :
1- anterior radioulnar ligament 2- posterior radioulnar ligament.
- Movements: supination and pronation.
NB: -The Articular Disk: triangular fibrocartilage placed transversely below the head of the ulna,
separates the ulnar notch from the carpal articular surface.
Supination & pronation
Definition: It’s the rotatory movements that occur in radioulnar joints
Joints at which movements occur: the superior and inferior radio-ulnar joints.
Axis of Supination and pronation: from the center of the head of radius above to the root of styloid
process of ulna below.

Supination:

- radius and ulna lie parallel to each other.

- Palm faced forwards and thumb directed laterally.
- Initiated by brachioradialis (midprone position)
- Its completed by - Biceps - Supinator.

Pronation:

- radius crosses obliquely infront of ulna.

- Palm faced backwards and thumb is directed medially.
- Initiated by brachioradialis.
- its completed by - pronator teres - pronator quadrates

WRIST (RADIOCARPAL) JOINT:

-Type: Condyloid (ellipsoidal) synovial joint.
-Articular surfaces: distally (convex): Scaphoid, Lunate and Triquetral bones.
proximally(concave): distal end of the radius+articular disc below head of ulna.
-Ligaments: - Radial collateral ligament. - Ulnar collateral ligament. - Dorsal radiocarpal ligament.
- Palmar radiocarpal ligament. - Strengthen capsule.

- Movements & Muscles that do it:

1- Flexion: FLex. Carpi Radialis (FCR), Flex. Carpi Ulnaris (FCU), palmaris longus
2- Extension: Ext. Carpi radialis longus (ECR longus), (ECR brevis), (ECU)
3- Adduction: (FCU), (ECU)
4- Abduction: (FCR), (ECR longus), (ECR brevis)
Joints of Hand and Fingers:
MIDCARPAL JOINT

Type: plane synovial joint.

Bones that form it: between proximal and distal rows of carpals.
Movements: as wrist joint.

INTERCARPAL JOINTS

Type: plane synovial

Bones that form it: between the individual carpal bones of the proximal row and the individual
carpal bones of the distal row.
Movements: Allows for gliding movement

CARPOMETATCARPAL JOINT

Type:
- At the thumb: saddle joint →flex/ ext , add/abd and rotation.
- Other 2-5 joints: plane synovial→ gliding – flex/ext.
Ligaments: dorsal and palmer ligaments.

METACARPOPHALAGEAL JOINTS

Type: Condyloid synovial joints (knuckles)

Movements: Flex/ ext.

INTERPHALANGEAL JOINTS (PIP AND DIP)

Type: Hinge synovial Joints.

Movements: Flexion Extension
 Muscles of The Upper Limb
Muscles that Act On Shoulder Girdle
6 muscles primarily involved in shoulder girdle movements.
- These muscles are: Trapezius, Rhomboids, Levator scapula, Serratus anterior and Pectoralis minor.
- All originate on axial skeleton & insert on scapula and/or clavicle, they do not attach to humerus & do
not cause shoulder joint actions.
- Essential in providing dynamic stability of the scapula so it can serve as a relative base of support for
shoulder joint activities such as throwing, batting, & blocking.

Trapezius
Origin:
* Medial ⅓ of superior nuchal line and external occipital protuberance. * Ligamentum nuchae. * 7th
cervical spine. * Spines of all thoracic vertebrae.
Insertion:
- Upper fibers: posterior aspect of lateral 1/3 of clavicle.
- Middle fibers: medial border of the acromion.
- Lower fibers: tubercle of the spine of the scapula.
Action:
a- Elevates shoulder by upper fibers.
b- Retracts scapula by middle fibers
c- Rotates scapula upwards by lower fibers.
N. supply:
- motor: by Spinal accessory (CN XI).
- sensory(proprioception): by branches from C3, C4.
LEVATOR SCAPULAE
Origin: Transverse processes of upper 4 cervical vertebrae.
Insertion: medial border of scapula from superior angle to root of the spine.
N. Supply: nerve to Rhomboides (dorsal scapular n.).
Action: - elevates the scapula. - Rotates scapula downwards.

RHOMBOID MINOR
Origin: Spine of 7th C and 1st Thoracic vertebrae.
Insertion: medial border of scapula opposite the root of spine.
N. Supply: nerve to Rhomboides.
Action: - Retract scapula. -Rotates scapula downwards.

RHOMBOID MAJOR
Origin: Spine of 2nd , 3rd, 4th and 5th Thoracic vertebrae.
Insertion: Back of medial border of scapula from root of spine to inferior angle.
N. Supply: nerve to Rhomboides (Dorsal scapular n).
Action:- Retract scapula -Rotates scapula downwards.

