THE SKELETAL

SYSTEM
The human skeletal system is mainly made up of bones and
their associated cartilages, ligaments and tendons. It
accounts for about 20 percent of the total body weight.
The human skeleton contains 206 bones, of which largest is
the femur and smallest being the ear ossicles.
Bodily movements are carried out by the interaction of the
muscular and skeletal systems. For this reason, they are often
grouped together as the musculo-skeletal system.
Femur
 APPENDICULAR
MUSCLES AND BONES

UPPER LIMB
Bones of the upper limb – 32 X 2
- Clavicle
- Scapula
- Humerus
- Radius
- Ulna
- 8 Carpal bones
- 5 metacarpal bones
- 14 phalanges
 The clavicle (collar bone)
Peculiarities of clavicle
- It is the only long bone placed horizontally in the body.
- It is subcutaneous throughout
- It is the first bone to ossify in the body.
- It is the only long bone to ossify in membrane.
- It is the only long bone which ossify from two primary centres
- It has no medullary cavity
- It is occasionally pierced by the middle supraclavicular nerve
- It is weakest at the junction between the medial 2/3 and lateral 1/3, hence the fracture is
common at this junction.
Right clavicle
Muscle attachment to clavicle

Ossification:
• Two primary centers for the shaft – appear around 5th or 6th week soon fuse around 45th day
• Secondary center for the medial end appear during 15-17th year and fuse with the shaft during
21-22 years
• Occasionally there may be secondary center for the acromial end
 The Scapula (Shoulder blade)

• It is a flat bone, connects the clavicle to the humerus.

• It is one of the bone of the shoulder girdle.
• It is triangular in shape and shows two surfaces, three borders, three angles and two
processes, the acromion process (continuation of spine of the scapula) and coracoid
process.
Surfaces - Costal or ventral surface
Dorsal surface
Borders - Superior border
Axillary or lateral border
Vertebral or medial border
Angles - Inferior angle
Medial angle
Lateral angle

Coracoid process is an example for

atavistic epiphysis - it has fused with
the scapula for functional reasons
humans, but is separate in four-legged
animals.
Muscle attachment to scapula
Muscle attachment to scapula
The winging of the scapula - "Injury to the long
thoracic nerve causing paralysis or weakness of the
serratus anterior muscle.
Patients with serratus anterior palsy may present with
pain, weakness, loss of abduction of the arm and rotation
of the inferior angle toward the mid line, and
prominence of the medial or vertebral border.
Ossification:
• It ossifies by one primary center and 7 secondary
centers
 The humerus
It is the bone of the arm. It has upper end, lower end and shaft in between.
The upper end shows, the head, greater tubercle, lesser tubercle, intertubercular sulcus
and three necks – surgical, anatomical and morphological neck.
Upper 1/3 of the posterior surface of the shows the radial groove.
Right humerus
The lower end shows the capitulum, trochlea, medial epicondyle, lateral epicondyle,
coronoid fossa, radial fossa and olecranon fossa.
Right humerus
The Humerus
Muscle attachment to humerus
The common sites of fracture of humerus are – the surgical neck, the shaft, and
the supracondylar region.
Fracture of surgical neck may result in injury to the axillary nerve
In supracondylar fracture the median nerve is commonly damaged.
Ossification
• Humerus ossifies by one primary center and 7 secondary centers
The common sites of fracture of humerus are – the surgical neck, the shaft, and the supracondylar region.
In supracondylar fracture the median nerve is commonly damaged.
There are three types of humerus fracture, depending on the location of the break:
Proximal humerus fracture is a break in the upper part of your humerus near your shoulder.
Mid-shaft humerus fracture is a break in the middle of your humerus.
Distal humerus fractures occur near your elbow. This type is usually part of a more complex elbow injury and sometimes
involves loose bone fragments.
• Any hard blow or injury to your arm can result in a humerus fracture, but some are more likely to cause certain types.
For example, breaking your fall with an outstretched arm can often cause mid-shaft and proximal humerus fractures. A
high-impact collision, such as a car accident or football tackle, is more likely to cause a distal humerus fracture.
• Humerus fractures can also be pathologic fractures, which happen as the result of a condition that weakens your bones.
This leaves your bones more vulnerable to breaks from everyday activities that wouldn’t usually cause any injuries.
• Things that can cause pathologic humerus fractures include: osteoporosis, bone cancer, bone tumour, bone
infection.
To determine the best treatment, your doctor will start by taking an X-ray of your arm.
In many cases, proximal and mid-shaft humerus fractures don’t require surgery because the broken ends usually stay close
together. Occasionally, surgery is required with either plates, screws or rods. Distal fractures usually require surgery. There
are two main approaches that your surgeon may use:
Pins and screws - they may use pins and screws and plates to hold the broken ends of your humerus in place.
Bone grafting - If some of the bone has been lost or severely crushed, your surgeon may take a piece of bone from another
area of your body or a donor and add it to your humerus.
 The radius
It is the lateral bone of the forearm. It has a
shaft and two ends – upper and lower.
The upper end shows head, neck and radial
tuberosity.
The lower end shows Lister’s tubercle, styloid
process and inferior surface - where the
scaphoid and lunate articulate.
Yellow arrow – ulnar tuberosity
Red arrow – interosseous crest
Ossification:
• One primary center for the shaft and two
secondary centers (one for each end)
• Primary center appears at 8th week
• Secondary center for the lower end appears
during first year fuse with the shaft at 20th
year (growing end of the bone)
• Secondary center for the upper end appears
during 4th year fuse with the shaft at 18th
year
 The ulna
It is the medial bone of the forearm. It has
following parts – upper end, shaft and lower
end.
Upper end shows – olecranon process, coronoid
process, radial notch and trochlear notch.
Lower end shows – head and styloid process.

Ossification:
• One primary center for the shaft and two
secondary centers (one for each end)
• Primary center appears at 8th week
• Secondary center for the lower end appears
during 5th year fuse with the shaft at 18th
year (growing end of the bone)
• Secondary center for the olecranon process
(upper end) appears during 10th year fuse
with the shaft at 16th year
Muscle attachment to radius and ulna
Muscle attachment to
radius and ulna
The radius commonly gets fractured about 2cm above its lower end, by a fall on the
outstretched hand.
In Colle’s fracture the distal fragment is displaced upwards and backwards.
In Smith’s fracture the distal segment being palmar flexed rather than dorsiflexed.
Congenital absence of radius is a rare anomaly.
Radioulnar synostosis is also a rare condition in which radius and ulna are fused
together, pronation and supination is impossible in these cases.
Subluxation of the head of the radius - A sudden jerk on the hand of a child may
dislodge the head of the radius from the annular ligament
• The shaft of the ulna may get fractured either alone or along with
radius. Cross union between the radius and ulna must be prevented to
preserve pronation and supination.
• Fracture of the olecranon process is common and is caused by a fall
on the point of the elbow.
• Dislocation of the elbow is produced by a fall on the outstretched
hand with the elbow slightly flexed.

