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Outline
• Introduction
• Bones of the upper limb
• Superficial structures of upper limb
• Axioappendicular Muscles
• Axilla
• Brachial plexus
• Arm
• Cubital fossa
• Forearm
• Hand
• Surface anatomy upper limb
• Joints of upper limb 2
 The Upper Limb

• Characterized:
 its mobility

 ability to grasp, strike, & conduct fine motor skills

(manipulation)
• The upper limb is divided into:
• The Shoulder girdle
- joining the arm to the trunk
The Arm (brachium)
- extends from the lower border of teres major to a
transverse line drown between the medial and lateral
epicondyles of the humerus.
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• The Forearm (antebrachium) - extends from
the transverse line joining the medial and
lateral epicondyles of the humerus to the
lower cutaneous fold of the wrist

• Hand - the part below the lower cutaneous

fold of the wrist.
• The arm and forearm are joined at the
elbow (cubitus) and the forearm is joined to
the hand at the wrist (carpus)
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 Bones of the upper limb
• The upper limb contains the following
bones
1. Shoulder girdle - Clavicle and scapula
2. Arm - Humerus
3. Forearm - Radius and ulna
4. Hand - Carpals, metacarpals and
phalanges

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 Upper Limb Skeleton

• Scapula
• Hummers
• Radius, ulna
• Carpals
-proximal
-distal
• Digits
– Metacarpals
– Phalanges

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 Shoulder girdle (Pectoral girdle)

• attaches the upper limb to the axial skeleton

• It forms no articulation with the vertebral column
• Each of the two shoulder girdles consists of two
bones, the clavicle (collar bone) and the Scapula
(Shoulder blade).
• The clavicle forms the anterior component of the
shoulder girdle and articulates with the sternum and
the scapula.
• The posterior component, the scapula, is freely
suspended from the thorax by complex muscular
attachments and articulates with the clavicle and the
humerus.
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 clavicle

scapula

humerus

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 Functions of the clavicle and the scapula

• They join the upper limb to the trunk

• They increase the range or extent of joint

movement at the shoulder

• They serve as origin and insertion for the

muscles of the shoulder girdle.

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 Clavicle
• a long slender bone with a double curvature

• It extends from the sternum laterally and

backwards across the first rib to the acromion
process of the scapula playing an important role
as outrigger in thrusting the scapula away from
the chest wall thereby increasing the range of joint
movement at shoulder and arm

• In its fracture the shoulder falls forward upon the

chest.
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 Clavicle
acromial end sternal end

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• The clavicle ossifies in a membrane and it is
the first bone to start ossification at around
the 5th week of development.

Parts of the clavicle

1. Sternal end - is rounded and articulates

with the sternum. It appears quadrangular
or triangular in cross section.

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2. Acromial end

 is a flattened part that articulates with the

acromion process of the scapula
 Nearer to the acromial end on the anterior
border of the clavicle there is a small
thickening called deltoid tubercle

3. Shaft - is the part between the two ends

having a double curvature in a horizontal
plane
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• The clavicle is the only long bone without a
medullary cavity

• The part of clavicle between its medial 2/3

(which is convex forward) and its lateral 1/3
(which concave forward) medial to the
coracoid process of the scapula is the
weakest part and is a frequent site of
fracture.

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• Muscles attached to the clavicle
1. Clavicular head of pectoralis major
2. Deltoid
3. Clavicular head of sternocleidomastoid
4. Lateral part of sternohyoid
5. Trapezius
6. Subclavius

• Other structures attached to the clavicle

1. Clavipectoral fascia
2. Anterior and posterior sternoclavicular
ligaments
3. Interclavicular ligament
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 Fracture of clavicle
• Commonly caused by an indirect
force transmitted from un
outstretched hand during a fall
• The weakest part is at the junction
of its middle and lateral thirds
• After fracture
– sternocleidomastoid (SCM)
muscle elevates the medial
fragment of bone
– trapezius muscle is unable to
hold up the lateral fragment
owing to the weight of the
upper limb
– thus the shoulder drops
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 The Scapula
• is a large triangular bone in the dorso-lateral
aspect of the thorax at the level of the 2nd -
7th ribs

• It articulates with the humerus and the

clavicle

• It is separated from the ribs by muscles

gliding on the chest wall in what has been
termed Scapulothoracic joint
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 acromion
process
coracoid process

glenoid
cavity
superior angle

Anterior Scapula
subscapular fossa inferior angle

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Posterior scapula
Posterior Scapula
acromion process

supraspinous fossa

infraspinous fossa spine

lateral border
medial border

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• The relatively smaller glenoid cavity is
enlarged by a fibrocartilaginous rim called
glenoidal labrum to accommodate the large
head of the humerus

• Above and below the glenoid cavity there

are supraglenoid and infraglenoid tubercles
that provide attachment sites for the long
heads of biceps and triceps muscles
respectively.

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• The two fossae communicate laterally via the
spinoglenoidal notch

• On the superior border just medial to the coracoid

process is the scapular (suprascapular) notch,
which is bridged over by the suprascapular
(superior transverse scapular) ligament forming a
foramen that transmits the suprascapular nerve to
the supraspinous fossa, while the suprascapular
vessels ride over the ligament.

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 Structures attached to the scapula

• Muscles
1. Deltoid 4. Coracobrachialis

2. Trapezius 5. Long head of triceps

3. Long and short heads of biceps
• Ligament
1. Coracoclavicular ligament
2. Coracoacromial ligament
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3. Suprascapular ligament
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 HUMERUS
has upper end, shaft and lower end.
• Upper end
1. Head-directed medially, backwards and
upwards
• articulates with the glenoid cavity to form
shoulder joint.
• covered by a hyaline cartilage
2. The line separating the head from the rest of
the upper end is called the Anatomical neck.
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3. Lesser tubercle is an elevation on the anterior
aspect of the upper end.
4. Greater tubercle is an elevation that forms the
lateral part of the upper end; its posterior
aspect is marked by three impressions, upper,
middle and lower.
5. Intertubercular sulcus ( Bicipital groove)
The sulcus has medial and lateral lips that
represent downwards prolongation of lesser
and greater tubercles.
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 Anterior Humerus
lesser
medial epicondyle deltoid tubercle
trochlea tuberosity

coronoid fossa intertubercular

groove greater
capitulum tubercle
lateral epicondyle

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•.

6. The line separating the upper end of the humerus from the
shaft is called the surgical neck.
• Shaft
is rounded in the upper half and triangular in the lower
half
has three borders and three surfaces
 At about the middle on the lateral side there is a V-
shaped rough raised area called deltoid tuberosity
to which the deltoid muscle is inserted
Radial sulcus (radial groove, radial fossa or spiral
groove
• Through this sulcus runs the radial nerve.
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 Lower End
• Forms condyle which is expanded from side
to side & has articular & nonarticular parts.
• Articular part
1.Capitulum is a rounded projection which
articulates between head of radius

2. Trochlea is a pulley shapes surface . It

articulates with the trochlear notch of the
ulna.
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1.-Three nerves are directly related to the
humerus and are therefore liable to injury.
-axillary nerve at the surgical neck
- radial nerve at the radial groove
- ulnar nerve behind the medial epicondyle
• Clinical features
2 Common sites of fracture are the surgical neck ,the
shaft & supracondylar region
3 The head of humerus commonly dislocates
inferiorly.
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 Fracture of the humerus
• Fractures of the surgical neck of the humerus
– common in elderly people
– usually result from a fall on the hand
• Transverse fractures of the shaft of humerus
• Supracondylar fracture
• Because nerves are in contact with the humerus,
they may be injured when the associated part of the
humerus is fractured
– Surgical neck – axillary nerve
– Radial groove – radial nerve
– Distal humerus – median nerve
– Medial epicondyle – ulnar nerve
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 BONES OF THE FOREARM
These are radius and ulna.
RADIUS
-lateral bone of the forearm & is homologous
with the Tibia.
-thinner proximally & progressively thickens
distally.
• has three parts
- proximal
- shaft
- distal
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trochlear notch
Ulna
coronoid process head

radial notch
styloid process
olecranon process

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 Radius
radial tuberosity

head styloid process

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• Proximal end
- consists of the head, neck & radial tuberosity
1 Head - is disc shaped & is covered with hyaline
cartilage.
- has superior concave surface which articulates with
capitulum on humerus at the elbow joint.
- has articular circumference that rotates in the
radial notch of the ulna, covered by hyaline
cartilage & surrounded by annular ligament.

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• Clinical features
- Radius commonly fractures ~2cm above
its lower end (Colle’s fracture) distal
fragment is displaced upwards &
backwards ( if upwards & forwards it is
called Smith’s fracture ) , caused by a
fall on outstretched hand.
- A sudden powerful jerk on the hand of
a child may dislodge the head of the
radius from the grip of the annular
ligament, this is known as subluxation
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 ULNA
• Is the medial and longer bone of the forearm
and is homologous to fibula of lower limb.
• Its thickness decreases in a distal direction or
viceversa.
• Proximal /Upper End.
-Presents the olecranon and coronoid process,
and the trochlear and radial notches.

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 Fracture of ulna and radius
• A direct injury usually produces transverse
fractures at the same level, often in the middle third
of the bones
• Colles fracture
– A complete fracture of the distal end of the radius
– The most common fracture of the forearm
– Results from forced dorsiflexion of the hand
– The distal fragment of the radius is displaced
dorsally and often broken into pieces
– Often, the ulnar styloid process is avulsed
(broken off)

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Colles fracture

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CARPAL BONES
The carpus is made up of 8 carpal bones- arranged in
two rows.
1. Proximal row contains (from lateral to medial side)
• scaphoid
• lunate
• triquetral
• pisiform .
2. Distal row contains in the same order
- trapezium
- trapezoid
- capitate
- hamate.
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Manus (Hand)

Carpals (8)

Metacarpals (5)
3
1 pollex

Digits (5)
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• IDENTIFICATION
1.Scaphoid , is boat shaped and has tubercle on
lateral side.
2. Lunate , half moon-shaped or crescentic.
3. Triquetal – is pyramidal in shape, has isolated
oval facet on the distal part of the palmar
surface.
4. Pisiform , is pea shaped and has only one oval
facet on the proximal part of its dorsal surface.

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5. Trapezium is quadrangular in shape, and has a
crest and a groove anteriorly. It has a
concavoconvex articular surface distally.
6. Trapezoid- resembles shoe of a baby.
7. Capitate- largest carpal bone with a rounded
head.
8. Hamate – is wedge shaped with a hook near
its base

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CLINICAL FEATURES
• Commonest injuries which occur in the carpus
are fracture of the scaphoid and dislocation of
the lunate.
METACARPAL BONES
• These are 5 miniature long bones, which are
numbered from lateral to medial side.
• Each bone has a head (placed distally), a shaft
and a base (at the proximal end)

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 PHALANGES
• There are 14 phalanges in each hand, 3 for
each finger and 2 for the thumb.
• Each phalanx has a base , a shaft and a head.

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• SESAMOID BONES OF THE UPPER LIMB.
• Sesamoid bones are small rounded masses of
bone located in some tendons at points where
they are subjected to great pressure.
1. Pisiform is often regarded as sesamoid bone
lying with in flexor carpi ulnaris.
2. Two sesamoid bones are always found on the
palmar surface of the hand of 1st metacarpal
bone.

