Musculoskeletal I module

(Upper limb)
 Scapula

*Site: Post. bone of shoulder girdle, covering post. parts of 2nd to 7th ribs.
*Type: Flat bone.
*General features:
2 Surfaces 3 Borders 3 Angles 3 Processes 3 Tubercles 3 Fossae 3 Notches
*Anterior *Upper(superior); *Lateral (head *Coracoid; *Supraglenoid; *Supraspinous; *Suprascapular;
(ventral) shortest. of scapula); -on lateral end of upper border. above glenoid cavity. above spine. on upper border
(costal). carries glenoid -Has tip, upper & lower surfaces, near its lateral end.
cavity which is medial & lateral borders.
directed laterally
*Medial(vertebral); for articulation with *Spine; *Infraglenoid; *Spinoglenoid;
*Infraspinous;
longest. humerus head -on upper part posterior surface. below glenoid cavity. below spine. between glenoid
(shoulder joint). -Has upper & lower surfaces. N.B.: Both are on cavity & lateral
Anterior, lateral & posterior (crest posterior surface. border of spine.
with upper & lower lips) borders.

*Posterior *Lateral; thickest. *Superior; *Acromion;

(dorsal). *Tubercle on *Subscapular; *Notch for
over 2nd rib. -Continuation of crest of spine.
lower lip of on anterior surface. circumflex
-Has medial (carries facet for
crest of spine scapular A.;
*Inferior; lateral end clavicle forming
th (near spine root). on dorsal aspect
over 7 rib. acromio-clavicular joint) &
of lateral border.
lateral (continuous with spine
at acromial angle) borders.
*Identification of side: *Spine; directed posteriorly *Glenoid cavity; directed laterally.
 Clavicle
*Site: Anterior bone of shoulder girdle, lying horizontally at neck root. It is
subcutaneous, extending from sternum medially to shoulder laterally.

*Type: Long bone, but differs; its lateral 1/3 has no medullary cavity, formed
by membranous ossification & 1st long bone to ossify in embryo, only long
horizontal bone.

*General features: It has 2 ends & a shaft;

Ends Shaft (S-shaped)

*Lateral (acromial) end: *Medial 2/3: *Lateral 1/3:
Flattened, articulate with facet on Cylindrical 4 surfaces; Flattened. 2 surfaces;
medial border acromion forming -Anterior: -Superior: Smooth.
acromio-clavicular joint. Convex forwards. -Inferior: Rough.
*Medial (sternal) end: -Posterior: 2 borders;
Enlarged prismatic, articulates with Concave backwards. -Anterior:
manubrium sterni & 1st costal cartilage -Superior: Smooth. Concave forwards &
forming sterno-clavicular joint. -Inferior: Rough. present deltoid tubercle.
-Posterior:
Convex backwards.
Inferior surface is rough:
*Medially: Rough impression for costo-clavicular ligament.
*Laterally: Conoid tubercle (at junction of medial 2/3 & lateral 1/3) & trapezoid line
(extending from conoid towards lateral end).
*Middle 1/3: Subclavius groove (longitudinal groove) for subclavius insertion.

*Identification of side:
*Medial end; large *Medial 2/3; Convex forwards.
*Superior surface; Smooth.

Humerus
*Site: Bone of arm. *Type: Long bone.

*General features: It has 2 ends & a shaft;

 Ends Shaft
*Upper end: *3 borders;
- Head: A)Anterior:
Forms less than half of a sphere, directed medially to Above continuous with lateral lip of
articulate with glenoid cavity forming shoulder joint. bicipital groove while below smooth.
-2 neck: B)Medial:
A)Anatomical; constriction adjoining head. Lower part is sharp (medial supra-condylar ridge).
B)Surgical; junction of upper end with shaft, commonest C)Lateral:
site of fracture. Lower part is sharp (lateral supra-condylar ridge).
-2 tuberosities:
A)Lesser; directed forwards.
B)Greater; shows 3 impressions (upper, middle & lower)
for muscle attachment.
N.B.: Bicipital (inter-tubercular) groove;
inbetween the 2 tuberosities, having medial & lateral
lips & floor inbetween.
*Lower end: *3 surfaces;
A)Articular part: A)Antero-medial:
Shows a nutrient foramen about its middle.
*Trochlea; pully shaped, articulates with trochlear notch
B)Antero-lateral:
of ulna forming part of elbow joint.
Shows deltoid tuberosity (V-shaped rough
*Capitulum; convex, articulates with radius head forming
area) at its middle.
another part of elbow joint.
C)Posterior:
B)Non-articular part:
Upper part shows faint ridge while middle
*2 epicondyles;
shows spiral (radial) groove.
A)Medial: Larger ,more prominent & subcutaneous.
B)Lateral: Smaller & less prominent.
*3 fossae;
A)Coronoid: Anteriorly & receives coronoid process of
ulna in elbow flexion.
B)Radial: Anteriorly & receives radius head in elbow flexion.
C)Olecranon: Posteriorly & receives olecranon process
of ulna in elbow extension.

*Identification of side: *Head; medially *Coronoid & radial fossae, anteriorly.

*Carrying angle: Med. margin of trochlea projects downwards more than lat.
margin producing angle (15 degrees, more in females) between long axis arm
& long axis supinated forearm, when elbow is extended. It allows forearm to
swing away from pelvis especially in females with wider pelvis. It disappears
when elbow is flexed or forearm is pronated.
 Radius & Ulna

Bone Radius Ulna

*Site Lateral bone of forearm. Medial bone of forearm.
*Type Long bone. Long bone.
*General Ends: *Upper end: Ends: *Upper end:
features -Head: -2 pocesses:
2 ends & a shaft Disc shaped, upper concave surface articulates with capitulum A)Olecranon; above, it projects in olecranon fossa of humerus
forming part of elbow joint & circumference articulates with when elbow is extended.
radial notch of ulna forming superior radio-ulnar joint. B)Coronoid; below, it projects in coronoid fossa of humerus
when elbow is flexed. Its anterior surface shows ulnar tuberosity.
-2 notches:
-Neck: Constricted part below head. A)Trochlear; anteriorly between olecranon & coronoid processes
& receives trochlea forming part of elbow.
B)Radial; on lateral surface of coronoid process, articulating with
circumference of radius head forming superior radio-ulnar joint.
-Radial tuberosity: Anterior smooth & posterior rough. N.B.: Below radial notch, there is supinator fossa which is
bounded posteriorly by supinator crest.

*Lower end: 5 surfaces; *Lower end:

-Head: Rounded, articulating with ulnar notch of radius forming
-Anterior: Smooth & concave.
-Posterior: Rough & convex, showing dorsal tubercle of lister. inferior radio-ulnar joint.
-Lateral: Projects downwards forming styloid process.
-Medial: Shows ulnar notch articulating with head ulna forming
inferior radio-ulnar joint.
-Inferior: Divided into lateral triangular part articulating with -Styloid process: Projection from postero-medial aspect of lower end.
scaphoid & medial quadrangular part articulating with lunate.
 Radius & Ulna

Shaft: *3 borders; Shaft: *3 borders;

A)Anterior: A)Anterior:
Begins from anterior part of radial tuberosity, its upper part is Begins from medial side of ulnar tuberosity.
called anterior oblique line.
B)Posterior: B)Posterior:
Begins from posterior part of radial tuberosity, its upper part is Begins from apex of triangle on olecranon process back.
called posterior oblique line.
C)Medial (interosseous). C)Lateral (interosseous)

*3 surfaces; *3 surfaces;
A)Anterior: Shows a nutrient foramen. A)Anterior: Shows a nutrient foramen.
B)Posterior B)Posterior:Shows oblique ridge (above) & vertical ridge(below).
C)Lateral: Shows pronator tuberosity at its middle. C)Medial

*Anterior surface of lower end; smooth & concave. *Trochlear notch of upper end; anteriorly.
*Identification
*Styloid process of lower end, laterally. *Radial notch of upper end, laterally.
of side
Bones of hand
1-Carpal bones: 8 bones arranged in 2 rows;

A)Proximal raw: 4 (from lateral to medial); Scaphoid (boat like, has a tubercle), lunate (semilunar), triquetral (pyramidal)
& pisiform (sesamoid, smallest of carpal bones).

B)Distal raw: 4 (from lateral to medial); Trapezium (has a crest), trapezoid (smaller than trapezium), capitate (largest of
carpal bones & 1st to ossify) & hamate (has a hook).
N.B.: -Scaphoid is commonest carpal bone to fracture after falling on out-
stretched hand, because it receives blood supply through distal part only & in
case of fracture at its middle , the proximal fragment is deprived from blood
& undergo avascular necrosis.

-Anterior dislocation of lunate is common in wrist injuries, as it is broader on

anterior than posterior aspect.

2-Metacarpal bones: 5 bones numbered from thumb to little finger.

Each has base (articulate with distal carpal bones forming carpo-metacarpal
joint), shaft & head (articulate with proximal phalanx of corresponding finger
forming metacarpo-phalangeal joint).
N.B.: 2 sesamoid bones located anterior to head of 1st metacarpal, are almost constant.

3-Phalanges: 2 in thumb (proximal & distal) & 3 in other fingers

(proximal, middle & distal). Each consists of base, shaft & head.

Pectoral region
*Def.: -Region on upper part of front of chest wall down to the 6th rib
-It includes: Skin, superficial fascia (mammary gland), deep
(pectoral) fascia & muscles.

*Cutaneous nerves of pectoral region:

-Supraclavicular nerves (C3,4): From cervical plexus, supplying skin between

clavicle & 2nd rib including skin on upper 1/2 deltoid.
-Ant. & lat. cutaneous branches of 2nd to 6th intercostals nerves:
Supplies skin below 2nd rib.

Mammary gland
*Shape & type: Modified sweat gland (rudimentary in male). Hemispherical
with circular base, nipple & areola on top & axillary tail.
*Position: *In superficial fascia of pectoral region at front & side of thorax.
Base extends from 2nd rib above to 6th rib below & from sternum medially to
midaxillary line (vertical line in middle of axilla, midway between ant. & post.
axillary folds) laterally . Base lies on deep fascia covering pectoralis major,
serratus ant. & external abdominal oblique aponeurosis.

*Axillary tail; tongue like prolongation from gland supero-lat. quadrant,

which curves around lower border of pectoralis major to pierce axillary fascia
& extends upwards in axilla.
 *Structure:

Internal structure Covering skin (nipple & areola)

th
-Consists of 16-20 lobes arranged in radial manner converging -Nipple: Conical projection over 4
towards nipple. Each lobe collects its secretion in lactiferous duct intercostal space, traversed by lacti-
which widens deep to areola forming lactiferous sinus then it ferous ducts to open on its summit.
narrows again traversing nipple to open on its summit. Nipple position changes after 1st
-Lobes are separated into compartments by fibrous septa childbirth & lactation to a variable
(cooper's ligament) extending from skin to chest wall deep lower level.
fascia. Cancer breast involving these septa may pull on over- -Areola: Circular pigmented skin
lying skin leading to nipple retraction. Also it may obstruct skin (containing sebaceous glands)
lymphatics causing skin oedema which is pitted by hair follicles surrounds nipple base. In virgins it
giving skin orange peel appearance (peau d'orange). is pinkish & becomes darker during
-Breast abscess is drained by radial incision to avoid infection 1st pregnancy & never returns again.
spread to neighbouring lobes & to minimize damage to radially
arranged ducts.
N.B.: The gland is small in children & enlarges in females at puberty due to increase in amount of
superficial fascia & fat. 2nd enlargement is during 1st pregnancy due to glandular tissue proliferation
reaching maximum size during lactation.
*Arterial supply: 1-Lat. thoracic branch of 2nd part axillary A.: To breast lat. 1/2.

2-Lat. branches of post. intercostals AA.: To lat. 1/2 (minimally).

3-Perforating branches of internal mammary A. (in 2nd, 3rd & 4th intercostal
spaces): To med. 1/2.
4-Pectoral branch of acromio-thoracic of 2nd part axillary A.
*Lymphatic drainage: A)Superficial (subareolar) plexus: Under areola, receiving
afferents from the gland & sending efferents to deep lymphatic plexus.

B)Deep plexus: On deep fascia on which gland lies, receiving afferents from
superficial plexus & from gland 4 quadrants, sending efferents as follows;

Lat. quadrants Med. quadrants

*To pectoral group of axillary L.N.s (mainly). *To para-sternal L.N.s, along internal mammary
*To subscapular group of axillary L.N.s (from tail). A. (mainly).
*To infra-clavicular L.N.s, its efferents pierce clavi- *To deep plexus opposite side, crossing
pectoral fascia to drain in apical group of axillary L.N.s middle line (some).
(from upper lat. part). *To sub-diaphragmatic plexus, pierceing
*To para-aortic L.N.s (inside thorax), following abdominal wall (from lower med. part).
post. intercostals AA. (few from lat. part).
N.B.: Axillary L.N.s receive more than 75% of breast lymph while most of remainder enters para-sternal L.Ns.
*Clinical importance: Cancer breast & breast abscess (see internal structure).
Pectoral fascia: Deep fascia covering pectoralis major muscle. It has 2
extensions; axillary fascia (in axilla floor) & clavipectoral fascia.

Clavipectoral fascia

*Site: Stong sheet of deep fascia occupying interval between subclavius &
pectoralis minor. It lies behind upper part of pectoralis major covering axillary
vessels & nerves.

*Attachment:

-Med.: Attached to 1st & 2nd costal cartilages.

-Lat.: Attached to coracoid process, blending with coraco-clavicular ligament.

-Above: Splits enclosing subclavius to become attached to subclavius groove.