LATISSIMUS DORSI
Origin: -lower 4 ribs, lower 6 thoracic spines, thoraco-lumbar fascia,
back of inferior angle of scapula, outer lip of iliac crest.
Insertion: Floor of bicipital groove of the humerus.
Nerve supply: Thoracodorsal n. {n. to Latissmus dorsi}.
Action: Adducts, extends and medially rotates the arm.
SERRATUS ANTERIOR
Origin: Outer surface of upper 8 ribs anterolaterally.
Insertion: Ventral aspect of medial border of the Scapula.
N. Supply: Long thoracic n. {n. to Serratus anterior}.
Action:
a- entire muscle: protracts scapula and holds it against ribs.
b- Lower 5/8: rotates scapula upwards.

SUPRASPINATUS
Origin: Medial ⅔ of supraspinous fossa of scapula.
Insertion: Top of greater tuberosity of humerus.[S-I-T].
Nerve supply: Suprascapular nerve.
Action: - Shoulder abduction from 0- 15 degrees. - Steady shoulder j.

INFRASPINATUS
Origin: medial ⅔ of infraspinous fossa.
Insertion: Middle of greater tuberosity of humerus.
Nerve supply: Suprascapular n.
Action: - adducts the arm and ratates it laterally. - steady head of humerus in glenoid cavity.

TERES MINOR
Origin: Upper 2/3 of dorsal aspect of lateral border of scapula.
Insertion: Lower part of greater tuberosity of the humerus.
Nerve supply: Axillary n.
Action: -Adduction & lateral rotation of shoulder Joint. - Stabilize Shoulder Joint.
TERES MAJOR
Origin: Lower 1/3 of dorsal aspect of the lateral border of the scapula.
Insertion: Medial lip of bicipital groove.
Nerve supply: Lower subscapular nerve.
Action: Adduction and Medial rotation of shoulder Joint.

SUBSCAPULARIS MUSCLE
Origin: Medial ⅔ of subscapular fossa.
Insertion: Lesser tuberosity of the humerus.
Nerve supply: Upper and lower subscapular n.
Action: adducts arm and rotates it medially, steadies the head of humerus.

Rotator cuff muscles: Supraspinatus, infraspinatus, teres minor and

subscapularis muscles are inserted very close to shoulder joint and
are blended with its capsule so they steady head of the humerus in
glenoid cavity during movements of the shoulder joint.
 DELTOID MUSCLE
Origin:
-anterior fibers: anterior border of lateral ⅓ of clavicle.
-middle fibers: lateral border of acromion.
- posterior fibers: lower lip of spine of scapula.
Insertion: Deltoid tubersity of the humerus.
Nerve supply: Axillary n.
Action:
- Anterior part: flexes and rotate the arm medially.
- Middle fibers: abducts the arm from 15- 90.
- Posterior fibers: extends and rotates the arm laterally
1- Muscles connecting scapula to trunk.
- Trapezius Rhomboid Levator scapulae
Serratus anterior - pectoralis minor.
2- Muscles connecting scapula to hunmerus.
- deltoid. Infraspinatus. supraspinatus. subscapularis. Teres minor.
Teres major. coracobrachialis.
3- Muscles connecting humerus to trunk:
- pectoralis major. - latissmus dorsi.

Pectoralis Major
N.S: med & lat pectoral nerves
Action: steadies clavicle, Adduction &medial rotation

Pectoralis Minor
Insertion: coracoid process
N.S: medial pectoral nerve
Action : protraction, elevation, depression of scapula

Subclavius
N.S: nerve to subclavius
Action: steadies clavicle
 Intermuscular Spaces Related to Shoulder Region
1- QUADRANGULAR SPACE
- Boundaries:
-medial: long head of triceps
-lateral: humeral shaft
-superior: teres minor
-inferior: teres major
- Contents: - axillary nerve. - posterior circumflex humeral A.

. 2-UPPER TRIANGULAR SPACE

'Boundaries:
- inferior: teres major
- lateral: long head of triceps
- superior: lower border of teres minor.
Contents: scapular circumflex artery

'3-LOWER TRIANGULAR SPACE

Boundaries
- superior: teres major
- lateral: shaft of humerus.
- medial: long head of the triceps.
Contents: - profunda brachii artery - radial nerve.
Muscles of The Arm
1- Muscles of the front of arm:
- biceps - coracobrachialis - brachialis.