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3. One sesamoid bone is found in the capsule of
interphalangeal joint of the thumb, in 75% of
subjects.
4. One sesamoid bone is found on the ulnar side
of intercarpophalangeal joint of little finger~
75% of subjects.
5. Less frequently there is a sesamoid on lateral
side of the metacarpophalangeal joint of index
finger.
6. sometimes found on other metacarpophalangeal
joints.
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 Anterior Humerus
A I H
B J

C F
G
D
E
Surface anatomy of upper limb bones
• The following structures are palpable
– Jugular notch
– Acromion
– Coracoid process of scapula
– Spine of scapula
– Greater tubercle of humerus
– Medial and lateral epicondyles
– Olecranon
– Styloid processes of radius and ulna
– Pisiform
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Fascia of upper limb
• Pectoral fascia
– Invests the pectoralis major
– Continuous inferiorly with fascia of anterior
abdominal wall
– Leaves lateral border of pectoralis major
and becomes axillary fascia

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• Clavipectoral fascia
– Deep to pectoralis major
– Descends from the clavicle, enclosing subclavius
and then the pectoralis minor
– Becoming continuous inferiorly with the axillary
fascia
– Costocoracoid membrane
• the part of clavipectoral fascia between pectoralis
minor and subclavius
• pierced by lateral pectoral nerve
– Suspensory ligament of axilla
• the part of the clavipectoral fascia inferior to pectoralis
minor
• supports the axillary fascia and pulls it upward and
forms axillary fossa 82
• Clavipectoral fascia …
a layer of deep fascia attaching to the
clavicle superiorly.
pierced by cephalic v., lateral pectoral n.,
thoracoacromial a.)
 It encloses the pectoralis minor m. then
continues inferolaterally to attach to the
axillary fascia, a part which is called the
suspensory ligament of the axilla.

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 Axillary fascia
• The axillary fascia as part of the superficial
fascia of the body lies under the skin in the
axilla stretching between the lateral border of
pectoralis major muscle and the anterior
border of the latissimus dorsi muscle

• It is continuous anteriorly with pectoral

fascia and laterally with the fascia brachii.

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 Brachial fascia :
 deep fascia which forms a tubular
investment of the arm
 attached to the humerus via medial and
lateral intermuscular septae and divide the
arm in to ant. and post. Compartments
continuos superiorly with deltoid,
pectoral,axillary and infraspinuos fascia.

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• Bicipital aponeurosis:
• an extension of the tendon of the biceps brachii m.
that blends with the antebrachial fascia on the
medial side of the antecubital fossa

• it is superficial to the brachial artery and median

nerve, but deep to the superficial veins of the upper
limb
 this provides some protection for the deeper
structures during venipuncture

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 The fascia of the arm is continues with the
fascia of the forearm, which extends between the
olecranon process and distal end of ulna being
attached to its posterior surface

 Intermuscular septae arising from it divide the

forearm muscles in to flexor and, extensor groups

 At the wrist it is thickened to form two

retinacula

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 1) Flexor retinaculum –
lies between the pisiform and hamate
bones on one side and the scaphoid and
trapizium on the other side

Behind the flexor retinaculum the joint

between the carpal bones forms a ventrally
concave sulcus to form the carpal canal or
tunnel.

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Structures traversing the retinacula of
the wrist
I. Flexor retinaculum
Structures passing through the carpal tunnel
1. Tendon of flexor pollicis longus muscle
2. Tendon of flexor digitorium superficialis muscle
3.Tendon of flexor digitorum profundus muscle
4.Median nerve

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B. Outside the carpal tunnel
1. Tendon of palmaris longus muscle
2. Ulnar artery and vein
3. Ulnar nerve
4. Tendon of flexor carpi ulnaris
5.Antebrachial veins
6.Tendon of flexor carpi radialis

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 In the carpal tunnel compression of the
median nerve can
occur due to various causes usually by the
fibres of the flexor retinaculum resulting in
pain and paresthesia (tingling, burning and
numbness) in the hand in the area of
distribution of the median nerve. This is called
carpal tunnel syndrome.

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 2. Extensor retinaculum
• found on the dorsal aspect of the lower part
of the forearm or the wrist

• It overlies 6 compartment containing

extensor tendons and called osseofoscial
or osseofibrous tunnels.

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 Structures passing anterior to the
Extensor retinaculum through the
osseofascial tunnels
1.Tendon of abductor pollicis longus muscle

2.Tendon of extensor pollicis brevis muscle

3.Radial artery and vein
4.Tendon of extensor pollicis longus muscle
5.Tendon of extensor carpi radialis longus
muscle
6.Tendon of extensor carpi radialis brevis
muscle
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7. Tendon of extensor indicis muscle
8. Tendon of extensor digitorum muscle
9. Tendon of extesor digiti minimi muscle
10. Tendon of extesor carpi ulnas muscle
B. Structures passing posterior to the
extensor retinaculum (outside the
osseofascial tunnels)
1. Superficial radial nerve
2. Cephahlic and basilic veins
 
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• palmar aponeurosis:
• a thickening of the deep fascia covering the palm of the
hand
• composed of very dense connective tissue that extends out
into each of the fingers as fibrous tendon sheaths

• It is thick tendinous, triangular compartment of the palm

• It’s apex, located proximally, is continuous with the tendon

of palmaris longus

• The base is formed by superficial transverse palmar

ligament.

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Dupuytren’s contracture-
• is a disease of the palmar fascia
resulting in thickening and contracture
of the fibrous bands on the palmar
surface of the hand and the fingers
• It usually affects the medial half of the
palmar aponeurosis resulting in a
progressive flexion of the little and ring
fingers at the metacarpophalangeal and
proximal interphalangeal joints.
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Superficial Veins of the Upper
Limb
superficial veins of the upper limb: the
basilic vein (medial,superficial in forearm, pierces
brachial fascia, runs parallel to brachial artery and
merges to form axillary vein at axilla). The
cephalic vein (lateral, anterior to elbow,
communicates with median cubital vein, pierces
clavipectoral fascia to empty into axillary vein)
originate in the subcutaneous tissue of the dorsum
of the hand from the dorsal venous network
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 The Axillary Vein
 Formed from the union of the brachial veins and
the basilic vein at the inferior border of teres minor

 lies on medial side of axillary artery

 Ends at lateral border of 1st rib where it becomes

the subclavian vein

 The cephalic vein enters the axillary vein close to

its transition to subclavian vein
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Deep Veins of Arm
paired veins which accompany brachial
artery
Encompass the artery within a common
vascular sheath
Begin at elbow by union of radial and
ulnar veins
End by merging with the basilic vein to
form the axillary vein
The brachial veins contain valves
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 Superficial Veins of the Forearm
The cephalic vein forms over the anatomical
snuffbox from the lateral side of the dorsal venous
network.
The basilic vein arises from the medial side of the
dorsal venous network.
The median antebrachial vein begins in the
superficial venous palamr arch and usually ends
in the basilic vein.
The perforating veins form communications
between the superficial and deep veins
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12/05/2008
114
114
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 Deep Veins of the Forearm
Deep veins accompanying the arteries
are plentiful in the forearm
These veins arise from deep venous
arcade (a series of anastamosing venous
arches) in the hand

Paired radial and paired ulnar veins arise

and accompany the arteries,
anastamosing freely .
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116
116
 Lymphatic drainage
• The superficial vessels accompany the superficial
veins in the fore arm until the elbow, where they
enter lymph nodes (cubital or epitrochlear).
• From the elbow most of the vessels run with the
basilic vein to the superficial axillary lymph nodes.
• The deep vessels follow the arteries and they
similarly open in to the superficial axillary nodes.
• The lymph from the superficial axillary nodes is
drained to the deep axillary lymph nodes and then
to the subclavian trunk.

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12/05/2008 117
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12/05/2008 118
 Axillary Lymph Nodes
 Five principal groups:
 pectoral (anterior):lies along the medial wall of
axilla. Receive lymph from the anterior thoracic wall.
 Subscapular (posterior):receive lymph from the
posterior thoracic wall and scapula.
 Humeral (lateral):receive lymph from u.limb
 Central: receive lymph vesseles from the above three
groups.
Apical: receive lymph from all groups and
lymph vesseles accompanying cephalic vein.
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Cutaneous Nerves of Upper Limb
 C3 and C4 innervate base of neck
 C5 supplies the arm laterally
 C6 supplies the forearm laterally and the
thumb
 C7 supplies the middle fingers and middle
posterior surface of limb
 C8 supplies little finger, medial side of hand
and forearm
 T1 supplies middle of forearm to axilla
 T2 supplies skin of axilla
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12/05/2008 122
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12/05/2008 126
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12/05/2008 127
- Most cutaneous nerves of upper limb are
derived from the Brachial Plexus
- The nerves of the shoulder however are
derived from the cervical plexus

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12/05/2008 128
 Cutaneous Nerves are:
The supraclavicular nerve (C3 and C4)
Posterior cutaneous nerve of arm(C5-8)
Posterior cutaneous nerve of forearm(C5-8)
Superior lateral cutaneous nerve of arm(C5,6)
Inferior lateral cutaneous nerve of arm(C5,6)
Lateral cutaneous nerve of forearm(C6,7)
Medial cutaneous nerve of arm(C8-T2)
Medial cutaneous nerve of forearm(C8,T1)
Intercostobrachial (T2)
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129
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Axioappendicular Muscles

131
Anterior Axioappendicular Muscles
• Four muscles that move the pectoral girdle
– Pectoralis major
– Pectoralis minor
– Subclavius
– Serratus anterior

132
Anterior Axioappendicular Muscles

133
Pectoralis
major
• Origin - clavicle,
sternum, and
cartilages of ribs 1 - 6
• Insertion - greater
tubercle of humerus
• Action - arm flexion,
arm medial rotation,
arm adduction
• Accessory muscle of
respiration in forceful
inspiration

• Innervation – lateral
and medial pectoral
nerves (C5-C7 &T1)

134
Pectoralis
minor
• Origin - anterior
surfaces of ribs 3-5
• Insertion - coracoid
process of scapula
• Action - ribs fixed
draws scapula
forward and
downward
• Innervation - medial
pectoral nerve (C8 &
T1)

135
136
 Serratus
anterior
• Origin – lateral
parts of ribs 1-8
• Insertion -
anterior surface of
medial border of
scapula
• Action - protract
the scapula;
rotates scapula
• Innervation - long
thoracic nerves
(C5-C7)
137
138
Paralysis of serratus anterior
• Due to injury of long
thoracic nerve
• Medial border of the
scapula moves laterally
and posteriorly away
from thoracic wall
– winged scapula
• Arm cannot be abducted
above horizontal
position

139
Subclavius
• Lies horizontally inferior to clavicle
• Small, round
• Protect subclavian vessels and superior
trunk of brachial plexus
• Origin: Junction of 1st rib and its costal
cartilage
• Insertion: Inferior surface of middle third of
clavicle
• Innervation: Nerve to subclavius
• Action: Anchors and depresses clavicle
140
141
Posterior Axioappendicular Muscles
• Attach the superior appendicular skeleton to
the axial skeleton
• Divided into three groups
– Superficial (extrinsic shoulder) muscles :
trapezius and latissimus dorsi
– Deep (extrinsic shoulder) muscles : levator
scapulae and rhomboids
– Scapulohumeral (intrinsic shoulder) muscles:
deltoid, teres major, and the four rotator cuff
muscles (supraspinatus, infraspinatus, teres
minor, and subscapularis) 142
Posterior Axioappendicular Muscles

143
Trapezius
• Origin - Occipital bone,
ligamentum nuchae,
spines of C7 & all
thoracic vertebrae
• Insertion - acromion
and spine of scapula
and lateral 1/3 of
clavicle
• Action - elevate and
rotate scapula
• Innervation - spinal
accessory nerve and
cervical nerves (C3 &
C4)

144
Latissimus
dorsi
• Origin - spines of T6
- T12 and
thoracolumbar
fascia, iliac crest
and inferior ribs
• Insertion - inter-
tubercular groove of
humerus
• Action - arm
extension,
adduction and
medial rotation
• Innervation
-thoracodorsal
nerve (C6-C8)
145
146
Rhomboid
major
• Origin - spinous
processes of T2 - T5
• Insertion - medial
border of scapula
• Action – retract,
rotate and stabilize
scapula
• Innervation - dorsal
scapular (C5) and
cervical nerves (C3
& C4)

147
Rhomboid
minor
• Origin - spinous
processes of C7
and T1
• Insertion - medial
border of scapula
• Action – retract,
rotate and stabilize
scapula
• Innervation -
dorsal scapular
nerve

