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Anatomical Spaces in the Upper Limb

Professor Alice Roberts

This lecture ties in nicely with what you’re currently covering in MJM - the musculoskeletal system.
It’s about a series of anatomical spaces - framed by bone, ligament and muscle - which are
clinically relevant because tendons, nerves and vessels may become impinged in them, or because
they are sites where you might need to access - or indeed, avoid - vessels and nerves.

The interscalene groove

• Between scalenus medius and scalenus anterior
• The roots/trunks of the brachial plexus emerge between these muscles
• Regional anaesthesia: interscalene block - local anaesthetic deployed in inter scalene groove to
numb brachial plexus

The subacromial space

• Superior to the head of the humerus; inferior to the acromion
• Contains supraspinatus tendon and subacromial bursa
• Rotator cuff injuries: rotator cuff tears are common sports injuries; may also follow shoulder
dislocation; degenerative tendinitis of supraspinatus common in elderly – tendon may rupture;
subacromial bursitis causes painful arc syndrome

Suprascapular notch
• Impingement under the transverse scapular ligament affects the suprascapular nerve - causing
wasting of supraspinatus and infraspinatus and shoulder pain

The quadrangular/quadrilateral space

• Bounded by the shaft of the humerus laterally, long head of triceps medially, teres minor
superiorly, teres major inferiorly
• Axillary nerve and posterior circumflex artery pass through this space
• Axillary nerve is at risk of damage in shoulder dislocations

The triangular space (aka upper triangular space)

• Bounded by the long head of triceps laterally, teres minor superiorly, teres major inferiorly
• Circumflex scapular artery (from subscapular artery) passes through it

The triangular interval (aka lower triangular space)

• Bounded by the lateral head of triceps laterally, long head of triceps medially, teres major
superiorly
• Radial nerve and profunda brachii artery pass through it
The axilla
• Space between upper arm & side of thorax; bounded anteriorly & posteriorly by axillary folds

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• Communicates with posterior triangle of neck above

• Floored by axillary fascia
• Contains: axillary artery & vein, brachial plexus, lymph nodes, fat
• Axillary artery lies in groove between long head of triceps & coracobrachialis; can be palpated
in lateral wall of axilla – may be compressed here to prevent excessive bleeding
• Cephalic vein pierces clavipectoral fascia above pectoralis minor, to drain into axillary vein;
often damaged in axillary wounds – dangerous as bleeds profusely, and air emboli may be
created
• Axillary lymph nodes - become enlarged and tender in infections of upper limb, pectoral
region, breast and upper abdominal wall; long thoracic and thoracodorsal nerves are at risk in
axillary lymph node dissection
• Brachial plexus injuries - may be produced by disease, stretching, compression or wounds in
neck & axilla

The cubital tunnel

• The ulnar nerve may become compressed behind the medial epicondyle, where it passes deep
to a fibrous retinaculum stretching between the olecranon and the medial epicondyle
• Cubital tunnel syndrome may involve numbness in ring and little finger, forearm pain,
weakness in hand

Cubital fossa (aka antecubital fossa)

• Bounded by a line between the epicondyles above, medial border of brachioradialis laterally,
lateral border of pronator trees medially
• Floor - brachial; roof - deep fascia
• Contains (medial to lateral): median nerve, brachial artery, biceps tendon, radial nerve,
posterior interosseous branch of radial nerve
• Brachial pulse felt medially to biceps tendon
• Superficial to the fossa - the median antecubital vein is often used for venipuncture or
cannulation

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Guyon’s canal
• Bounded by hamate and pisiform bone; roofed by pisohamate ligament
• Ulnar nerve may be impinged here - paraesthesia and muscle weakness - ‘handlebar palsy'

The carpal tunnel

• Bounded by the carpal tunnel and flexor retinaculum
• median nerve passes through carpal tunnel with deep and superficial digital flexor tendons,
FPL - compression produces sensory loss in the lateral 3 ½ digits and weakness of the thenar
muscles

The anatomical snuffbox

• Bounded by the tendon of epl medially, epb and apl laterally, styloid process of radius
proximally
• Floor - scaphoid and trapezium (scaphoid palpated here in suspected fracture)
• Contains - radial artery, superficial branch of radial nerve, cephalic vein

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