2- Muscles of the back of arm: - triceps

BICEPS BRACHII
-Origin: By 2 heads,
1- long: from supraglenoid tubercle.
2- short: from the tip of coracoid process.
-Insertion: By 2 insertions;
1- biceps tendon: into the rough posterior part of radial tubersity.
2- bicipital apponeurosis: into deep fascia of medial side of upper part of forearm.
-Action:
a- powerful flexor and supinator of forarm.
b- flexion of arm.
c- long head steadies head of hunmerus in the glenoid cavity.
d- bicipital apponeurosis protect the underlying structures.
-N.S: musculocutanous nerve
CORACO-BRACHIALIS
Origin: from the tip of coracoid process of scapula.
Insertion: Middle of medial surface of humerus.
Action: Weak flexor and adductor of the arm.
N..S: musculocutanous nerve

BRACHIALIS
Origin: Lower ½ of front of humerus.
Insertion: Ulnar tubersity
Action: main flexor of elbow joint.
Nerve supply of Biceps, Coraco-brachialis and Brachialis: by musculocutaneous n.

TRICEPS BRACHII
Origin: By 3 heads,
1- long: from infraglenoid tubercle of scapula.
2- medial: from posterior surface of humerus below the spiral groove.
3-lateral: from posterior surface of humerus above the spiral groove.

Insertion : Posterior part of upper surface of olecranon process of ulna.

Action: --
main extensor of elbow joint by the whole muscle
Long head: weak extensor of shoulder joint.

Nerve supply : radial nerve

 Muscles of the forearm
. Muscles of the front of forearm "flexor group"
Superficial group Deep group
1- Pronator teres 1- Flexor pollicis longus.
2- Flexor Carpi Radialis 2- Flexor Digitorum profundus.
3- Palmaris longus 3- pronator quadrates. -
4- Flexor digitorum superficialis.
5- Flexor Carpi ulnaris.

"Muscles of back of forearm "extensor group"

Superficial group
1- brachioradialis
2- Extensor carpi Radialis longus.
3- Extensor carpi Radialis brevis.
4- Extensor digitorum.
5- Extensor digititi minimi.
6- Extensor carpi ulnaris.
7- Anconeus.
Deep group
1- supinator
2- Abductor Pollicis longus
3- Extensor Pollicis brevis
4- Extensor Pollicis longus.
5- Extensor indicis.

PRONATOR TERES.
. Origin: by 2 heads;
- humeral head: from common flexor origin (CFO).
- ulnar head: from medial border of coronoid process of ulna.
Insertion: Pronator tubersity of radius (middle of its lateral surface).
Nerve supply: Median n.
Action: - flexion of forearm. – pronation.

FLEXOR CARPI RADIALIS

Origin: CFO (from front of medial epicondyle).
Insertion: base of the 2nd, 3rd metacarpal bone.
Nerve supply: Median n.
Action: - flex elbow joint. . - flex and abducts wrist joint.
PALMARIS LONGUS
Origin: - CFO.
Insertion: Apex of palmar apponeurosis
Nerve supply: Median n.
Action: Protect hand (tense the palmar apponeurosis).

FLEXOR DIGITORUM SUPERFICIALIS

Origin: by 2 heads;
- humero-ulnar head: from CFO.
- radial head: from anterior oblique line of the radius.
Insertion: Sides of shaft of middle phalanx of medial 4 fingers.
Nerve supply: Median nerve.
Action: - flex elbow and wrist joints.
- flex proximal and middle phalanges.

FLEXOR CARPI ULNARIS

Origin:
-humeral head: from CFO.
-ulnar head: medial border of olecranon process and upper ⅔ of ulnar apponeurosis.
Insertion: - pisiform bone. - hamate bone. - base of the 5th metacarpal bone.
Nerve supply: ulnar nerve.
. Action: - flex elbow joint. - flex and adducts wrist joint.

FLEXOR POLLICIS LONGUS

Origin: - upper ⅔ of anterior surface of the radius. - interosseous membrane.
Insertion: palmar surface of base of distal phalanx of thumb.
Nerve supply: Anterior interosseous nerve.
Action: - flex wrist joint.
- flex all thumb joints '
FLEXOR DIGITORUM PROFUNDUS
Origin: - upper ¾ of anterior surface of the ulna.
- interosseous membrane. - upper ⅔ of ulnar apponeurosis.
Insertion: palmar surface of base of distal phalanx of medial 4 fingers.
Nerve supply: Anterior interosseous and ulnar nerves.
Action: - flex wrist joint. - flex all joints of medial 4 fingers.

PRONATOR QUADRATUS
Origin: lower ¼ of the front of the ulna.
Insertion: lower ¼ of the front of the radius.
Nerve supply: anterior interosseous nerve.
Action: Pronation.

BRACHIORADIALIS
Origin: upper ⅔ of lateral supracondylar ridge of the humerus.
Insertion: lower end of radius laterally.
Nerve supply: Radial n.
Action: - Initiates supination and pronation
- Flex the forearm in midprone position..