Fracture of the ulnar shaft

Fracture of the olecranon process

Posterior elbow dislocation

 Carpal bones
The skeleton of the hand is made up of carpal, metacarpal and phalangeal bones.
The carpus is made up of 8 carpal bones, which are arranged in two rows.
Proximal row – Scaphoid, Lunate, Triquetral & Pisiform (from L – M)
Distal row – Trapezium, Trapezoid, Capitate & Hamate (from L – M)
• The scaphoid and lunate articulate with the lower end of the radius to
form the wrist joint.
• The distal row carpal bones articulate with the metacarpal bones to
form carpometacarpal joints
Fracture of the scaphoid bone
• Is common when compared to the other carpal bones.
• The fracture can result in avascular necrosis of scaphoid.
• It is commonly seen in patients between 15 and 35 years of age caused by a fall on
the outstretched hand.
Bennett’s fracture –Intra-articular fracture/dislocation of base of 1st metacarpal bone.
Mallet finger - Mallet finger injuries occur when the tip of a finger or the thumb is
forcefully bent. This condition is also known as baseball finger. It happens when a ball
or other object strikes the tip of the digit.
Ossification:
Proximal row P T L S
12 3 4 5 (years)
Distal row H C T T
1 1 5 5 (years)
Metacarpal bones – there are five metacarpal bones
Phalanges – they are 14 in number in each hand, 3 for each finger and 2 for thumb.
 MUSCLES OF THE UPPER LIMB
The Pectoral region - It is located on the anterior chest wall. It contains the breast and four
muscles that exert a force on the upper limb; the pectoralis major, pectoralis minor, serratus
anterior and subclavius.
The superficial fascia contains the breast, cutaneous nerves and vessels, and platysma muscle
The deep fascia over the pectoralis major – pectoral fascia
Clavipectoral fascia
It is a fibromuscular sheet situated deep
to the clavicular portion of the pectoralis
major muscle
Extent:
Vertically – superiorly it splits to enclose
the subclavius muscle, and is attached to
the clavicle. Posterior lamina is fuses
with the investing layer of deep fascia
and axillary sheath
Horizontally – medially, it is attached to
the first rib, the costocorocoid ligament
Laterally it is attached to the corocoid
process and blends with the
coracoclavicular ligament
The clavipectoral fascia is pierced by:
Lateral pectoral nerve, cephalic vein,
thoracoacromial vessels and lymphatics
 MUSCLES OF THE UPPER LIMB
Pectoral region - It is located on the anterior chest wall.
It contains the breast and four muscles that exert a force
on the upper limb; the pectoralis major, pectoralis minor,
serratus anterior and subclavius.
Pectoralis major
Origin –
Clavicular head: anterior surface of medial ½ of
clavicle
Sternocostal head: anterior surface of sternum, second
to sixth costal cartilages, and aponeurosis of external
oblique muscle
Insertion - Lateral lip of bicipital groove of humerus.
Action - Adduction and medial rotation of the shoulder;
draws scapula anteriorly and inferiorly. Acting alone:
clavicular head brings flexion of the arm and sternocostal
head extends the flexed arm.
Innervation - Lateral and medial pectoral nerves
Pectoralis minor
Origin – From 3rd to 5th ribs near their costochondral junction.
Insertion – To the Medial border and superior surface of coracoid
process of the scapula.
Action – Draws the scapula forward, depresses the point of the shoulder
and helps in forced inspiration.
Innervation - Medial and lateral pectoral nerves.
Subclavius
Origin – First rib at the costochondral junction
Insertion – Subclavian groove in the middle third of the inferior surface
of the clavicle.
Action – Steadies the clavicle during the movements of the shoulder.
Innervation – Nerve to subclavius (C5) from the upper trunk of the
brachial plexus
Serratus anterior
Origin – Arises by eight digitations from the
outer surface of upper eight ribs, and from the
fascia covering the intervening intercostal
muscles.
Insertion – To the costal surface of the scapula
along the medial border. The first digitation is
inserted from the superior angle to the root of
the spine. The next 2-3 digitations are inserted
lower down on the medial border. The last 4 or
5 digitations are inserted into a large triangular
area over the inferior angle.
Actions – Protracts the scapula around the
chest wall in pushing and punching
movements, helps in forced inspiration.
Innervation – Long thoracic nerve (C5,6,7)
The “winging of the scapula” - "Injury to the long thoracic nerve
causing paralysis or weakness of the serratus anterior muscle. Patients
with serratus anterior palsy may present with pain, weakness, loss of
abduction of the arm and rotation of the inferior angle toward the mid
line, and prominence of the medial or vertebral border“.
MUSCLES OF THE PECTORAL REGION
 The axilla
The axilla or armpit is a pyramidal space situated between the upper arm and the chest
wall.
• It resembles a four sided pyramid, and has an apex, base and 4 walls – anterior,
posterior, medial and lateral.
• The axilla is disposed obliquely in such a way that the apex is directed upwards and
medially towards the root of the neck, and the base is directed downwards.
Boundaries
Apex – it is directed upwards and medially, it shows a passage called cervico-axillary canal.
This canal is bounded:
In front - by the clavicle
Behind - by the superior border of the scapula
Medially - by the outer border of the first rib.
Base – is directed downwards, and is formed by the skin and fasciae.
Anterior wall – is formed by the pectoralis major, clavipectoral fascia, pectoralis minor
and subclavius muscle.
Posterior wall – subscapularis, teres major and latissimus dorsi.
Medial wall – upper 4 ribs with their intercostal muscles and upper 4 digitations of
serratus anterior.
Lateral wall – is very narrow since the anterior and posterior walls converge on it. It is
formed by the upper part of shaft of the humerus in the region of bicipital groove and
coracobrachialis and short head of biceps brachii.
Contents of the axilla
• Axillary artery and its branches
• Axillary vein and its tributaries
• Infra-clavicular part of brachial plexus
• Five groups of axillary group of lymph nodes
• Long thoracic nerve
• Intercostobrachial nerve
• Axillary pad of fat and areolar tissue
Axillary artery – continuation of subclavian artery
It extends from the outer border of the first rib to the lower border of the teres major muscle,
beyond which it continues as the brachial artery
The course of the axillary artery is divided into three parts
by the pectoralis minor muscle
• First part proximal to the muscle
• Second part deep to the muscle
• Third part distal to the muscle

Branches:
First part: Superior thoracic artery - supplies pectoral muscles
Second part: Thoracoacromial trunk – gives deltoid, acromial, clavicular and pectoral branches.
Lateral thoracic artery – it supplies the pectoral muscles and breast
Third part: Subscapular artery – supplies latissimus dorsi, serratus anterior. Its circumflex
scapular branch passes through the triangular space to take part in the scapular anastomosis
Anterior circumflex humeral artery – smaller branch, takes part in the anastomosis
around the surgical neck of humerus. It gives an ascending branch which runs in the
bicipital groove to supply the shoulder joint
Posterior circumflex humeral artery – larger than anterior branch, passes through the
quadrangular space to supply the deltoid, triceps and shoulder joint
Axillary vein
• Is formed at the lower border of teres major
muscle by the union of basilic vein and the vein
accompanying the brachial artery
• It runs along the medial side of the axillary artery
and continues as subclavian vein at the outer
border of the first rib
Tributaries of axillary vein:
• Corresponds to the branches of the axillary artery
• Cephalic vein joins it after piercing the
clavipectoral fascia
Spontaneous thrombosis of the axillary vein:
Occasionally, a muscular band called the axillary
arch, overlies the vein and this arch when present
may compress the vein and cause thrombosis of
axillary vein
Axillary lymph nodes
• About 20-30 lymph nodes are scattered in the
fibro-fatty tissue of the axilla. They are
grouped into:
Anterior or pectoral group:
• They lie along the lateral thoracic vein at the
lower border of pectoralis minor muscle
• They receive lymph from major part of breast
and upper half of trunk anteriorly
• Axillary tail of Spence is in contact with these
lymph nodes, hence cancer involving axillary
tail may be misdiagnosed as enlarged lymph
node
Posterior or subscapular group:
• They lie along the subscapular vein on the
posterior axillary fold
• They receive lymph from the upper half of the
trunk posteriorly and from the axillary tail of
breast
Axillary lymph nodes …..
Lateral group:
They lie along the upper part of humerus in relation to axillary
vein
They drain the lymph from the upper limb
Central group:
Situated in the upper part of the axilla
They receive lymph from other axillary group of lymph nodes
The intercosto-brachial nerve passes between these lymph nodes,
hence in cancer (or enlargement) of these lymph nodes, the nerve
gets compressed resulting in pain along the inner border of the
arm
Apical or infraclavicular nodes:
Situated deep to the clavipectoral fascia at the apex of the axilla
Receive lymph directly from the upper part of the breast and
indirectly from the rest of the breast through the central lymph
nodes, hence has got great clinical significance
Efferent from this lymph nodes goes to thoracic duct on the left
side and subclavian lymph nodes on the right side
They can be palpated by pushing the fingers of one hand into the
apex of axilla from below and fingers of other hand behind the
clavicle from above
Clinical importance of axilla:
• Axilla has abundant axillary hairs. Infections of the hair follicles and sebaceous
glands give rise to boils.
• Examination of axillary lymph nodes are important in clinical practice,
particularly in the context of metastasis of malignancy of the breast to regional
lymph nodes.
• Axillary abscess arises from infection and suppuration (soft tissue infection) of
axillary lymph nodes. The pus is drained by giving incision in the floor of the axilla,
midway between anterior and posterior axillary folds nearer the medial wall, to avoid
injury to the nerves and vessels which run in relation to the other walls of axilla
 THE BRACHIAL PLEXUS
Brachial plexus is a network of nerves, formed in
the posterior triangle of the neck, lies
between the scalenus medius and scalenus
anterior muscle. It is formed by the ventral
rami of C5-T1 spinal nerves
It consists of roots, trunks, divisions, cords and
branches from the cords.
In a prefixed brachial plexus, the contribution
from C5 is large, C4 is present, T1 is small
and T2 is absent.
In a post fixed brachial plexus the contribution
from T1 is large, T2 is present, C5 is small
and C4 is absent.
The roots unite to form the trunks. Roots of C5
and C6 unite to form the upper trunk. Root of
C7 continue as middle trunk. Roots of C8
and T1 unite to form the lower trunk.
Each trunk divides into anterior and posterior
division (which ultimately supply the
anterior and posterior muscles of the limbs).
These divisions unite to form the cords.
Brachial plexus
Erb’s point – is a region in the upper trunk where six nerves meet, injury to this this
region causes Erb’s paralysis.
Brachial plexus
Brachial plexus
Erb’s point: C5 and C6 fibers, ventral and dorsal division of upper trunk, suprascapular
nerve and nerve to subclavius

