M1 Anatomy Tutorial: Bones, Joints and Proximal Muscles of the Upper Limb

Bones, Joints and Proximal Muscles of the Upper Limb * Black font: Essential for Tutorial
(Compiled from Yunnan + Em’s + Moore + Wee’s) Red font: Notes for understanding

General Objectives
a) To know the major bones of the upper limb and their main features, and understand how they articulate
(join) to produce different movements and maintain stability.
b) To understand how the proximal muscles of the upper limb help to produce movements of the scapula
and at the proximal joints.

Specific Objectives
1. What is the basic composition of a synovial joint and what are the principles/factors determining the possible
movements at this joint and its stability?

Basic composition of a synovial joint

Structure
Hyaline cartilage
Synovial membrane
Tough fibrous capsule
Ligaments
Articular discs
(Fibrocartilaginous)
Fatty pad (Bursae)
Function
- Covers articular surface of bones
- Encloses the joint cavity, together with which permits great degree of free movement between
the bones they join
- Lines the internal surface of the fibrous capsule, and reflected onto the surface of the bone, but
not covering the articular hyaline cartilage
- Consists of vascular connective tissue
- Produces synovial fluid which nourishes the hyaline cartilage and lubricates the joint surface to
reduce friction
- Covers joint and protects synovial membrane
- Reinforces the joint, covering the capsule; but limits movement
- Separates the synovial cavities, permitting separate movements to occur in each space
- Permits more even distribution of forces, increasing the stability of the joints, especially when
articular surfaces of bones are incongruous
- Found between synovial membrane and fibrous capsule
- Acts as a cushion between the bones
- Elastic fibers bring about recovery from deformation caused by pressure across a moving joint;
lubrication

Remarks:
1. General approach for joints should be as follows: articular surface  hyaline cartilage  synovial
membrane  capsule  bursa  fat pads  articular discs  ligaments  muscles.

Principles/factors determining possible movements and stability

Factor Explanation
Bony - Shape, size and arrangement of bones determine type of joint and movements
- Presence of fossae to accommodate processes of another bone increases stability, but limits range of
movement
Muscular Normal state of partial contraction of a resting muscle is maintained by reflex activity. Good muscle tone supports
bones and ligaments at the joint, preventing dislocations of the joint
Ligaments Ligaments aid in stabilizing the joint, holding the bone in its place, while limiting the range of movements the joint
is capable of.
- Fibrous ligaments prevent excessive movement, but stretch after prolonged stress
- Elastic ligaments return to their original length after stretching, supporting the joints and assisting in the
return of bones to their original position after movement
Atmospheric Intra-articular pressure is about -4 mmHg (negative to atmospheric pressure) in joints, and this pressure falls
Pressure farther when the muscle contracts. The difference between atmospheric pressure on overlying tissues and sub-
atmospheric values within the joint helps to hold the joint members together and thus provides a stabilizing force

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 M1 Anatomy Tutorial: Bones, Joints and Proximal Muscles of the Upper Limb

2. The scapula contributes to the mobility and range of movements of the upper limb. Review the movements of
the scapula and the muscles (including main attachments) responsible in raising the arm to the vertical
position through abduction. What causes winging of the scapula?

Movements of scapula

Movements Muscles involved Movements Muscles involved

Elevation
Protraction / Drawing
against thoracic wall
Rotation elevating glenoid
cavity
- Superior trapezius Depression - Inferior trapezius
- Levator scapulae - Pectoralis minor
- Serratus anterior Retraction - Middle trapezius
- Pectoralis minor - Rhomboid major
- Pectoralis major - Rhomboid minor
- Superior trapezius Rotation depressing glenoid - Levator scapulae
- Inferior trapezius cavity - Rhomboid major
- Serratus anterior - Rhomboid minor

Muscles involved in raising the arm to the vertical position

- Scapular-Humeral Mechanism: Abduction of the arm involves the rotation of the scapula and movement at
the shoulder joint. For every 3⁰ of abduction, a 2⁰ abduction occurs in the shoulder joint and 1⁰ abduction
occurs by rotation of the scapula.