EXTENSOR CARPI RADIALIS LONGUS

Origin: lower ⅓ of lateral supracondylar ridge of humerus.
Insertion: back of base of 2nd metacarpal bone.
Nerve supply: Radial nerve.
Action: -Extension of wrist j. -abduction of the hand.
EXTENSOR CARPI RADIALIS BREVIS -
Origin: common extensor origin (CEO).
Insertion: back of base of 3rd metacarpal bone.
Nerve supply: posterior interosseous nerve.
Action: -Extension of wrist joint. - abduction of the wrist joint.

EXTENSOR DIGITORUM
Origin: CEO (from front of lateral epicondyle).
Insertion: extensor expansion (bases of middle and distal phalanges) of the
medial 4 fingers.
Nerve supply: posterior interosseous nerve.
Action: -Extension of medial 4 fingers joints. -Extension of wrist joint.

EXTENSOR DIGITI MINIMI

Origin: - CEO. - ulnar apponeurosis.
Insertion: extensor expansion of the little finger.
Nerve supply: posterior interosseous nerve.
Action: -Extension of all little finger joints. -Extension of wrist.

EXTENSOR CARPI ULNARIS

Origin: CEO and ulnar apponeurosis (posterior border of the ulna).
Insertion: back of base of 5th metacarpal bone.
Nerve supply: posterior interosseous nerve.
Action: Extension and adduction of wrist joint.
NB: ulnar aponeurosis gives a common origin to the Flexor carpi ulnaris, Extensor carpi
ulnaris, and Flexor digitorum profundus.
 ANCONEUS
Origin: back of lateral epicondyle of the humerus.
Insertion: lateral border of olecranon process and ulnar
apponeurosis.
Nerve supply: Radial nerve.
Action: Helps in extension of elbow joint.
SUPINATOR
Origin: - Superficial fibers: from CEO.
- Deep fibers: from supinator fossa of the ulna.
Insertion: upper ⅓ of lateral surface of the radius.
Nerve supply: posterior interosseous nerve.
Action: - forearm supination. - fixation of radius to ulna ..

ABDUCTOR POLLICIS LONGUS

Origin: middle of the posterior surface of radius and ulnar apponeurosis.
Insertion: lateral side of base of 1st metacarpal bone.
Nerve supply: posterior interosseous nerve.
Action: Abduction and extension of thumb.

EXTENSOR POLLICIS BREVIS KA

Origin: lower ⅓ of the posterior surface of radius and interosseus membrane.

Insertion: back of the base of proximal phalanx of the thumb.
Nerve supply: posterior interosseous nerve.
Action: Extension of proximal phalanx of thumb

EXTENSOR POLLICIS LONGUS

Origin: Ulnar apponeurosis and interosseous membrane.
Insertion: back of base of terminal phalanx of the thumb.
Nerve supply: posterior interosseous nerve.
Action: Extension of all thumb joints.

EXTENSOR INDICIS
Origin: ulnar apponeurosis and interosseous membrane.
Insertion: extensor expansion of the index finger.
Nerve supply: posterior interosseous nerve.
Action: Extension of index finger joints.
 Intrinsic Muscles of the Hand

1- Thenar muscles:
- muscles on palm of the hand just beneath the thumb;
1- Abductor pollicis brevis.
2- Flexor pollicis brevis.
3- Opponens pollicis.
4- Adductor pollicis.
Nerve supply: median nerve except adductor pollicis (by ulnar n.).
Action: movements of the thumb according to the name of each muscle

2- Hypothenar muscles:
muscles on the palm of the hand just beneath the little finger, it includes:
1- Abductor digiti minimi.
2- Flexor digiti minimi.
3- Opponens digiti minimi.
Nerve supply: ulnar nerve.
Action: movements of little finger according to name of each muscle.

Movements of the thumb

Actions of the thumb expressed with respect to the plane of the palm.
- Extension and flexion: parallel to the plane of the palm.
- Abduction and adduction: at right angles to the plane of palm.
- apposition: The ability to touch your thumb and other fingers. .

3- Intermediate muscles:
includes Interossei and Lumbricals;
A- Interossei: includes palmar and dorsal;

Dorsal Interossei Palmar Interossei

- 4 bipennate muscles. - 4 unipennate muscles,1st may be absent.
- middle finger has 2 muscles. - middle finger has no muscles.
Action of Interossei:
— Dorsal Interossei Abducts MP joints of digits 2,3 and4.
— Palmar Interossei Adducts MP joints of digits 2,4 and5