Branches from the cords

Lateral cord - Lateral pectoral nerve
Lateral root of median nerve
Musculocutaneous nerve
Medial cord – Medial pectoral nerve
Medial cutaneous nerve of the arm
Medial cutaneous nerve of the forearm
Medial root of the median nerve
Ulnar nerve
Posterior cord - Upper subscapular nerve
Lower subscapular nerve
Thoracodorsal nerve
Radial nerve (related to the shaft of the humerus)
Axillary nerve (Related to the surgical neck of the humerus)
Clinical anatomy of brachial plexus
Erb’s paralysis: It can occur if the infant's head and neck are
pulled toward the side at the same time as the shoulders pass
through the birth canal. The condition can also be caused by
excessive pulling on the shoulders during a cephalic
presentation (head first delivery), or by pressure on the
raised arms during a breech (feet first) delivery
This baby presents with an asymmetric posture of the arms. The
left arm is not flexed and hangs limply. An Erb paralysis is
indicative of a birth injury to the upper part of the brachial
plexus.
The features of a left-sided Erb’s paralysis are :
- a painless left upper arm paralysis
- the left arm is extended and the baby is unable to flex it
- the forearm is turned inwards with the hand palm rotated
outwards resembling the "waiter's tip“ position
- the grasp reflex and wrist action remain intact.
Klumpke’s paralysis –
Undue abduction of the arm may involve the lower trunk roots (C8, T1).
• So the intrinsic muscles of the hand and ulnar flexors of the wrist and fingers are
paralyzed, resulting in claw hand.
Wrist drop: It is due to the injury to the radial nerve.
• This injury results in paralysis of the triceps, anconeus and the long extensors of the
wrist. The patient is unable to extend the elbow joint, the wrist joint and the fingers.
Claw hand: Results from injury to ulnar nerve
• The muscles paralyzed are FCU, medial half of FDP, medial two lumbricals, all
interossei and adductor pollicis.
• The medial two fingers are hyper extended at the metacarpophalangeal joints but
flexed at the distal phalangeal joints. The hand resembles a "claw" and is called a
claw hand (it can affect 4th & 5th or 1st & 2nd fingers or all fingers).
 MUSCLES OF THE BACK
These muscles connect the upper limb to the vertebral column. They
include –
Superficial layer: trapezius & latissimus dorsi;
Deep layer: levator scapulae, rhomboideus major and rhomboideus
minor.
Trapezius
Origin - Medial third of superior nuchal line; external occipital
protuberance, ligamentum nuchae, and spinous processes of C7 - T12
vertebrae.
Insertion - Lateral third of clavicle, medial margin of the acromion
process, and upper lip of the crest of spine of the scapula.
Action - superior fibers elevate, middle fibers retract, and inferior
fibers depress scapula; superior and inferior fibers act together in
superior rotation of scapula.
Innervation – Motor supply is by the spinal part of accessory nerve
and pain and proprioception is carried by the C3 and C4 fibres
Trapezius develops from post 6th branchial arch, the nerve of the
arch is spinal part of accessory nerve, hence it supplies the
trapezius and sternocleidomastoid muscle
Latissimus dorsi
Origin - Spinous processes of lower 6 thoracic vertebrae,
posterior layer of thoracolumbar fascia, posterior one third of
the outer lip of the iliac crest, inferior angle of the scapula and
inferior 3 or 4 ribs.
Insertion - Floor of intertubercular groove of humerus.
Action - Extends, adducts, and medially rotates humerus;
raises body toward arms during climbing.
Innervation - Thoracodorsal nerve (C6, C7, and C8)