-Below: Splits enclosing pectoralis minor, then continues to axillary fascia

(in axilla floor) as suspensory ligament of axilla. Fascia from clavicle to axilla
floor is called axillary septum.

*Structures piercing: -Acromio-thoracic artery -Cephalic vein.

-Lat. pectoral n. -Lymph vessels from infraclavicular to apical group of

axillary lymph nodes.
 Muscles connecting upper limb with thoracic wall

Muscles Muscle Origin Insertion Nerve supply Action

Pectoralis -Clavicular head: By a bilaminar tendon into lat. lip Lat. & med. pectoral -Whole muscle: Adduction & med. rotation
major Ant. surface of med. of bicipital groove of humerus. nerves. of arm (shoulder joint).
1/2 clavicle. N.B: *Clavicular head forms ant. -Clavicular head: Flexion of arm.
-Sternocostal head: lamina, while sternocostal head -Sternocostal head: Extends flexed arm as in
of .Ant. surface sternum. forms post. lamina, both laminae swimming, rowing & climbing.
.Ant. surface upper 6 are continous from below.
costal cartilages. *Twisting of tendon lower border
.External abdominal forms ant. axillary fold.
oblique aponeurosis.
pectoral
Pectoralis Outer surfaces of 3rd, 4th Upper surface & med. border of Med. pectoral nerve. -Protraction & depression of scapula
minor & 5th ribs near their coracoid process of scapula. (shoulder girdle).
costal cartilages. -Accessory muscle of forced inspiration.
region Subclavius Upper surface of 1st Subclavius groove of clavicle. N. to subclavius Steadies clavicle preventing excessive
costochondral junction. (C5, 6) . movements of shoulder girdle.

Muscle Serratus By 8 digitations from outer Ventral surface of med. border N. to serratus ant. -Powerful protraction of scapula.
anterior surfaces of upper 8 ribs, scapula. (long thoracic n. ) -Upward rotation of scapula (abduction
of side midway between angles & -1st digit: Sup. angle. (N. of bell) (C5, 6 & 7). from 90-180) by lower 5 digitations.
costal cartilages. 1st digitation -2nd, 3rd digits: Whole med. border. -Fixation of scapula to chest wall (if the nerve
arises from 1st & 2nd ribs. -Lower 5 digits: Inf. angle. is injured, the muscle will be paralysed & the
of chest med. border will project backwards like a wing in
pushing against resistance; winging of scapula).
-Accessory muscle of forced inspiration.
 Muscles connecting upper limb with vertebral column (muscles of back)

Muscle Origin Insertion Nerve supply Action

Trapezius -Back of skull: Med. 1/3 of sup. V shaped -Motor: -Maintain shoulder level, if paralysed
Superficial nuchal line & external occipital -Upper fibres: Post. border Spinal root of accessory n. shoulder drop.
(Triangular muscle protuberance. of lat. 1/3 clavicle. (11th cranial n.). -Upper fibres: Elevation of scapula.
covering upper -Back of neck: Nuchal ligament -Middle fibres: Med. border -Sensory: C3, 4. -Middle fibres: Retraction of scapula.
1/2 back) & 7th cervical spine. acromion & upper lip of N.B.: It is the only muscle -Upper & lower fibres: Upward
-Back of thorax: All thoracic spines crest of spine scapula. in upper limb which is not rotation of scapula.
& their supraspinous ligaments. -Lower fibres: Tubercle supplied by brachial plexus.
on lower lip of crest of
spine scapula.
Latissimus -Lower 6 thoracic spines. Floor of bicipital groove of N. to latissimus dorsi -Adduction, extension & med.
Dorsi -Thoracolumbar fascia. humerus. ‫(ز‬thoracodorsal n.) rotation of arm (swimming & rowing).
(Triangular muscle -Post. part of outer lip of iliac crest. N.B.:It has triple relation -Acting with pectoralis major,
covering lower -Outer surfaces of lower 4 ribs. with teres major (1st behind, it pulls trunk upwards as in climbing.
layer 1/2 back) -Dorsal aspect of inf. angle then below & finally infront -Accessory muscle of forced expiration
scapula. of teres major) forming as in coughing.
together post. axillary fold.
Levator Transverse processes of upper Dorsal surface of medial -Motor: N. to rhomboids Elevation, retraction & downward
Deep scapulae 4 cervical vertebrae. border scapula above root (dorsal scapular n.) (C5). rotation of scapula.
of spine. -Sensory: C3, 4.
Rhomboideus Nuchal ligament , C7 & T1 spines. Dorsal surface of medial N. to rhomboids Retraction & downward
minor border scapula, opposite to (dorsal scapular n.). rotation of scapula.
root of spine.
layer Rhomboideus T2,3,4,5 spines & their Dorsal surface of medial N. to rhomboids Retraction & downward
major supraspinous ligaments. border scapula, below root (dorsal scapular n.). rotation of scapula.
of spine.
 Muscles of shoulder (scapular) region

Muscle Origin Insertion Nerve supply Action

Supraspinatus Med. 2/3 of supraspinous fossa. Upper impression of Suprascapular n. (C5,6). -Abduction of arm from 0-15.
greater tuberosity of -Stabilization of shoulder joint from above
humerus. (rotator muscle cuff).

Infraspinatus Med. 2/3 of infraspinous fossa. Middle impression of Suprascapular n. (C5,6). -Adduction & lat. rotation of arm.
greater tuberosity of -Stabilization of shoulder joint from behind
humerus. (rotator muscle cuff).

Teres minor Dorsal surface of upper 2/3 Lower impression of Axillary (circumflex) n. (C5,6). -Adduction & lat. rotation of arm.
of lat. border of scapula. greater tuberosity of -Stabilization of shoulder joint from behind
humerus. (rotator muscle cuff).

Teres major Dorsal surface of lower 1/3 of Med. lip of bicipital Lower subscapular n. (C5,6). Adduction, extension & med. rotation of arm.
lat. border of scapula. groove of humerus.

subscapularis Med. 2/3 of subscapular fossa. Lesser tuberosity Upper & lower subscapular -Adduction & med. rotation of arm.
of humerus. nerves (C5,6). -Stabilization of shoulder joint from infront
(rotator muscle cuff).

Deltoid V shaped Deltoid tuberosity Axillary (circumflex) n. (C5,6). -Ant. fibres: Flexion & med. rotation of arm.
(Thick triangular, -Ant. fibres: Ant. border of lat. 1/3 of humerus -Middle fibres: Abduction of arm from 15-90.
forms rounded clavicle. -Post. fibres: Extension & lat. rotation of arm.
contour of shoulder) -Middle fibres: Lat. border acromion N.B.: Deltoid paralysis leads to flat shoulder &
process. loss of abduction from 15-90.
-Post. fibres: Lower lip of crest of
spine scapula.
 Triangles related to latissimus dorsi muscle
Triangle Auscultation triangle Lumbar triangle
Boundaries -Above: Lat. border trapezius. -Med.: Lat. border latissimus.
-Below: Upper border latissimus. -Lat.: Post. border external abdominal oblique.
-Lat.: Lower part med. border of scapula. -Below: Iliac crest.
Floor -Rhomboideus major. Internal abdominal oblique & transversus
-6th & 7th ribs with space inbetween. abdominis.
Clinical Breath sounds are clearly heard here. Might be site of lumbar hernia.
importance
Rotator muscle cuff (musculo-tendinous cuff of shoulder)
Supraspinatus, infraspinatus, teres minor & subscapularis blend with
shoulder joint capsule stabilizing head of humerus in glenoid cavity.

Quadrangular & triangular spaces

Space Quadrangular (lat.) Upper triangular (med.) Lower triangular
Boundaries -Above: Teres minor (behind) -Above: Teres minor (behind) -Above: Teres major.
& subscapularis (infront). & subscapularis (infront). -Med.: Long head triceps.
-Below: Teres major. -Below: Teres major. -Lat.: Lat. head triceps
-Med.: Long head triceps. -Lat.: Long head triceps. & shaft of humerus.
-Lat.: Surgical neck humerus.
Contents -Post. circumflex humeral vessels. Circumflex scapular artery. -Profunda brachii vessels.
-Circumflex nerve. -Radial nerve.
Relations of deltoid muscle
A)Deep relations:
*Bones: Upper end of humerus (lesser & greater tuberosities) & scapula
(supra & infra- glenoid tubercles, coracoid process).
*Muscles: -Subscapularis, supraspinatus, infraspinatus, teres minor & lat.
head of triceps.

-Long heads of biceps & triceps, pectoralis minor, short head

of biceps & coracobrachialis.
*Vessels & nerves: Ant. & post. circumflex humeral vessels & circumflex nerve.

*Bursa: Subacromial bursa separates deltoid from capsule of shoulder joint &
supraspinatus tendon.

B)Deltopectoral groove:
*Site: Just below clavicle, between pectoralis major & deltoid.
*Contents: Deltoid branch of acromio-thoracic artery, cephalic vein (upper
part) & deltopectoral lymph nodes.
 Axilla
*Def., shape & site: Intermuscular space, pyramidal shaped (having apex, base & 4
walls), lying between upper part of side of chest wall & upper part of med. side arm.

*Boundaries: a)Apex (cervicoaxillary canal): - Directed upwards &

medially, connecting axilla with root of neck, transmitting axillary vessels &
nerves from neck to axilla.
-Triangular, bounded by: back of clavicle (ant.), upper border of scapula (post.)
& outer border of 1st rib (med.).

b)Base (floor): -Directed downwards & laterally

-Formed of skin (containing hair, sweat & sebaceous glands), superficial fascia
& deep (axillary) fascia (receiving attachment of suspensory ligament of axilla).

c)Ant. (pectoral) wall: 2 layers: 1-Superficial layer: Pectoralis major.

2-Deep layer (axillary septum): Subclavius, clavipectoral fascia, pectoralis

minor & suspensory ligament of axilla (attached to axillary fascia).
Ant. axillary fold: Lower border ant. wall; twisted lower border of pectoralis major.

d)Post. (subscapular) wall: Subscapularis, teres major & latissimus dorsi.

Post. axillary fold: lower border post. wall; teres major & latissimus dorsi.

N.B.: Post. fold lies at a slightly lower level than ant. fold because ant wall is
slightly shorter than post. wall.

e)Med. (costal) wall: Upper 4 ribs & their intercostal muscles, covered by
upper part of serratus ant.

f)Lat. (humeral) wall: Bicipital groove, hidden by short head biceps &
coracobrachialis (narrowest wall).
*Contents: 1)Axillary vessels: -Axillary artery & its branches.
-Axillary vein & its tributaries.
2)Nerves: -Brachial plexus (cords & branches) -Long thoracic N.

-Intercostobrachial N. (lat. cutaneous branch of 2nd thoracic N.)

3)Axillary lymph nodes: 5 groups (ant., post. lat., central & apical).
4)Special contents: - Mammary gland tail -Axillary fat & loose areolar tissue.

N.B.: Axillary vessels & brachial plexus run from apex to base of axilla, along
lat. wall & nearer to ant. wall.
 Brachial plexus
*Def.: Net work of spinal nerves , lying partly in neck & partly in axilla, supplying
muscles & skin of upper limb.

*Formation (Stages) & site: A-Roots: They lie in neck. Formed of ant. rami of
lower 4 cervical (C5,6,7,8) & 1st thoracic (T1) nerves..
B-Trunks (3): They lie in neck above clavicle;
Uppertrunk: C5,6. -Middle trunk: C7 -lower trunk: C8 & T1.
C-Divisions: They lie behind clavicle (at apex of axilla). Each trunk divides into
ant. & post. divisions..

D-Cords (3): They lie in axilla; -Post. cord: Union of post. divisions of the 3 trunks.
-Lat. cord: Union of ant. divisions of upper & middle trunks
-Med. cord: Ant. division of lower trunk.
E-Branches:
Branches from roots
1-N. to rhomboideus
(dorsal scapular n.) (C5):
It descends on dorsal
aspect of med. border
scapula supplying levator
scapulae, rhomboideus
minor & major muscles.
2-N. to serratus ant.
(long thoracic N.) (N. of
Bell) (C5,6,7): It descends
on serratus ant. in mid-
axillary line supplying it.
Branches from trunks
(upper trunk only)
1-N. to subclavius (C5,6):
Descends infront of brachial
plexus supplying subclavius.
2-Suprascapular N. (C5,6):
*It enters suprascapular
foramen to reach supra-
spinous fossa, supplying
supraspinatus.
*It passes through
spinoglenoid notch to reach
infraspinous fossa, supplying
infraspinatus. It also supplies
shoulder joint.
Branches from cords
(They lie in axilla)
-Lat. cord (C5,6,7):
1-Lat. pectoral n.: It pierces clavipectoral fascia &
ends by supplying pectoralis major.
2-Lat. root of median n.
3-Musculocutaneous n. (largest branch).
-Med. cord (all C8 & T1, except ulnar n. C7,8 &T1):
1-Med. pectoral n.: It pierces & supplies pectoralis
minor to end by supplying pectoralis major.
2-Med. root of median n.
3-Med. cut. n. arm: To skin on lower part of med. side arm.
4- Med. cut. n. forearm: Descends med. to axillary
& brachial arteries, then iierces deep fascia at middle arm
becoming superficial. It divides into ant. & post. branches,
supplying skin on med. side forearm to wrist.
5-Ulnar n. (largest branch).
-Post. cord:
1-Upper subscapular n.(C5,6):To upper part
subscapularis.
2-lower subscapular n.(C5,6):To lower part
subscapularis & teres major.
3-N. to latissimus dorsi (thoracodorsal n.)
(C6,7,8): Descends till inf. angle scapula to supply
latissimus dorsi.
4-Axillary (circumflex) n. (C5,6) (smaller terminal).
5-Radial n. (C5,6,7,8 & T1) (larger terminal).
N.B.: Branches of lat. & med. cords supply flexor side while
branches of post. cord supply extensor side of upper limb.
 Axillary ( circumflex) n.

