The Forearm

Elbow Joint
• Elbow joint is the point of articulation of the humerus, ulna
and radius forming 2 joints
• It is a synovial joint of the hinge variety.
• The joint communicates with the proximal radioulnar joint.
• Capitulum is a spherical lateral portion of the distal end of
the humerus, articulates with the head of the radius.
• Trochlea is the grooved medial part of the distal end of the
humerus extending from the anterior to the posterior
surfaces of the humerus.
• The trochlea is limited by a sharp ridge medially and a blunt
ridge laterally which blends with capitulum surface.
• The head of radius and coronoid process of ulna fit into the
fossae above the capitulum and trochlea respectively in full
flexion.
• The olecranon of the ulna is received in the posterior fossa in
full extension.
• The upper surface of the radial head is spherically concave to
fit the capitulum, while the deep trochlea notch of the ulna
fits the trochlea.
• The coronoid process and olecranon are connected by a ridge
that fits the groove of the trochlea.
• The oblique orientation of the ulna in relation to the ridge
and the tilt at the lower humeral end accounts for the
carrying angle.
• The joint capsule is attached to the outer edges of the
capitulum and trochlea, extending above the anterior fossae
(coronoid and radial) and above the olecranon fossa
posteriorly.
• The synovial membrane is attached to the 3 bones at their
articular margins lining the capsule and the lower part of
annular ligament.
• Annular ligament; encircle the head and neck of radius in the
proximal radioulnar joint attached to the anterior and posterior
margins of the radial notch of ulna. Radius freely rotates in it.
• Ulnar collateral ligament; triangular with 3 bands, anterior passes
from medial epicondyle to the tubercle on the medial border of
coronoid process (sublime tubercle). It is the strongest.
• Posterior band joins the sublime tubercle to the medial border of
the olecranon. Middle band connects the 2
• Radial collateral ligament; a triangular band with its apex
attached to the lateral epicondyle and base blending with the
annular ligament of radial head.
• Elbow joint is innervated by musculocutaneous, median,
ulnar and radial nerves.
• The ulna-humerus axis deviates laterally at 1700 resulting in
obliquity which is eliminated in pronation. Flexion and
extension of 1400 permitted.
• Carrying angle more prominent in female
• Deviation between forearm and arm lost in pronation
• Ulnar nerve palsy possible from heightened deviation (lateral
epicondyle fracture/ epiphyseal damage).
Anterior compartment of the forearm
• Flexor compartment consist of 5 superficial group that
crosses the elbow joint and 3 deep group.
• Bulkier than the extensor compartment
• 5 superficial muscles have common origin on the anterior
surface of the medial epicondyle of the humerus.
• Position represented by the direction of the digit with heel
on the opposing medial epicondyle.
Pronator Teres; from the common origin and the lower part
of medial supracondylar ridge for the main superficial belly.
Deep belly arises from the medial border of the coronoid
process of ulna distal to the tubercle.
Superficially oblique across forearm, inserted as a flat
tendon into the middle of lateral surface of radial shaft
convexity.
Forms the medial border of cubital fossa
Median nerve lie between the 2 heads, ulnar artery is deep
to deep head.
Innervated by highest muscular branch of median nerve C6,
7
Weakly flex elbow and pronate the forearm.
Flexor carpi radialis; arise from the common origin, long
tendon at middle of forearm insert into bases of 2nd and 3rd
metacarpals.
Tendon runs in its carpal tunnel compartment grooving the
trapezium with radial artery lateral and median nerve medial
to it.
Innervation by median nerve C6, 7.
Flexes and radially abduct the wrist.
Flexor Digitorum Superficialis; arises from the common origin,
medial ligament of elbow joint and tubercle on medial border
of coronoid process of ulna.
• Its oblique origin forms the upper limit of the space of
Parona.
• Its tendons are on either sides of the tendon of palmaris
longus above the wrist, beneath the flexor retinaculum
middle and ring finger tendons are above the other 2.
• Median nerve lies deep to it in the forearm.
• Nerve supply is from median nerve C7, 8. flexes the proximal
interphalangeal joint and the metacarpophalangeal and wrist
joints
Palmaris longus; absent in 13% of
people, arises from common origin.
Its tendon flattens passing in front
of the flexor retinaculum, split in
the palm to form palmar
aponeurosis.
Tendons are superficial to the
median nerve.
Innervation by median nerve C7, 8.
Weak flexor of wrist, protect
against shearing forces in hand.
Tendon useful for transplant.