Clinical correlation
The latissimus dorsi is supplied by a single dominant
vascular pedicle formed by dorsal scapular artery. This
single vascular pedicle makes this muscle along with the
overlying skin in the form of musculocutaneous flap,
which is often used in reconstructing a breast following
mastectomy.
Levator scapulae
Origin - Posterior tubercles of transverse processes of C1 - C4 vertebrae
Insertion - Superior part of medial border of scapula
Action - Elevates scapula and tilts its glenoid cavity inferiorly by rotating scapula
Innervation - Dorsal scapula (C5) and cervical (C3 and C4) nerves
Rhomboideus major and minor
Origin - Minor: lower part of ligamentum nuchae and spinous processes of C7 & T1
Major: spinous processes of T2 - T5 vertebrae
Insertion - Medial border of scapula from level of spine to inferior angle.
Action - Retract scapula and rotate it to depress glenoid cavity; fix scapula to thoracic
wall.
Innervation - Dorsal scapular nerve ( C4 and C5)
Triangle of auscultation: Is a small triangular gap in the
musculature on the back of the thorax near the inferior angle
of the scapula
Boundaries
Medially – lateral border of trapezius
Laterally – medial border of scapula
Inferiorly - upper border of latissimus dorsi
Floor - formed by 7th rib, 6th & 7th intercostal spaces and
rhomboideus major muscle
• This is the only part of the back which is not covered by
muscles.
• The breath sounds are supposed to be better heard
there than anywhere else in the back
• On the left side, the cardiac orifice of the stomach lies
deep to the triangle, and in pre-Roentgen days (before
the invention of X-rays) the splash of swallowed liquid
was timed in cases of oesophageal obstruction
Muscles of the back
 MUSCLES OF THE SCAPULAR REGION
These muscles protect and give additional support to the week capsular ligament of the shoulder
joint, and they act on the shoulder joint. The scapular muscles include the deltoid, supraspinatus,
infraspinatus, teres minor, subscapularis and teres major.
Supraspinatus
Origin - Supraspinous fossa of scapula
Insertion - Superior facet on greater tuberosity of humerus
Action – Initiates (0°- 15°) and assists deltoid in abduction of arm and acts with other rotator cuff
muscles
Innervation - Suprascapular nerve (C4, C5 and C6)
Infraspinatus
Origin - Infraspinous fossa of scapula
Insertion - Middle facet on greater tuberosity of humerus
Action - Laterally rotate arm; helps to hold humeral head in glenoid cavity of scapula
Innervation - Suprascapular nerve (C5 and C6)
Teres minor
Origin - Superior part of lateral border of scapula
Insertion - Inferior facet on greater tuberosity of humerus
Action - Laterally rotate arm; helps to hold humeral head in glenoid cavity of scapula
Innervation - Axillary nerve (C5 and C6)
Teres major
Origin - Dorsal surface of inferior angle of scapula
Insertion - Medial lip of intertubercular groove of humerus
Action - Adducts and medially rotates arm
Innervation - Lower subscapular nerve (C6 and C7)
Subscapularis
Origin - Subscapular fossa of scapula
Insertion - Lesser tuberosity of humerus
Action - Medially rotates arm and adducts it; helps to hold humeral head in glenoid cavity of
scapula
Innervation - Upper and lower subscapular nerves (C5, C6 and C7)
Deltoid
Origin – anterior border of the lateral third of clavicle, lateral border of the acromion process,
and lower lip of the crest of the spine of scapula
Insertion - Deltoid tuberosity of humerus
Action: Anterior fibres (unipinnate): flexes and medially rotates arm
Middle fibres (multipinnate): powerful abductor of the arm (15°- 90°)
Posterior fibres (unipinnate): extends and laterally rotates arm
Innervation - Axillary nerve (C5 and C6)
Intramuscular injections are often given into the deltoid muscle.
Musculotendinous cuff or rotator cuff
• It is a fibrous sheath formed by the four flattened tendons which blend with the
capsule of the shoulder joint and strengthen it.
• They are subscapularis, supraspinatus, infraspinatus and teres minor. Their tendons
while crossing the shoulder joint, become flattened and blend with each other on one
hand and with the capsule of the shoulder joint on the other hand, before reaching
their point of insertion.
• The rotator cuff gives strength to the capsule of the shoulder joint all round except
inferiorly. This explains why dislocations of the humerus occur most commonly in a
downward direction.
Muscles of the scapular region:
Rotator cuff muscles: Supraspinatus, infraspinatus, teres minor, subscapularis
In case of rupture of the tendon of supraspinatus the patient can not do the initial
abduction (0-15 degrees of abduction)
 Deltoid
Intramuscular injections are often given into the deltoid muscle.
Intermuscular spaces
The scapular muscles, with the
humerus and long head of the triceps
form three intermuscular spaces
• Quadrangular space
• Upper triangular space
• Lower triangular space
Quadrangular space
Boundaries
Superior – from before backwards:- Subscapularis
- Capsular ligament of shoulder joint
- Teres minor
Inferior – Teres major
Medial – Long head of triceps
Lateral – Surgical neck of humerus
Contents – Axillary nerve and posterior circumflex humeral vessels
Upper triangular space
Boundaries
Medial – Teres minor
Lateral – long head of triceps
Inferior – Teres major
Contents: Circumflex scapular artery – it anastomosis with suprascapular artery
Lower triangular space
Boundaries
Medial – Long head of triceps
Lateral – Medial border of humerus
Superior – Teres major
Contents – Radial nerve and profunda brachii vessels
The axillary (circumflex) nerve:
• Arises from the posterior cord of the brachial plexus near the lower border of the
subscapularis
• It runs backwards to pass through the quadrangular space along with posterior circumflex
humeral artery
• Here it is closely related to the surgical neck of the humerus, immediately inferior to the
capsular ligament of shoulder joint
• The nerve gives a branch to shoulder joint and then runs laterally to divide into anterior and
posterior branches deep to deltoid muscle
The anterior branch winds round the surgical neck along with posterior circumflex humeral
artery, deep to the deltoid. It gives muscular branch to deltoid and a small cutaneous branch
Posterior branch supplies the teres minor and posterior part of deltoid and continues as upper
lateral cutaneous nerve of the arm; which supplies the skin over the lower part of the deltoid and
upper part of long head of triceps. Nerve to teres minor contains a pseudoganglia.
Clinical correlation
In inferior dislocation of the head of the humerus and fracture of surgical neck of the
humerus, the axillary nerve is at risk of damage. The damage to axillary nerve presents:
• Impaired abduction of the shoulder – due to paralysis of deltoid muscle
• Loss of sensation over the lower half of deltoid – due to involvement of upper
lateral cutaneous nerve of the arm
• Loss of round contour of shoulder – due to wasting of deltoid muscle
 ARM
• It is the part of the upper limb
between the shoulder and the elbow
• The bone of the arm humerus
articulates above with the scapula to
form shoulder joint and below with
radius and ulna to form elbow joint
Surface landmarks
Greater tubercle of humerus – can be
felt just below and lateral to the acromion
process
Shaft of humerus – can be felt
indistinctly in thin individuals
Medial epicondyle of humerus – can be
felt on the medial side of elbow
Lateral epicondyle of humerus – can be
felt in the upper part of the depression on
the posterolateral aspect of the extended
elbow
 ARM…..
Deltoid and biceps muscle
Pulsation of brachial artery – can be felt in front of
the elbow just medial to the tendon of biceps
Ulnar nerve – lies behind the medial epicondyle of
the humerus
Superficial veins of the elbow – cephalic vein,
basilic vein and median cubital vein
Head of radius – can be felt just distal to the lateral
epicondyle
Olecranon process – readily palpable on the back of
the elbow
Compartments of the arm
• Deep fascia encloses the arm like a sleeve
• The medial and lateral intermuscular septae arising from the deep fascia (which get
attached to medial and lateral supracondylar ridges) divide the arm into anterior
flexor compartment and posterior extensor compartment
• Each compartment has its own muscles, nerve and vessels
Contents of the flexor or extensor compartment of the arm
• Muscles – Biceps brachii, coracobrachialis and brachialis
• Nerve – Musculocutaneous nerve
• Artery – Brachial artery
Coracobrachialis
Origin - Tip of coracoid process of scapula
Insertion - Middle third of medial border of the humerus
Action - Helps to flex and adduct the arm
Innervation - Musculocutaneous nerve (C5, C6 and C7)
Biceps brachii
Origin - Short head: tip of coracoid process of scapula
Long head: supraglenoid tubercle of scapula
Insertion - Tuberosity of radius and deep fascia of forearm
via bicipital aponeurosis
Action – strong supinator of the forearm and, when it is
supine, flexes the forearm. It is a flexor of the elbow. Long
head prevents upward displacement of the head of the
humerus.
Innervation - Musculocutaneous nerve
Brachialis
Origin - Distal half of anteromedial and anterolateral surface
of the humerus, medial and lateral intermuscular septae.
Insertion - Coronoid process and tuberosity of ulna.
Action - Major flexor of forearm at the elbow joint.
Innervation - Musculocutaneous nerve (C5 and C6) and
radial nerve (Hybrid muscle)
Musculocutaneous nerve
• Nerve of the flexor compartment of the arm
• Arises from the lateral cord of the brachial
plexus in the axilla
• Runs downwards and laterally pierces the
coracobrachialis, which it supplies
• Then it passes between the biceps and
brachialis to appear on the lateral margin of
biceps brachii tendon and pierces the deep
fascia just above the elbow to run over the
lateral aspect of the forearm as lateral
cutaneous nerve of forearm
Branches
Muscular branches to biceps brachii,
brachialis and coracobrachialis
Cutaneous branch – lateral cutaneous nerve
of the forearm, which supplies the skin on the
front and lateral aspect of the forearm
Articular branch – to elbow joint through its
branch to brachialis
Musculocutaneous nerve
Brachial artery
• Main artery of the arm. Begins
at the lower border of teres
major muscle as a continuation
of axillary artery
• It runs downwards and laterally
from the medial side of the arm
to the front of the elbow, where
it terminates at the level of neck
of the radius by dividing into
radial and ulnar artery
• The artery is superficial
throughout is course, being
covered by the skin and fascia,
hence easily accessible
Branches
• Muscular branches – supply the
muscles of the flexor compartment
• Profunda brachii artery – largest
branch, accompanies the radial
nerve to enter the spiral groove on
the posterior surface of humerus,
through the lower triangular
intermuscular space.
• Nutrient artery – enter the humerus
near the insertion of coracobrachialis
• Superior ulnar collateral artery –
accompanies the ulnar nerve
• Inferior ulnar collateral artery –
divides into anterior and posterior
branch to take part in the
anastomosis around the elbow joint
• Two terminal branches – medial
ulnar and lateral radial artery
Clinical correlation
• The brachial pulse is felt in the cubital fossa
medial to the tendon of biceps brachii
• Brachial pulsations are auscultated in front
of the elbow for recording the blood
pressure
• The biceps tendon is easily palpable on
flexing the elbow

 The brachial artery can be effectively

compressed against the shaft of humerus at
the level of insertion of coracobrachialis to
stop the hemorrhages in the upper limb
occurring from any artery distal to the
brachial artery. e.g. bleeding wounds of the
palmar arterial arches