148
Rhomboid Mj,Mi & Levator scapulae

149
Scapulohumeral Muscles
• Six muscles
– Deltoid
– Teres major
– Supraspinatus
– Infraspinatus
– Subscapularis
– Teres minor
• Short muscles that pass from scapula to
humerus
• Act on glenohumeral joint 150
Deltoid muscle
• Thick powerful muscle forming the rounded contour
of the shoulder
• Divided into clavicular (anterior), acromial (middle),
and spinal (posterior) parts that can act separately
or as a whole
• When all three parts contract simultaneously, the
arm is abducted
• The clavicular and spinal parts steady the arm as it
is abducted
• Act as a shunt muscle, resisting inferior
displacement of the head of the humerus from the
glenoid cavity
151
• Origin: Lateral third of clavicle; acromion and
spine of scapula
• Insertion: Deltoid tuberosity of humerus
• Innervation: Axillary nerve
• Action:
– Anterior part: flexes and medially rotates
arm
– Middle part: abducts arm
– Posterior part: extends and laterally
rotates arm
152
153
Teres major
• Thick rounded muscle that lies on the
inferolateral third of the scapula
• Along with the deltoid and rotator cuff
muscles it is an important stabilizer of the
humeral head in the glenoid cavity during
movement
• Origin: Posterior surface of inferior angle of
scapula
• Insertion: intertubercular groove of humerus
• Innervation: Lower subscapular nerve
• Action: Adducts and medially rotates arm 154
Rotator cuff muscles
• Four of the scapulohumeral muscles: supraspinatus,
infraspinatus, teres minor, and subscapularis
• Called rotator cuff because they form a musculotendinous
cuff around glenohumeral joint
• All except the supraspinatus are rotators of the humerus
• The supraspinatus initiates and assists the deltoid in the
abduction of the arm
• The tendons of the rotator cuff muscles blend with the joint
capsule of the glenohumeral joint, which protects the joint
and gives it stability
• Tonic contraction of these muscles holds the relatively large
head of the humerus firmly against the small and shallow
glenoid cavity during arm movements

155
156
157
Supraspinatus
• Origin: Supraspinous fossa of scapula
• Insertion: greater tubercle of humerus
• Innervation: Suprascapular nerve
• Action: Initiates and assists deltoid in abduction of
arm and acts with rotator cuff muscles
Infraspinatus
• Origin: Infraspinous fossa of scapula
• Insertion: greater tubercle of humerus
• Innervation: Suprascapular nerve
• Action: Laterally rotate arm; help hold humeral
head in glenoid cavity of scapula
158
Teres minor
• Origin: Middle part of lateral border of scapula
• Insertion: greater tubercle of humerus
• Innervation: Axillary nerve
• Action: Laterally rotate arm; help hold humeral head
in glenoid cavity of scapula
Subscapularis
• Origin: Subscapular fossa
• Insertion: Lesser tubercle of humerus
• Innervation: Upper and lower subscapular nerves
• Action: Medially rotates and adduct arm; helps hold
humeral head in glenoid cavity 159
Injury to axillary nerve
• Occur when surgical neck of humerus is
fractured
• Results in atrophy of deltoid
• Rounded contour of shoulder disappears
• To test deltoid (function of axillary nerve) the
arm is abducted against resistance
Rotator cuff injuries
• Produce instability of glenohumeral joint
• Rapture of supraspinous tendon is the most
common injury
160
Surface anatomy

161
Surface anatomy
• Triangle of auscultation
– The area formed by the superior border of
latissimus dorsi, the medial border of the
scapula, and the inferolateral border of the
trapezius
– This gap in the thick back musculature is a good
place to examine posterior segments of the
lungs with a stethoscope
– When the scapulae are drawn anteriorly by
folding the arms across the thorax and the trunk
is flexed, the auscultatory triangle enlarges
162
 Axillary region
• In the axillary region two parts should be
distinguished.
1. Axillary fossa (arm pit)
2. Axillary cavity (Axilla)
• Axillary fossa - is the visible deepening or groove
between the arm and the lateral thoracic wall.

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• Boundaries
- Anterior - anterior axillary fold
- Posterior - posterior axillary fold
- Lateral - medial side of the upper part of the
arm.
- Medial - lateral wall of the thorax

• The anterior axillary fold is formed by pectoralis

major muscle while the posterior axillary fold is
formed by the latissimus dorsi and teres major
muscles

04/19/20 05:55 PM 164

• Axilla - is a pyramidal space .
. Its base is formed by the axillary fascia.
. Its apex open to the lateral neck region
through a triangular space between the first
rib, the clavicle and scapula. This space is
known as cervicoaxillary canal.
. The main function of the axilla is to
transmit and protect blood vessels and
nerves that run from the neck to the arm or
vice versa.
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• In the upper part of the axilla these vessels
and nerves are related to each other in such
a way that the axillary vein lies ventromedial
(ventral), the axillary artery at the middle
and the brachial plexus dorsolateral
(dorsal).
• Additionally the axilla gives a greater
possibility of movement to the shoulder
girdle.

04/19/20 05:55 PM 166

• Walls of the axilla:
. Anterior - pectoralis major and minor
muscles
. Medial - serratus anterior muscle
. Lateral
-bony part
-intertuercular groove of the
humerus
. Posterior - subscapularis (upper part)
- latissimus dorsi and teres
major
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(lower part) 167
168
04/19/20 05:55 PM 169
• The vessels and nerves give important
branches in the axilla. Some of these
branches run to the posterior aspect of the
shoulder by passing through two openings.
1. A medial triangular space or Medial
axillary hiatus (interval) - contains the
circumflex scapular artery and vein.
2. A quadrangular space or lateral axillary
hiatus - containing the axillary nerve and the
posterior circumflex humeral vessels (artery
and
04/19/20 vein).
05:55 PM 170
• Related to these on the adjacent part of the
arm there is a lateral triangular space that
contains the profunda brachii artery and the
radial nerve.
• Contents of the axilla
1. Axillary vessels
2. Infraclavicular part of the brachial plexus
3. Lateral cutaneous branches of the
intercostal nerves
4. Axillary lymph nodes
5. Adipose
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 Axillary artery
• The axillary artery is continuous proximally
with the subclavian artery and distally with
the brachial artery.
• It begins at the outer border of the upper
surface of the first rib and ends at the lower
border of teres major muscle after which it
becomes brachial artery.

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• The pectoralis minor muscle crosses over
the artery and divides it into three parts.
1. First or proximal part - between the first
rib and the medial border of pectoralis
minor.
2. Second or posterior part - behind or
posterior to the muscle.
3. Third or distal part - between the lateral
border of pectoralis minor and the lower
border of teres major.
• Each of these parts gives branch to one,
two and three arteries respectively.
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176
04/19/20 05:55 PM 177
A. Branch from the first part:
• Superior thoracic artery - it supplies the
muscles and the wall of the thorax in the
upper part of the pectoral region. It forms
anastomosis with the intercostal and the
internal thoracic arteries.
• Sometimes the superior thoracic artery may
arise from the thoracoacromial artery.

04/19/20 05:55 PM 178

B. Branches from the second part:
1. Thoracoacromial artery - gives rise to the
following four branches.
a. Pectoral branch
b. Acromial branch
c. Clavicular branch
d. Deltoid branch
2. Lateral thoracic artery - descends to the
lateral thoracic wall along the lateral border
of the pectoralis minor muscle.
C. Branches from the third part:
1. Subscapular artery - descends along the
lateral border of the scapula and divides in
to thoracodorsal and circumflex scapular
arteries.
04/19/20 05:55 PM 179
• The thoracodorsal artery runs with the
thoracodorsal nerve to the latissimus dorsi muscle
• the circumflex scapular artery turns backwards
around the lateral border of the scapula and
passes through the medial triangular space to
form anastomosis with the suprascapular artery
and the deep and superficial branches of the
transverse cervical artery in the posterior part of
the scapula forming the so called scapular
anastomosis
• This anastomosis provides an adequate collateral
blood flow in either directions.

04/19/20 05:55 PM 180

2. Anterior circumflex humeral artery - a
small branch that runs dorsally anterior to
the surgical neck of the humerus.

3. Posterior circumflex humeral artery - it

courses posteriorly around the surgical
neck of the humerus with the axillary nerve
and passes through the quadrangular
space.

04/19/20 05:55 PM 181

182
 Axillary vein
• The axillary vein that lies anteromedial to
the axillary artery is formed by the fusion of
the brachial veins and basilic veins and
drains into the subclavian vein.
• Below the clavicle its lumen is kept open by
the clavipectoral fascia, because of which
its open injury results in air embolism.
• Its tributaries correspond to the branches of
the axillary artery, which are venae
commitantes.
04/19/20 05:55 PM 183
04/19/20 05:55 PM 184
 MUCLES OF THE UPPER LIMB
Muscles of the arm 
• The muscles of the arm are divided
in to extensors ( the posterior
compartment) and flexors ( anterior
compartment.
• Muscles of the same compartment
are similar in:
Their actions on the elbow joint
Innervation and development
Have the same covering fascia 
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04/19/20 05:55 PM 186
Flexor group of arm muscles
This group is composed of three
muscles, namely biceps brachii,
coracobrachialis and brachialis
muscles

04/19/20 05:55 PM 187

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189
Biceps brachii 
O:Long head: supraglenoid tubercle and the
superior portion of the glenoid labrum.
Short head: lateral aspect of the apex of the
coracoid process of the scapula.   
I:Radial tuberosity and the biceptal
aponeurosis. 
In: Musculocutaneous nerve (C5, 6). 
B/s: Muscular branches from the brachial
artery.
 
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04/19/20 05:55 PM 191
 

Action
1. Flexion of the forearm at the elbow
Biceps brachii flexes the elbow with the
forearm supinated
2. Assists with flexion of the arm at the
shoulder
3. Assists with supination of the forearm

04/19/20 05:55 PM 192

Coracobrachialis 
O: apex of the coracoid process of the scapula.
 I:Medial aspect of the mid shaft of the
humerus 
In: Musculocutaneous nerve (C5, 6, 7). 
B/ s:Muscular branches from the brachial
artery. 
Action
1.Flexion of the arm at the shoulder 
2.Assists with adduction of the arm at the
shoulder
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Brachialis 
O:Lower half of the anterior aspect of humerus 
I:Tuberosity and coronoid process of the ulna. 
In: Musculocutaneous nerve (C5, 6). 
B/s:Muscular branches from brachial artery and
radial recurrent artery from the radial artery. Action
Flexion of the forearm at the elbow
Flexor carpi radialis will contract during flexion of
the elbow against a heavy resistance and pronator
teres may also assist.
04/19/20 05:55 PM 195
Triceps brachii:
O:long head:Infraglenoid tubercle of the scapula
Lateral head:posterior surface of humerus,
superior to radial groove
Medial head: Posterior surface of humerus
,inferior to radial groove
I:Posterior surface of the olecranon process of
the ulna. 
In: Radial nerve (C6, 7,8)
B/s:muscularbranches,superiorulnarcollateral,
profundal brachial arteries(branches of brachial
artery.
04/19/20 05:55 PM 196
197
Lateral head of tricepts

Long head of triceptis

Middle head

04/19/20 05:55 PM 198

Action
Chief extensor of the forearm
Long head resists dislocation of shoulder
important during abduction.