• Flexor Carpi Ulnaris; arises from common origin, medial
border of olecranon and upper 2/3rd of subcutaneous
border of the ulna.
• Ulnar nerve pass between its humeral and ulnar heads to
gain access to flexor compartment.
• In the forearm, the muscle overlies the ulnar nerve and
artery, while at the wrist, its tendon is medial to the nerve
and artery.
• Tendon insert into the pisiform extended to the hamate and
5th metacarpal by pisohamate and pisometacarpal ligament
• Innervation by ulnar nerve C7, 8. It flexes and ulnar adduct
the wrist
Deep muscles of forearm
• Flexor Digitorum Profundus; Bulky muscle arising from
medial surface of olecranon, proximal 3/4th of the antero-
medial surface of ulna and interosseous membrane
• Tendon of index finger separate in forearm, others separated
fully in the palm.
• Innervated by the anterior interosseous branch of median
nerve and ulnar nerve C8, T1.
• Innervation distribution 2:2 (60%), 1:3 (20%), 3:1 (20%),
belly-lumbricals innervation maintained.
• Flexes the terminal interphalangeal joint.
• Flexor Pollicis longus; arises from the surface of radial bone
between the anterior oblique line and line of attachment of
pronator quadratus muscle
• Additional fibers come from the interosseous membrane.
• All fibers are on the radial side while the tendon is on ulnar side
running deep to that of flexor carpi radialis in the carpal tunnel
before spiraling to its ulnar side.
• Insert into the base of the distal phalanx of the thumb.
• Innervation is by anterior interosseous branch of median nerve
C7,8.
• Flexes the interphalangeal, metacarpophalangeal and
carpometacarpal joints.
• Pronator Quadratus; arise on
the anteromedial surface of
the distal part of ulna and
insert on the distal 4th of the
anterior surface of radius and
triangular area above ulnar
notch.
• Innervation by anterior
interosseous branch of median
nerve C7,8.
• Pronates forearm and
stabilizes distal end of radius
and ulna in weight bearing.
Posterior compartment of the forearm
• The compartment contain 12 muscles
• Brachioradialis; from the upper 2/3rd of the lateral
supracondylar ridge to the base of the radial styloid as a flat
tendon.
• The radial artery and nerve are deep to the muscle and its
tendon.
• The abductor pollicis longus and extensor pollicis brevis
spiral superficial to the lower end of the tendon.
• Nerve supply is from Radial nerve (C5,6), it flexes the elbow
joint, best at semi-pronated position.
• Extensor Carpi Radialis Longus;
from the lower third of the
lateral supracondylar ridge to
the base of the second
metacarpal as a flat tendon.
• Muscle runs between
brachioradialis and the pollicis
muscles.
• Nerve supply from Radial nerve
(C6,7), it extends and abducts
the wrist, assist in elbow
flexion.
• Extensor Carpi Radialis Brevis;
from the common extensor origin
on the lateral epicondyle, running
deep to its longus counterpart.
• It is inserted as a flat tendon into
the base of the 3rd metacarpal.
• Nerve supply is from a branch of
the posterior interosseous nerve
(C7,8) before piercing the
supinator muscle
• It is an extensor of the wrist.
• Extensor Digitorum; from the common extensor origin,
expand into a rounded muscular belly at mid forearm.
• Its tendons run deep to the extensor retinaculum superficial
to the extensor indicis
• Fusion of the 3rd and 4th tendons does occur extending to
the metacarpophalangeal joint by a tendinous band.
• Nerve supply is from the posterior interosseous nerve (C7,8)
• It extends the wrist, metacarpophalangeal joint and
interphalangeal joint
• Extensor Digiti Minimi; arises
together with extensor digitorum,
separated later.
• Tendon passes deep to extensor
retinaculum dorsal to the
radioulnar joint.
• Tendon then split into 2 to form an
expansion alongside the extensor
digitorum band to the little finger.
• Innervated by posterior
interosseous nerve (C7,8)
• Extends the little finger and wrist
joint.
• Extensor Carpi Ulnaris; from the common extensor origin and
the aponeurosis from the subcutaneous border of ulna which it
shares with flexor carpi ulnaris muscle
• Tendon lies in the groove on the side of ulnar styloid to insert
at the base of 5th metacarpal.
• Innervated by the posterior interosseous nerve (C7,8).
• It extends and adduct the wrist.
• Anconeus; from the posterior surface of the lateral epicondyle,
fanning out to the lateral side of olecranon and adjacent parts
of ulna.