 Rupture of the brachial artery in

supracondylar fracture of humerus may lead
to Volkmann’s ischemic contracture
Larger nerves of the arm
Median nerve
• Arises from the lateral and medial cord of the brachial plexus in the axilla
• Closely related to the brachial artery throughout its course in the arm; hence superficially
located except at the elbow where it is crossed by the bicipital aponeurosis
• In its course it crosses the artery from lateral to medial aspect, by running in front of the
artery
• In the arm it gives vasomotor branches to the brachial artery and articular branches to the
elbow joint
Ulnar nerve
 Arises from the medial cord in the axilla
 Runs downwards on the medial side of the arm medial to the brachial artery upto the insertion
of coracobrachialis
 Here it pierces the medial intermuscular septum along with superior ulnar collateral artery to
enter the posterior compartment of the arm
 At the elbow it passes behind the medial epicondyle of humerus, where it can be easily
palpated.
 It will not give any branch in the arm
Radial nerve
• Arises from the posterior cord of the brachial plexus in the axilla
• In the arm it lies posterior to the axillary artery
• Then it winds around the back of the arm to enter the spiral groove between the lateral and
medial head of humerus
• In its course it is accompanied by profunda brachii artery
• At the lower end of the spiral groove it pierces the lateral intermuscular septum to enter the
flexor compartment of the arm
• It runs between the brachialis and brachioradialis, where it lies in front of the elbow in the
cubital fossa
• In relation to the cubital fossa it terminates by dividing into superficial and deep branch
• The deep branch runs in the substance of supinator to enter the extensor compartment of the
forearm
Branches of radial nerve
In the axilla
• Nerve to long and medial head of triceps
• Posterior cutaneous nerve of arm
In the spiral groove
• Nerve to lateral and medial head of triceps
• Nerve to anconeus
• Lower lateral cutaneous nerve of the arm
• Posterior cutaneous nerve of the forearm
In the anterior compartment of the arm
• Branch to brachialis, brachioradialis and
extensor carpi radialis longus
• Articular branch to elbow joint
• Terminal branches: superficial branch and deep
branch
Triceps brachii
Origin - Long head: infraglenoid tubercle of scapula
Lateral head: posterior surface of humerus, superior to radial
groove
Medial head: posterior surface of humerus, inferior to radial
groove, medial & lateral intermuscular septa
Insertion – posterior part of the superior surface of the olecranon process of
ulna and fascia of forearm
Action - Chief extensor of forearm; long head steadies head of abducted
humerus
Innervation - Radial nerve (C6, C7 and C8)
In radial nerve injury in the arm, the triceps usually escapes paralysis because
the nerves supplying it arise in the axilla.
Profunda brachii artery
• Largest branch of brachial
artery, arises from its
posterolateral aspect just below
the teres major muscle
• It accompanies the radial nerve
through the radial groove,
where it terminates by dividing
into anterior and posterior
descending branches
Branches
• Deltoid branch (ascending
branch)
• Nutrient branch to humerus
• Anterior ascending branch
(radial collateral branch) – takes
part in the anastomosis around
the elbow joint
• Posterior descending branch (
middle collateral branch) - takes
part in the anastomosis around
the elbow joint
 CUBITAL FOSSA
• It is a triangular hollow region situated in front of the elbow joint.
• It is homologous to the popliteal fossa of the lower limb which is situated behind the knee
joint.
Boundaries
Laterally – medial border of the brachioradialis
Medially – lateral border of the pronator teres
Base – is directed upwards, and is formed by an imaginary line joining the two epicondyles of the
humerus.
Apex – directed downwards and is formed by the overlapping of medial and lateral boundaries.
Roof – is formed by skin, superficial fascia with its contents, deep fascia and bicipital
aponeurosis.
Floor – brachialis above and supinator below.
Contents of cubital fossa
- Median nerve
- Tendon of biceps brachii
- Termination of brachial artery with its 2 terminal branches
Ulnar artery – anterior ulnar recurrent
- posterior ulnar recurrent
- common interosseous – anterior interosseous
- posterior interosseous
: interosseous r. br.
Radial artery – radial recurrent branch
- Radial nerve
Clinical anatomy
• The median cubital vein is often the vein of choice for
collecting blood samples or for intravenous injections
• The brachial blood pressure is universally recorded by
auscultating the brachial artery in front of the elbow.
 THE FOREARM
• The forearm extends from the elbow to the wrist joint.
• Like the arm it also contains anterior or flexor compartment and posterior or
extensor compartment.
• Radius and the ulna form the skeleton of the forearm
Front of the arm or flexor compartment
of the arm:
The front of the arm contains
• 5 superficial muscles – PT, FCR, PL,
FDS, FCU
• 3 deep muscles – FPL, FDP, PQ
• Radial and ulnar arteries
• Median, ulnar and radial nerves.
- Radial artery is used for feeling the pulse
at the wrist.
The muscles of the anterior/flexor compartment of
the forearm
These muscles are supplied by the ulnar and median
nerves.
These muscles (pronator teres, flexor carpi
radialis, palmaris longus, flexor carpi ulnaris,
flexor digitorum superficialis, flexor digitorum
profundus, flexor pollicis longus &pronator
quadratus) produce flexion at the wrist and the
fingers.
The muscles of the posterior/extensor
compartment of the forearm (anconeus,
brachioradialis, extensor carpi radialis longus,
extensor radialis brevis, extensor digitorum,
extensor digiti minimi, extensor carpi ulnaris,
supinator, abductor pollicis longus, extensor
pollicis brevis, extensor indicis) extend the wrist
and fingers.
They are supplied by the radial nerve or by its
posterior interosseous branch.
 Pronator teres
Origin - Medial epicondyle of humerus and
coronoid process of ulna
Insertion - Middle one-third of lateral surface of
radius
Action - Pronates and flexes forearm (at elbow)
Innervation - Median nerve (C6 and C7)

Flexor carpi radialis

Origin - Medial epicondyle of humerus
Insertion - Base of 2nd and 3rd metacarpal bones
Action - Flexes and abducts the hand (at wrist)
Innervation - Median nerve (C6 and C7)

Palmaris longus
Origin - Medial epicondyle of humerus
Insertion - Distal half of flexor retinaculum and
apex of the palmar aponeurosis
Action - Flexes hand (at wrist) and tightens the
palmar aponeurosis
Innervation - Median nerve (C7 and C8)
 Flexor digitorum superficialis
Origin - Humeroulnar head: medial epicondyle of
humerus, ulnar collateral ligament, and coronoid
process of ulna
Radial head: superior half of anterior
border of radius
Insertion - Bodies of middle phalanges of digits 2 - 5
Action - Flexes middle phalanges at proximal
interphalangeal joints of medial four digits; acting
more strongly, it also flexes proximal phalanges
at metacarpophalangeal joints and hand
Innervation - Median nerve (C7, C8 and T1)
Flexor carpi ulnaris
Origin - Humeral head: medial epicondyle of
humerus
Ulnar head: olecranon and posterior
border of ulna
Insertion - Pisiform bone, hook of hamate bone, and
5th metacarpal bone
Action - Flexes and adducts hand (at wrist)
Innervation - Ulnar nerve (C7 and C8)
 Flexor digitorum profundus
Origin - Proximal 3/4 of medial and anterior surfaces of ulna and
interosseous membrane
Insertion - Base of the distal phalanx of digits 2 - 5
Action - Flexes distal phalanges at distal interphalangeal joints of
medial four digits; assists with flexion of hand
Innervation - Medial part: ulnar nerve (C8 and T1)
Lateral part: anterior interosseous branch of
median nerve (C8 and T1)
Flexor pollicis longus
Origin - Anterior surface of radius and adjacent interosseous
membrane
Insertion - Base of distal phalanx of thumb
Action - Flexes phalanges of 1st digit (thumb)
Innervation - Anterior interosseous nerve from median nerve (C8
and T1)
Pronator quadratus
Origin - Distal 1/4 of anterior surface of ulna
Insertion - Distal 1/4 of anterior surface of radius
Action - Pronates forearm; deep fibers bind radius and ulna
together
Innervation - Anterior interosseous nerve from median nerve (C8
and T1)
Flexor retinaculum
• Is a strong fibrous band which bridges the anterior
concavity of the carpus and converts it into a
tunnel, the carpal tunnel.

Attachment - medially to pisiform bone and hook of

the hamate.
- laterally to the tubercle of the scaphoid
and crest of the trapezium.