Phase Muscles Involved Proximal attachment Distal attachment

Abduction of the Supraspinatus Supraspinous fossa of Superior fa et of greater
arm up to 120⁰ Initiates abduction for first 15⁰, by stabilizing the head scapula tubercle of humerus
of humerus against glenoid fossa of scapula, rotating
the glenoid cavity superiorly by pulling acromion
laterally and inferiorly.
Middle fibers of deltoid Lateral third of clavicle; Deltoid tuberosity of
Contracts to abduct humerus at glenohumeral joint acromion and spine of humerus
scapula
Rotation of scapula Superior trapezius Medial third of superior Lateral third of clavicle;
beyond 120⁰ Pulls clavicle superiorly and medially nuchal line; external acromion and spine of
Inferior trapezius occipital protuberance; scapula (trapezius ends
Pulls scapula inferiorly and medially nuchal ligament; spinous where the deltoid
processes of C7 – T12 begins)
vertebrae
Serratus anterior External surfaces of Anterior surface of
Depresses scapula and rotates the glenoid cavity lateral parts of 1st – 8th medial border of scapula
ribs

Causes for winging of the scapula

- Caused by the injury of the long thoracic nerve (C5-7), which innervates the serratus anterior, resulting in its
paralysis.
- The scapula is no longer held against the thoracic wall, and hangs away from it. The medial border of
scapula moves laterally and posteriorly away.

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 M1 Anatomy Tutorial: Bones, Joints and Proximal Muscles of the Upper Limb

3. The shoulder (glenohumeral) joint allows a wide range of movements for the upper limb. It is, however, prone
to dislocation and, in old age, painful stiffness. Endoscopic examination of this joint is possible because it has a
synovial cavity.
a. What are the structural features of this joint that allow a high degree of mobility? How is stability achieved
and what happens in a dislocation? What features of this joint may be observed through an endoscope?

Structural features of glenohumeral joint

- Glenoid labrum
- Capsule
- Synovial membrane
- Long head of biceps
- Glenohumeral ligaments

Mobility of the glenohumeral joint

- Laxity of its articular capsule
- Only 1/3 of large humeral head is received by a very shallow pear-shaped glenoid cavity
- Ball-and-socket arrangement of bones allow 3 axes of movement

Stability of the glenohumeral joint

Factor Explanation
Bony Deepening of the relatively shallow glenoid cavity by fibrocartilaginous glenoid labrum
Muscular Rotator cuff (tendons of the subscapularis, supraspinatus, infraspinatus and teres minor) protects the joint
medially, laterally and superiorly. These tendons cross the joint and reinforce its strength.
Ligaments - Coracohumeral ligament strengthens capsule superiorly
- Glenohumeral ligaments, e.g. the coracoacromial ligament strengthens capsule anteriorly by limiting
excessive movement (degree of abduction)
- Transverse humeral ligament
Joint capsule Acts as a support feature for the inferior part of the joint. As it is attached medially to the anatomical head of
the humerus and laterally to the margin of the glenoid cavity outside glenoid labrum.

Endoscopic features of the glenohumeral joint

- Tendon of long head of biceps covered by fibrous synovial sheath
- Head of humerus
- Glenoid labrum (ring of fibrocartilage around rim of shallow pear-shaped glenoid cavity)
- Synovial space, enclosed by synovial membrane
- Articular surfaces lined with hyaline cartilage, with any fractures or cracks
- Joint cavity and ligaments (e.g. glenohumeral ligaments)
- Strands of fibrous capsule

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 M1 Anatomy Tutorial: Bones, Joints and Proximal Muscles of the Upper Limb

b. List the normal movements at this joint and indicate the muscles (mentioning attachments) involved.