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04/19/20 05:55 PM 200
Anconeus 
O:Posterior surface of the lateral epicondyle of
the humerus.
I; Lateral aspect of the olecranon, extending to
the lateral part of the ulnar body.
 In: Radial nerve (C7, 8). 
B/ s:Profunda brachii artery from the brachial
artery. 
Actions
Anconeus is a weak extensor of the elbow,
stabilizes elbow joint, may abduct ulna during
pronation
04/19/20 05:55 PM 201
 
Anconeus

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04/19/20 05:55 PM 203
04/19/20 05:55 PM 204
Cubital fossa
• Shallow triangular depression on anterior surface
of the elbow
• Boundaries
– Superiorly, an imaginary line connecting the medial and
lateral epicondyles
– Medially, pronator teres
– Laterally, brachioradialis
• Floor
– brachialis and supinator muscles
• Roof
– the continuity of brachial and antebrachial (deep) fascia,
reinforced by the bicipital aponeurosis, subcutaneous
tissue and skin
205
• Contents
– Brachial artery and branches, radial and ulnar
arteries
– Accompanying veins of the arteries
– Biceps brachii tendon
– Median nerve
– Radial nerve, dividing into its superficial and
deep branches
– Median cubital vein

206
207
208
 MUSCLES OF THE FORE ARM
Flexor-pronator muscles
Superficial layer
pronator teres m. Palmaris longus m.
Flexor carpi radialis m. Flexor carpi ulnaris m .
Intermediate layer
flexor digitorum superficialis
Deep layer
flexor digitorum profundus m
flexor policis longus m.
pronator quadratus
04/19/20 05:55 PM 209
• Superficial layer
– Four muscles: Pronator teres, Flexor carpi radialis,
Palmaris longus, Flexor carpi ulnaris
– All are attached proximally by a common flexor tendon to
medial epicondyle of humerus (common flexor origin)
• Intermediate layer
– One muscle: Flexor digitorum superficialis
• Deep layer
– Three muscles: Flexor digitorum profundus, Flexor pollicis
longus, Pronator quadratus
• Superficial and intermediate muscles cross the
elbow joint; deep muscles do not
• Functionally, the brachioradialias is a flexor of
forearm, but it is located in posterior or extensor
compartment and is thus supplied by radial nerve
211
The superficial layer
of muscles
Has 4 groups of
muscles (pronator
teres, flexor carpi
radialis, palmaris
longus, and flexor
carpi ulnaris)
has a common
origin (medial
epicondyle of the
humerus.)
Nerve supp. Median
N. with few
exception(ulnar)
Action: flexion at
carpal, MCP and
Interphalangeal
joints
04/19/20 05:55 PM 213
• Pronator teres 
O:Humeral head: superior portion of the medial
epicondyle via the common flexor tendon.
Ulnar head: coronoid process of the ulna. 
I:Lateral aspect of the mid shaft of the radius. 
In:Median nerve (C6, 7). 
B/ s:Muscular branches from the ulnar and radial
arteries. 
Action
1. Pronation of the forearm  

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04/19/20 05:55 PM 215
2. Assists with flexion of the forearm at the
elbow. Pronator teres as pronator of the
forearm
Flexor carpi radialis 
O:Medial epicondyle of the humerus via the
common flexor tendon. 
I:Base of the second metacarpal.
In:Median nerve (C6, 7). 
B/s:Muscular branches from the radial artery.
 
04/19/20 05:55 PM 216
 Action
1. Flexion of the wrist  
Flexor digitorum superficialis, flexor digitorum
profundus, and flexor pollicis longus assist
with flexion of the wrist.  
2. Abduction of the wrist
. 
3. Assists with flexion of the forearm at the
elbow .

04/19/20 05:55 PM 217

Palmaris longus
Fusiform muscle, may be absent
O: medial epicondyle of humerus
I:distal ½ of f.retinaculum and apex of
palmar aponeurosis.
In.: Median nerve
Action
Flexes hand at wrist joint and tenses
palmar aponeurosis.
04/19/20 05:55 PM 218
Flexor carpi ulnaris 
O;Humeral head: medial epicondyle via
the common flexor tendon.
Ulnar head: medial aspect of the
olecranon and the proximal three- fifths
of the dorsal ulnar shaft. 
I:Pisiform and hamate bones
Base of the fifth metacarpal
In:Ulnar nerve (C8, T1). 
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04/19/20 05:55 PM 220
 
B/s:Muscular branches from the ulnar
artery. 
Action
1. Flexion of the wrist
Flexor digitorum superficialis, flexor
digitorum profundus, and flexor pollicis
longus assist with flexion of the wrist.
2. Ulnar deviation of the wrist
.
04/19/20 05:55 PM 221
Flexor digitorum superficialis 
O:Ulnar head: medial epicondyle of humerus
via the common flexor tendon, medial border
of the base of the coronoid process of the
ulna, and ulnar collateral ligament.
Radial head: oblique line of the radius along
its supero-anterior border. 
I:shaft of each middle phalanx of the four
digits via a bifurcated tendon. 
In:Median nerve (C7, 8, T1). 
B/S:Muscular brs. from ulnar and radial
arteries.
04/19/20 05:55 PM 222
04/19/20 05:55 PM 223
Action
1.Flexion of the digits at the proximal
interphalangeal joints  
2. Assists with flexion of the digits
at the metacarpophalangeal joints
3. Assists with flexion of the wrist
Flexor pollicis longus and flexor
digitorum profundus assist with flexion
of the wrist.
04/19/20 05:55 PM 224
 Flexor digitorum profundus
O:Anteromedial surfaces of the superior three-
quarters of the ulna and adjacent interosseous
membrane.
I: bases of the distal phalanx of the medial four
digits (travels through a split in the tendon of
flexor digitorum superficialis). 
In: Medial portion: ulnar nerve (C8, T1).
Lateral portion: anterior interosseous branch
of median nerve (C8, T1). 
B/s:Muscular branches and the anterior
interosseous artery from the ulnar artery and
04/19/20 05:55 PM 225
muscular branches from the radial artery. 
04/19/20 05:55 PM 226
Actions
1. Flexion of the digits at the proximal
interphalangeal joints  
2.Flexion of the digits at the distal
interphalangeal joints
3. Assists with flexion of the digits at
the metacarpophalangeal joints  
4.Assists with flexion of the wrist
Flexor pollicis longus and flexor digitorum
superficialis also assist with flexion of
the wrist. 
04/19/20 05:55 PM 227
Flexor policis longus
Long flexor of the thumb,lies lateral to FDP
O:anterior surface of radius and adjacent
interosseous membrane
I:base of distal phalanx of thumb
In: anterior interosseous nerve, from median
nerve
Action
Flexes the distal phalanx of the thumb
Flexes the proximal phalanx and the first
metacarpal bone
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Pronator quadratus
O:Distal one-fourth of the anteromedial surface
of the ulna.
I:Distal one-fourth of the anterolateral surface
of the radius.
In: Anterior interosseous branch of the
median nerve (C8, T1).
 B/S:Muscular branches from the radial artery
and the anterior interosseous artery from the
ulnar artery.
  Action
1. Pronation
04/19/20 05:55 PM of the forearm (Anim)  229
04/19/20 05:55 PM 230
04/19/20 05:55 PM 231
EXTENSOR MUSCLES OF THE FORE
ARM
Are in the posterior(extensor –supinator)
compartment.
All are innervated by branches of radial nerve
Are organized in to 3 functional groups
1.Mm. that extend and abduct or adduct the hand at
the wrist joint
extensor Carpi radialis longus
extensor Carpi radialis brevis
extensor Carpi ulnaris
2.Mm. that extend the medial 4 digits(extensor
digitorium,extensor indicis, extensor digiti minimi
04/19/20 05:55 PM 232
3.Muscles that extend or abduct the thumb
abductor policis longus
extensor policis longus
extensor policis brevis
The extensor tendons are held together at the
wrist by the extensor retinaculum, which
prevents bow stringing of the tendons when
the hand is extended at the wrist joint.
The tendons are covered by synovial tendon
sheaths as they traverse the dorsum of the
wrist.
04/19/20 05:55 PM 233
Extensor mm. are organized
anatomically in to:
Superficial extesnsors
ECRB Originated from later.

ED epicondyle by comm.
EDM Extensor origin
ECU
Brachioradialis originate from lateral
ECR supra condylar ridge
04/19/20 05:55 PM 234
• Deep extensors
• EPL
• EPB
• APL
• EI
• Supinator

04/19/20 05:55 PM 235

Brachioradialis 
O:Upper lateral supracondylar ridge of the humerus
(between triceps brachii and brachialis). 
I:Superior aspect of the styloid process and the lateral
side of the distal radius.
In: Radial nerve (C5, 6). 
B/s:Radial recurrent artery from the radial artery. 
Action
1. Flexion of the forearm at the elbow
Flexor Carpi radialis will contract during flexion of the
elbow against a heavy resistance .

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04/19/20 05:55 PM 237
Extensor carpi radialis longus 
O:Lower lateral supracondylar ridge (below
brachioradialis).
I:Dorsal surface of the base of the second
metacarpal.
In:Radial nerve (C5, 6). 
B/ s;Radial recurrent artery from the radial artery. 
Actions
1. Extension of the wrist
2. Radial deviation of the wrist . 
Extensor pollicis brevis and abductor pollicis
longus
04/19/20 05:55 PM
assist with radial deviation of the wrist. 
238
Extensor Carpi radialis brevis
O:Lateral epicondyle of the humerus via the
common extensor tendon and the radial
collateral ligament of the elbow. 
I:Dorsal surface of the base of the third
metacarpal. 
In:Radial nerve (C6, 7). 
B/s:Radial recurrent art. from the radial artery 
Actions
1. Extension of the wrist
2. Radial deviation of the wrist
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04/19/20 05:55 PM 240
Extensor digitorum
O:Lateral epicondyle of the humerus via the
common extensor tendon. 
I:Main attachment: dorsal aspect of the base of
the proximal phalanx of each of the four digits.
Central slip: dorsal aspect of the base of the
middle phalanx of each of the four digits.
Lateral bands: via two slips to the dorsal aspect
of the base of distal phalanx of each of the 4
digits. 
In:Radial nerve (C6, 7, 8). 
B/s:Post. interosseous artery from the ulnar art.
 04/19/20 05:55 PM 241
 Actions
1.Extension of the digits at the metacarpophalangeal
(mcp) joints
2.Extension of the digits at the proximal
interphalangeal joints when mcp joints are flexed  
3. Extension of the digits at the distal
interphalangeal joints when mcp joints are flexed
4.Assists with extension of the wrist with digits flexed
at the metacarpophalangeal joints
Extensor digiti minimi and extensor pollicis longus
assist with extension of the wrist. 
5. Abduction of the digits during extension of the
carpometacarpal
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joints of the digits 242
Extensor digiti minimi 
O:Lateral epicondyle of the humerus via
the common extensor tendon and the
ulnar aspect of extensor digitorum. 
Is: via two slips to the dorsal surface of
the base of the distal phalanx of the fifth
digit. 
In:Radial nerve (C6, 7, 8). 
B/s:Posterior interosseous artery from the
ulnar artery. 
04/19/20 05:55 PM 243
Actions
1.Extension of the fifth digit at the proximal
interphalangeal joint
2.Extension of the fifth digit at the distal
interphalangeal joint
3.Assists with extension of fifth digit at the
metacarpophalangeal joint  
4.Assists with abduction of the fifth digit at the
carpometacarpal joint
5.Assists with extension of the wrist  
Extensor digitorum and extensor pollicis
longus
04/19/20 05:55 PM also assist with extension of the wrist.
244
04/19/20 05:55 PM 245
 
Extensor carpi ulnaris
O:from the common extensor origin
I:Tubercles on the medial side of the base of the fifth
metacarpal. 
In:Radial nerve (C6, 7, 8). 
B/s:Posterior interosseous artery from the ulnar
artery. 
Actions
1. Extension of the wrist  
Extensor digitorum, extensor digiti minimi, and
extensor pollicis longus assist with extension of the
wrist. 
2. Ulnar deviation of the wrist

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Supinator 
O:Lateral epicondyle of the humerus, the radial
collateral ligament, the supinator crest of the
ulna, and annular ligaments. 
I:Proximal portion of the anterolateral surface
of the radius. 
In:Radial nerve (C6, 7, 8). 
B/s:Radial recurrent artery from the radial
artery. 
Action
1.Supination of the forearm
 
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04/19/20 05:55 PM 248
EXTENSOR INDICIS
O:posterior surface of distal third of ulna
I:Extensor expantion of second finger
In:posterior interosseous
nerve(c7,c8),C0ntinuatin of deep
branch of radial nerve.
Action
Extends second finger, helps extend
hand at wrist

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04/19/20 05:55 PM 250
Abductor pollicis longus
O:Posterior surfaces of the ulna and
the radius and the interosseous
membrane. 
I:Lateral aspect of the base of the
first metacarpal. 
In:Radial nerve (C6, 7, 8). 
B/s:Posterior interosseous artery
from the ulnar artery. 
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Actions
1. Radial abduction of the thumb at the
trapeziometacarpal joint
2. Extension of the thumb at the
carpometacarpal joint
3. Assists with extension of the thumb at the
metacarpophalangeal joint 
4. Assists with radial deviation of the wrist
Extensor pollicis brevis may also assist with
radial deviation of the wrist.
 