Structures passing superficial to it: tendon of

palmaris longus, palmar cutaneous branch of median
and ulnar nerve, ulnar nerve and vessels
Structures passing deep to it: median nerve, ulnar
bursa, radial bursa, tendons of FDS, FPL, FDP.
Carpal tunnel syndrome
• Usually occurs in females between the age of 40-70.
• In this condition there will be motor, sensory, vasomotor and trophic symptoms in the hand
caused by compression of median nerve in the carpal tunnel.
• Your doctor may suggest you to work with a physical or occupational therapist.
• If all attempts to control your symptoms fail, surgery may be suggested to reduce the pressure
on the median nerve.
The Forearm - extends from the elbow to the wrist joint
Flexor compartment of the forearm contains:
• 5 superficial muscles – PT, FCR, PL, FDS, FCU
• 3 deep muscles – FPL, FDP, PQ
 Radial and ulnar arteries
• Radial artery is used for feeling the pulse at the wrist
• Median and ulnar nerves
Front of the arm or flexor compartment of the arm:
The flexor muscles of the forearm
Flexor retinaculum
• Is a strong fibrous band which bridges the anterior concavity of the carpus and
converts it into a tunnel, the carpal tunnel.
Carpal tunnel syndrome
• Usually occurs in females between the age of 40-70.
• In this condition there will be compression of median nerve in the carpal tunnel.
• Surgery may be suggested to reduce the pressure on the median nerve to relieve
the pain.
 EXTENSOR COMPARTMENT OF THE FOREARM
It consists of superficial (anconeus, brachioradialis, ECRL, ECRB, ED, EDM, ECU) and deep
group (Supinator, APL, EPB, EPL, EI) of muscles, which by their contraction mainly bring
about extension at the wrist joint.
The nerve of the compartment is the radial nerve or its branch, posterior interosseous nerve.
Extensor retinaculum
• Is a thick fibrous band present on the back of the wrist joint, formed by the thickening of deep
fascia.
• Before passing into the dorsum of the hand the extensor tendons are held in position by the
extensor retinaculum.
• It is attached laterally to the lower part of the anterior border of the radius, medially to the
styloid process of the ulna, triquetral and pisiform bones.
 SUPERFICIAL MUSCLES OF THE EXTENSOR
COMPARTMENT
Anconeus
Origin – Posterior aspect of lateral epicondyle of humerus
Insertion - Lateral surface of olecranon and superior part
of posterior surface of ulna
Action – Weak extensor of the elbow; stabilizes elbow
joint; abducts ulna during pronation
Innervation - Radial nerve (C7, C8 and T1)

Brachioradialis
Origin - Proximal 2/3 of lateral supracondylar ridge of
humerus and lateral intermuscular septum.
Insertion - Lateral surface of distal end of radius just
above the styloid process.
Action – Flexor of forearm, especially in mid-prone
position.
Innervation - Radial nerve (C5, C6 and C7)
 Extensor carpi radialis longus
Origin – lower one-third of lateral supracondylar ridge of
humerus, lateral intermuscular septum, common
extensor origin.
Insertion – dorsal surface of the base of 2nd metacarpal
bone
Action - Extension and abduction of hand at the wrist
joint
Innervation - Radial nerve (C6 and C7)

Extensor carpi radialis brevis

Origin – common extensor origin and radial collateral
ligament of the elbow joint.
Insertion – dorsal aspect of bases of 2nd and 3rd
metacarpal bones.
Action - Extension and abduction of hand at the wrist
joint
Innervation – posterior interosseous nerve (C7 and C8)
 Extensor digitorum
Origin – common extensor origin
Insertion - Extensor expansions of medial four digits
Action – extension of interphalangeal,
metacarpophalangeal and wrist joint
Innervation - Posterior interosseous nerve (C7 and
C8)
Extensor digiti minimi
Origin – common extensor origin
Insertion - Extensor expansion of 5th digit
Action - Extends 5th digit at metacarpophalangeal
and interphalangeal joints
Innervation - Posterior interosseous nerve (C7 and
C8)
Extensor carpi ulnaris
Origin – common extensor origin and posterior
border of ulna
Insertion – medial side of base of 5th metacarpal
Action - Extends and adducts hand at wrist joint
Innervation - Posterior interosseous nerve (C7 and
C8)
 DEEP MUSCLES OF THE EXTENSOR
COMPARTMENT
Supinator
Origin - Lateral epicondyle of humerus, radial collateral
and annular ligaments, supinator fossa and crest of ulna
Insertion - Lateral, posterior and anterior surfaces of
proximal 1/3 of radius
Action – Supination of the forearm
Innervation - Posterior interosseous nerve (C5 and C6)

Abductor pollicis longus

Origin - Posterior surfaces of ulna, radius and interosseous
membrane
Insertion - Base of 1st metacarpal and to the trapezium
Action - Abducts thumb and extends it at carpometacarpal
joint
Innervation - Posterior interosseous nerve (C7 and C8)
 Extensor pollicis brevis
Origin - Posterior surfaces of radius and interosseous membrane
Insertion - Base of proximal phalanx of thumb
Action - Extends proximal phalanx of thumb at carpometacarpal
joint
Innervation - Posterior interosseous nerve (C7 and C8)
Extensor pollicis longus
Origin - Posterior surface of middle 1/3 of ulna and interosseous
membrane
Insertion - Base of distal phalanx of thumb
Action - Extends distal phalanx of thumb at carpometacarpal and
interphalangeal joints
Innervation - Posterior interosseous nerve (C7 and C8)
 EXTENSOR COMPARTMENT OF THE FOREARM
Superficial muscles - anconeus, brachioradialis, ECRL, ECRB, ED, EDM, ECU
Deep muscles - Supinator, APL, EPB, EPL, EI
Nerve supply is by radial nerve or its branch, the posterior interosseous nerve
Extensor retinaculum – Is a thick fibrous band present on the back of the wrist joint,
formed by the thickening of deep fascia.
Superficial and deep muscles of the extensor compartment of the forearm
 THE HAND
• Hands are capable of a wide variety of functions,
including gross and fine motor movements
• Gross motor movements allow us to pick up large
objects or perform heavy labor
• Fine motor movements enable us to perform
delicate and skilled tasks, such as holding small
objects or performing skilled work
• Only humans have the ability to bring our thumbs
across the hand to connect with other fingers
• This ability provides us with the skill to use tools
and also for powerful grip
The hand can be considered in four segments:
Fingers: Digits that extend from the palm of the
hand, and make it possible to grip the smallest of
objects
Palm: This is the bottom of the body of the hand
Back of the hand: shows the dorsal venous network
and extensor tendons
Wrist: The connection point between the arm and
the hand, the wrist enables hand movements.
The Hand …..
Each hand consists of 19 bones. The palm includes five metacarpals, and each finger except the
thumb contains one proximal phalanx, one middle phalanx, and one distal phalanx. The thumb
doesn’t have a middle phalanx. Each bone is connected by a series of ligaments.
Although fully functional hands can accomplish great things, they are susceptible to a
number of ailments, including:
1.Arthritis
2.Deformities 1
2 3&5
3.Nerve disorders
4.Finger clubbing
5.Tendinitis
6.Carpal tunnel syndrome
7.Fractured bones
8.Sprains, strains, cuts, and bruises 4

6
7

8
Palmar aponeurosis
• It is triangular in shape, the apex of which proximally blends
with the flexor retinaculum and is continuous with the tendon of
palmaris longus.
• The base is directed distally and divides at the
metacarpophalangeal joint into 4 slips for the medial four digits.
• Each divides into 2 parts which are continuous with the fibrous
flexor sheath
Dupuytren’s contracture:
• Is due to the inflammation involving the ulnar side of the palmar
aponeurosis.
• There is thickening and contraction of the palmar aponeurosis.
• As a result the proximal phalanx and later the middle phalanx
become flexed and can not be straightened. The terminal phalanx
remains unaffected.
• The ring finger is most commonly involved.
• Surgery is not a cure for this condition, since the symptoms can
recur in a few years. But surgery helps many patients regain a
better range of finger motion.
• After surgery by doing exercises and wearing a splint if needed,
you can speed up recovery.
 INTRINSIC MUSCLES OF THE HAND
The 20 intrinsic muscles of the hand serve the function of adjusting the hand during gripping
and also for carrying out fine skilled movements.
Four thenar muscles - Abductor pollicis brevis
Flexor pollicis brevis
Opponens pollicis brevis
Adductor pollicis
Four hypothenar muscles - Palmaris brevis
Abductor digiti minimi
Flexor digiti minimi
Oppenens digiti minimi
Four lumbricals
Three palmar interossei
Four dorsal interossei
 THE THENAR MUSCLES

Abductor pollicis brevis

Origin - Flexor retinaculum and tubercle of scaphoid
and crest of trapezium.
Insertion - Lateral side of base of proximal phalanx
of thumb
Action - Abducts the thumb at the
metacarpophalangeal and carpometacarpal joints.
Abduction is associated with medial rotation.
Innervation - median nerve (C8 and T1)