Movements Muscles involved Movements Muscles involved

Flexion - Deltoid (Ant. fibers)
- Pectoralis major (Clavicular
fibers)
- Biceps brachii
- Coracobrachialis
Abduction - Deltoid (Mid. fibers)
- Supraspinatus
Lateral Rotation - Infraspinatus
- Teres minor
- Deltoid (Post. fibers)
Extension - Deltoid (Post. fibers)
- Latissimus dorsi
Adduction - Pectoralis major
- Latissimus dorsi
- Teres major
Medial rotation - Subscapularis
- Latissimus dorsi
- Teres major
- Deltoid (Ant. fibers)

Remarks:
1. To achieve a greater-than-normal degree of abduction, the 1 has to undergo lateral rotation so that the
greater tubercle of humerus does not go in the way of the acromiocoracoid ligament.

c. What is the innervation of this joint?

Innervation of the glenohumeral joint

The capsule and ligaments receive an abundant sensory nerve supply. A sensory nerve supplying the joint also
supplies the muscles moving the joint (somatic motor nerve supply) and the skin overlying the insertions of
these muscles. (Hilton’s Law)

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 M1 Anatomy Tutorial: Bones, Joints and Proximal Muscles of the Upper Limb

4. The elbow (humeroulnar) joint is a typical hinge joint which is occasionally dislocated.
a. Review this articulation and the basis for its relative stability (e.g. compared to the glenohumeral joint).

Elbow joint
The elbow joint is a hinge joint, which occurs between the trochlea and capitulum of the humerus and the
trochlear notch of the ulnar and head of the radius. The major collateral ligaments are lateral and medial
ligaments. The joint capsule communicates with the proximal radioulnar joint.

Stability of the elbow joint

- Bony factors
o Olecranon process fitting into the olecranon fossa increases stability
o Wrench-shaped articular surface of the olecranon and the pulley-shaped trochlea
 In flexion, boundaries of the fossa form an equilateral triangle
 In extension, the medial and lateral epicondyles, and the olecranon process form a straight line
- Muscular factors
o Extension is limited by the brachialis muscle and anterior ligament
o Tendons crossing the joint increase stability
- Ligamentous factors
o Strong collateral, anterior and posterior ligaments strengthen the articular capsule
o These ligaments prevent abduction, adduction and rotation
- Other factors: fatty pads present
o Flexion limited by surface of arm and forearm coming into contact

Remarks:
1. The ulna bone is only involved in flexion/extension; the radius is involved in pronation/supination.

b. What would be the organization/location of muscles primarily responsible for movements at this joint?
(may be done later)

Muscle Location Action

Biceps brachii Anterior fascial compartment of arm Flexion, Supination
Brachialis Flexion
Brachioradialis Lateral fascial compartment of forearm Flexion
Triceps brachii Posterior fascial compartment of arm Extension
Pronator teres Anterior fascial compartment of forearm Flexion, Pronation
Pronator quadratus Pronation
Anconeus Posterior fascial compartment of forearm Extension
Supinator Supination

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 M1 Anatomy Tutorial: Bones, Joints and Proximal Muscles of the Upper Limb

5. The wrist (radiocarpal) joint allows the hand to have a good range of movements to execute its functions.
Sprains and fractures (e.g. distal end of radius) can severely limit wrist movements.
a. Outline the composition, movements (muscles to be done later) and basis for stability at the wrist joint.

Composition of wrist joint

- Synovial ellipsoid joint
- Distal end of radius articulates with scaphoid and lunate bones
- Articular disc (fibrocartilage) between head of ulna and triquetrum
- Proximal surface concave, distal surface convex
- No communication with distal radioulnar joint
- Anterior and posterior collateral ligaments

Movements of wrist joint

Movements Muscles involved Movements Muscles involved

Flexion - Flexor carpi radialis
- Palmaris longus
- Flexor carpi ulnaris
- Flexor digitorum superficialis
- Flexor digitorum profundus
- Flexor pollicis longus
Abduction - Flexor carpi radialis
- Extensor carpi radialis longus
- Extensor carpi radialis brevis
- Abductor pollicis longus
- Extensor pollicis longus
- Extensor pollicis brevis
Extension - Extensor carpi radialis longus
- Extensor carpi radialis brevis
- Extensor carpi ulnaris
- Extensor digitorum
- Extensor indicis
- Extensor digiti minimi
- Extensor pollicis longus
Adduction - Flexor carpi ulnaris
- Extensor carpi ulnaris

Basis for stability at the wrist joint

- Shape of articular surfaces
- Capsule encloses joint, attached proximally to the distal end of radius and ulna, distally to the proximal row
of carpal bones.
- Presence of 4 sets of ligaments: The anterior and posterior ligaments, ulnar collateral ligament and radial
collateral ligament.