Origin & root In axilla, as smaller of the 2 terminal branches of post. cord of brachial plexus (C5,6).
value
Course & end -In axilla, it lies between 3rd part axillary a. & subscapularis.
-It passes backwards below capsule of shoulder joint through quadrangular space,
accompanied by post. circumflex humeral a.,to reach back of surgical neck humerus.
Branches *Articular: To shoulder joint.
*Muscular: .Ant. branch: Continues its course round surgical neck, ends by
supplying deltoid.
.Post. branch: Supplies teres minor, then pierces deep fascia to become
upper lat. cut. n. of arm which supplies skin on lower 1/2 of deltoid.
Injury Causes: Injury is frequent: 1-Badly adjusted axillary crutch.
2-Downwards dislocation shoulder joint 3-Fracture surgical neck humerus.
Results:
Motor loss, disability & deformity:
-Paralysis of deltoid & teres minor.
-Loss of arm abduction from 15-90 degrees.
-Flat shoulder (loss of rounded contour) due to deltoid wasting.
Sensory loss: Loss of sensation on lower 1/2 of deltoid.
Axillary artery
*Beginning: At outer border 1st rib as continuation of subclavian A.
*Course: It enters axilla through apex & descends along its lateral wall.
*End: At lower border teres major by becoming brachial A.

*Parts: Pectoralis minor divides it into 3 parts;

1st: Above muscle 2nd: Deep to muscle 3rd: Below muscle (longest).
*Relations:
Part 1st 2nd 3rd
Ant. Clavicular head pectoralis major. - Pectoralis major. -Med. root of median N
-Clavipectoral fascia. -Pectoralis minor.

Post. -1st digitation serratus ant. - Subscapularis. - Subscapularis.

-N. to serratus ant. -Post. cord brachial plexus. -Post. cord branches.
-Med. cord brachial plexus

Med. - Axillary V. - Axillary V. - Axillary V.

-Med. cord brachial plexus. -Med.cord branches.
Lat. - Lat. & post. cords brachial plexus. - Lat. cord brachial plexus. - Lat. cord branches.

*Branches:
 1st part *Sup. thoracic A.: Runs along pectoralis minor upper border to supply thoracic wall upper part, pectoral muscles & breast.
branches
2nd part *Lat. thoracic A.: Runs along pectoralis minor lower border reaching chest side to supply serratus ant. In female it gives lat. mammary
branches branches supplying gland lat. part.
*Acromio-thoracic A.: Pierces clavipectoral fascia & divides into 4 branches: -Acromial : To acromion (anastomosis around shoulder).
-Pectoral: Supplies pectoral muscles & breast -Clavicular: Supplies clavicle & subclavius -Deltoid: Supplies pectoralis major & deltoid
(anastomosis around shoulder).
3rd part *Ant. circumflex humeral A.: Runs infront of surgical neck, giving ascending branch to shoulder (anastomosis around shoulder) &
branches ending by anastomosis with post. circumflex humeral a. (anastomosis around surgical neck).
*Post. circumflex humeral A.: Runs backwards reaching surgical neck back, giving descending branch anastomosing with ascending
branch of profunda brachii a. & finally anastomoses with ant. circumflex humeral a. (anastomosis around surgical neck).
*Subscapular A. (largest branch): Runs along subscapularis lower border & gives circumflex scapular a., then continues as thoraco-
dorsal a. reaching & supplying latissimus dorsi (anastomosis around scapula).

*Anastomosis shared by axillary a.:

Anastomosis around Anastomosis around surgical neck Anastomosis around scapula
shoulder joint (Cruciate anastomosis)
st st
*1 part subclavian a.: *1 part subclavian a.: *1st part subclavian a.(thyro-cervical trunk):
Suprascapular a. Descending branch of suprascapular a. -Suprascapular a. -Deep branch pf transverse cervical a.
nd
*2 part axillary a.: *3rd part axillary a.: rd
*3 part axillary a.:
Acromial & deltoid branches -Ant. circumflex humeral a. -Subscapular a. -Circumflex scapular a.
of acromio-thoracic a. -Post. circumflex humeral a. with its *Descending aorta: Post. intercostals aa.
*3rd part axillary a.: ascending & descending branches. Clinical importance: This anastomosis can bypass any obstruction between
Ascending branch of ant. *Brachial a.: 1st part subclavian a. & 3rd part axillary a. maintaining blood flow to upper limb.
circumflex humeral a. Ascending branch of profunda brachii a. Also it maintains blood flow to body lower half in case of aortic coarctation.
 Axillary vein
*Beginning: At lower border teres major by union of basilic V. & venae
comitantes of brachial A.
*Course: It descends on med. side of axillary A.
*End: At outer border 1st rib (apex axilla) by becoming subclavian V.
*Tributaries: Correspond to axillary A. branches, cephalic V., basilic V. & venae
comitantes of brachial A.

Deep fascia of arm (brachial fascia)

It sends 2 septa (lat. & med.) among arm muscles, separating flexor from
extensor muscles & providing additional surfaces for muscles attachment.

Septum Lat. intermuscular septum Med. intermuscular septum

Attachment Lat. border, lat. supra-condylar ridge Med. border, med. supra-condylar ridge &
& lat. epicondyle. med. epicondyle.

Muscles of front arm (Flexor group)

Muscle Origin Insertion N. supply Action
Biceps brachii -Long head: -Bicipital tendon: Musculo- -Flexion of elbow joint.
Supraglenoid tubercle Radial tuberosity cutaneous N. -Powerful forearm
by a long tendon (post. rough part). supination (when
(intracapsular, -Bicipital elbow is flexed).
extrasynovial). aponeurosis: -Flexion of shoulder
It leaves capsule to From bicipital tendon, joint (short head).
descend in bicipital descending med. to -Stabilization of
groove where it is blend with deep fascia shoulder joint from
retained by transverse in cubital fossa roof. above (long head).
humeral ligament.
-Short head: Tip of
coracoid process, in
common with coraco-
brachialis.
Coraco- Tip of coracoid Middle of med. border Musculo- Flexion & adduction
brachialis process, in common humerus. cutaneous N. of arm.
with short head biceps.
Brachialis -Front of lower 1/2 Ant. surface of coronoid Musculo- Powerful elbow
shaft of humerus. process & ulnar tuberosity. cutaneous & flexion.
-Front of med. & lat. radial (small
intermuscular septa. lat. part) NN.
 Musculocutaneous n.
Origin & In axilla, from lat. cord of brachial plexus (C5,6,7).
root value
Course -It descends lat. to 3rd part axillary a. & upper part brachial a.
& end -It pierces coracobrachialis , then it passes between biceps & brachialis.
-One inch above elbow, lat. to biceps tendon, it pierces deep fascia to become lat. cut. n. forearm.
Branches -Muscular: Biceps, brachialis (except small lat. part) & coracobrachialis.
-Sensory: Lat. cut. n. forearm: Continuation of musculocutaneous n., it divides into ant. &
post. branches, supplying skin on lat. side forearm to wrist & skin on upper part of thumb ball.
Brachial artery
*Beginning: At lower border teres major as continuation of axillary A.
*Course: Its upper part descends on med. side arm then its lower part descends infront
of arm passing midway between med. & lat. epicondyles to enter cubital fossa.

*End: 1 cm below elbow at level of radius neck by dividing into radial & ulnar
terminal branches.
*Relations:

Ant. Post. Med. Lat.

Skin & fascia (in upper part), Long & med. Ulnar N. & basilic V. (in Median N., biceps & coraco-
median N. cross it from lat. to heads triceps, upper part), median N. brachialis (in upper part),
med. (in middle part) & bicipitial coracobrachialis (in lower part). biceps tendon (in lower part).
aponeurosis (in lower part). & brachialis
N.B.: 1-Brachial A. is superficial throughout its course (covered by skin & fascia), which makes it easily accessible
2-Median N. has triple relation to brachial a. (lat., then crosses it at level of coracobrachilis insertion &
finally becomes med.)

*Branches:
 Branch Profunda brachii Nutrient Sup. ulnar collateral Inf. ulnar collateral Radial & ulnar
*Origin: Largest & highest branch, from postero-med. Arises at middle Arises at middle of Arises 5 cm above elbow,
aspect of brachial A. near its beginning. of arm & enters arm, pierces med. divides into;
*Course: Accompanied by radial N. it passes backwards nutrient foramen septum with ulnar
through lower triangular space, reaching spiral groove near coraco- N., reaching back *Ant. branch; reaching
where it passes between lat. & med. heads triceps. brachialis of med. epicondyle
front of med. epicondyle
*Branches: insertion. anastomosing with
post. ulnar anastomosing with ant.
1-Muscular : To triceps 2-Nutrient : To humerus. ulnar recurrent A.
recurrent A.
3-Ascending: Anastomoses with descending branch of (anastomosis (anastomosis around
post. circumflex humeral A. on back of surgical neck elbow).
around elbow)
(cruciate anastomosis).
4-Ant. descending terminal (radial collateral): Muscular *Post. branch; pierces
Pierces lat. septum with radial N., reaching front of lat. Supply biceps, med. septum to reach back
epicondyle anastomosing with radial recurrent A. brachialis & of med. epicondyle,
coracobrachialis anastomosing with sup. ulnar
(anastomosis around elbow).
5-Post. descending terminal (middle collateral): collateral & post. ulnar
recurrent AA. (anastomosis
Reaches back of lat. epicondyle anastomosing with post. around elbow).
interosseous recurrent (anastomosis around elbow).
*Anastomosis around elbow:
Anastomosis Around medial epicondyle Around lateral epicondyle Transverse anastomosis
Front *Ant. branch of inf. ulnar collateral (brachial A.). *Radial collateral (profunda brachii A.). *Inf. ulnar collateral (brachial A.).
*Ant. ulnar recurrent (ulnar A.). *Radial recurrent (radial A.). *Middle collateral (profunda
Back *Sup. ulnar collateral (brachial A.). *Middle collateral (profunda brachii A.). brachii A.).
*Post. branch of inf. ulnar collateral (brachial A.). *Post. interosseous recurrent of post.
.*Post. ulnar recurrent (ulnar A.). interosseous (ulnar A.).
 Muscles of back arm (extensor group)
Muscle Origin Insertion N. supply Action
Triceps -Long head: *Upper surface Radial n. (in -Powerful elbow
Infraglenoid tubercle. olecranon process. axilla to long extension.
-Lat. head: Upper lip of *Few fibers & med. heads, -Articularis cubiti pulls
spiral groove on back of (articularis cubiti) in spiral groove back of elbow capsule
humers. from deep surface to lat. & med. up during elbow
-Med. head.: Back of of lower part heads). extension, preventing
humerus below spiral triceps insert in its insinuation inside.
groove, back of med. & back of elbow
lat. intermuscular septa. joint capsule.

Radial n.
Origin, In axilla, as larger of the 2 terminal branches of post. cord of brachial plexus (C5,6,7,8 & T1).
root value
Course -In axilla: It descends between 3rd part of axillary a. & post. wall of axilla.
& end -In arm:
.In upper 1/3 arm; it descends between upper part brachial a. & long head of triceps.
.In middle 1/3 arm; it passes backwards between long & med. heads of triceps to reach spiral
groove, where it runs downwards & laterally between lat. & med. heads of triceps,
accompanied by profunda brachii A.
. In lower 1/3 arm; it pierces lat. intermuscular septum accompanied by radial collateral A.,
reaching front arm where it descends between brachialis & brachioradialis muscles.
-In cubital fossa: It enters cubital fossa, where it ends infront of lat. epicondyle by
giving a deep branch called post. interosseous N. (mainly motor) & then radial N. continues
as superficial radial n. (mainly sensory).
Branches In axilla In spiral groove In lower 1/3 arm
.Muscular: Long & .Muscular: Lat. & med. heads of .Muscular: Small lat. part of
med. heads of triceps. triceps & anconeus. brachialis, brachioradialis &
.Cutaneous: .Cutaneous: extensor carpi radialis longus.
Post. cut. n. of arm: -Lower lat. cut. n. of arm: To Terminals
To skin on back of arm skin on lower 1/2 of lat. side arm. Ends by giving post. interosseous
(from deltoid tuberosity -Post. cut. n. of forearm: To skin N. & then radial N. continues as
to elbow). on back of forearm down to wrist. superficial radial n.
 Deep fascia of forearm (antebrachial fascia)
Thicker post. than ant., with 3 sites of thickening: -Strengthened by bicipital aponeurosis.
-Along ulna post. border forming an aponeurosis & giving origin to; Flexor carpi ulnaris, flexor digitorum profundus & extensor carpi ulnaris.
-In wrist region forming flexor retinaculum (infront) & extensor retinaculum (behind).
Muscles of front forearm (Flexors)
A- Superficial flexors
General rules: -Common flexor origin: Front of med. epicondyle humerus -Common insertion: Palmar aspect of hand except pronator teres.
-Common N.: Median n., except flexor carpi ulnaris (ulnar n.) -Common action: Flexion of wrist (except pronator teres) & weak flexion of elbow.