• Innervated by Radial nerve (C7,8), same branch that supply
triceps.
• Supinator; from the distal edge of the
lateral epicondyle, lateral ligament of
the elbow joint, annular ligament of
radius, supinator crest of ulna and
adjoining fossa.
• Two layers of muscle with posterior
interosseous nerve running between
them as it exits the cubital fossa.
• Innervated by the posterior
interosseous nerve (C6,7).
• Fixes the forearm in supination,
initiates supination in fully extended
elbow.
• Abductor Pollicis Longus; arises from
the posterior surface of ulna (proximal)
and radius (distal) alongside the
interosseous membrane.
• Tendon split into 2 inserting into the
base of the 1st metacarpal and the
other to the trapezium.
• Innervated by posterior interosseous
(C7,8)
• Extends the thumb at the
carpometacarpal joint. Abduct and
flexes the wrist.
• Extensor Pollicis Brevis; arises
below the radial attachment of
abductor pollicis longus and
adjoining interosseous membrane.
• Inserted as a slender tendon into
the base of the proximal phalanx.
• Innervated by the posterior
interosseous nerve (C7,8).
• Extends the carpometacarpal and
metacarpophalangeal joints of the
thumb.
• Extensor Pollicis Longus; arises distal to the ulna attachment
of abductor pollicis longus.
• Inserted into the base of distal phalanx, the tendon changing
direction around the dorsal tubercle of radius.
• It forms the ulna border of the anatomical snuffbox
• Occlusion of anterior interosseous artery in Colle’s fracture
results in the rupture of the tendon.
• Unopposed action of flexor pollicis longus results in flexion
deformity of distal phalanx (hammer’s thumb).
• Innervation by posterior interosseous nerve (C7,8)
• It extends terminal phalanx of thumb, extends and abduct
the wrist.
• Extensor Indicis; arise from
the ulna distal to the
extensor pollicis longus to
insert into the dorsal
expansion of the index
finger.
• It runs deep to the extensor
digitorum, sharing synovial
sheath
• Innervated by the posterior
interosseous nerve (C7,8).
• It extends the index finger.
• Anatomical snuffbox; bounded on
the ulna side by tendon of
extensor pollicis longus and on
the radial side by extensor pollicis
brevis and abductor pollicis
longus.
• Cutaneous branches of radial
nerve run superficial to the ulnar
border
• Cephalic vein begins in its roof
while radial artery is on its floor
on the radial styloid, scaphoid,
trapezium and base of thumb
metacarpal proximo-distally.
• Extensor Retinaculum; 2.5cm wide deep fascia thickening,
lying obliquely across the extensor wrist surface.
• Attached proximally to the anterolateral border of radius and
distally to the pisiform and triquetral bones.
• Fibrous septa attached to the forearm bones dividing the
extensor tunnel into 6 compartments
• Each transmitting different tendons.
Blood supply of the forearm
The Wrist and Hand
• 8 carpal bones arranged in 2 rows of 4 bones each
• Cuboidal in shape with roughened anterior and posterior
surfaces.
• 4 other surfaces in articulation with others covered by
cartilages.
• The largest and most central is the capitate, while trapezium
and trapezoid are the smallest.
• Carpal ossification starts with the capitate and ends with
pisiform in the 1st and 12th postnatal year respectively.
• Midcarpal joint is sinusoidal with lateral limitations
permitting extensive flexion.
• Trapezium has saddle-shaped articular surface for 1st
metacarpal.
• Wedged-shaped articular surface by trapezium and trapezoid
for 2nd metacarpal
• Capitate articulates with the 3rd metacarpal via a flat surface.
• Hamate provide 2 convex articular surfaces for 4th and 5th
metacarpals.
• Intermetacarpal articulation at the metacarpal bases of 2nd -
5th metacarpals.
• 2nd and 3rd metacarpals are least mobile
• Intercarpal ligaments radiates from the capitate.
• Triquetrium and pisiform do not transmit force to the radius
• Radiocarpal joint presents ellipsoid articular surface, permits
flexion, extension, adduction and abduction.
• Radiocarpal ligament extends from the distal end of radius
to the proximal row of carpal bones extending to capitate
(Palmar and Dorsal)
• Radial and ulnar collateral ligaments from styloid processes
of radius and ulna to the scaphoid and triquetrium
respectively.
• The head of the metacarpals are spheroidal fitting into the
concave proximal articular surface of the 1st phalanx.