Nerve supply: all interossei are supplied by Ulnar nerve

. B- Lumbricals: 4 small, narrow, elongated muscles

Origin: from the radial side of a flexor digitorum profundus tendons
Insertion: extensor expansion of the medial 4 fingers
Nerve supply: medial 2→ Ulnar nerve, but lateral 2→ Median nerve
Action: Flex MCP joints and extend IP joints (writing position)
 Innervations Of the Upper Limb
Brachial plexus
Formation: formed by anterior primary rami of 5th, 6th, 7th, 8th cervical nerves and 1st
thoracic nerve.
Parts:.
1- Roots: formed of C5, C6, C7, C8 and T1.
2- Trunks:........ upper, middle and lower trunks.
* Upper trunk is formed by C5 and C6.
* Middle trunk is formed by C7.
* Lower trunk is formed by C8 and T1.
3- Divisions: Each trunk is divided into anterior and posterior divisions.
4- Cords: medial, lateral and posterior cords.
* lateral cord: formed by union of anterior divisions of upper+ middle trunks.
* medial cord : formed by anterior division of the lower trunk.
* posterior cord: formed by union of posterior divisions of the 3trunks.
Site of parts: roots and trunks lie in the neck (supraclavicular) while the cords and their
branches lie in axilla (infraclavicular)..
5- Branches:
1- Branches from the roots: 2- Branches from the trunks, from the upper trunk only:
-branch to phrenic nerve. - Suprascapular nerve.
-Nerve to scalenus anterior. - Nerve to subclavius.
-Nerve to rhomboids.
-Nerve to serratus anterior.
3- Branches from the cords are:
Lateral cord: Medial cord: Posterior cord:
- lateral pectoral nerve. - Medial cutaneous nerve of arm. Upper subscapular n.
- lateral root of median n. - Medial cutaneous n. of forearm. Lower subscapular n.
- Musculocutaneous n - Medial pectoral nerve. Nerve to latissmus dorsi.
- Medial root of median n. Circumflex (axillary) n.
- Ulnar nerve. Radial (spiral) nerve.

Injury of brachial plexus:

1- Injury of upper trunk (Erbs paralysis): lead to paralysis of proximal muscles of UL, this deformity
is called porter tip hand.
2- Injury to lower trunk (klumpke paralysis): lead to paralysis of distal muscles of UL, this
deformity is called claw- hand deformity.
 MEDIAN NERVE
Beginning: in the axilla by 2 roots from medial and lateral cords of brachial plexus.
End: in the hand by dividing into medial and lateral branches
- In the arm:
- It enters the arm lateral to the brachial artery.
- at the middle of arm, it crosses in front of the artery, descending medial to it
- In the forearm:
- It enters the forearm between the 2 heads of pronator teres. It descends through the middle
line of forearm
- In the hand:
- It enters the palm of the hand by passing deep to flexor retinaculum in the ‘carpal tunnel'
→its compression → carpal tunnel syndrome.
Branches:
A- In the arm: no branches.
B- In the forearm:
1- Muscular branches: arise near elbow joint to pronator teres, flexor carpi rad., palm.
longus and flexor digit. superf.
2- Anterior interosseous nerve: descends anterior to the interosseous membrane and gives:
# Muscular branches to:
- Flexor pollicis longus - pronator quadrates. - Lateral 1⁄2 of flexor digitorum profundus.
# Articular branches to distal radio-ulnar, wrist and carpal joints.
3- Palmar cutaneous branch: it supplies the lat. 2⁄3 of skin of palm of the hand
4- Articul ar branches: to elbow and the proximal radio-ulnar joints.
C- In the hand:
1- lateral branch: gives;
- Muscular branches: to 3 thenar ms. (flex. Poll. brevis, abd. Poll. brevis and opponens poll.) and
1st lumbrical ms.
- Cutaneous breanches: 3 palmar digital branches.
2- Medial branch. : gives
- Muscular branches: to 2nd lumbrical ms.
- Cutaneous branches: 2 palmar digital branches.
NB: The palmar digital branches of medial and lateral branches supply the skin of lat. 3 1⁄2
fingers.

Injury leads to:

1- Motor affection: loss of action of muscles supplied by the nerve.
2- Sensory loss: of areas supplied by the nerve.
3- Deformity: produced due to lesion of the median nerve called monkey (ape) hand deformity.
 ULNAR NERVE
Beginning: in the axilla from medial cord of brachial plexus
End: in the hand, it divides into superficial and deep terminal branches.
In the arm:
- It descends in the axilla and upper arm medial to the brachial artery.
- In the midarm, it pierces the medial intermuscular septum, to reach the back of medial
epicondyle.
In the forearm:
- It descends in ulnar side of forearm with ulnar artery in its lateral side.
In the hand:
- It enters the palm of the hand by passing superficial to flexor retinaculum in a special canal
called (Guyon's canal).