Muscle Origin Insertion N. supply Action

PRONATOR TERES -Humeral head (larger & more Pronator tuberosity of radius. Median N. -Weak elbow flexion.
superficial): Common flexor origin & lower N.B.: Median N. passes between the 2 heads -Powerful pronation forearm.
part med. supracondylar ridge. while ulnar A. passes deep to the 2 heads.
-Ulnar head (smaller & deeper): Med. side
coronoid process of ulna.
FLEXOR CARPI Common flexor origin. Palmar aspect of bases of 2nd & 3rd metacarpals. Median N. -Weak elbow flexion.
RADIALIS N.B.: Its tendon passes in a special tunnel, -Flexion & abduction wrist
through lat. part of flexor retinaculum. (hand).
PALMARIS LONGUS Common flexor origin. Apex of palmar aponeurosis. Median N. -Weak elbow & wrist flexion.
(slender with long N.B.: Its tendon passes superficial to flexor retinaculum. -Makes palmar aponeurosis
tendon, may be absent) tense, giving more protection.
FLEXOR CARPI -Humeral head (small): Common flexor origin. Pisiform bone. Ulnar N. -Weak elbow flexion.
ULNARIS -Ulnar head: -Med. side of olecranon N.B.: Between its heads passes ulnar N. (reaching -Flexion & adduction wrist.
process of ulna. front of forearm).
-Upper 2/3 post. border ulna (by aponeurosis).
 FLEXOR -Humero-ulnar head: Common flexor It divides into 4 tendons passing deep to flexor Median N. -Elbow & wrist flexion.
DIGITORUM origin & med. side coronoid process of ulna. retinaculum. each tendon splits at proximal -Flexion of proximal phalanges
SUPERFICIALIS -Radial head: Ant. oblique line radius. phalanx into 2 slips, inserted into sides of shaft (metacarophalangeal joints) &
(SUBLIMIS) of middle phalanx of each of med. 4 fingers. middle phalanges (proximal inter-
phalngeal joints) of med. 4 fingers.
B- Deep flexors
General rules: -Common origin: Front of interosseous membrane, except pronator quadratus.
-Common insertion: All tendons pass deep to flexor retinaculum, to be inserted in palmar aspect hand, except pronator quadratus.
-Common n. supply: Ant. interosseous branch of median n., except med. 1/2 of flexor digitorum profundus (ulnar n.)
-Common action: Flexion of wrist , except pronator quadratus.

Muscle Origin Insertion Nerve supply Action

FLEXOR -Upper 2/3 of front shaft of radius, Its tendon passes through carpal tunnel, deep to flexor retinaculum to Ant. interosseous N. -Flexion wrist.
pollicis below ant. oblique line. insert in palmar aspect of base of terminal phalanx of thumb. -Flexion all joints
longus -Front interosseous membrane. N.B.: Its tendon is surrounded by radial bursa. thumb.

FLEXOR -Upper 3/4 of ant. & med. surfaces It divides into 4 tendons which pass through carpal tunnel, deep -Lat. 1/2: Ant. -Flexion wrist.
DIGITORUM shaft of ulna. to flexor retinaculum. Each tendon passes in tunnel between the interosseous N. -Flexion all joints
profundus -Front interosseous membrane. 2 slips of each tendon of flexor digitorum superficialis, to be inserted -Med. 1/2: Ulnar N. med. 4 fingers.
-Upper 2/3 post. border ulna (by aponeurosis) into base of terminal phalanx of each of med. 4 fingers.
N.B.: The 8 tendons of superficialis & profundus are surrounded
by ulnar bursa.
PRONATOR Oblique ridge on lower 1/4 of front Lower 1/4 of ant. & med. surfaces of shaft of radius. Ant. interosseous N. Pronation forearm
quadratus shaft of ulna. (radioulnar joints).
 Cubital fossa
*Def, shape & site: Intermuscular space, inverted triangular shaped, lying infront of elbow & occupies upper 1/3 of front of forearm.

*Boundaries: -Above (base): Transverse imaginary line between the 2 epicondyles.

-Med.: Pronator teres -Lat.: Brachioradialis -Below (apex): Meeting of brachioradialis overlapping pronator teres.

*Floor: -Med.: Brachialis - Lat.: Supinator.

*Roof: A-Skin. B-Superficial fascia; containing:

1-Basilic vein 2-Cephalic vein 3-Median cubital vein 4- Ant. branch of med. cut. nerve forearm.

5 -Ant. branch of lat. cut. nerve forearm 6-Supratrochlear L.N.s (in upper med. part of roof).

C-Deep fascia: Reinforced by bicipital aponeurosis (separates median cubital v. superficially from brachial a. & median n. deeply) .

*Contents (from med. to lat.):

1-Median N. (leaves fossa between 2 heads of pronator teres).

2-End of brachial A. (in middle of fossa) & beginning of radial (leaves fossa through apex) & ulnar (leaves fossa deep to the 2
heads of pronator teres) arteries. 3-Tendon of biceps (inserted in post. part of radial tuberosity).

4-Radial N. & beginning of its post. interosseous branch (leaves fossa by piercing supinator).
 Hand
Deep fascia of palm (Consists of 3 parts)

A)Lat.: Thin & covers thenar eminence

B)Med.: Thin & covers hypothenar eminence.

C)Central (palmar aponeurosis): Thick & covers intermediate compartment.

Palmar aponeurosis

*Def.: Central part of deep fascia of palm (strongest & thickest part).

*Function: Protection of underlying tendons, vessels & nerves.

*Shape: Triangular, having;

*Apex (above): Fused with flexor retinaculum & receives Palmaris longus tendon.

*Base: Divides into 4 slips, each becomes continuous with fibrous flexor
sheath at root of each of med. 4 fingers.

*Lat. & med. margins: Continue with deep fascia covering thenar &
hypothenar eminences respectively.

*Fibrous septa:

A)Lat.: From the aponeurosis lat. margin to 1st metacarpal bone.

B)Med.: From the aponeurosis med. margin to 5th metacarpal bone.

C)Intermediate: From the aponeurosis deep surface near its lat. margin to
3rd metacarpal bone.

Muscles of hand

Lat. muscles Med. muscles Intermediate muscles

A-Muscles thenar
eminence:
-Common origin: From lat.
side of flexor retinaculum.
-Common N. supply: Median
N. (recurrent muscular branch).
A-Muscles hypothenar
eminence:
-Common origin: From med.
side of flexor retinaculum.
-Common N. supply: Deep
branch of ulnar N.
A-Lumbricals (4 muscles):
*Origin: -Lat. 2; each arise from lat.
side of corresponding lat. tendon of flexor
digitorum profundus.
-Med. 2; each arise from adjacent sides of
med. 3 tendons of flexor digitorum profundus.

1-Abductor pollicis
brevis: *Lat. side of base of
proximal phalanx of thumb.
*Abduction thumb (carpo-
metacarpal joint).
2-Flexor pollicis brevis:
*Lat. side of base of proximal
phalanx of thumb.
*Flexion thumb (carpo-metacarpal
& metacarpo-phalangeal joints).
3-Opponens pollicis:
*Lat. side of shaft of 1st
metacarpal bone.
*Opposition (flexion & med.
rotation) thumb (carpo-
metacarpal joint).
B-Adductor pollicis:
*Origin: -Oblique head; bases
of 2nd & 3rd metacarpals.
-Transverse head; shaft of 3rd
metacarpal.
*Insertion: Med. side of base of
proximal phalanx of thumb.
*N. supply: Deep branch of
ulnar N.
*Action: Adduction thumb
(carpo-metacarpal joint).
1-Abductor digiti minimi;
*Med. side of base of proximal
phalanx of little finger.
*Abduction little finger (metacarpo-
phalangeal joint).
2-Flexor digiti minimi:
*Med. side of base of proximal
phalanx of little finger.
*Flexion little finger (metacarpo-
phalangeal joint).
3-Opponens digiti minimi:
*Med. side of shaft of 5th
metacarpal bone.
*Opposition of little finger
against thumb.
B-palmaris brevis;
*Origin: Flexor retinaculum &
palmar aponeurosis.
*Insertion: Skin on med. side palm.
*N. supply: Superficial branch of
ulnar N.
*Action: Wrinkles skin on med. side
hand to provide a firm hand grip.
*Insertion: Each turns backwards around
metacarpo-phalangeal joint to join
extensor expansion of each of med. 4
fingers & finally become inserted into
distal phalanx.
*N. supply: -Lat. 2: Median N.
-Med. 2: Deep branch of ulnar N.
*Action: Writing position (flexion of
metacarpo-phalangeal & extension of
interphalangeal joints) of med. 4 fingers.
B-Interossei:
1-Four palmar:
st nd
*Origin: From palmar surface of 1 , 2 ,
4th & 5th metacarpals.
*Insertion: -1st; Med. side of base of
proximal phalanx of thumb.
-2nd, 3rd & 4th; Each turns backwards
around metacarpo-phalangeal joint to join
extensor expansion of index, ring & little
fingers & finally become inserted into
distal phalanx.
*N. supply: Deep branch of ulnar N.
*Action: -Adduction of thumb, index, ring
& little fingers. -Writing position.
2-Four dorsal:
*Origin: Each arises from adjacent sides of
the 2 metacarpal bones between which it lies.
*Insertion: Each turns backwards around
metacarpo-phalangeal joint to join
extensor expansion of index, middle
(receives 2 dorsal interossei) & ring fingers ,
finally become inserted into distal phalanx.
*N. supply: Deep branch ulnar N.
*Action: -Abduction of index, middle &
ring fingers. -Writing position.
 Fascial spaces of hand
Space Mid palmar Thenar
Boundaries *Lat.: Intermediate palmar septum. *Lat.: Lat. palmar septum.
*Med.: Med. palmar septum. *Med.: Intermediate palmar septum.
*Ventrally: Palmar aponeurosis. *Ventrally: Palmar aponeurosis.
*Dorsally: 3rd, 4th & 5th metacarpals with *Dorsally: Transverse head of
related interossei. adductor pollicis with covering fascia.

Contents *Long flexor tendons of flexor digitorum *Long flexor tendons of index &
superficialis & profundus of 3rd, 4th & 5th fingers. thumb fingers.
*2nd, 3rd & 4th lumbricals (attached to previous *1st lumbrical (related to index finger).
tendons of profundus).
*Digital vessels & nerves to med. 3 1/2 fingers. *Digital vessels & nerves to lat. 1 1/2 fingers.
Communications *Distally: With webs between med. 4 fingers. *Distally: With web of thumb.
*Proximally: With space deep to common *Proximally: With space deep to common
synovial sheath in carpal tunnel. synovial sheath in carpal tunnel.
N.B.: Space of parona: Space between flexor tendons of forearm (ant.) & pronator quadratus (post.).
It is continuous with deep palmar spaces through carpal tunnel behind long flexor tendons. Infection
can extend from parona space to palmar spaces & vice versa.

Superficial distal pulp space of finger

-Pulp space of distal phalanx (at finger tip). It is tightly packed with small
lobules of subcutaneous fat separated by fibrous septa, passing from skin to
periosteum of distal phalanx. When inflamed it becomes painful due to pus
entrapment & compresses on nerves.

-Blood vessels of shaft & head (not base) of distal phalanx traverse pulp
space. Severe infection may result in thrombosis of shaft & head of distal
phalanx & their death (base is spared).
 Fibrous flexor sheaths
*Def.: Deep fascia on finger ant. surface, which is thickened to hold flexor
tendons in contact with ant. surfaces of phalanges during fingers flexion.

*Attachment: -Proximal end: Continuous with a slip of palmar aponeurosis.

-Distal end: Attached to ant. surface of distal phalanx beyond insertion of

flexor digitorum profundus tendon.

-The sheath with the phalanx form canal for flexor tendons & their synovial
sheaths. At each finger crease skin is attached to fibrous flexor sheath, so pulp
over each phalanx is a separate space & infection can spread between pulps
along neurovascular digital bundle.