 
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Extensor pollicis longus 
O:Post. surface of the ulna and the i.osseous
membrane. 
I:Distal phalanx of the thumb. 
In:Radial nerve (C6, 7, 8). 
B/s:Post. interosseous art. from the ulnar art. 
Action
1.Extension of thumb at the interphalangeal jt.  
2. Assists with extension of the thumb at the mcp
joint  and assists extension of the wrist

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Extensor pollicis brevis 
O:Post. surface of distal third of the radius and the
i.oss. memb.
I:proximal phalanx of the thumb. 
In:Radial nerve (C6, 7, 8).
B/s:Post. interosseous artery from the ulnar art. 
Actions

1. Extension of the thumb at the CMC joint

2. Assists with extension of the thumb at the MCP
joint  
3. Assists with extension of the wrist

4. 
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04/19/20 05:55 PM 255
04/19/20 05:55 PM 256
 Muscles of the hand
• The intrinsic muscles of the hand are located in
five compartments
– Thenar muscles in thenar compartment: abductor
pollicis brevis, flexor pollicis brevis, and opponens
pollicis
– Hypothenar muscles in hypothenar compartment:
abductor digiti minimi, flexor digiti minimi brevis and
opponens digiti minimi
– Adductor pollicis in adductor compartment
– Lumbricals in central compartment
– Interossei in interosseous compartment
 All intrinsic muscle except thenar & lateral two
lumberical-innervated by deep branch of ulnar nerve257
258
259
 Palmaris brevis
In the subcutanous tissues of hypothenar
eminence
Cover & protect ulnar nerve & artery
Not part of hypothenar compartment
Dorsal
interosseo
us(bipenna
te)

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264
 Palmar
interosseous
(unipannate)

04/19/20 05:55 PM 266

266
 Brachial plexus

• The brachial plexus is mainly formed by the

ventral rami of the spinal nerves C5 - C8 and
Th1, but sometimes C4 and T2 may also
contribute.
• If the contribution of C4 is larger than that of
T2, then the plexus C4 – C8 is known as
prefixed and if the contribution of T2 is
larger than that of C4, the plexus thus
formed by C6 - T2 is called post-fixed.
04/19/20 05:55 PM 268
• The brachial plexus passes through the
scalen gap and enters the axilla through the
cervicoaxillary canal behind the clavicle.
Therefore supraclavicular and Infraclavicular
parts can be distinguished.
• In the supraclavicular part the three trunks of
the brachial plexus are formed.
1. Upper (superior) trunk - formed by roots
from C5 and C6
2. Middle trunk - formed by the root from C7
3. Lower (inferior) trunk - formed by roots
04/19/20 05:55 PM 269
from C8 and T1
• After passing between the clavicle and the first rib
it becomes the infraclavicular part where the
trunks branch in to ventral and dorsal divisions
and the divisions of the three trunks fuse with
each other to form three cords or fasciculi

• The dorsal divisions of all the three trunks form

the posterior cord

• The ventral divisions of the upper and middle

trunks form the lateral cord whereas the ventral
division of the lower trunk forms the medial cord.
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• These three cords (posterior, lateral and
medial) give the following branches to the
shoulder girdle, the arm and forearm and
extend.
1. Posterior cord - axillary and radial nerves
2. Lateral cord - musculocutaneous nerve
and lateral root of median nerve.
3. Medial cord - ulnar nerve, medial root of
median nerve, medial cutaneous nerve of
the arm (medial brachial cutaneous nerve) and
the medial cutaneous nerve of the forearm
(medial antebrachial cutaneous nerve).
04/19/20 05:55 PM 271
 Branches of the brachial plexus to the

shoulder girdle
• All the branches of the brachial plexus to the
shoulder girdle are motor nerves except the
axillary nerve that has both motor and
sensory components.
• To these nerves belong:
1. Dorsal scapular nerve (C4 & C5 mainly from
C5) - passes through the scalenus medius
muscle and innervates the levator scapulae,
and rhomboid major and minor.
. It runs in the direction of the scapula 272
04/19/20 05:55 PM
under the rhomboid muscles.
04/19/20 05:55 PM 273
04/19/20 05:55 PM 274
04/19/20 05:55 PM 275
276
Supraclavicular
branches (root
and trunk)
1.The dorsal
scapular nerve
(C5)
2.The long
thoracic nerve
(C5, 6, 7)
3.The nerve to
subclavius (C5,
6)
4.The
suprascapular
nerve (C5, 6)
2. Long thoracic nerve (C5, C6 & C7) - It also
passes through the scalenus medius
muscle and descends dorsal to the
brachial plexus and the first part of the
axillary artery along the midaxillary line to
the serratus anterior muscle.
. In its paralysis the arm can not be
elevated in addition to the appearance of a
clinical condition known as winged
scapula or scapula alata (this is a
condition where the medial border of the
scapula protrudes away from the thoracic
wall).

04/19/20 05:55 PM 278

3. Nerve to subclavius or subclavius nerve (C5)
- innervates the subclavius muscle and the
sternoclavicular joint.
. Frequently it contributes fibres to the
phrenic nerve as accessory phrenic nerve.
4. Medial pectoral (C8 & Th1) and lateral
pectoral (C5 - C7) - innervate the pectoralis
major and minor muscles.
5. Suprascapular nerve (C5 & C6) - it is the
upper most branch of the trunk of the
brachial plexus running with the
suprascapular vessels to reach the supra-
and infraspinatus muscles.
04/19/20 05:55 PM 279
• In its paralysis the scapular spine
becomes prominent and the lateral
rotation of the shoulder joint is affected.
6. Subscapular nerves (C5 & C6) - they are
two in number
a. Upper (superior) subscapular - small
and enters the upper part of subscapularis
muscle and teres minor muscle.
b. Lower (inferior) subscapular -
innervates the lower part of subscapularis
muscle and teres major muscle.
04/19/20 05:55 PM 280
7. Thoracodorsal nerve (C6 - C8) - also
referred to as middle Subscapular nerve for
it arises from the posterior cord between
the upper and lower Subscapular nerves.
. It runs with the thoracodorsal vessels to
the latissimus dorsi muscle.
8. Axillary or circumflex nerve (C5 & C6) - it
runs through the quadrangular space being
related to the surgical neck of the humerus.
Therefore it can be injured by fracture of
the surgical neck, subluxation of the
shoulder and by a crutch pressing on it.
04/19/20 05:55 PM 281
 . It gives a motor supply to the deltoid and
teres minor muscles.
. Its paralysis results in the atrophy of
these muscles and loss of sensation in the
lower half of the deltoid region.
. The paralysis and atrophy of the deltoid
muscle results in a prominent greater
tuberosity and impairment of abduction of
the arm.
04/19/20 05:55 PM 282
04/19/20 05:55 PM 283
 Branches of the brachial plexus to the arm
• The brachial plexus gives six branches to the
arm. Out of the six two of them are cutaneous
sensory nerves and four of them are mixed
nerves.
a. Cutaneous nerves as direct branches of the
brachial plexus
1. Medial cutaneous nerve of the arm or
medial brachial cutaneous nerve (C8 & Th1)
2. Medial cutaneous nerve of the fore arm
or Medial antebrachial cutaneous nerve (C8 &
Th1)
04/19/20 05:55 PM 284
b. Mixed branches
1. Musculocutaneous nerve (C5 - C7)
2. Median nerve (C6 - Th1)
3. Ulnar nerve (C7 - Th1)
4. Radial nerve (C5 - C8)

04/19/20 05:55 PM 285

 Classification of branches of the
brachial plexus
• Branches of the brachial plexus can be
classified with reference to the clavicle as
branches from the supraclavicular part
and branches from the infraclavicular part
or on the basis of the different parts of the
brachial plexus as branches from the
roots, from the trunks and from the cords.

04/19/20 05:55 PM 286

1. Classification with reference to the clavicle
A. Branches from the supraclavicular part
1. Subclavius nerve
2. Dorsal scapular nerve
3. Suprascapular nerve
4. Long thoracic nerve
B. Branches from the infraclavicular part
1. Branches to the shoulder girdle
a. Medial and lateral pectoral
nerves
b. Subscapular nerves
04/19/20 05:55 PM 287
c. Thoracodorsal nerve
 2. Branches to the arm
a. Musculocutaneous nerve
b. Median nerve
c. Ulnar nerve
d. Medial brachial cutaneous nerve
e. Medial antebrachial cutaneous nerve
f. Radial nerve
g. Axillary nerve

04/19/20 05:55 PM 288

2. Classification on the basis of their origin from
the parts of the brachial plexus.
A. Branches from the roots
1. Dorsal scapular (C4 & 5)
2. Long thoracic (C5, 6, 7)
B. Branches from the trunks
1. Suprascapular nerve - upper trunk
2. Subclavius nerve - upper trunk
• Sometimes medial pectoral from the lower
trunk and lateral pectoral nerve from the
anterior division of the upper and middle
trunk of the brachial plexus.
04/19/20 05:55 PM 289
 C. Branches from the cords
1. From the lateral cord
a. Lateral pectoral
b. Musculacutaneous
c. Lateral root of median
2. From the posterior cord
a. Upper subscapular
b. Thoracodorsal (Middle subscapular)
c. Lower subscapular
d. Radial
e. Axillary
04/19/20 05:55 PM 290
 3. From the medial cord
a. Medial pectoral
b. Medial brachial cutaneous
c. Medial antebrachial cutaneous
d. Ulnar
e. Medial root of median

04/19/20 05:55 PM 291

Brachial plexus injuries
• Injuries to brachial plexus affect
movements and cutaneous sensations in
the upper limb
• Disease, stretching and wounds in
posterior triangle of neck or in axilla may
produce brachial plexus injuries

292
• Injuries to superior parts of brachial plexus
(C5 and C6) (Erb-Duchenne palsy)
– result from an excessive increase in the angle
between the neck and the shoulder (A & C)
– results in paralysis of the muscles of shoulder
and arm supplied by C5 & C6
– apparent by the characteristic position of the limb
("waiter's tip position") (B)
• an adducted shoulder, medially rotated arm, and
extended elbow
– lateral aspect of the upper limb also loses
sensation

293
• Injuries to inferior parts of brachial plexus
(Klumpke paralysis)
– less common
– occur when the upper limb is suddenly pulled
superiorly (D & E)
– injure the inferior trunk (C8 & T1) and may tears
the roots of spinal nerves
– muscles of the hands are affected and results in
claw hand (F)

294
295
• Brachial plexus can also be injured by
compression e.g. crutch paralysis,
Saturday night palsy, etc.
If C7 (middle trunk) is involved it leads to
the paralysis of triceps, weakness of the
extensors of the wrist and fingers. This
weakness of the extensors of the wrist
and the fingers results in wrist drop of
radial nerve type.