Branches:
A- In the arm: NO branches
B- In the forearm:
1- Muscular branches: to flexor carpi ulnaris and the medial 1⁄2 of flexor digitorum profundus.
2- Dorsal cutaneous branch: winds backwards and downwards to supply:
- Skin of the medial 1⁄3 of dorsum of the hand.
- Skin of the dorsum of medial 11⁄2 finger.
3- Palmar cutaneous branch: it supplies the skin of the medial 1⁄3 of the palm of the hand.
4- Articular branches: to the elbow joint.
C- In the hand:
1- Superficial terminal branch: gives;
- Muscular branches: to Palmaris brevis muscle.
- Cutaneous branches: 2 palmar digital branches (supply the skin of medial 11⁄2 fingers).
2- Deep terminal branch: gives
- Muscular branches: to
# The 3 hypothenar ms. # medial 2 lumbrical ms.
# All interossei muscles (8) # adductor pllicis ms.
- Articular branches: to wrist and M.P. joints.

Injury leads to :
1- Motor affection: loss of action of muscles supplied by the nerve .
2- Sensory loss: of areas supplied by the nerve.
3- Deformity: produced due to lesion of the ulnar nerve called claw hand deformity.
 RADIAL NERVE
KA

Beginning: in the axilla from posterior cord of brachial plexus.

End: in the cubital fossa, by dividing into:
- Superficial radial nerve: sensory.
- Deep radial nerve (posterior interosseous nerve): motor.
in axilla and upper of the arm:
It descends behind the 3rd part of the axillary artery and the upper part of the brachial
artery.
in the middle of the arm(in the spiral groove):
With the profunda brachii artery it inclines dorsally then spirals obliquely across the back of the
humerus in the spiral groove.
in the lower 1⁄3 of the arm:
On the lateral side of the humerus it pierces the lateral IM septum to enter the anterior
compartment.

Branches:
A- in axilla and upper 1⁄3 of the arm:
1- Muscular branches: to long head and medial head of triceps.
2-Cutaneous branches
- Posterior cutaneous nerve of the arm: supply the skin on the dorsal surface of the arm nearly
as far as the elbow.
B- in the middle1⁄3 of the arm(in the spiral groove):
1- Muscular branches: 2 branches,
- To the lateral head of triceps.
- To the medial head of triceps+ anconeus.
2-Cutaneous branches
- Lower lateral cutaneous nerve of the arm: supplies skin of the lateral part of the lower 1⁄2 of
the arm.
- Posterior cutaneous nerve of the forearm: supply the skin of back of forearm from elbow to the
wrist.
3-Articular branches: to elbow joint.
C- in the lower 1⁄3 of the arm:
3 Muscular branches: to lateral part of brachialis, brachioradialis and extensor carpi radialis longus.

Injury leads to :
1- Motor affection: loss of action of muscles supplied by the nerve (mention them).
2- Sensory: loss of areas supplied by the nerve.
3- Deformity: produced due to lesion of the radial nerve called elbow, wrist and finger drop
deformity according to the level of lesion and the branch injured.
NB: radial nerve also called musculo-spiral and spiral nerve.
 POSTERIOR INTEROSSEOUS NERVE
Beginning: in front of the lateral epicondyle as the deep terminal branch of the radial nerve
End: in the back of the wrist
- It reaches back of the forearm, descends with posterior interosseous vessels→pass deep to
extensor retinaculum to reach back of the wrist

Branches: all are motor to,

- Before piercing supinator:
extensor carpi radialis brevis and supinator
- After piercing supinator:
- extensor digitorum
- extensor pollicis brevis
- extensor digiti minimi
- abductor pollicis longus
- extensor indicis
- extensor pollicis longus
- extensor carpi ulnaris
 SUPERFICIAL RADIAL NERVE
Beginning: in front of the lateral epicondyle as the superficial terminal branch of the radial nerve.
End: in the back of the hand by dividing into 5 dorsal digital nerves
- In the upper 2⁄3 of the forearm: It descends ateral to the radial artery
- In the lower 1⁄3 of the forearm: it curves around the lateral side of the radius to reach
the dorsum of the hand.
Branches: all are sensory to,
- skin of the dorsum of lateral 31⁄2 fingers.
- skin of the lateral 31⁄2 of the dorsum of the hand

MUSCULOCUTANEOUS NERVE
Beginning: from the lateral cord of brachial plexus..
End: in the cubital fossa as the lateral cutaneous nerve of the forearm.
- It leaves the axilla by piercing coracobrachialis muscle.
- It descends downwards and laterally in the arm.
Branches:
1- Muscular branches: 3 branches,
- To coracobrachialis muscle - To biceps - To brachialis.
2- Cutaneous branches
- Lateral cutaneous nerve of the forearm: It supplies the lateral border of the forearm and the
lateral part of the front of the forearm.
3- Articular branches: to elbow joint.