Synovial sheaths

Common flexor sheath Flexor pollicis sheath Digital synovial sheaths

(Ulnar bursa) (Radial bursa) (Digital bursae)

-For 8 tendons of superficialis & -For tendon of flexor pollicis -They enclose flexor tendons of each of
profundus passing through longus passing through med. 4 fingers in digital canals made of
carpal tunnel. carpal tunnel. fibrous flexor sheath & phalanges.
-It has a visceral layer applied to -Proximally it extends in fore- -Proximally they extend to heads of
tendon & a parietal layer lining arm for 1 inch above flexor metacarpals (except little finger which
the tunnel (tendons invaginate retinaculum, while distally it is continuous with ulnar bursa), while
sheath from lat. side). extends to muscle insertion. distally they extend to tendons insertion
-Proximally it extends in fore- N.B.: Radial & ulnar bursae
arm for 1 inch above flexor retinaculum, usually communicate in
while distally it ends opposite carpal tunnel.
middle of metacarpal bones
(except at med. side which becomes
continuous with little finger sheath).
N.B.: *The 2 layers of sheath are separated by very narrow space with minimal amount of synovial fluid.
*Sheaths of index, middle & ring fingers are separated from ulnar bursa by 1-3 cm. Infection of these
fingers sheaths remain localized to them, while infection of thumb & little fingers may extend to palm,
carpal tunnel & forearm through radial & ulnar bursae.
*Flexor carpi radialis tendon has its own synovial sheath in a special tunnel on trapezium.
 Median & ulnar nerves
Nerve Median n.
Origin In axilla, by 2 roots: Med. root from med. cord & lat. root from lat. cord of
& brachial plexus (C5,6,7,8 & T1).
root N.B.: Med. root crosses infront of axillary A. to join lat root.
value
Course -In axilla: It descends lat. to 3rd part of axillary A.
& end
-In arm:
.In upper 1/2 arm; it descends lat. to upper 1/2 brachial A.
.In middle arm (opposite insertion coracobrachialis); it crosses brachial A.
from lat. to med. side (either infront or behind A.).
.In lower 1/2 arm; it descends med. to lower 1/2 brachial A. on brachialis.
-In cubital fossa:
. It descends med. to lower part of brachial A. & upper part of ulnar A., being
separated from median cubital V. by bicipital aponeurosis.
.It leaves cubital fossa & enters forearm by passing between 2 heads of
pronator teres, being separated from ulnar A. by deep head pronator teres.
-In forearm:
.It descends in middle of front forearm, between flexor digitorum superficialis &
profundus.
.Above wrist, it becomes superficial, between tendons of flexor carpi radialis
(lat.) & flexor digitorum superficialis (med.).
-At wrist: It enters palm by passing through carpal tunnel, deep to flexor
retinaculum, where it ends by dividing into med. & lat. terminal branches.
Ulnar n.
In axilla, from med. cord of brachial plexus (C7,8 & T1).
N.B.: Fibers C7 reach ulnar n.; lat. cord in axilla or median n. in forearm.
-In axilla: It descends med. to 3rd part of axillary A.
-In arm:
.In upper 1/2 arm; it descends med. to upper 1/2 brachial A.
.In middle arm (opposite insertion coracobrachialis); it passes
backwards piercing med. intermuscular septum (accompanied by sup.
ulnar collateral A.) to reach post. compartment arm.
.In lower 1/2 arm; it descends in post. compartment arm on med.
head triceps.
-At elbow:
. It passes behind med. epicondyle.
.It enters forearm by passing between 2 heads of flexor carpi ulnaris.
-In forearm:
.It descends on med. side of front forearm, between flexor carpi ulnaris
& med. 1/2 flexor digitorum profundus.
.Above wrist, it becomes superficial, between tendons of flexor carpi
ulnaris (med.) & flexor digitorum superficialis (lat.)
-At wrist: It passes superficial to flexor retinaculum, where it ends by
dividing into superficial & deep terminal branches.
 Median & ulnar nerves
Branches -In axilla & arm: No branches.
-In forearm:
.Muscular (in cubital fossa): Pronator teres, flexor carpi radialis, Palmaris
longus & flexor digitorum superficialis.
.Articular: (in cubital fossa): Elbow joint.
.Ant. interosseous n.: -It descends infront of interosseous membrane
(accompanied by ant. interosseous A.), between flexor pollicis longus (lat.) &
flexor digitorum profundus (med.), then it disappears deep to pronator
quadrates to end by supplying inf. radio-ulnar & wrist joints.
-It supplies flexor pollicis longus, lat. 1/2 flexor digitorum profundus
& pronator quadrates.
.Palmar cutaneous n.: It arises 1 inch above wrist, it passes superficial to
flexor retinaculum. It supplies skin of lat. 2/3 palm, except proximal part
othenar eminence (supplied by lat. cut n. of forearm).
-In palm:
.Lat. terminal branch: -It gives a recurrent branch suppling thenar eminence
muscles (abductor pollicis brevis, flexor pollicis brevis & opponens pollicis).
-It then divides into 3 palmar digital branches; 2 for skin of palmar aspect of
both sides thumb, one for skin of palmar aspect of lat. side index & 1st lumbrical.
.Med. terminal branch: It divides into 2 branches;
-1st branch: Supplies 2nd lumbrical, then divides into 2 palmar digital branches,
supplying skin of palmar aspect of adjacent sides of index & middle fingers.
-2nd branch: Divides into 2 palmar digital branches, supplying skin of palmar
aspect of adjacent sides of middle& ring fingers.
N.B.: The palmar digital branches supplies the palmar aspects & distal
halves of dorsal aspects of lat. 3 & 1/2 fingers.
-In axilla & arm: No branches.
-In forearm;
.Muscular: Flexor carpi ulnaris & med. 1/2 flexor digitorum profundus.
.Articular: Elbow joint.
.Cutaneous:
-Palmar cut. n.: It passes superficial to flexor retinaculum. It
supplies skin of med. 1/3 palm.
-Dorsal cut. n.: It reaches dorsum hand, where it divides into 2
dorsal digital branches. It supplies skin of dorsal aspect med. 1/3 hand &
med. 1 & 1/2 fingers.
-In palm:
.Superficial terminal branch: Supplies palmaris brevis, then divides into 2
palmar digital branches, supplying skin of palmar aspect med. 1 & 1/2 fingers.
.Deep terminal branch:-It dips between abductor & flexor digiti
minimi, then it pierces opponens digiti minimi (accompanied by deep
palmar branch of ulnar A.) & curves lat. in concavity of deep palmar
arch to end in adductor pollicis.
-It supplies hypothenar muscles (abductor, flexor & opponens digiti
minimi), 3rd & 4th lumbricals, interossei (4 palmar & 4 dorsal), adductor
pollicis & may also supply flexor pollicis brevis.
-It also gives articular branches to wrist & metacarpo-phalangeal joints.
 Median & ulnar nerves
Injury A-Above elbow: Supracondylar fracture humerus.
B-Pronator syndrome: Median N. entrapment caused by N.
compressio n between 2 heads of pronator teres due to trauma,
muscular hypertrophy or fibrous bands.
Results:
. Motor loss, disability & deformity:
1-Supination of forearm (paralysis of pronator teres & quadrates).
2-Weak flexion wrist & ulnar deviation (paralysis of muscles front
of forearm, except flexor capi ulnaris & med. 1/2 of flexor digitorum
profundus).
3-Extension index & middle fingers (paralysis of flexor digitorum
superficialis & lat. 1/2 of profundus). When patient tries to make a
fist, index & middle remain straight (pointing fingers).
4-Loss thumb flexion (paralysis of flexor pollicis longus & brevis).
5-Loss thumb opposition with lat. rotation (paralysis opponens pollicis).
6- Monkey (Ape) hand: Adduction thumb (paralysis abductor
pollicis brevis).
.Late trophic changes: Wasting thenar muscles & flat thenar eminence.
.Sensory loss: Loss of sensation from lat. 2/3 palm (except
proximal part thenar eminence), palmar aspects & distal halves of
dorsal aspects lat. 3 & 1/2 fingers.
A-At elbow: -Fracture med. epicondyle, dislocation or
compression elbow joint.
B-Cubital tunnel syndrome: Ulnar N. compression in
cubital tunnel (tendinous arch connecting the 2 heads of
flexor carpi ulnaris).
Results:
. Motor loss, disability & deformity:
1 –Radial deviation wrist (paralysis of flexor capi ulnaris).
2- Abduction thumb (paralysis of adductor pollicis). Patient is unable to
grip piece of paper between thumb & index.
3-Loss of fingers adduction & abduction (paralysis of interossei).
Patient is unable to grip piece of paper between fingers.
4- Claw hand (patient cannot put hand in writing position, due to
paralysis of med. 2 lumbricals & interossei). There will be extension
metacarpo-phalangeal joints & equal semiflexion interphalangeal
joints med. 4 fingers (lat. 2 lumbricals are intact & med. 1/2 of
profundus is paralysed).
.Late trophic changes: Wasting hypothenar muscles & flat hypothenar
eminence , hollowing between metacarpals on hand dorsum (paralysis interossei).
.Sensory loss: Loss of sensation from palmar & dorsal aspects of med.
1/3 hand & med. 1 & 1/2 fingers.
 Median & ulnar nerves
C-At wrist: Cut or stab wounds.
2- Carpal tunnel syndrome (compression of median n. in carpal
tunnel by lunate dislocation, carpal bone osteophytes, arthritic
changes of intercarpal joints, inflammation of flexor synovial sheaths or
fluid accumulation).
Results:
.Motor loss ,disability & deformity: Adduction thumb (monkey
hand) & loss thumb opposition with lat. rotation (paralysis of
abductor pollicis brevis & opponens pollicis).
.Late trophic changes: Wasting thenar muscles & flat thenar eminence.
.Sensory loss:
- If the cause is cut wrist there will be loss of sensation from palmar
aspects & distal halves of dorsal aspects lat. 3 & 1/2 fingers, there will be
also sensory loss from lat. 2/3 palm, if palmar cut. branch is involved.
- If the cause is carpal tunnel syndrome, there will be paresthesia
over lat. 3 1/2 fingers.
C-At wrist: Cut or stab wounds.
Results:
.Motor loss ,disability & deformity:
1- Abduction thumb (paralysis of adductor pollicis). Patient is unable to
grip piece of paper between thumb & index.
2-Loss of fingers adduction & abduction (paralysis of interossei).
Patient is unable to grip piece of paper between fingers.
3- Partial claw hand, which is more apparent than that occurring in
ulnar n. injury at elbow, because of marked flexion of med. 2 fingers
(med. 1/2 of flexor digitorum profundus is intact).
.Late trophic changes: Wasting hypothenar muscles & flat
hypothenar eminence , hollowing between metacarpals on hand
dorsum (paralysis of interossei).
.Sensory loss: Loss of sensation from palmar aspect of
med. 1 & 1/2 fingers. If palmar cut. branch is involved, there
will be also sensory loss from med. 1/3 palm.
 Radial & ulnar arteries
Artery Radial
Beginning In cubital fossa, at level of radius neck as smaller of 2 terminal
branches of brachial A.
Course 1-In forearm & at wrist: It runs downwards & laterally along lat.
& part of front forearm till wrist, where it turns backwards around
relations its lat. side.
*Ant.: -In upper part: Brachioradialis.
-In lower part: Skin, superficial & deep fascia.
N.B.: Radial A. is quiet superficial throughout its course as
compared to ulnar A.
*Post.: It lies on muscles attached to radius forming radial A. bed;
Biceps, supinator, pronator teres, flexor digitorum superficialis,
flexor pollicis longus & pronator quadratus.
*Lat.: Superficial radial N. (in middle).
*Med.: Pronator teres & flexor carpi radialis.
2-In hand:. It crosses anatomical snuff box floor reaching hand
dorsum where it passes between 2 heads of 1st dorsal interosseous
muscle reaching palm, where it emerges between 2 heads of
adductor pollicis & runs med. distal to metacarpal bases.
End In palm as deep palmar arch.
Ulnar
In cubital fossa, at level of radius neck as larger of 2 terminal branches of
brachial A.
1-In forearm & at wrist: Its runs obliquely downwards & med. reaching med. side
of front forearm (upper 1/3), then it descends vertically along med. side forearm
(lower 2/3) till wrist where it passes superficial to flexor retinaculum reaching hand.
*Ant.: -In upper part: 5 superficial forearm muscles; Pronator teres, flexor carpi
radialis, Palmaris longus, flexor digitorum superficialis & flexor carpi ulnaris.
-In lower part: Skin, superficial & deep fascia.
*Post.: Brachialis , flexor digitorum profundus & flexor retinaculum.
*Lat.: Flexor digitorum superficialis.
*Med.: Ulnar N. & flexor carpi ulnaris.
.
2-In hand: It lies lat. to ulnar N. & pisiform, being covered by palmaris brevis.
On flexor retinaculum by dividing into superficial & deep branches.
 Radial & ulnar arteries

A)Near elbow:
*Ant. ulnar recurrent: Ascends to anastomose with ant. branch of inf.
Branches
ulnar collateral A. infront of med. epicondyle.
*Post. ulnar recurrent: Ascends to anastomose with sup. & inf. ulnar
collateral AA. on back of med. epicondyle.
*Common interosseous: Short trunk passing backwards, reaching inter-
osseous membrane upper margin, dividing into ant. & post. interosseous AA.
1-Ant. interosseous: -Descends infront of interosseous membrane
(accompanied by ant. interosseous N.) between flexor pollicis longus &
flexor digitorum profundus.
-At upper border pronator quadratus, it pierces interosseous membrane
reaching forearm back & descends deep to extensor retinaculum (in 4th
compartment.) to end by joining post. carpal arch.
Branches: •Median A.: Supplies median N.
•Muscular: To forearm deep flexors & extensors.
•Nutrient: To radius & ulna.
•Anastomotic: Join ant. & post. carpal arches.
2-Post. interosseous: Passes backwards above interosseous membrane
reaching forearm back, descending between superficial & deep forearm
extensors (accompanied by post. interosseous N.). It ends by anastomosing
with ant. interosseous A.
Branches: •Post. interosseous recurrent: Ascends to anastomose with
middle collateral A. on back lat. epicondyle.
•Muscular: To forearm extensors.
 Radial & ulnar arteries

A)In forearm & at wrist: B)In forearm: *Muscular: To muscles on ulnar side forearm.
*Radial recurrent: Ascends to anastomose with radial
collateral A. infront of lat. epicondyle.
*Muscular: To muscles on radial side forearm.
*Ant. carpal: Passes med. infront of carpus to anastomose with C)At wrist: *Ant. carpal: Passes lat. infront of carpus to anastomose
ant. carpal branch of ulnar A. forming ant. carpal arch. with ant. carpal branch of radial A. forming ant. carpal arch.
*Superficial palmar: Descends through thenar muscles & ends by *Post. carpal: Turns backwards behind carpus to anastomose with post.
anastomosing with ulnar A. completing superficial palmar arch. carpal branch of radial A. forming post. carpal arch.