04/19/20 05:55 PM 296

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Brachial plexus block
• Injection of anesthetic solution into axillary
sheath interrupts nerve impulses to
structures supplied by branches of cords
• Approaches: interscalene, supraclavicular,
and axillary

297
Injuries to Brachial plexus
The brachial plexus becomes
completely paralysed only in severe
injuries but usually some parts of it are
injured. Its injury that frequently occurs
during delivery is called brachial birth
paralysis. Three types of such paralysis
are recognised
1. Whole arm paralysis
2 Erb’s palsy of the arm and
3 Klumpke's paralysis of forearm.
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 Erb’s Duchenne paralysis or palsy
It is due to injury to nerves arising from
C5 and C6 (upper trunk).
Musculocutaneous n, axillary n
suprascapular n ,n to subclavius are
injured
Is the most common type of brachial
plexus injury. Characterised by paralysis
and atrophy of the deltoid, flexor
muscles and the long supinator
muscles of the arm, in which case
flexion and supination are weakened,
abduction
04/19/20 05:55 PM
and lateral rotation are lost
299
04/19/20 05:55 PM 299
 The arm and hand then assume the
Waiter's tip position (a medial rotated
upper limb hanging by the side), sensation
is lost over the deltoid and radial side of the
forearm and hand.
The injury is usually caused by traction
during delivery and in adults from excessive
separation of the head from the neck.
Klumpke’s paralysis (Dejerine
klumpke’s syndrome) :
Injuries to the lower segments C8 and Th1
(lower trunk).
Mainly the ulnar nerve is involved.
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04/19/20 05:55 PM 300
Manifested by:
paralysis of the small muscles of the hand
and flexors of the wrist (claw hand) and
loss of sensation on the skin area innervated
by ulnar n.
Causes: Birth trauma or cervical rib .
It causes atrophic paralysis of the forearm
muscles and small muscles of the hand
associated with paralysis of cervical and
arm sympathetic innervation( results in
oedema of the skin, cyanosis and atrophic
nail changes). It can be associated with the
injury of the sympathetic trunk(may lead to
04/19/20 05:55 PM 301
Horner’s syndorme )
04/19/20 05:55 PM 301
• Brachial plexus can also be injured by
compression e.g. crutch paralysis,
Saturday night palsy, etc.
If C7 (middle trunk) is involved it leads to
the paralysis of triceps, weakness of the
extensors of the wrist and fingers. This
weakness of the extensors of the wrist
and the fingers results in wrist drop of
radial nerve type.

04/19/20 05:55 PM 302

04/19/20 05:55 PM 302
• Signs of single nerve involvement
 Long thoracic (C5-7) - paralysis of
serratus anterior, which causes “winging”
of the scapula when the arm is extended
and pressed against a fixed object in front
of the patient and difficulty of raising the
arm above the horizontal plane.
Suprascapular nerve (C5 &6) -
Paralysis of supra- and infraspinatus
muscle leading to subluxtion of the
shoulder joint. Patients with such paralysis
will have difficulty of lifting heavy
weight.
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04/19/20 05:55 PM 303
 Dorsal scapular nerve (C5)
• Paralysis of the rhomoides. The scapula
becomes slightly winged and can not be
drawn close to the vertebral column.
• Thoracodorsal nerve (C7& 8) -
• Paralysis of the latissimus dorsi with
weakened adduction and medial rotations
of the arm
• Lateral (C5-C7) and medial (C8 & Th1)
pectoral nn. Injury results in paralysis of
the pectoralis mm. The force of adduction
in the arm is lost and the patient is unable
to touch the opposite shoulder
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04/19/20 05:55 PM
304
304
 Nerves of the upper limb
• Musculocutaneous nerve (C5 -C7) –
• Motor part - innervates flexors of the arm
such as coracobrachialis, biceps and
brachialis. After passing through the
corachbrachialis it runs between the biceps
and brachialis muscles to the elbow where it
terminates.
• Sonsory - it gives supply to the radial side
of the forearm up to the thenar eminence, by
a branch called lateral cutaneous nerve of
the forearm.
Paralysis-paralysis of flexors of the arm
04/19/20 05:55 PM 305
esp. Biceps.
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04/19/20 05:55 PM 306
04/19/20 05:55 PM 307
04/19/20 05:55 PM 307
 Median nerve (C6-Th1)
• Innervates all the flexors of the forearm
except FCU and the ulnar two heads of FDP.It
arises from the lateral cord of the br. plexus
by its lat. root and from medial cords by its
med. root .
• These two roots unite on the ventral surface of
the axillary artery to form the median nerve.
• In the arm it lies lateral to the brachial artery
and in the elbow it lies medial to the artery. By
passing under the biceptal aponeurosis it runs
through the space between the two heads of
pronator teres muscle with the ulnar artery to
enter the
04/19/20 05:55
04/19/20 05:55 PM
PM flexor compartment of the forearm.
308
308
04/19/20 05:55 PM 309
04/19/20 05:55 PM 310
04/19/20 05:55 PM 310
.
By passing under the biceptal aponeurosis it
runs through the space between the two heads
of pronator teres m. with the ulnar artery to
enter the flexor compartment of the forearm.
Here it lies between FDS and FDP.
In the lower 1/3 of the forearm it runs on the
medial (ulnar) side of the tendon of FCR
muscle and in the wrist between the tendons of
FCR and palmaris longus then enters the palm
through the carpal tunnel.
In the palm it divides in to its three terminal
branches called the common palmar digital
nerves
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04/19/20 05:55 PM
311
311
04/19/20 05:55 PM 312
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• The proper palmar digital nerves run on both
sides of the 1st - 3rd fingers and only on the
radial side of the 4th finger. In the hand gives a
motor Innervation to the 1 st and 2nd lumbricals
and thenar muscles with the exception of deep
head of flexor pollicis branches 
• Branches of median nerve in the forearm
 
• no branch in the arm.
articular branches - sensory supply to elbow
joint
• Anterior interosseus nerve of the forearm
- 04/19/20
innervates
05:55 PM
04/19/20 05:55 PM
pronator quadratus, FPL, FDP. 313
313
 . Palmar branch - gives a sensory supply to
the thenar eminence and radial side of the
palm.
• Recurrent branch - arises in the carpal
tunnel and supplies the thenar muscles (APB),
opponens pollicis and superficial part of FPB. 
• Branches of the median nerve in the hand
• Communicating branch - connects the
median nerve to the superficial branch of the
ulnar nerve.
• Common palmar digital nerves.
• Proper palmar digital nerves, which are
sensory to the radial 31/2 fingers. 
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04/19/20 05:55 PM 315
04/19/20 05:55 PM 315
04/19/20 05:55 PM 316
04/19/20 05:55 PM 316
• Applied Anatomy of the median nerve
• Paralysis of the median nerve (supracondylar
fracture of the humerus) results in :
• Restricted pronation and flexion of the
forearm.
• The proximal and distal interphalangeal joint
of 1st - 3rd fingers remain extended (due to
paralysis of FPL and radial parts of the FDP).
• Due to the paralysis of the FDS the flexion at
the metacarpophalangeal and the proximal
interphalangeal joints is restricted.
• Opponens pollicis will be paralysed
opposition movements of the thumb are
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restricted.  
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 Abduction of the thumb is absent
due to paralysis of abductor
pollicis. With this defect when the
patient tries to make a fist the
radial three fingers remain
extended resembling an Ape like hand
or obstetrician’s examining hand.
 

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• Ulnar nerve
• Arises from the medial cord of the brachial
plexus and runs medial to the brachial
artery until half way down the arm and
then pierces the medial intermuscular
septum in order to pass to the extensor
side. Then it descends through the ulnar
sulcus of the humerus.
• Through the space between the two heads
of the flexor Carpi ulnaris it runs back to
the flexor side of the forearm.
• In this part it runs with ulnar artery under
the cover of the FCU muscle to reach the
wrist where it passes ventral to the flexor
retinaculum
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• . In the palm it divides in to deep
and superficial branches.
• proximal to the wrist, it divides in to:
• Palmar cutaneous branch - for the
sensory supply of the ulnar side of
the palm and divides in to two
common palmar digital nerve which
give rise to 3 proper palmar digital
nerves. These supply the palmar side
of the 5th and a half of 4th fingers and
their dorsal sides distal to proximal
interphalangial joint.
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• Dorsal branch- it runs on dorsal side
between the flexor Carpi ulnaris and the
ulna, where it divides in to dorsal digital
nerves, which give sensory supply to the
dorsal side of the ulnar 11/2 fingers up to
their proximal interphalangeal joints.

• Usually the dorsal branch of ulnar nerve

and the superficial radial nerve are
interconnected by means of a
communicating branch.
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324
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 Branch of ulnar nerve in the palm 
Deep branch - it is a motor branch
innervating all the hypothenar muscles, the
palmar and dorsal interosseous muscles,
the 3rd and 4th lumbricales, adductor pollicis
and deep head of flexor pollicis brevis
muscles.
Superficial branch- is motor nerve to
Palmaris brevis. It runs under the palmar
aponeurosis and divides in to comon
palmar digital nerves which gives rise to
the proper palmar digital nerves for the
sensory supply of the fingers (to the 5th
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finger and ulnar half of the 4 finger).
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The ulnar nerve may be injured in the ulnar
sulcus of the humerus by longstanding
pressure or fracture of the medial
epicondyle. This manifests by the paralysis
of the interossei muscles. Normally these
muscles flex at the MCP joints and extend
the interphalangeal joint. Their paralysis
leads to the over domination of the
antagonistic muscles resulting in extension
at the metacarpo-phalangeal joints and
flexion of both interphalangeal joints,
showing claw hand.
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. Medial cutaneous nerve of the
forearm (C8-Th1) Branches.
a. Anterior branch - gives a sensory
supply to the flexor side of the forearm
b. Ulnar branch - for sensory innervation
of the ulnar side of the forearm.
Medial cutaneous nerve of the arm
(C8 -Th2) - it is connected to the
intercostobrachial nerve that arises from
the 2nd and 3rd intercostal nerves.
It gives a sensory innervation
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Axillary nerve (C5-C7)-
Innervates the deltoid and teres minor mm
and gives a sensory supply to the skin on the
dorsolateral aspect of the arm.
It runs with the posterior circumflex humeral
artery and veins through quadrilateral space
and gives branch to the superior lateral
cutaneous nerve of the arm.
It may be injured by fracture of the surgical
neck of humerus; leading to paralysis of
deltoid resulting in difficulty of abduction of
the arm against resistance and loss of
sensation in the skin of the deltoid region.
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. Radial nerve (C5 -Th1)-
Gives both motor and sensory
innervation to the arm and forearm. It
runs with the deep brachial artery
between the medial and lateral heads
of triceps laying in the spiral (radial)
sulcus of humerus.
Then it passes to the flexor side and
then descends between brachioradialis
and brachialis muscles. In the elbow, at
the level of the head of the radius, it
divides in to its deep and superficial
branches.
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335
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Branches of radial nerve in the arm 
1. Motor branches to triceps, anconeus,
brachioradialis and extensor carpi radialis
longus -the nerves to triceps and
anconeus arise above the radial sulcus.
2. Posterior cutaneous nerve of the arm - it
branches from the radial nerve in the
axilla and gives sensory innervation to the
dorsal or extensor side of the arm.
3. Inferior lateral cutaneous nerve of the
arm - is sensory to the lateral aspect of
the lower part of the arm. It may also arise
in the axilla.
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338
 Branches radial nerve in the forearm 
1. Posterior cutaneous nerve of the forearm
- for the sensory innervation of extensor side
of the forearm up to the wrist joint. It arises in
the radial sulcus.
2. Deep radial nerve -it passes through the
supinator muscle and runs spirally around the
neck of the radius to enter the extensor side
and becomes posterior interosseous
nerve.
It gives muscular branches to supinator,
ECRB, EDM, EPB and extensor indicis.
Its sensory branches, the posterior
interosseous
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 Superficial radial nerve - it runs with the
radial art. as cutaneous branch of the radial
nerve on the flexor side deep on the ulnar side
of the brachioradilis . In the lower 1/3 of the
forearm it under crosses the tendon of
brchioradialis to pass to the dorsum of the hand.
At the back of the hand it is joined to the dorsal
ramus of the ulnar nerve through the
communicating branch of ulnar nerve. Then it
terminates as the dorsal digital nerve that
receives sensory fibres from the radial side of
the dorsum of the hand and radial 31/2 fingers
up to the middle phalanx.
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 Applied Anatomy of the radial nerve
Radial nerve is usually injured by the
fracture of the shaft of the humerus in the
region of the radial sulcus and by
fractures of the neck of radius. In this
case the extensors of the wrist and
fingers are paralysed leading to the
clinical condition called wrist drop

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 Axillary Artery
• Begins at the lateral border of
1st rib as the continuation of
subclavian artery
• Ends at inferior border of
teres major, becomes brachial
artery
• Passes posterior to the
pectoralis minor into the arm
• For descriptive purpose it is
divided into three parts
relative to pectoralis minor
 Parts of axillary Artery
First part
–located between lateral border of 1st rib and medial border
of pectoralis minor
–has one branch: superior thoracic artery
Second part
–lies posterior to pectoralis minor
–has two branches: thoracoacromial artery and lateral
thoracic artery
Third part
–extends from lateral border of pectoralis minor to the inferior
border of teres major
–has three branches: subscapular artery, anterior circumflex
humeral artery and posterior circumflex humeral artery
Arterial anastomoses around scapula

• Several arteries join to form networks on ant. & post.

surfaces of the scapula
– Dorsal scapular
– Suprascapular
– Subscapular (via the circumflex scapular branch)

• The collateral circulation made possible by these

anastomoses when ligation of a lacerated subclavian
or axillary artery is necessary or vascular stenosis
(narrowing) of the axillary artery occurs
 Arteries of Arm
Brachial artery
•Provides the main arterial supply to the arm
•Is the continuation of the axillary artery
•Begins at the inferior border of teres major
•Ends in the cubital fossa opposite the neck of the
radius under cover of the bicipital aponeurosis, where
it divides into the radial and ulnar arteries
Brachial artery…
• Branches
– muscular
branches
– humeral nutrient
artery
– deep artery of
arm
– superior and
inferior ulnar
collateral arteries
 Deep br. a
Brachial
artery
Superior
collateral
art.