AXILLARY NERVE
Beginning: from the posterior cord of brachial plexus.
End: in the back of the surgical neck by dividing into anterior and posterior branches.

- It turns around the surgical neck of the humerous under cover of deltoid where it ends by
dividing into anterior and posterior branches.

Branches:
1- Muscular branches: 2 branches,
- To deltoid muscle - To teres minor.
2- Cutaneous branches
- Upper lateral cutaneous nerve of the arm: to skin of the upper lateral border of the arm.
3- Articular branches: to shoulder joint.
 Upper Limb Blood and Lymphatic Vessels

Axillary artery

Beginning: As a continuation of subclavian artery at outer border of 1st rib.

End: As brachial artery at the lower border of teres major muscle.
Parts: Divided into 3 parts by pectoralis minor muscle:
# First part: above level of pectoralis minor muscle.
# Second part: deep to (behind) the muscle.
# Third part: below level of the muscle.
Branches:
- 1st part give→ Superior thoracic A
- 2nd part give→
1- Thoraco-acromial A.
2- Lateral thoracic A.
- 3rd part give→
1-Anterior circumflex humeral A.
2- Posterior circumflex humeral A.
3- Subscapular A
 BRACHIAL ARTERY

Beginning: as a continuation of axillary artery at lower border of teres major muscle.

End: by dividing into 2 terminal branches; radial and ulnar at the cubital fossa.
Course:
- Its upper part lies medial to humerus, while its lower part lies on front of it.
- It passes deeply into the cubital fossa where it end. '
NB:
- brachial artery is accompanied by 2 veins (brachial veins = venae comitantes).
- Median nerve: first lateral, crosses in front of the artery (at middle of arm), to become medial to
A. till end.

Branches:
1-Profunda brachii A
- Largest branch, arises high up (at beginning of brachial A.).
-Winds backwards and laterally in spiral groove (with radial n.).
- Divides into 2 branches: ascending and desending branches
# Ascending branch: share in cruciate anastomosis.
# Descending branch: divide into,
- Anterior branch(radial collateral): → shares in anastomosis around elbow.
- Posterior branch: → shares in anastomosis around elbow.
2-Superior ulnar collateral A: accompanies ulnar n.→shares in anastomosis around elbow.
3-Inferior ulnar collateral A: → shares in anastomosis around elbow.
4-Nutrient: To humerus.
5-Muscular To surrounding muscle.
6-Cutaneous. To overlying skin.
7-2 terminal branches: RADIAL and ULNAR.
 ULNAR ARTERY

'Beginning: in the cubital fossa, opposite the neck of radius as the larger terminal branch of
brachial artery.
Course:
1- In upper 1⁄3 of forearm: it descends downward and medially.
2- in the lower 2⁄3 of forearm: it descend vertically downwards along the ulnar side of
forearm.
3- At the wrist: it passes superficial to flexor retinaculum.
4- in the hand: it curves laterally to form the superficial palmar arch.
End: by forming superficial palmar arch in the hand.
Branches:
1- Anterior ulnar recurrent artery (in cubital fossa): to Shares in anastomosis around
medial epicondyle.
2- Posterior ulnar recurrent artery (in cubital fossa): Shares in anastomosis around
medial epicondyle.
3- Common interosseous artery (in cubital fossa): It passes back to the proximal border
of the interosseous membrane, where it divides into:
# anterior interosseous artery: it descends on the anterior aspect of the interos. then it
pierces the membrane posteriory to descend on the dorsum of the carpus to join the post.
carpal arch. Its branches are: - Muscular (to surrounding muscles) and nutrient branches (to
radius and ulna).
# Posterior interosseous artery: it passes at the back of the interos. Membrane it ends by
anastomosing with the terminal part of the anterior interosseous artery and the dorsal carpal
arch, Its branches are:
- Muscular (to surrounding muscles)
- Posterior interosseous recurrent artery: Shares in anastomosis around lateral epicondyle.
4- Anterior carpal artery: at wrist and anastomose with that of radial A.
5- Posterior carpal A.: at the wrist and anastomose with that of radial A.
6- Muscular branches: to muscles on the ulnar side of the forearm.
7- Branches in the hand:
- Deep division (Deep palmar branch): It anastomoses with the radial artery, completing the
deep palmar arch.
-Superficial division: the continuation of ulnar A.: curves laterally to form the superficial palmar
arch.
 RADIAL ARTERY