Flexor pollicis brevis

Origin – superficial head from the flexor retinaculum
and crest of the trapezium, the deep head arises from
the trapezoid and capitate bones.
Insertion - Lateral side of base of proximal phalanx
of thumb
Action - Flexes thumb
Innervation - median nerve (C8 and T1)
 Opponens pollicis
Origin - Flexor retinaculum and crest of trapezium.
Insertion - Lateral side of 1st metacarpal bone
Action - Draws 1st metacarpal laterally to oppose
thumb toward center of palm and rotates it medially
Innervation - median nerve (C8 and T1)
Adductor pollicis
Origin - Oblique head: bases of 2nd and 3rd
metacarpals, capitate, and adjacent carpals
Transverse head: palmar surface of 3rd
metacarpal bone
Insertion - Medial side of base of proximal phalanx
of thumb
Action – The muscle adducts the thumb from the
flexed or abducted position.
Innervation - Deep branch of ulnar nerve (C8 and
T1)
 THE HYPOTHENAR MUSCLES
Abductor digiti minimi
Origin - Pisiform bone
Insertion - Medial side of base of proximal phalanx of little
finger
Action - Abducts little (5th) finger
Innervation - Deep branch of ulnar nerve (C8 and T1)
Flexor digiti minimi
Origin - Hook of hamate and flexor retinaculum
Insertion - Medial side of base of proximal phalanx of little
finger
Action – Flexes the little finger at the metacarpophalangeal
joint
Innervation - Deep branch of ulnar nerve (C8 and T1)
Opponens digiti minimi
Origin - Hook of hamate and flexor retinaculum
Insertion - Medial border of the shaft of fifth metacarpal bone.
Action - Draws 5th metacarpal anteriorly and rotates it
laterally, bringing little finger (5th digit) into opposition
with thumb
Innervation - Deep branch of ulnar nerve (C8 and T1)
 Palmaris brevis
It lies in the superficial fascia of the hypothenar
region.
Origin – flexor retinaculum and palmar aponeurosis
Insertion – skin along the medial border of the hand
Action – helps in gripping by making the
hypothenar eminence more prominent, and by
wrinkling the skin over it.
Nerve supply – superficial branch of the ulnar
nerve.
Interossei muscles
Dorsal interossei – 4 in number
Origin - Adjacent sides of two metacarpals
(bipennate muscle)
Insertion - Extensor expansions and bases of
proximal phalanges of digits 2 – 4
Action - Abduct digits (DAB) from axial line
(middle finger) and act with lumbricals to flex
metacarpophalangeal joints and extend
interphalangeal joints.
Innervation - Deep branch of ulnar nerve (C8 and
T1)
 Palmar interossei
Three in number
Origin - Palmar surfaces of 2nd, 4th and 5th
metacarpals (unipennate muscles)
Insertion - Extensor expansions of digits and bases
of proximal phalanges of digits 2, 4 and 5
Action - Adduct digits (PAD) toward axial line and
assist lumbricals in flexing metacarpophalangeal
joints and extending interphalangeal joints
Innervation - Deep branch of ulnar nerve (C8 and
T1)
Lumbrical muscles
They are 4 in number
Origin – from the tendons of flexor digitorum
profundus
Insertion – to the dorsal digital expansion
Action – flex the metacarpo-phalangeal joints and
extend the interphalangeal joints (writing
muscles).
Nerve supply – 1st and 2nd lumbricals by median
nerve, 3rd & 4th lumbricals by deep branch of
ulnar nerve.
Paralysis of intrinsic muscles of the hand produces claw hand in which there is hyper-
extension at the metacarpophalangeal joints and flexion at the interphalangeal joints.
 The Hand
Palmar aponeurosis – It is triangular in shape, the apex of which proximally blends
with the flexor retinaculum and is continuous with the tendon of palmaris longus.
Dupuytren’s contracture – is due to the inflammation involving the ulnar side of the
palmar aponeurosis
Intrinsic muscles of the hand
The 20 intrinsic muscles of the hand serve the function of adjusting the hand during gripping and
also for carrying out fine skilled movements.
4 thenar muscles - Abductor pollicis brevis
Flexor pollicis brevis
Opponens pollicis brevis
Adductor pollicis
4 hypothenar muscles - Palmaris brevis
Abductor digiti minimi
Flexor digiti minimi
Opponens digiti minimi
Four lumbricals
Three palmar interossei
Four dorsal interossei
Muscles of the palm
Subclavian artery and its continuity in the
upper limb
Axilla: Axillary Artery
The axillary artery lies deep to the pectoralis
minor and is enclosed in the axillary sheath (a
fibrous layer that covers the artery and the three
cords of the brachial plexus).
Importantly, the artery can be divided into three
parts based on its position relative to
the pectoralis minor muscle:
First part – proximal to pectoralis minor An axillary artery aneurysm is a
Branches – Superior thoracic artery dilation of the vessel to more than twice
its original size. It is a rare but serious
Second part – posterior to pectoralis minor
condition. The dilated portion of the
Branches – Thorocoacromial and axillary artery can compress the brachial
lateral sacral arteries plexus, producing neurological
Third part – distal to pectoralis minor symptoms such as paraesthesia and
muscle weakness. Axillary artery
Branches – Subscapular, anterior and aneurysm can be treated surgically.
posterior circumflex humeral arteries
Subclavian artery and its continuity in the
upper limb
The brachial artery is a continuation of the
axillary artery beyond the lower border of
the teres major, it mainly supplies the arm.
Immediately distal to the teres major, the
brachial artery gives rise to the profunda
brachii, which travels with the radial nerve
in the radial groove of the humerus and
supplies structures in the extensor
compartment of the arm. The brachial artery
descends down the arm to enter the cubital
fossa underneath the bicipital aponeurosis.
In the cubital fossa the brachial
artery terminates by bifurcating into the
radial and ulnar arteries
The arm has relatively good anastomotic supply.
However, if the brachial artery is completely
occluded, the resulting ischaemia can
cause necrosis of forearm muscles. Muscle fibres
are replaced by scar tissue and shorten
considerably – this can cause a characteristic
flexion deformity, called Volkmann’s ischaemic
contracture.
Subclavian artery and its continuity in the upper limb
The brachial artery terminates in the cubital fossa by
dividing into radial and ulnar arteries.
Radial artery – supplies the posterolateral aspect of the
forearm. It contributes to anastomotic networks
surrounding the elbow joint and carpal bones.
The radial pulse can be palpated in the distal forearm,
immediately lateral to the prominent tendon of the flexor
carpi radialis muscle.
Your pulse is your heart rate, or the number of times your
heart beats in one minute. Pulse rates vary from person to
person. Your pulse is lower when you are at rest and
increases when you exercise (more oxygen-rich blood is
needed by the body when you exercise).
Normal heart rates at rest:
Children (ages 6 - 15) 70 – 100 beats per minute
Adults (age 18 and over) 60 – 100 beats per minute
Ulnar artery – supplies the anteromedial aspect of the
forearm. It contributes to an anastomotic network
surrounding the elbow joint. Also gives rise to the anterior
and posterior interosseous arteries, which supply deeper
structures in the forearm.
These two arteries anastomose in the hand by forming
two arches – the superficial palmar arch, and the deep
palmar arch to supply the hand.
Venous system
The median cubital vein is the
vein of choice for intravenous
injections.
The cephalic vein is usually
located in the delto-pectoral
groove, making this site a good
candidate for venous access.
Permanent pacemakers are
often placed in the cephalic
vein in the delto-pectoral
groove. The vein may be used
for intravenous access, as large
bore cannula may be easily
placed. Since the cannulation
of the vein is close to the radial
nerve sometimes it may lead to
nerve damage.
Venous system
PICC – peripherally inserted
central catheter.
 THE SHOULDER JOINT
It is a Ball and Socket variety of synovial joint.
The joint is formed by the articulation of the scapula and head of
the humerus (glenohumeral articulation).
Structurally it is a weak joint because the glenoid cavity is too
small and shallow to hold the head of the humerus in place.
However this arrangement permits great mobility, but at the cost of
stability.
The stability of the joint is maintained by :
- The coracoacromial arch: secondary socket for the head of the
humerus
- Musculotendinous cuff of the shoulder: strengthens the weak
capsular ligament
- The glenoidal labrum: helps to deepen the glenoid fossa.
- Tendon of long head of biceps brachii prevents the upward
displacement of head of the humerus
The ligaments of the shoulder joint include:
• The Articular Capsule
• The Glenohumeral ligament
• The Coracohumeral ligament
• The Transverse Humeral ligament
• The Glenoidal Labrum
Capsular ligament – it is very loose and permits free movements.
It is least supported inferiorly where dislocations are common.
Attachment of capsular ligament:
• Medially to the scapula beyond the supra-glenoid tubercle and the margins of the labrum.