Inferior
ulnar
colateral a
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 Rete articularis cubiti 
This is a network of arteries around
the elbow joint. It is formed by the
anstomoses between:
1. The middle & radial collateral branch of
profunda brachii
2.Superior and inferior ulnar collateral branches
of the brachial artey
3. Radial recurrent artery from radial artery
4. Interosseous recurent artery from common
interosseous artery.
5. Ant. & post. ulnar recurrent artery from ulnar artery

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353
Arteries and veins of forearm
• Brachial artery ends in distal part of cubital fossa
opposite neck of radius by dividing into ulnar and
radial arteries
• There are superficial and deep veins in the forearm
– Superficial veins lie in subcutaneous tissue
– Deep veins accompany deep arteries
Ulnar artery
Branches
–Ant. ulnar recurrent
artery
–Post. ulnar recurrent
artery
–Common
interosseous a.
–Ant. interosseous a.
–Post. Interosseous a.
–Recurrent
interosseous a.
–Palmar carpal
branch
–Dorsal carpal branch
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Radial artery
Branches
–Radial
recurrent artery
–Palmar carpal
branch
–Dorsal carpal
branch
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 Artery of hand
Ulnar artery
Terminal branch
Superficial palmar
deep palmar
Superficial palmar branch- main termination of
ulnar artery
Branch into three common palmar digital artery
Each common palmar digital branch into a pair of
proper palmar digital artery
Deep palmar branch –palmar metacarpal artery
04/19/20 05:55 PM 361
 Radial artery
•Ends by anastomosing with the deep branch of
the ulnar artery to form the deep palmar arch
Deep palmar arch
–formed mainly by radial artery
–lies across the metacarpals just distal to their
bases
–gives rise to three palmar metacarpal arteries,
princeps pollicis artery and radialis indicis
artery
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Areas of palpation of arterial
pulse on the upper limb
1. Brachial artery
a. In the medial biceptal sulcus
b. Supero-ventral to the medial
epicondyle at the elbow
c. In the elbow deep and medial to
the
biceptal aponeurosis
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2. Radial
a. Proximal to the wrist between the
tendons of flexor carpi radialis
and
brachioradialis
b. In the anatomical snuff-box
3. Ulnar
- at or near the wrist lateral to the
tendon of flexor carpi ulnaris.
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 Veins of hand
Superficial and deep palmar venous arches
–associated with superficial and deep palmar arterial
arches
–drain into the deep veins of the forearm
Dorsal digital veins
–drain into three dorsal metacarpal veins, which unite
to form the dorsal venous network
–this network is prolonged proximally on the lateral
side as cephalic vein and on the medial side as
basilic vein
Deep vein
Brachial veins
• Paired deep veins, accompany the brachial artery
• Begins at the elbow by union of the accompanying
veins of the ulnar and radial arteries
• Ends by merging with the basilic veins to form the
axillary vein
Superficial veins…
•Basilic vein
– Ascends from medial part of dorsal venous network
– Merges with the accompanying veins (venae
comitantes) of the axillary artery to form the axillary
vein
• Median antebrachial vein (median vein of
forearm)
– Ascends in the middle of anterior aspect of forearm
between cephalic and basilic veins
Veins upper limb
Superficial veins
• Dorsal venous network
– On dorsum of the hand
– Give rise to cephalic and basilic veins
• Cephalic vein
– Ascends from lateral part of dorsal venous network
– Anterior to elbow communicate with median
cubital vein
– Pierces clavipectoral fascia and joins axillary vein
Axillary vein

• Lies initially (distally) on the anteromedial side of

the axillary artery
• Formed by the union of brachial veins and basilic
vein at the inferior border of teres major
• Ends at lateral border of 1st rib where it becomes
subclavian vein
• Wounds in the axilla often involve the axillary vein
because of its large size and exposed position
Axillary lymph nodes
•Found in the axillary fat
•There are 5 principal groups of axillary lymph
nodes:
pectoral,
subscapular
humeral
Central and
apical
•Pectoral (anterior) nodes
–receives lymph mainly from anterior thoracic wall,
including most of the breast
Enlargement of axillary lymph nodes
• An infection in the upper limb can cause the
axillary nodes to enlarge and become tender and
inflamed, a condition called lymphangitis
• The humeral group of nodes is usually the first ones
to be involved
• Infections in the pectoral region and breast,
including the superior part of the abdomen, can also
produce enlargement of the axillary nodes
• These nodes are also the most common site of
metastases (spread) of cancer of the breast
 Brachial artery -
The continuation of axillary art. that
begins at the lower border of teres major
m.
They lie medially in the upper arm but
turn anteriorly as they approach the
elbows.
Enters elbow by passing under the
biceptal aponeurosis where it divides in to
radial and ulnar arteries.
In its course brachial veins and median n.
accompany the brachial art. In the
proximal part the median n. lies lateral to
the artery, but in the distal part medial to
it.
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 Deep br. a
Brachial
artery
Superior
collateral
art.

Inferior
ulnar
colateral a
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 Branches of the brachial artery
1. Profunda brachii artery (deep brachial
artery)
2. muscular branches to the flexors of the arm
3. Superior ulnar collateral artery
4. Inferior ulnar collateral artery
5. Humeral nutirent artery
Profunda brachii artery 
Arise in the medial biceptal sulcus and run to
the dorsal side with the radial nerve, where
they lie in a canal formed by the radial sulcus
of humerus and lateral and medial heads of
triceps .
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 Branches of profunda brachii
artery
1. Posterior descending or middle
collateral - descends behind the
lateral Intermuscular septum and
lateral epicondyle
2. Anterior descending or radial
collateral
3. Ascending (deltoid) branch
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382
 Rete articularis cubiti 
This is a network of arteries around
the elbow joint. It is formed by the
anstomoses between:
1. The middle collateral branch of
profunda brachii
2.Superior and inferior ulnar collateral
branches of the brachial artey
3. Radial recurrent artery from radial
artery
4. Interosseous recurent artery from
common interosseous artery.
 
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 Radial artery 
Begins in the elbow as branch of brachial
a.
It descends medial to the superficial radial
nerve under the cover of the
brachioradialis m. by crossing over the
tendon of biceps.
In the lower 1/3 of the forearm superficial
branch of radial n. accompanies it.
Proximal to the wrist joint it lies between
tendons of flexor carpi radialis and
brachioradialis opposite the broad distal
end of radius, where its pulse could be
palpated. Then enters the anatomical
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snuff-box .
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• Enters the anatomical snuff-box and
passes to the dorsum of the hand after
giving some branches that form rete
carpi palmare.
• Then it runs between the two heads of the
1st dorsal interoseous muscle between 1st
and 2nd metacarpal bones to enter the
palm of the hand where it forms the deep
palmar arch together with a smaller
deep palmar branch from ulnar a.
• It also gives branches for the formation of
the rete (dorsal network) carpi
dorsalis at the back of the hand and
dorsal digital arteries to the thumb and
index finger. 
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386
386
Anatomical snuff-box
A triangular depression at the base of
thumb Boundries
Proximally by the styloid process of radius,
Distally by the base of the 1st metacarpal
bone
Medially by the tendon of EPL
laterally by EPB and APL
This depression is clearly visible when the
thumb is fully extended. It contains the
cephalic v., superficial branch of radial n.
superficially and radial artery with the
tendons
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387
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 Branches of the radial artery
1. Radial recurrent (in the elbow)
2.Superficial palmar branch (superficial palmar
branch of ulnar arch superficial palmar.
3.Principes pollicis artery to the thumb
4.Radialis indicis artery to radial side of the
index finger
5 .Deep palmar arch
found between the flexor tendons and
interossei muscles. It give branch to palmar
metacarpal arteries that form anastomosis
with the digital branches of the superficial
palmar arch directly and with the dorsal
metacarpal arteries through perforating
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branches .
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 contd
• 6. palmar carpal branch
– Form palmar carpal arch
• 7. dorsal carpal branch
– Dorsal carpal arch
• 8. muscular branch
– Lateral side

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 ,n

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Ulnar artery 
Larger branch of brachial a.
In the elbow it runs under the superficial
flexors to the ulnar side of the forearm
then it descends along the radial side of
FCU to the wrist being accompanied by
the ulnar n.
In the wrist it gives branches that
contribute to the formation of the palmar
and dorsal arterial networks of wrist. Then
runs anterior to the flexor retinaculum but
on the radial side of the pisiform bone to
the
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394
394
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1.Deep palmar branch (smaller) - that forms
anastomosis with larger deep palmar branch of
radial artery to complete the deep palmar
arch.
2.Superficial palmar branch (larger)- forms
anastomosis with the smaller superficial palmar
branch of radial artery to form the superficial
palmar arch.
• The superficial palmar arch gives branch to 3
common palmar digital arteries each of which
re-branch to two proper palmar digital arteries
to supply the fingers.
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396
396
 Important Branches of ulnar
artery 
1.Recurrent ulnar artery :-Anterior &
posterior
2.Superficial and deep palmar
branches
3.. Common interosseous artery
(usually arises from ulnar but it can
also arise directly from brachial
artery).
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Common interosseous artery 
It lies on the interosseous membrane
being covered by the origins of the
deep flexors. It divides in to anterior
and posterior interosseous arteries
The posterior interosseous artery
pierces through the interosseous
membrane to pass to the extensor side
and descends between the superficial
and deep extensors to join the dorsal
carpal arterial network of arteries. .
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• After passing through the interosseous
membrane it give branch to the
interosseous recurrent a. that joins the
articular arterial network of the elbow .
• The anterior inerosseous a. descends on
the anterior surface of the interosseous
membrane and supplies adjacent
muscles proximal to the pronator
quadratus muscle.
• It then penetrates through the
interosseous mem. to pass to the
extensor side and ends in the dorsal
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carpal network of arteries. 
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Areas of palpation of arterial
pulse on the upper limb
1. Brachial artery
a. In the medial biceptal sulcus
b. Supero-ventral to the medial
epicondyle at the elbow
c. In the elbow deep and medial to
the
biceptal aponeurosis
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2. Radial
a. Proximal to the wrist between the
tendons of flexor carpi radialis
and
brachioradialis
b. In the anatomical snuff-box
3. Ulnar
- at or near the wrist lateral to the
tendon of flexor carpi ulnaris.
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 Veins of the arm 
Superficial veins
-Cephalic & Basilic vein
Deep veins
- similar with the accompaning arteries
- paired Brachial veins
Veins of the forearm
Superfical veins
- Cephalic vein
- Basilic vein

 
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 Median cubital vein
Antebrachial vein
Deep veins
Radial veins
Ulnar veins

Veins of the Hand

Superfical palmar venous arch
Deep palmar venous arch
Dorsal venous net work
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404
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 Classification of synovial joint
•Based on the type of movements they permit and the
shapes of the articular surfaces, they are classified as
– Plane (gliding)
– Hinge
– Pivot
– Condyloid
– Saddle or
– Ball-and socket joints

407
Plane/ Gliding:
– Allows only side-to-side and back-and-
forward movements.
– The articulating surface can be nearly flat.
– E.g., Intercarpal and intertarsal joints

408
 Hinge
– The surface of one of the articulating bones is
always concave and the other, convex.
– Allows flexion & extension movement
– E.g., knee and elbow.