• Sesamoid bone (2) at the head of the 1st metacarpal.
• Abduction and adduction occurs with respect to the axial line
of the hand at the metacarpophalangeal joint.
• Abduction and adduction of the thumb is at the saddle-
shaped carpometacarpal joint.
• The Thenar Muscles; arise from the flexor retinaculum,
tubercle of scaphoid and trapezium.
• The abductor pollicis brevis is the superficial part
• Deep part consist of the opponens pollicis which is inserted
into the metacarpals and the flexor pollicis brevis which is
inserted into the phalanx.
• Flexor pollicis brevis is inserted via the lateral sesamoid bone
at the head of the metacarpal.
• They pronate the thumb, flex it at the metacarpophalangeal
joint.
• Innervation by the recurrent branch of the median nerve,
can be supplied by the deep branches of ulna nerve.
• The Hypothenar Muscles; from the flexor retinaculum,
pisiform and hook of Hamate
• They include the abductor digiti minimi and opponens
digiti minimi.
• They are supplied by the deep branches of the ulnar
nerve.
• Adductor Pollicis; arises from palmar border of middle
metacarpals and the capitate and inserted into the
base of the 1st phalanx of the thumb.
• Innervation by the ulnar nerve.
• Ulnar Nerve; gain access to the hand superficial to the flexor
retinaculum between pisiform and hook of hamate.
• Divides into a superficial and deep branches
• The superficial branch give cutaneous supply to the medial 1.5
fingers and motor supply to palmaris brevis muscle
• The deep branch supplies the hypothenar muscles before going
deep to supply the short muscles of the hand except for those
supplied by median nerve.
• Median Nerve; pass through the carpal tunnel deep to the
palmar aponeurosis in the palm dividing into the recurrent and
digital branches
• Supplies the thenar muscles and 2 lateral lumbricals respectively.
• Palmar Aponeurosis; formed by the diverging bands of the
tendon of the palmaris longus muscle which courses
superficial to the flexor retinaculum.
• It blends with the subcutaneous tissue sending fibrous septa
to the palmar ligament and deep fascia in the distal half of
the palm.
• The tendons of the superficialis and profundus are deep to
the palmar aponeurosis.
• The tendons enter the fibrous digital sheath to insert into the
anterior part of the base of the distal phalanx (profundus)
while superficialis splits into lateral and medial part to insert
on the sides of the middle phalanx.
• The lumbricals; arises from
the tendon of Profundus.
• First and second are
unipennate while the other 2
are bipennate.
• Lie dorsal to the digital
neurovascular bundle
• Join the extensor expansion
distal to the interossei
• Medial 2 supplied by ulnar
nerve, others by the median
• Interosseous muscles; They are intrinsic muscles of the hand
• Divided into the palmar and dorsal groups
• Palmar interossei are attached to the metacarpals of digit 2,
4 and 5 and inserted into the base of the proximal phalanx
and the extensor expansions.
• Dorsal interossei arise with metacarpals 1 to 5 and insert into
the bases of proximal phalanges and extensor expansions of
digits 2 to 4.
• Nerve supply is from the deep branch of the Ulnar nerve
• Dorsal abduct, palmar adduct
• Palmar Spaces; 4 of them, important for infection
delineation
• Thenar and Hypothenar occupied by muscles
• Central space between the muscular space bounded
superficially by the palmar aponeurosis and dorsally by
the 3 medial metacarpals, ligaments, medial interossei
and adductor pollicis muscle.
• Side walls formed by attachment of the palmar
aponeurosis to the thenar and hypothenar fasciae.
• The 4th space lies deep to the adductor pollicis muscle
Palmar Arches
• Consist of the superficial and deep part
• Providing vascular infrastructure for the hand
• Superficial; Predominantly from the Ulnar artery with
contribution from the superficial palmar branch of the Radial
artery.
• Radial contribution is not constant
• Give 3 common palmar digital arteries which run on the
palmar surface of the 2nd to 4th lumbricals respectively.
• CPGA divides into 2 proper palmar digital arteries at the
metacarpophalangeal joint.
• Deep; primarily from the terminal part of radial artery with
ulnar artery contribution.
• Lies on the bases of the metacarpals and interossei muscles
of hand.
• Superficial to it are the adductor pollicis, flexor tendons and
lumbricals.
• It lies proximal to the superficial in the palm, a finger width
proximal to the Boeckel’s line.
• Give rise to the palmar metacarpal arteries supplying the
thumb and lateral side of index finger.