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 M1 Anatomy Tutorial: Bones, Joints and Proximal Muscles of the Upper Limb

6. As the most important single digit in the hand, the thumb enjoys special movements because of the first
carpometacarpal joint.
a. Review the first carpometacarpal articulation with respect to the kind of joint and possible movements.

First carpometacarpal joint

- Type of joint : synovial saddle joint
- Articulation : trapezium and base of first metacarpal bone

Movements of the first carpometacarpal joint

Movements Muscles involved Movements Muscles involved
Flexion - Flexor pollicis brevis Extension - Extensor pollicis longus
- Opponens pollicis - Extensor pollicis brevis
Abduction - Abductor pollicis longus Adduction - Adductor pollicis
- Abductor pollicis brevis
Opposition - Opponens pollicis

b. Understand the structural basis for movements and stability at the interphalangeal joints.

Interphalangeal joints
- Composition: Articulation between phalangeal bones
- Articulation: Form synovial hinge joints

Movements at interphalangeal joints

Hinge joints can only flex and extend

Stability at the interphalangeal joint

Stability maintained by COLLATERAL LIGAMENTS (taut when joint is in flexion and lax when joint is in extension)

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 M1 Anatomy Tutorial: Bones, Joints and Proximal Muscles of the Upper Limb

For self integration

a. Relate your understanding of ossification with the healing of a fracture. What is the significance of fusion of
an epiphysis? Have you seen an X-ray showing epiphyses in a developing long bone?

Healing of a fracture
Bones are living organs that have blood vessels, lymphatic vessels, and nerves. For a fracture to heal properly,
the broken ends must be brought together, approximating their normal position, called reduction of a fracture.
During bone healing, the surrounding fibroblasts (connective tissue cells) proliferate and secrete collagen,
which forms a collar of callus to hold the bones together. Bone remodeling occurs in the fracture area, and the
callus calcified. Eventually, the callus is resorbed and replacedby bone. Fractures in growing bones heal faster
than those in adult bones

Significance of fusion of an epiphysis

- During growth of a long bone, cartilaginous epiphysial plates intervene between the diaphysis and epiphysis
- Growth plates are eventually replaced by bone at each of its two sides, diaphysial and epiphysial
- When this fusion of an epiphysis occurs, bone growth ceases and the diaphysis fuses with the epiphysis
- The seam formed is recognizable in section bone or radiographs as an epiphysial line

X-ray differences between epiphyses and fracture

- On X-ray, the edges of epiphysis are smoothly curved in the region of the epiphysial plate.
- Bone fractures always leave a sharp, often uneven edge of bone.
- An injury that causes a fracture in a n andult usually causes the displacement of an epiphysis in a child.

b. What are the types of cartilage that may be found in association with synovial joints? How will you
distinguish them histologically?

Type of cartilage found in synovial joints and histological features

- Hyaline cartilage
o Small aggregations of chondrocytes embedded in an amorphous matrix of ground substance reinforced
by collagen fibres
o Chondrocytes are usually arranged in clusters (of 2 – 4 cells)

Type of cartilage found in non-synovial joints and histological features

- Fibrocartilage
o Alternating layers of hyaline cartilage matrix and thick layers of dense collagen fibres oriented in the
direction of the funcitojnal stresses
o Chondrocytes are arranged in rows between dense collagen layers
- Elastic cartilage
o Presence of numerous bundles of branching elastic fibres in the cartilage matrix

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