• Laterally it is attached to the anatomically neck of the humerus, except inferiorly where the
attachment extends to the surgical neck of the humerus.
• Anteriorly the fibrous capsule is reinforced by the superior, middle and inferior
glenohumeral ligaments.
• The capsular ligament is lined by the synovial membrane.
The coracohumeral ligament – extends from the root of the coracoid process to the neck of the
humerus opposite the greater tubercle.
Transverse humeral ligament – bridges the upper part of the bicipital groove (between the
greater and lesser tubercle) of the humerus. The tendon of long head of biceps brachii passes
deep to it.
The glenoidal labrum – is a fibrocartilagenous rim which covers the margins of the glenoid
cavity, thus increasing the depth of the cavity.
Musculotendinous cuff or rotator cuff
It is a fibrous sheath formed by the four flattened tendons which blend with the capsule of the shoulder joint
and strengthen it.
They are subscapularis (in front), supraspinatus (above), infraspinatus and teres minor (behind).
Their tendons while crossing the shoulder joint, become flattened and blend with each other on one hand and
with the capsule of the shoulder joint on the other hand, before reaching their point of insertion.
The rotator cuff gives strength to the capsule of the shoulder joint all round except inferiorly. This
explains why dislocations of the humerus occur most commonly in a downward direction.
Blood supply – anterior and posterior circumflex humeral vessels, suprascapular vessels and
subscapular vessels.
Nerve supply – axillary nerve, musculocutaneous nerve and suprascapular nerve.
Movements:
Flexion – anterior fibres of deltoid, clavicular fibres of P. major.
Extension – posterior fibres of deltoid, latissimus dorsi
Adduction – P. major, T major, latissimus dorsi.
Abduction – Intermediate fibres of deltoid, supraspinatus
Medial rotation – Pectoralis major, subscapularis, teres major, anterior fibers of deltoid.
Lateral rotation – Infraspinatus, teres minor, posterior fibres of deltoid.
Circumduction – Combination of flexion, adduction, abduction and extension in succession.
Dislocation of the shoulder joint is common in abducted position of arm (inferior
dislocation)
It can injure the axillary nerve which is closely related to the lower part of the joint
capsule.
Frozen shoulder
• "Frozen" shoulder is defined as a painful
stiff shoulder. It is also known as adhesive
Capsulitis.
• In this condition the shoulder movements
are restricted due to tendinitis involving
the rotator cuff.
• Adhesions develop within the capsule of the
shoulder joint causing the shoulder to get stiff
and painful.
Shoulder tip pain
• Irritation of the diaphragm from any
surrounding pathology causes referred pain
over the shoulder region.
• This is because the phrenic nerve and
supraclavicular nerves both arise from spinal
segments C3,C4.
 The Sternoclavicular Joint
• Is the joint between the manubrium sterni and the clavicle.
• It is saddle type of synovial joint.
• Despite the saddle-like form of its articular surfaces, this joint moves in many directions like
a ball and socket joint.
• This joint is supplied by the medial branch of supraclavicular nerve.
The Acromioclavicular Joint
• This is a plane type of synovial joint that is located between the lateral end of the clavicle
and the acromion of the scapula.
• It is supplied by the supraclavicular, lateral pectoral, and axillary nerves.
 The Elbow Joint
• This is a uni-axial hinge variety of synovial joint, since it is a uniaxial joint, only flexion
and extension takes place.
• The trochlea & capitulum of the humerus articulate with the trochlear notch of the ulna & the
head of the radius respectively.
• But the elbow joint includes three articulations – humeroulnar articulation (between trochlea
of humerus and trochlear notch of ulna), humeroradial articulation (between capitulum of
humerus and head of the radius) and proximal radioulnar articulation (between the head of the
radius and radial notch of the ulna).
• The articular surfaces are covered with hyaline cartilage.
Ligaments of the elbow joint:
Fibrous capsule: it is thickened in front and behind to form
the anterior ligament and posterior ligament.
Ulnar collateral or medial collateral ligament
Radial collateral or lateral collateral ligament
Actions:
Flexion – brachialis, biceps brachii and brachioradialis.
Extension – triceps and anconeus.
Nerve supply – ulnar nerve, median nerve, radial nerve &
musculocutaneous nerve.
Applied Anatomy:
Distension – distension by effusion occurs posteriorly since the capsule is weak here, but the
aspiration is done on any side of the olecranon process.
Dislocation – occurs posteriorly, usually associated with the fracture of the coronoid process.
Subluxation (pulled elbow)
• Occurs in children, when the forearm is suddenly pulled in pronation the radius slips from the
annular ligament.
• The supination is limited and painful.
Tennis elbow
• In this there will be pain and tenderness over the lateral epicondyle.
• This may be due to sprain of radial collateral ligament, tearing of fibres of extensor carpi
radialis brevis (ECRB) or inflammation of the bursa of ECRB.
 RADIO-ULNAR JOINTS
Superior radioulnar joint
• It is pivot variety of synovial joint.
• The head of the radius articulates with the radial notch
of the ulna.
• The ligaments of the joint are the annular ligament and
the quadrate ligament.
Middle radioulnar joint
• Syndesmosis variety of fibrous joint.
• The shaft of the radius and the ulna are connected to
each other by the interosseous membrane and by the
oblique cord degenerated tendon of FPL).
The interosseous membrane which is directed
downwards and medially - binds the radius and ulna,
provides attachment for muscles and transmits the
weight of the hand from radius to ulna.
Inferior radioulnar joint
• Pivot variety of synovial joint.
• The head of the ulna articulates with the ulnar notch of the
radius.
• The ligaments of the joint include the fibrous capsule,
articular disc
Nerve supply – musculocutaneous, median and radial nerves.
Action – supination and pronation.
Wrist (radiocarpal joint) joint
• It is ellipsoid variety of synovial joint.
• The lower end of the radius and the articular disc of the inferior radioulnar joint articulate
with the scaphoid, lunate and triquetral bones.
Ligaments of the joint –
• Fibrous capsule
• Anterior (palmar radiocarpal) ligament
• Posterior (palmar radiocarpal) ligament
• Medial and lateral collateral ligament.
Nerve supply – anterior and posterior interosseous nerve.
Actions – flexion, extension, adduction, abduction and circumduction.
Applied anatomy
• In adults, particularly the elderly, fractures near the wrist can cause a large amount of
swelling and deformity.
• The radius commonly gets fractured about 2cm above its lower end, by a fall on the
outstretched hand.
• In Colle’s fracture the distal fragment is displaced upwards and backwards.
• In Smith’s fracture the distal segment being palmar flexed rather than dorsiflexed.
Scaphoid fractures
• The scaphoid is occasionally injured by a fall on an outstretched hand.
• It is the second most common wrist fracture and occurs almost exclusively in active young
adults.
• This is a slow-healing fracture because of less vascularity, requiring an average of 3 months
in a cast that extends over the thumb.
The Carpometacarpal Joints
• These are plane synovial joints that permit a gliding movement.
• They share a common joint cavity with the intercarpal joints.
• These articulating bones are united by dorsal, palmar, and interosseous ligaments.
The Carpometacarpal Joint of the Thumb
• It is a saddle type of synovial joint.
• The trapezium articulates with the saddle-shaped base of the first metacarpal bone.
• The fibrous capsule encloses the joint and is attached to the margins of the articular surfaces.
• The looseness of its capsule facilitates its movements.
Nerve supply: anterior and posterior interosseous nerves, and ulnar nerve.
Movements of the Carpometacarpal Joint of the Thumb:
• Flexion, extension, abduction, adduction, and opposition.
The functional importance of the thumb lies in its ability to be opposed to the other digits.
The Metacarpophalangeal Joints
• Condyloid variety of synovial joints that allow movement in
two directions.
Nerve supply is by digital branches of ulnar and median nerves.
Movements taking place:
• Flexion, extension, abduction, adduction, and
circumduction.
The Interphalangeal Joints
• Uniaxial hinge variety of synovial joints.
• They joint the head of one phalanx with the base of the more
distal phalanx.
• They are structurally similar to the metacarpophalangeal
joints and are reinforced dorsally by the extensor expansions
of the digits.
Nerve supply is by digital branches of ulnar and median nerves.
Movements: They permit only flexion and extension
movements.
The joints of the upper limb
THANK YOU