B)On dorsum hand: *Post. carpal: Passes med. on carpus

back to anastomose with post. carpal branch of ulnar A.
forming post. carpal arch.
*1st dorsal digital: Supplies lat. side thumb.
*1st dorsal metacarpal: Arises on hand dorsum before radial a. D)In hand: *Superficial branch: Curves lat. across palm forming
passes between 2 heads of 1st dorsal interosseous, supplying superficial palmar arch.
adjacent sides of thumb & index fingers. *Deep branch: Passes between abductor & flexor digiti minimi then
penetrates oppenens digiti minimi (accompanied by deep branch of ulnar
C)In palm : *Princeps pollicis: Arises from radial as it N.), anastomosing with deep palmar arch at base of 5th metacarpal.
emerges between 2 heads of 1st dorsal interosseous supplying
both sides of thumb palmar aspect.
*Radialis indicis: Supplies lat. side of index palmar aspect.
*Deep palmar arch.
 Radial & ulnar arteries

Arterial arches in hand

Arch Ant. carpal arch Post. carpal arch Superficial palmararch Deep palmar arch
Site Deep to flexor tendons. Deep to extensor tendons. Deep to palmar aponeurosis, but Deep to flexor tendons of palm.
superficial to flexor tendons &
median n. digital branches.
Level Infront carpus On back carpus Mid shaft of metacarpals, 1/2 Just distal to bases of metacarpals, 1/2
inch distal to deep palmar arch. inch proximal to superficial palmar arch.
Formation *Ant. carpal of radial A. *Post. carpal of radial A. *Ulnar A. (mainly). *Radial A. (mainly).
*Ant. carpal of ulnar A. *Post. carpal of ulnar A. *Superficial palmar branch of *Deep palmar branch of ulnar A.
*Anastomotic of ant. *Ant. interosseous A. radial A. (completed). (completed)
interosseous A. *Post. interosseous A.
*Recurrent of deep palmar arch.
branches *2nd, 3rd & 4th dorsal *3 common palmar digital AA.: *3 palmar metacarpal AA.: Join 3
meta-carpal AA.: Each Run to clefts between med. 4 fingers, common palmar digital branches of
divides into 2 dorsal digital each divides into 2 palmar digital superficial palmar arch.
branches supplying palmar aspects of
branches, supplying adjacent *3 perforating AA.:
adjacent sides of med. 4 fingers.
sides of med. 4 fingers. Pass dorsally through 2nd, 3rd & 4th
intermetacarpal spaces to join dorsal
*Palmar digital A.: To med.
*Dorsal digital A.: To metacarpal AA.
side little finger.
med. side little finger. *Reccurent AA.: Ascend deep to flexor
retinaculum to join ant. carpal arch.
Surface Curved line across hand (convexity Curved line 4 cm across hand from
anatomy directed distally) from distal proximal border of root of extended
border of root of extended thumb. thumb (just distal to hamate hook).
Relations Deep branch of ulnar N. lies in arch concavity.
 Flexor retinaculum
*Def. & site: Thick transverse band of deep fascia, infront of carpal bones,
converting their ant. concave surface into a tunnel called carpal tunnel.

*Attachments: -Med.: Pisiform & hook of hamate -Lat.: It splits into 2 laminae;

-Superficial: Scaphoid (tubercle) & trapezium (crest)

-Deep: Medial lip of trapezium groove.

N.B.: In between the 2 laminae, there is a special tunnel, for flexor carpi
radialis tendon & its sheath.

-Above: Continuous with deep fascia of front forearm.

-Below: Continuous with apex of palmar aponeurosis.

*Structures passing superficial: From med. to lat.

1-Ulnar N. 2-Ulnar A. 3- Palmar cutaneous branch of ulnar N.

4-Tendon of Palmaris longus. 5 -Palmar cutaneous branch of median N.

*Structures passing deep:

A: In carpal tunnel;

1-One nerve: Median N. (most superficial structure).

2-Nine tendons: Tendon of flexor pollicis longus, 4 tendons of flexor

digitorum superficialis & 4 tendons of flexor digitorum profundus.

3-Two synovial sheaths (bursae): Radial & ulnar bursae.

4-Recurrent branches of deep palmar arch: Deepest structure.

B- In special tunnel: Flexor carpi radialis tendon & its sheath.

*Muscles attached: -Lat.: Origin thenar muscles -Med.: Origin hypothenar

muscles. - In middle: Insertion of palmaris longus tendon.
 Carpal tunnel
*Boundaries: -Sides & floor: Carpal arch, formed by ant. concave surface carpal bones.
-Roof: Flexor retinaculum.

*Contents: 1-One nerve: Median n. (most superficial structure).

2-Nine tendons: Tendon of flexor pollicis longus, 4 tendons of flexor

digitorum superficialis & 4 tendons of flexor digitorum profundus.

3-Two synovial sheaths (bursae): Radial & ulnar bursae.

4-Recurrent branches of deep palmar arch: Deepest structure.

*Clinical importance: Carpal tunnel syndrome

Causes: Compression of median n. in carpal tunnel by lunate dislocation,

carpal bone osteophytes, arthritic changes of intercarpal joints, inflammation
of flexor synovial sheaths or fluid accumulation).

Results:

.Motor loss ,disability & deformity: Adduction (monkey hand) & loss
of thumb opposition with lat. rotation (paralysis of abductor pollicis
brevis & opponens pollicis).

.Late trophic changes: Wasting of thenar muscles & flat thenar eminence.

.Sensory loss: There will be paresthesia over lat. 3 1/2 fingers.

 Muscles of Back forearm (Extensors)

A- Superficial extensors
General rules:
-Common extensor origin: Front of lat. epicondyle humerus, except brachioradialis, extensor carpi radialis longus & anconeus.
-Common insertion: All tendons pass deep to extensor retinaculum, to be inserted in dorsal aspect hand, except brachioradialis & anconeus.
-Common n.supply: Post. interosseous branch of radial n., except brachioradialis, extensor carpi radialis longus & anconeus (radial n.).
-Common action: Extension of wrist, except brachioradialis & anconeus.

Muscle Origin Insertion N. supply Action

Brachio-radialis -Upper 2/3 lat. supracondylar ridge. Lat. surface of lower end radius, above base styloid process. Radial n. -Put forearm in mid-prone
-Front of lat. intermuscular septum. position (mid way between
supination & pronation).
-Elbow flexion.
Extensor carpi -Lower 1/3 lat. supracondylar ridge. Dorsal aspect of base of 2nd metacarpal bone. Radial n. Extension & abduction wrist.
radialis longus -Front of lat. intermuscular septum. N.B.: Its tendon passes deep to extensor retinaculum.
Extensor carpi Common extensor origin. Dorsal aspect of base of 3rd metacarpal bone. Post. Extension & abduction wrist.
radialis brevis N.B.: Its tendon passes deep to extensor retinaculum. interosseous n.
Extensor Common extensor origin. It divides into 4 tendons, each joins extensor expansion Post. Extension wrist & med.
digitorum on dorsum of proximal phalanx of each of med. 4 fingers. interosseous n. 4 fingers (metacarpo-
N.B.: Its tendons pass deep to extensor retinaculum. phalangeal & inter-
*Extensor expansion: Short inverted triangular fibrous phalangeal joints).
sheet on dorsum of proximal phalanx of each of med. 4
fingers, receiving extensor digital tendons, tendons of
lumbricals & interossei. Approaching proximal inter-
phalangeal joint, it divides into intermediate slip (to base
of middle phalanx) & 2 collateral slips (unite reaching
base of distal phalanx).
 Muscles of Back forearm (Extensors)

Extensor Common extensor origin. Extensor expansion little finger. Post. Extension wrist & little finger.
digiti minimi N.B.: Its tendon passes deep to extensor retinaculum. interosseous n.

Extensor carpi -Common extensor origin. Dorsal aspect of base of 5th metacarpal bone. Post. Extension & adduction wrist.
ulnaris -Upper 2/3 post. border ulna by (aponeurosis) N.B.: Its tendon passes deep to extensor retinaculum. interosseous n.
Anconeus Back of lat. epicondyle humerus. Lat. side & triangular area on back of olecranon process ulna. Radial n. Extension elbow
N.B.: Considered 4th head triceps due to: (assisting triceps).
1-Covered by expansion from triceps tendon.
2-Radial N. supplies it while running in spiral groove.
3-Assists triceps in elbow extension.
B- Deep extensors
General rules: -Common origin: Back of interosseous membrane, except supinator.
-Common insertion: All tendons pass deep to extensor retinaculum, to be inserted in dorsal aspect hand, except supinator.
-Common n.supply: Post. interosseous branch of radial n.

Muscle Origin Insertion N. supply Action

Supinator -Lat. epicondyle humerus, lat. collateral
ligament of elbow & annular ligament.
-Supinator fossa & crest of ulna.
Abductor Back of ulna (below insertion anconeus),
pollicis longus back of radius (below insertion supinator)
& back of interosseous membrane.
Extensor Back of radius (below origin abductor pollicis
pollicis brevis longus) & back of interosseous membrane.
Post. , lat. & ant. surfaces of upper 1/3 radius Post. Supination of forearm, when
(above ant. & post. oblique lines). interosseous n. elbow is extended.
N.B.: It is pierced by post. interosseous N. which
curves around radius splitting muscle into 2 layers.
Lat. side of base of 1st metacarpal bone. Post. *Abduction of wrist & thumb
N.B.: Its tendon passes deep to extensor retinaculum. interosseous n. (carpometacarpal joint).
*It can flex wrist when median &
ulnar nerves are paralysed.
Dorsal aspect of base of proximal phalanx thumb. Post. Extension of proximal phalanx
N.B.: Its tendon passes deep to extensor retinaculum. interosseous n. thumb (carpo-metacarpal &
metacarpo-phalangeal joints).
 Muscles of Back forearm (Extensors)

Extensor Back of ulna (below origin abductor pollicis Dorsal aspect of base of terminal phalanx thumb. Post. Extension of all joints thumb.
pollicis longus longus) & back of interosseous membrane. N.B.: Its tendon passes deep to extensor retinaculum. interosseous n.
Extensor Back of ulna (below origin extensor pollicis Extensor expansion of index finger. Post. *Extension of index finger
indicis longus) & back of interosseous membrane. N.B.: Its tendon passes deep to extensor retinaculum. interosseous n. (metacarpo-phalangeal joint).
*Helps in wrist extension.
Extensor retinaculum
*Def. & site: Thick band of deep fascia of forearm, lying obliquely across back of wrist.
*Attachments: -Lat.: Ant. border of lower end radius. -Med.: Pisiform & triquetral.
*Compartments: 5 septa descend from its deep surface to ridges on back of lower end radius, dividing the space deep to it into 6 compartments;
Compartment Site Structures passing through
1S On lat. side of lower end radius. -Tendon of abductor pollicis longus.
-Tendon of extensor pollicis brevis.
2nd On back of lower end radius, lat. to dorsal tubercle of lister. -Tendon of extensor carpi radialis longus.
-Tendon of extensor carpi radialis brevis.
3rd On back of lower end radius, med. to dorsal tubercle of lister. Tendon of extensor pollicis longus.
4th On most med. part of back of lower end radius. -Tendons of extensor digitorum -Tendon of extensor indicis.
-Post. interosseous n. -Ant. interosseous a.
5th On back of inf. radioulnar joint. Tendon of extensor digiti minimi.
6th On back of lower end ulna, between head & styloid process. Tendon of extensor carpi ulnaris.
*Relations: -Lat.: Crossed by superficial radial N. (termination) & cephalic V. (lower part).
-Med.: Crossed by dorsal cutaneous branch of ulnar N. & basilic V. (lower part).
 Anatomical snuff box
*Def., shape & site: Triangular hollow, lying on dorso-lat. aspect of wrist. It
becomes clearly visible when thumb is fully extended.
*Boundaries: -Lat.: Tendons of abductor pollicis longus & extensor pollicis brevis.
-Med.: Tendon of extensor pollicis longus.
-Floor: Styloid process radius, scaphoid & trapezium.
-Roof: Skin, superficial fascia (containing cephalic v. & dorsal
digital branches of superficial radial n.) & deep fascia.
*Contents: 1-Tendons of extensor carpi radialis longus & brevis.
2-Radial a. (its pulsation can be felt here).
Superficial radial N.
*Origin: Infront of lat. epicondyle as continuation of radial n., below post.
interosseous N. origin.
*Course & end: *It descends on lat. side of front of forearm deep to brachioradialis
(in upper 1/3 it is separated from radial A. by triangular gap, in middle 1/3 it is
closely lat. to A. & finally in lower 1/3 it leaves A. by turning backwards around
lat. surface radius reaching back of forearm).
*It pierces deep fascia & descends in roof of anatomical snuff box reaching
dorsum of hand, where it ends by dividing into 5 dorsal digital branches.

*Branches: -Two for sides of thumb -One for lat. side index.
-Two for clefts between index, middle & ring fingers supplying adjacent sides.
N.B.: Dorsal digital branches supply skin of lat. 2/3 of dorsum hand & proximal
halves of dorsal aspect of lat. 3 1/2 fingers (median N. supplies distal halves of
dorsal aspect of lat. 3 1/2 fingers & overlap whole skin area supplied by superficial
radial N. except triangular area on dorsum of web between thumb & index
which is supplied by superficial radial N. only).

Posterior interosseous N.
*Origin: From radial N. infront of lat. epicondyle.
*Course & end: -It supplies supinator & extensor carpi radialis brevis, then pierces
supinator to wind around lat. side of upper 1/3 of shaft radius (within supinator substance,
splitting it into superficial & deep layers) reaching back of forearm, where it descends
(with post. interosseous A.) between superficial & deep forearm extensors.

-It leaves A. by passing deep to extensor pollicis longus, reaching back of inter-
osseous membrane joining ant. interosseous A., both of which pass deep to
extensor retinaculum in 4th compartment, reaching back of wrist where it ends
in a pseudoganglion giving terminal articular branches.
 *Branches: -Muscular: All extensors on back forearm except; brachioradialis,
extensor carpai radialis longus & anconeus.