Beginning: in the cubital fossa, opposite neck of radius as one of the 2 terminal branches of the
brachial A.
Course:
- It descends on the radial side of front of forearm.
- At the wrist, it curves backwards to enter the anatomical snuff-box then 1st dorsal interosseous
space to reach the palm to form the deep palmar arch.
End: by forming deep palmar arch in the hand.
Branches:
A- in the forearm
1- Radial recurrent artery: anastomoses with the descending branch of the profunda
brachii artery infront of lateral epicondyle.
2- Muscular branches: to the muscles on the radial side of the forearm.
3- Anterior carpal A.: anastomose with that of ulnarl A. to form the anterior carpal arch.
4- Superficial palmar A: complete the superficial palmar arch.
B- At the wrist:
-Posterior carpal A.: arise in anatomical snuff-box and anastomose with that of ulnar A. to
form the posterior carpal arch.
-1st dorsal metacarpal A: for adjacent sides of thumb and index fingers.
- Dorsal digital A.: To lateral side of thumb.
C- In the hand:.
- Princeps polllicis A.: give 2 digital branches to supply the thumb.
- Radialis indicis A: supply the lateral side of index finger.
Branches of the deep palmar arch:
- 3 palmar metacarpal A.
- 3 perforating branches.
- Recurrent A.
 Anastomosis of the upper limb
1- Anastomosis around the scapula:
It is an important anastomosis between branches from the 1st part of the subclavian artery and
the 3rd part of the axillary artery.
The following arteries enter in the anastomosis :
A- Arteries from the 1st part of the subclavian
1) suprascapular artery.
2) The deep branch of the transverse cervical artery.
B- Arteries which arise from the 3rd part of the axillary artery
1) subscapular artery.
2) circumflex scapular artery.
C- The posterior intercostals branches of descending thoracic aorta.
Importance of this anastomosis: to allow collateral circulation in case of obstruction of axillary
artery.

2- Anastomosis around surgical neck of humerus (cruciate anastomosis):

formed by the following arteries;
A- Ant. Circumflex humeral A.
B- post. Circumflex humeral A.
C-ascending br. of profunda brachii A.
D- deltoid br. of thoracoacromial A.

3-Anastomosis around elbow:

Anastomosis around lateral epicondyle
- in front of lateral epicondyle: the radial recurrent artery anastomoses with the ant. descending
branch of profunda brachii artery.
- behind lateal epicondyle: Pos. interosseous recurrent artery anastomoses with post. desendig
branch of profunda brachii artery.
Anastomosis around medial epicondyle
- in front of medial epicondyle: ant. br. of inferior ulnar collateral A. anastomose with ant.
ulnar recurrent artery of ulnar artery.
- behind medial epicondyle: superior ulnar collateral A. and the post. br. of inferior ulnar
collateral A. anastomose with pos. ulnar recurrent artery of ulnar artery.

4- Anastomosis between anterior and posterior carpal arteries.

5- Anastomosis between superficial and deep palmar arteries(see
the hand).
 VENOUS DRIANGE OF THE UL

Superficial veins
Site: in superficial fascia (superficial to deep fascia), and includes;
1- Dorsal venous plexus (arch) of hand.
- Lies on dorsum of hand. ......Drained on the lateral side by cephalic vein. .......Drained on the
medial side by basilic vein.
2- Cephalic vein
— The cephalic vein arises from the lateral side of the dorsal venous arch.
— It ascends around the lateral border of the forearm.
— It runs along the lateral border of the biceps in the arm.
— On reaching the interval between the deltoid and pectoralis major muscle, the cephalic vein
pierces the deep fascia and joins the axillary vein.
3- Basilic vein
— It arises from the medial side of the dorsal venous network.
— It ascends on the posterior surface of the forearm.
— Just below the elbow, it inclines forwards to reach the cubital fossa.
— It then ascends medial to the biceps and pierces the deep fascia at the middle of
the arm, it joins venae comitantes of the brachial artery to form the axillary vein.
4- Median cubital vein
— It connects the cephalic vein to the basilic vein.
— It lies superficial to bicipital aponeurosis (separates it from brachial artery).
5- Median vein of the forearm
— It is a small vein that arises in the palm and ascends on the front of forearm.
— It drains into the basic or the median cubital vein.

Deep Veins
Site: deep to deep fascia & accompany main arteries.
1- Venae comitantes: The 2 venae comitantes of the brachial artery join the basilic vein to
form the axillaty vein.
2- Axillary vein:
Beginning: by the union of venae comitantes of brachial artery with basilic vein.
End: it continue as subclavian vein at the outer border of the 1st rib.
Course: ascends along the medial border of the axillary artery in axilla.
Tributaries: it receives:
1- Tributaries that correspond to the branches of axillary artery. 2- Cephalic vein.
 Axillary lymph nodes

Drain lymph vessels from:

1- Entire upper limb
2- lateral part of breast
3- Superficial lymph vessels from thoracoabdominal wall above umbilicus.