409
 Pivot
•In a pivot joint, the rounded end of one bone
fits into a ring that is formed by another bone
plus an encircling ligament
•Permits rotation about a central axis. E.g.,
radioulnar joints.

410
 Condyloid
– An oval, convex articular surface fits into an
elliptical, concave depression
– This permits angular movement in two
directions such as flexion-extension and
abduction-adduction motion.
•E.g., metacarpophalangeal joint

411
 Saddle
– The articular process has a concave surface in
one direction and a convex surface in another.
– It’s a modified condyloid joint that allows a wide
range of movement.
– Permit flexion-extension and abduction-
adduction motion.
– It is the structure of this joint that allows for
opposition of the thumb.
– E.g., first carpometacarpal joint, in the ball of
the thumb.
412
Ball-and-socket
– Formed by the articulation of a rounded
convex surface with a cuplike cavity .
– This provides the greatest range of movement
of all synovial joints.
– Permit rotation, flexion-extension and
abduction-adduction motion.
– E.g., hip and shoulder joints

413
414
Joints of the shoulder girdle
I. Sternoclavicular joint
A. Articulating surfaces
Clavicular notch of the sternum
  Articular facet of the sternal end of the
clavicle
Articular disc (oval fibro cartilaginous disc)
B. Articular capsule - is wide and attached to the
margins of the articular
surface and
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C. Ligaments
1. Anterior and posterior sternoclavicular
ligaments –reinforce the joint anteriorly and
posteriorly.
2. Interclavicular ligament –strengthen the joint
capsule superiorly.
3. Costoclavicular ligament -helps to prevent the
upward displacement of the clavicle and
dislocation of the sternoclavicular joint.
D. Axes - it is a multiaxial saddle joint
Functionally ball-and-socket synovial joint.
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04/19/20 05:55 PM 417
• E. Movements  
• 1. On the sagittal axis - elevation of the
shoulder (600) and depression (only 100) of the
elevated shoulder.  
• 2. On vertical axis - Forward and backward
movement of the shoulder(200 - 00 - 200).  
• 3. On the longitudinal axis - rotation of
the clavicle, which is associated with
sliding movement of the scapula on the thorax
and the movements on the other two axes.  
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 II. Acromioclavicular joint
Articulating surfaces(facets)
an incomplete articular disc is usually
found between the two surfaces.
Articular capsule - is wide and attached to the
margins of the articular surfaces.
Ligaments
Acromioclavicular ligament -It reinforces
the superior aspect of the articular capsule.
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Coracoclavicular ligament: It has two parts:
Conoid ligament - the medial inverted shaped
part of the coracoclavicular ligament.
Trapezoid ligament - is the lateral quadrilateral
part of the coracoclavicular ligament
The coracoclavicular ligament prevents the
upward displacement of the clavicle and
dislocation of the acromioclavicular joint.
D. Axes similar to SC joint
E. Movements
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The Shoulder (Glenohumeral) joint 
Articular surfaces
Glenoid cavity of the scapula and head of the
humerus.
Both the articulating surfaces are covered by
hyaline cartilage.
The glenoid cavity can receive only 1/4 - 1/3 of
the head of the humerus
The cavity is widened and slightly deepened
by a lip of fibrocartilage the glenoidal labrum.
.
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Articular capsule - is very wide
Attachment
superiorly : to outer part of the glenoidal labrum,
Inferomedially :to surgical neck and
inferolaterally : to anatomical neck of humerus.
It is reinforced only anteriorly by the
coracohumeral ligament.
In the intertubercular sulcus the capsule covers the
tendon of the long head of biceps forming the
intertubercular synovial sheath.

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• Ligaments
• Coracohumeral lig. - extends from coracoid process
to greater and lesser tubercles. It reinforces the
superior part of the capsule
• Glenohumeral ligs. (Sup., middle and inf.)
• they extend between the glenoid labrum and the
anatomical neck of the humerus.
• Transverse humeral ligament -holds the long head of
biceps in the groove.
• Coracoacromial ligament - forms a fibrous arch
roofing the shoulder joint. It also prevents the
upward dislocation of the humerus
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Bursae -
1. Communicating bursae
a. Subacromial bursa b. Subcoracoid bursa
c. Subtendinous bursa of subscapularis m.
2. Non-communicating bursae
a. Subdeltoid bursa
b. Subcutaneous acromial bursa
The subdeltoid bursa may sometimes
communicate with the synovial cavity through
the subacromial bursa.
 
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Axes –multiaxial(ball-and-socket)
Movements
On the sagittal axis
- Abduction
-Adduction
On the transverse axis
- Flexion (anteversion)
- Extension (Retroversion)
3. On the longitudinal axis
Medial rotation
Lateral rotation
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• The movements at the shoulder joint are usually associated
with movements of the clavicular joints thereby increasing
the range of movement, that is:

• Abduction - Adduction : 1800 - 00 - 400

• Flexion - Extension : 1800 - 00 - 400
• Medial rotation - Lateral rotation :
• The stability of the shoulder joint is assisted by the muscles
forming the rotator cuff( supraspinatus, infraspinatus,
subscapularis and teres minor muscles)

•  04/19/20 05:55 PM 430

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•The shoulder joint is one of the most common sites
of dislocation or subluxation in our body. When it
occurs the dislocation is usually in a distal
direction(inferiorly)..

•There are three factors that make the shoulder joint

the most common site of dislocation (subluxation).

•The small contact area between the articular

surfaces

•The wide articular capsule

•The presence of only very few ligaments.
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 ELBOW JOINT
A synovial joint of hinge variety
There are three joints in the elbow region,
1, Humeroulnar joint
2, Humeroradial joint
3, Proximal radioulnar joint
The three joints have a common capsule &
they share a single synovial cavity , due to
this they are considered together as a single
joint.
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• Articular Capsule
- covers the articulating parts including the
olecranon , coronoid & radial fossa of the
humerus. It doesn’t cover the epicondyles.
- around the neck of the radius it forms an
outpocketing called sacciform recess of
elbow joint.

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- A transverse line passing 2-3cm below the
epicondyles indicates the level of humeroulnar
& humeroradial joints.
Articular surfaces
1, Trochlea of humerus & trochlear notch of
ulna.
2, capitulum of humerus & articular fovea of
head of radius.
3, Articular circumference of the head of the
radius & radial notch of the ulna .

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Humeroulnar Joint
main joint of the elbow which is hinge in
type. ( uniaxial )
formed b/n trochlea of the humerus &
trochlear notch of the ulna.
Movement - flexion & extension.

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Humeroradial Joint
- with regard to the articulating surfaces it
is ball & socket type of joint. But
functionally it is hinge in type.
- From an extended position ( called in
orthopedics 0 or Zero position ) a flexion
of 140 * is possible , Degree of flexion
depends on muscle volume of the arm &
forearm.

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- In the extended arm the tips of olecranon
& the two epicondyles lie in a straight
line ( Hueter’s line ).
During flexion of the arm to 90º they
form an equilateral triangle.
Most often there is a subcutaneous bursa
on the olecranon. This bursa may be
inflammed by repeated trauma resulting
in olecranon bursitis ( students elbow or
miner’s elbow ).
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– Relations of elbow joint
-Anteriorly - Brachialis , median nerve ,
brachial aa , tendon of biceps.
-Medially- ulnar nerve , flexor carpi
ulnaris , common flexor origin.
-Posteriorly - triceps & anconeus
-Laterally - Supinator , extensor carpi
radialis brevis , & other common
extensors.

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RADIOULNAR JOINTS
1, Proximal-(pivot joint)
- Articular surfaces
- articular circumference of head of
radius
- radial notch of ulna
Ligaments
-radial collateral -annular

Articular capsule -similar to elbow joint

Movement
-pronation & supination
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• 2, Distal radio ulnar
- Articular surfaces
- ulnar notch of radius
- articular circumference of head of ulna.
• Articular Capsule
- Is wide & attached at the boundary b/n
the bones & their articular cartilage
above & to the margins of the articular
disc below.
- part of the capsule extends proximally
b/n the radius & ulna for about 1-2cm
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• Ligament
- Interosseous membrane connects the
interosseous border of radius & ulna.
- keeps pressure balance b/n radius & ulna.
- prevents friction / rubbing b/n the bones
- sometimes referred as middle radioulnar
joint
- In its upper 1/3 it is strengthened by the
oblique cord ( Weitbrecht’s cord , Coopers
ligament.
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 – Axis of movement
-Uniaxial pivot joint , axis runs diagonally
from the center of the head of radius
proximally to the middle part of the head of
the ulna distally.
– Movements
-supination
-pronation
-The ‘O’ position during pronation & supination
movements is when the transverse axis of
the forearm lies in sagittal plane.
•
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• Applied Anatomy
-In cases of forearm fracture POP casts should be
applied in a supinated position.
3. RADIOCARPAL JOINT ( Proximal wrist jt )
• synovial joint of the ellipsoid variety.
• Articular surfaces
• Upper - inferior surface of the lower end of the
radius & articular disc of the inferior radioulnar
joint.
• Lower - the three proximal carpal bones;
-scaphoid - lunate
triquetrium
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• Articular capsule
- Surrounds the joint & is attached above to
the lower ends of radius & ulna & below
to the proximal row of carpal bones.
- Is wide , thin & is strengthened by
ligaments in its palmar , dorsal & lateral
aspects.
• Ligaments
• Anterior ( palmar radiocarpal )
• Strong band directed to medially &
downwards from radius to lunate bone.
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 Posterior ( dorsal radiocarpal )
Is weaker than the anterior ligament, is directed
downwards & medially to lunate bone.
Lateral ( radial collateral )
-Extends from styloid process of the radius to
the lateral side of the scaphoid bone.
- Medial ( ulnar collateral )
- Extends from styloid process of the ulna to
the triquetral & pisiform bones.

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Relations - Anterior – long flexor tendons with
their synovial sheath & median nerve.
- Posterior - extensor tendons of the wrist &
fingers with their sheath.
- Lateral - radial artery.
Blood Supply
-Anterior & Posterior carpal arches
Nerve Supply
-Anterior & posterior interosseous nerves

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• Movements
1, A transverse radioulnar axis passing through
lunate bone.
-Palmar & dorsal flexion both for 90* from ‘O’
position
2, A sagittal dorsopalmar axis passing through
capitate bone.
-Abduction ( radial deviation ) for ~15*
-Adduction ( ulnar deviation ) for ~45* from ‘O’
position.
flexion is usually combined with adduction &
extension
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MIDCARPAL ( Distal wrist ) JOINT
A jt b/n distal & proximal row of carpal bones
Articular cavity is S- shaped , due to the
downward projection of scaphoid from the
proximal row & upward projection of capitate
from distal row.
Articular capsule
attached at the transition b/n bones & their
articular cartilage.
Axes & movement
- as in radiocarpal joint
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Movements
-Adduction, abduction, opposition, reposition.
-Opposition is the combined movement of
abduction, flexion, adduction which can be
done with in a range of 50-60º.
- It is most important joint in the hand , the
loss of the thumb carries a function loss of
~25 % in the hand.
Muscles involved in the movement of the
carpometacarpal joint of the thumb
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JOINTS OF THE FINGERS
-All the fingers except the thumb contain the ff
joints.
1. Metacarpophalangeal joint between the
metacarpal and proximal phalanx.
2. Proximal interphalangeal joints
- between proximal and middle phalanx.
3. Distal interphalangeal joints
- between the middle and distal phalanx
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