-Articular: Inf. radioulnar, wrist & intercarpal joints.

Injury of radial N.
Causes Motor effects Sensory effects
*In axilla; by badly -Impairment of elbow extension -Paresthesia on back of arm, fore-arm,
adjusted crutch or due to triceps affection. lower part of lat. side arm, lat. 2/3
drunkard falling asleep -Failure of supination of extended dorsum hand & dorsum of proximal
with arm over chair back forearm due to supinator affection. phalanges of lat. 3 1/2 fingers.
(saturday night palsy). -Wrist & finger drop due to paralysis -Small area of complete sensory loss
*In spiral groove; of all wrist & finger extensors (very on dorsum hand between 1st & 2nd
by fracture of humerus shaft. disabling due to impossibility to metacarpals due to overlap by adjacent
*Post. interosseous n.; perform firm grip with wrist flexed). nerves in areas of radial distribution.
fracture head, neck or -In post. interosseous N. injury; -Sensory loss patch over lower 1/2 deltoid.
upper part shaft radius. only finger drop as extensor carpi
Dislocation radius head. radialis longus is intact.

Brachial plexus injuries

Injury Upper trunk injury
(Duchenne-Erbs paralysis)
Causes -Excessive head displacement to one side with
shoulder depression on other side, leading to
excessive traction or tearing of C5,6 roots.
-It may occur as birth injury during delivery.
Results Motor (porters tip deformity):
*Shoulder is adducted (paralysis of supra-
spinatus & deltoid) & med. rotated (paralysis
of infraspinatus & teres minor).
*Elbow is extended (paralysis of biceps & most of
brachialis) & forearm is pronated (paralysis biceps).
Lower trunk injury
(klumpkes paralysis)
-Excessive arm abduction leading to excessive
traction or tearing of C8 & T1 roots. May occur
in person falling from height clutching an object
to save himself or arm traction during delivery.
-Malignant lower deep cervical L.N.s.
-Cervical rib.
Motor: C8 & T1 are mainly distributed through
median & ulnar nn. to lumbricals & interossei):
*Claw hand (extension of metacarpo-
phalangeal joints by extensor digitorum
& flexion of interphalangeal joints by flexor
digitorum superficialis & profundus).
*Loss of fingers adduction & abduction.

Sensory: Loss on lat. side upper limb. Sensory: Loss on med. side arm, forearm,
med. 1/3 hand & med. 1 1/2 fingers.
 Cutaneous innervation of upper limb
Shoulder region, axilla & arm Forearm
Back: Back:
Post. cut. N. arm: From radial N. (in axilla), supplies Post. cut. N. forearm:
skin on back of arm from deltoid tuberosity to elbow. From radial N. (in spiral
groove), supplies skin in
middle of back forearm.
Med. side: Med. side:
*Intercosto-brachial N.: Lat. cut. branch of Med. cut. N. forearm:
2nd intercostal N., supplies skin of floor axilla & From med. cord brachial
upper part of med. side arm. plexus, divides into ant. &
*Med. cut. N. arm: From med. cord brachial post. branches, supplies
plexus, supplies skin on lower part of med. side arm. skin on med. side forearm.
Hand
Palm:
*Palmar cut. branch of median N.: Supplies lat. 2/3 palm, except
proximal part of ball thumb (lat. cut. N. forearm).
*Palmar cut. branch of ulnar N.: Supplies med. 1/3 palm.
Palmar aspect fingers:
*Med. & lat. terminal branches of median N.: Supplies lat. 3 &
1/2 fingers & distal halves of their dorsal aspects.
*Superficial terminal branch of ulnar N.: Supplies med. 1 & 1/2 fingers.
Dorsum hand:
*5 dorsal digital branches of superficial radial N.: Supplies
lat. 2/3 dorsum hand.
*Dorsal cut. branch of ulnar N.: Supplies med. 1/3 dorsum hand.

Lat. side: Lat. side:

*Lat. supraclavicular N.: From C3 & 4 N.,
supplies skin on upper 1/2 deltoid.
*Upper lat. cut. N. arm: Continuation of post.
branch axillary N., supplies skin on lower 1/2 deltoid.
*Lower lat. cut. N. arm: From radial N. (in spiral
groove), supplies skin on lower 1/2 of lat. side arm.
Lat. cut. N. forearm:
Continuation of musculo-
cutaneous N., divides into ant.
& post. branches, supplies
skin on lat. side forearm.
Dorsal aspect fingers:
*5 dorsal digital branches of superficial radial N.:
Supplies lat. 3 & 1/2 fingers, except distal halves (supplied by median N.).
*Dorsal cut. branch of ulnar N.: Supplies med. 1 & 1/2 fingers.
N.B.: Branches of median N. overlap whole skin area supplied by
superficial radial N. except small triangular area on dorsum web
between thumb & index (supplied by superficial radial N. only).
 Veins of upper limb
A)Superficial veins

Dorsal venous arch Cephalic V. Basilic V. Median cubital Median V. of forearm

*Over metacarpal heads, *Begins from lat. end of dorsal venous
receives VV. from dorsum arch in roof of anatomical snuff box &
hand, palm & fingers. winds above wrist reaching front of
*It drains lat. in cephalic forearm, where it ascends lat.
V. & med. in basilic V.
*It crosses roof of cubital fossa to arm
where it runs along lat. border biceps
reaching deltopectoral groove (accompanied
by deltoid branch of acromio-thoracic A.
& delto-pectoral L.N.s).
*Begins from med. end of dorsal
venous arch & ascends along postero-
med. surface forearm reaching
front of forearm just below elbow.
*It crosses roof of cubital fossa to
arm where it pierces deep fascia
opposite insertion of coraco-
brachialis to become deep &
ascends med. to brachial A.
V.
It connects It begins near wrist by union
cephalic & basilic of few VV. from palm, then
VV. in cubital fossa ascends in middle of front
roof, where bicipital forearm to end below elbow
aponeurosis separates in cephalic or basilic V., or it
the V. from brachial
divides into median cephalic
A. & median V.
V. (joins cephalic V.) & median
basilic V. (joins basilic V.).

*Just below clavicle it pierces *At lower border teres major it

clavipectoral fascia ending in axillary V. is joined by venae comitantes of
brachial A. forming axillary V.

B)Deep veins

A)Venae comitants: Accompany main AA. (2 veins usually accompany each main A. & anastomose together). Venae comitants of
radial & ulnar AA. form the 2 venae comitants accompanying brachial A.

B)Axillary V.: See before.

 Lymph drainage of upper limb

Lymph vessels a)Superficial 1-Vessels on wrist med. side: Follow basilic V. in forearm, some of them end in supratrochlear
L.N.s, their efferents with other vessels which donot end in supratrochear L.Ns pierce deep fascia to end in lat. group axillary L.N.s.
2-Vessels on wrist lat. side: Follow cephalic V. in forearm, at deltoid insertion most of them pierce deep fascia to end in lat. group axillary L.N.s,
while few end in infra-clavicular (delto-pectoral L.N.s) which send efferents piercing clavipectoral fascia ending in apical group axillary L.N.s.

b)Deep Follow main vessels (brachial, radial, ulnar & interosseous) ending in lat. group axillary L.N.s.

Lymph nodes a)Superficial 1-Supratrochlear: In superficial fascia of cubital fossa roof, above med. epicondyle & med. to
basilic V. Receive few vessels from med. side forearm & send efferents to lat. group axillary L.N.s.
2-Infraclavicular (delto-pectoral): Just below clavicle in delto-pectoral groove. Receive few vessels from lat. side forearm & send
efferents piercing clavipectoral fascia to end in apical group axillary L.N.s

b)Deep Axillary (5 groups):

Group Ant. (pectoral) Post. (subscapular) Lat. (humeral) Central Apical
Site On axilla ant. wall On axilla post. wall Near axilla lat. wall, along axillary v. In fat just above In axilla apex, behind clavicle & subclavius.
(pectoralis minor), (subscapularis), along axilla base.
along lat. thoracic a. subscapular a.
Afferents -Mammary gland lat. part. -Mammary gland tail. U.L. lymphatics; deep & most Ant., post. & lat. -Ant., post., lat. & central groups.
-Ant. abdominal wall -Trunk back down to superficial. groups. -Efferents from infraclavicular group
above umbilicus. iliac crest. (few superficial lat. U.L. lymphatics & small
upper lat. part mammary gland).
Efferents Central & apical groups. Central & apical groups. Central & apical groups. Apical group. -On Rt. side: Subclavian lymph trunk to Rt.
lymph duct to Rt. brachiocephalic v.
-On Lt. side: Subclavian lymph trunk to
thoracic duct to Lt. brachiocephalic v.
 Joints of shoulder girdle
A)Sterno-clavicular joint
*Articular surfaces: -Clavicular notch of manubrium sterni & 1st costal cartilage.
-Med. (sternal) end of clavicle.

*Type: Synovial, modified saddle.

*Capsule: Surrounds joint, thicker infront & behind.

*Intra-articular disc: -Flat circular disc of cartilage between articulating surfaces,

attached to capsule & divided joint cavity into 2 separate compartments.
-It absorbs force transmitted to the joint from shoulder region through clavicle
& prevents dislocation of med. end clavicle.

*Ligaments:
Ant. sternoclavicular Post. sternoclavicular Interclavicular Costoclavicular
Covers ant. surface Covers post. surface Extends between -Short inverted conical,
joint, extending from joint, extending from upper aspects of attached below to 1st costo-
from front of sternal from back of sternal end sternal ends of both chondral junction & above
end clavicle to front of clavicle to back of upper clavicle, along upper to impression on inf. surface
upper part manubrium. part manubrium. margin manubrium. of med. end clavicle.

-Prevents excessive elevation

& protraction of clavicle
(same subclavius function).
*Stability: Stable joint, depending on ligaments & intra-articular disc.
*N. supply: Med. supraclavicular N. & N. to subclavius.
*Arterial supply: Suprascapular & internal mammary AA.
B)Acromio-clavicular joint
*Articular surfaces: -Med. margin acromion -Lat. (acromial) end clavicle.
*Type: Synovial, plane.

*Capsule: Surrounds joint, strengthened above by acromioclavicular ligament.

*Intra-articular disc: It usually contains a disc of cartilage which divides joint
cavity into 2 incomplete compartments

*N. supply: Suprascapular & lat. pectoral NN.

*Arterial supply: Suprascapular & thoraco-acromial AA.
*Functions: -Share little in movements of shoulder girdle.
-Share in transmitting force from upper limb to clavicle, but the main medium
transmitting it is coraco-clavicular ligament.
 N.B.: Coraco-clavicular ligament;

*Parts: -Trapezoid part; forms anterolateral part of ligament, quadrilateral,

extending from upper surface of coracoid process to trapezoid line on inf.
surface of lat. 1/3 clavicle.
-Conoid part; forms posteromedial part of ligament, dense band of fibrous
tissue, extending from bend of coracoid procss to conoid tubercle on inf.
surface of lat. 1/3 clavicle.
*Functions: -Main medium suspending & transmitting force from upper limb
to clavicle, if clavicle is fractured med. to ligament attachment, upper limb droops.
-It limits movements of acromioclavicular joint & prevents dislocation of lat. end clavicle.
Movements & muscles acting on shoulder girdle
Occur at acromio-clavicualr & sterno-clavicular joints. Movement of scapula
on clavicle at acromio-clavicular joint is limited, while movement at sterno-
clavicular joint increases range of scapula movement.
Elevation Depression Protraction Retraction Upwards Downwards
rotation rotation
-Upper fibers -Pectoralis minor. -Pectoralis -Middle fibers -Serratus ant. -Levator scapulae.
of trapezius. -Lower fibers minor. trapezius. -Upper & -Rhomboids minor.
-Levator trapezius. -Serratus ant. -Rhomboids minor. lower fibers -Rhomboids major.
scapulae. -Rhomboids major. trapezius.
shoulder joint
*Articular surfaces:
-Head of humerus; spherical but less than half of a sphere, much larger than glenoid cavity.
-Glenoid cavity; Deepened by a rim of fibrocatilage (labrum glenoidal), which
is attached to its circumference for widening of the cavity & protection of its edges.

*Type: Synovial, ball & socket (polyaxial).

*Capsule:
A)Attachment: Medially; Attached to circumference of glenoid cavity
beyond labrum glenoidal. It encroaches on root of coracoid process, so that
supraglenoid tubercle lies within capsule.
Laterally; Attached to anatomical neck of humerus & descends for half an
inch on to med. side of surgical neck to include this part within the capsule.
 b)Perforations: 1-Ant.: Below coracoid process, allowing joint cavity to
communicate with subscapular bursa.
2-Post. (not constant): May communicate with bursa deep to infraspinatus tendon.
3-Lat.: Between greater & lesser tuberosities for passage of long head biceps.

*Synovial membrane & bursae related:

It lines capsule & covers intracapsular non-articular bony parts. It is continuous wih
subscapular bursa through capsule ant. perforation. It forms tubular sheath for tendon
long head biceps & extends around it outside capsule. 5 bursae lie around capsule;

-Subscapular bursa: Between subscapularis tendon & front of capsule.

-Bursa: Between infraspinatus tendon & back of capsule.
-Bursa: Between capsule & coracoid process.
-Bursa: On acromion upper surface (subcutaneous).
-Subacromial bursa: Between deltoid & capsule, it is prolonged under coraco-acromial
arch separating it from supraspinatus tendon (does not communicate with joint cavity).

*Intracapsular structures: -Head of humerus & med. part of its surgical neck.
-Glenoid cavity & labrum glenoidal, supraglenoid tubercle & tendon long head biceps.
-Synovial membrane.

*Ligaments:

3 glenohumeral Coracohumeral Transverse humeral

-Extends from ant. margin -Extends from coracoid -Extends between lesser & greater
glenoid cavity to anatomical neck process to upper border of tuberosities of humerus, converting
& lesser tuberosity of humerus. greater tuberosity humerus. bicipital groove into canal.

-Strengthens capsule ant. -Strengthens capsule sup. -Acts as retinaculum for tendon long head biceps.

Stability: Unstable joint because of following factors;

-Bony factor: Articulating bones are not well fitted, head of humerus is very
large while glenoid cavity is small & shallow forming poor socket.
-Ligamentous factor: Capsule & ligaments are weak & lax.
-Muscular factor: Capsule is not directly supported by muscle from below.

Stability depends on:

 Muscular factor Coracoacromial arch
-Above: Supraspinatus & long head biceps. Coracoacromial ligament: Flat triangular,
-Below: No muscle, where capsule is lax & folded to bulge in attached by its apex to acromion tip &
axilla & becomes directly related to circumflex N. & post. by its base to coracoid process.
circumflex humeral A. (long head triceps supports joint from -The ligament with the 2 processes, form
below when arm is abducted). coracoacromial arch which lies above
-Infront: Subscapularis. shoulder joint, forming secondary socket
-Behind: Infraspinatus & teres minor. for head humerus, supporting it from above.
N.B.: -Tendons of these muscles (except biceps & triceps) form
rotator muscle cuff which fuse with capsule & support joint.
-Deltoid covers joint infront, behind & lat.

*N. supply: Suprascapular, axillary & lat. pectoral NN.

*Arterial supply: Suprascapular, ant. & post. circumflex humeral AA.
*Movements & muscles acting on shoulder joint:

Flexion Extension Abduction Adduction Med. Lat.

rotation rotation
-Pectoralis major -Latissimus dorsi. -Supraspinatus(0-15). -Pectoralis major. -Pectoralis major. -Teres minor.
( clavicular head). -Teres major. -Middle fibers deltoid -Latissimus dorsi. -Latissimus dorsi. -Infraspinatus.
-Ant. fibers deltoid. -Post. fibers (15-90). -Teres major. -Teres major. -Post. fibers
-Short head biceps. deltoid. -Teres minor. -Subscapularis. deltoid.
-Coracobrachialis. N.B.:*After this range -Infraspinatus. -Ant. fibers
head cannot move -Subscapularis. deltoid.
anymore because it -Coracobrachialis.
N.B.:Sterno-
impinges on coraco-
costal head acromial ligament.
pectoralis major,
extend flexed arm. *Abduction of shoulder
(90-180) is upwards
rotation of scapula
(serratus ant., upper
& lower fibers trapezius).
N.B.:*During abduction there is simultaneous movement of shoulder joint & girdle, for each 10 degrees
shoulder joint abduction there is an addition of 5 degrees due to scapula upward rotation. This continues
until range of 90 degrees. *Circumduction ia a combination of above mentioned movements.
Elbow joint
*Articular surfaces:
-Proximally: Trochlea & capitulum of humerus.
-Distally: Trochlear notch of ulna (receives trochlea) & upper surface head of
radius (receives capitulum)
*Type: Synovial, hinge (uniaxial).
 *Capsule: Elbow & sup. radio-ulnar joints have a common capsule which is
thin infront & behind, but thick on sides due to strong collateral ligaments.
Above & infront; Attached to humerus just above coronoid & radial fossae &
extends to roots of med. & lat. epicondyles.
Above & behind; Attached to lower end humerus just above olecranon fossa.
Below; Attached to margins of coronoid & olecranon processes & annular
ligament which encircles radius head.

*Intracapsular structures: -Articular surfaces.

-Coronoid, radial & olecranon fossae of humerus.
-Synovial membrane; continuous with that of sup. radioulnar joint.

*Ligaments:
Medial (ulnar) collateral ligament Lateral (radial) collateral ligament
-Fan shaped, attached to med. epicondyle (above) -Triangular shaped, attached to lat. epicondyle
& med. margin of trochlear notch ulna (below). (above) & annular ligament (below).
-It prevents abduction of elbow joint. -It prevents adduction of elbow joint

*N. supply: Median, ulnar, musculocutaneous & radial nerves.

*Arterial supply: From anastomosis around elbow.
*Movements & muscles acting on elbow joint:

Flexion Extension
-Biceps, brachialis & brachioradialis. -Triceps.
-Superficial flexors of forearm. -Anconeus.
Radio-ulnar joints
A)Superior radio-ulnar joint
*Articular surfaces: Only 1/4 of circumference of radius head articulates with
radial notch of ulna (remaining 3/4 of radius head articulates with annular ligament).
*Type: Synovial, pivot (uniaxial).
*Capsule: Continuous with elbow capsule (joint spaces are continuous together).
*Synovial membrane: Downward prolongation of that of elbow joint.
*Ligaments:
Anuular ligament Quadrate ligament
*3/4 of fibroosseous ring, encircling head of radius to be *Quadrangular band connecting lower margin radial
attached to ant. & post. margins of radial notch ulna. notch ulna to med. aspect radius neck above tuberosity.
*It gives attachment to capsule & lat. collateral ligament of *It lies below the joint closing its cavity from below.
elbow. It is slightly narrower below preventing radius head
from downward dislocation.
 B)Inferior radio-ulnar joint
*Articular surfaces: -Head ulna -Ulnar notch radius -Articular disc.
*Type: Synovial, pivot (uniaxial)

*Capsule: Slightly thickened ant. & post., while being lax above to allow wide pronation.
*Synovial membrane: Lines capsule & sends a small pouch (recessus
sacciformis) infront of interosseous membrane between radius & ulna.

*Articular disc: -Triangular fibrocartilaginous disc, attached by its apex to

depression between styloid process & head of ulna while base attached to
lower edge of ulnar notch radius.

-Its upper surface is concave & articulates with ulna head while its lower
surface is also concave & articulates with lunate. It separates cavity of inf.
radio-ulnar joint from that of wrist joint.

Supination & pronation

*Joints: Sup. & inf. radio-ulnar joints (pivot joints).
*Axis of movement: Vertical axis from center of radius head to rough
impression at ulna head (attachment of articular disc apex).
*Mechanism of movement: -Head of radius rotates within ring formed of
radial notch ulna & annular ligament (at sup. radio-ulnar joint).
-Shaft of radius swing while that of ulna remains relatively fixed.
-Lower end radius with articular disc rotate around ulna head (at inf. radio-
ulnar joint) carrying hand with it (ulna head acts as fixed bone around which
radius lower end rotates).

In supination In pronation
-Radius & ulna are parallel. -Shaft radius lie across front of shaft ulna, lower end radius lies on
-Palm faces forwards. med. side ulna.
-Thumb directed laterally. -Palm faces backwards -Thumb directed medially.
-Interosseous membrane tense. -Interosseous membrane lax -Carrying angle at elbow disappears.
*Muscles: Supination; biceps (most powerful supinator of flexed elbow) &
supinator (main supinator of extended elbow).
Pronation; pronator teres & pronator quadrates.
N.B. -Supinators are more powerful than pronators.
-Brachioradialis put forearm in mid prone position.

Interosseous membrane
In addition to sup. & inf. radio-ulnar joints, radius & ulna are joined by fibrous
membrane (interosseous membrane).
*Attachments: *Lat.: Interosseous border radius.
 *Med.: Interosseous border ulna.
*Above (free border): 2.5 cm below radial tuberosity.
*Below: Blends with inf. radio-ulnar joint capsule.
*Fibers direction: Obliquely downward & med. from radius to ulna.
*Functions: *Increases area for forearm muscles origin;
(flexor pollicis longus & flexor digitorum profundus (ant.), abductor pollicis
longus, extensor pollicis longus & brevis, extensor indicis (post.).
*Radius receives force from hand & interosseous membrane (due to direction
of its fibers) transmits it to ulna which transmits it upward to humerus.

*Relations: *Ant. interosseous N. & vessels lie on its ant. surface.

*Ant. interosseous A. pierces it 5 cm above its lower end.
*Post. interosseous vessels pass backward above its upper border.
*Pronator quadratus crosses infront of its lower part.

Wrist joint
*Articular surfaces:
-Proximally: Inf. surface lower end radius (lat. triangular part & med. quadrilat. Part) & inf. surface of articular disc of inf.
radio-ulnar joint (elliptical concave surface with 5 cm transverse & 2 cm antero-post. diameters).
-Distally: 3 carpal bones (oval convex surface); scaphoid, lunate (below radius) & triquitral (below articular disc).
N.B.: Ulna doesnot share in wrist joint formation due to presence of articular disc, so wrist joint is called radio-carpal joint.
*Type: Synovial, ellipsoid (biaxial).
*Capsule: Attached to margins of articular surfaces.

*Ligaments: *Radial collateral ligament: From tip of styloid process radius

to lat. side scaphoid & trapezium.
*Ulnar collateral ligament: From tip of styloid process ulna to med. side
triquetral & pisiform.
*Palmar radiocarpal ligament: From ant. margin of radius lower end to ant.
surface of scaphoid, lunate & triquetral.
*Dorsal radiocarpal ligament: From post. surface of radius lower end to post.
surface of scaphoid, lunate & triquetral.
*Palmar ulnocarpal ligament: From base styloid process ulna & ant. margin of
articular disc to ant. surface of lunate & triquetral.

*N. supply: Ant. & post. interosseous nerves.

*Arterial supply: Ant. & post. carpal arches.
 *Movements & muscles acting on wrist joint:
Flexion Extension Adduction Abduction
-Flexor carpi radialis. -Extensor carpi radialis longus. -Flexor carpi ulnaris. -Flexor carpi radialis.
-Flexor carpi ulnaris. -Extensor carpi radialis brevis. -Extensor carpi ulnaris. -Extensor carpi radialis longus.
-Palmaris longus. -Extensor carpi ulnaris. -Extensor carpi radialis brevis.
-Flexor digitorum -Extensor digitorum. -Abuctor pollicis longus.
superficialis & profundus. -Extensor digiti minimi.
-Flexor pollicis longus. -Extensor indicis.
Relations: *Ant.: Flexor retinaculum with structures superficial & deep to it.
*Post.: Extensor retinaculum with structures superficial & deep to it.
*Postero-laterally: Anatomical snuff box.
Midcarpal joint
*Articular surfaces: Proximal & distal rows of carpal bones.
*Type: Synovial, modified ellipsoid.
*Movements: Complimentary to those of wrist, but much more limited.
Carpo-metacarpal joints
A)Carpo-metacarpal joint of thumb
*Articular surfaces: Trapezium with 1st metacarpal base.
*Type: Synovial, saddle (biaxial).
*Movements:
Flexion Extension Adduction Abduction Opposition
-Flexor pollicis longus. -Extensor pollicis longus. -Adductor pollicis. -Abductor pollicis longus. -Opponens pollicis.
st
-Flexor pollicis brevis. -Extensor pollicis brevis. -1 palmar -Abductor pollicis brevis. -Adductor pollicis.
-Oppenens pollicis. interosseous. -Flexor pollicis brevis.

N.B.: Circumduction; is a combination of 1st 4 movements.

B)Carpo-metacarpal joints of med. 4 fingers
*Type: Synovial, plane (non-axial).
*Movements: Gliding movement (minimal).
Metacarpo-phalangeal joints
*Articular surfaces: Heads of metacarpals & bases of proximal phalanges.
*Type: Synovial, ellipsoid (the thumb joint is regarded as hinge as adduction &
abduction are restricted at this joint).
*Movements:
Metacarpo-phalangeal joints med. 4 fingers Metacarpo-phalangeal joint thumb
*Flexion: Flexor digitorum superficialis & profundus, lumbricals & interossei. *Flexion: Flexor pollicis longus & brevis.
*Extension: Extensor digitorum, extensor digiti minimi & extensor indicis. *Extension: Extensor pollicis longus & brevis.
*Adduction: Palmar interossei.
*Abduction: Dorsal interossei.
inter-phalangeal joints
*Type: Synovial, hinge (uniaxial) *Movements:
Inter-phalangeal joints of med. 4 fingers Inter-phalangeal joint of thumb
*Flexion: Flexor digitorum superficialis & profundus. *Flexion: Flexor pollicis longus.
*Extension: Extensor digitorum, extensor digiti minimi, extensor indicis, *Extension: Extensor pollicis longus.
lumbricals & interossei.
 Mammary gland development
*Mammary line Mammary gland develops from ectodermal thickening line in
epidermis (mammary or milk line –ridge-), which extends on ventral body wall
from axilla down to inguinal region med. part. Major part of line disappears
shortly after it's appearance, leaving only limited part in thoracic region where
the gland develops.

*Formation of glandular tissue: -Mammary gland arises as 1ry ectodermal

bud which gives 15-20 solid 2ry ectodermal buds at mammary line, which
shift into underlying mesoderm, where they elongate & branch repeatedly.
Then buds become canalized shortly before birth to form lactiferous tubules.
(ducts), each of which forms separate gland lobe. Lactiferous tubules open
into a pit (depression) on surface. Shortly after birth, this pit becomes everted
& protrudes on surface, forming nipple.

-At puberty, mammary gland enlarges in size under influence of ovarian hormones,
which lead to new branching of lactiferous tubules & to deposition of more fat
between gland lobules.

*Anomalies: 1-Polythelia (supernumerary nipple); presence of more than

one nipple on one side, anywhere along mammary line.
2-Polymastia; presence of an accessory whole gland, from mammary line rudiment.
3-Inverted nipple; nipple failure to become everted.