Lab 10

Surface Anatomy
Upper Extremity
(2020-2021)

Anatomy team (RS2040)

Department of Rehabilitation Sciences
The Hong Kong Polytechnic University

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 Instruction (Palpation of Bony Structures)

1. Student work in pairs, alternating their roles and learn from each other:
o One student practices palpation. This student should:
 Pay particular attention to the technique of palpation, applying
the appropriate amount of pressure; take precautions so as not
to cause discomfort;
 Being aware of the partner’s reaction and respond to the
palpation
 Adjust the technique of palpation according to partner’s
comments
o The student being palpated should:
 Focus on the feeling and sensation on the part being palpated.
 Inform the palpator of these sensations (too much pressure
causing pain, too light, too quick, too slow and any other
uncomfortable or unpleasant sensations etc)

2. Appropriately expose the part to be palpated

3. For palpation of most skeletal parts, the muscles must be relaxed.

Contraction of a muscle tends to obscure any bony prominence near it.

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 Instruction (Muscle Action & Palpation)

1. The practical sessions emphasize in developing both manual and verbal

skills.

2. Students should learn the attachments, nerve supply and actions of the
relevant muscle prior to each session.

3. Students work in pairs and alternate their roles.

4. Each student, while practicing muscle testing should:

o Pay attention in developing:
 The skills in giving instructions to the patient
 The technique of palpating and testing muscle actions
 The technique in testing the normal physiological length of
muscles
 The appropriate hand placement and application of resistance to
muscle contraction
 Appropriate positioning of the subject
 Necessary precautions so as not to cause discomfort
o Be aware of the partner’s reaction and respond to muscle testing
o Adjust the technique of muscle testing according to partner’s com-
ments
o Appropriately expose the part to be tested and palpated

5. Each student, when palpating and testing the strength of a muscle should:
o First note the shape, contour and texture of a normal muscle at rest

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 o The palpating finger(s) should rest gently on the distal tendon (occa-
sionally on the proximal attachment) of the muscle or on its fleshly
part before and during its contraction
o Instruct the partner clearly and concisely on how to perform the re-
quired active concentric contraction
o Apply resistance to the action in the middle range to bring the muscle
into more prominent contraction
o Practice observing for deviations and substitution
o Allow your partner to relax and rest between each test

6. Each student, while testing the physiological length of a muscle, should:

o Appropriately position the partner
o Stabilize the proximal segment
o Take precaution not to over-stretch the muscle

7. The student partner also has to play an active role during the practical
sessions. The partner should:
o Focus on the feeling and sensation on the part being tested
o Inform the assessor of these sensations:
 Positioning causing discomfort
 Too much pressure causing pain, hand placement inappropriate
 Instructions: too quick, too slow or incomprehensible
 Any other uncomfortable or unpleasant sensations

8. The following sections provide instructions on how to bring the important

muscles into active contraction so that students can practice by themselves at
home, or practice with a partner.

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Lab 10: Surface Anatomy II: Upper Extremity
Table 1: Hand & Wrist

Hand & Wrist

1. Heads of metacarpals 1-5

 Starting position: Sitting, with hand supported on table
 Location: Knuckles of the fisted hand.
 Palpation process: Most clearly shown when the MCP joints are in full flexion.

2. Carpal bones: capitates

 Starting position: Sitting, with hand supported on table
 Location: Proximal to 3rd metacarpal
 Palpation process: With wrist in flexion, the capitate (forming the highest point
on the dorsal surface of the wrist) is in line with metacarpal III. With wrist in
extension, it can be felt as a depression. Confirm by repeated flexion and
Extension.

3. Carpal bones: scaphoid

 Starting position: Sitting, with hand supported on table
 Location: Radial side of wrist
 Palpation process: At the most distal transverse skin crease at the wrist, the
prominence at the junction of the middle and lateral 1/3 of the crease is the
tubercle of the scaphoid.

4. Carpal bones: trapezium (tubercle)

 Starting position: Sitting, with hand supported on table
 Location: The trapezium lies between the scaphoid and the base of metacarpal I.
 Palpation process: After locating the tubercle of the scaphoid, feel for another
slight prominence just distal and lateral to it. This should be the tubercle of the
trapezium. Use the movement of the carpo-metacarpal joint of digit I to help
determine the distal limit of the carpal region.

5. Carpal bones: pisiform

 Starting position: Sitting, with hand supported on table
 Location: Use the distal transverse crease as a guide, it forms the prominence on
the proximal medial side of the palm.
 Palpation process: With the wrist held in relaxed flexion, this small bone may
be grasped between the thumb and index finger and easily pushed from side to
side.

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6. Carpal bones: hook of hamate
 Starting position: Sitting, with hand supported on table
 Location: Palpate it about one finger's breadth below and lateral to the pisiform
bone.
 Palpation process: May also be felt, indistinctly, by placing the palpating IP
joint of the thumb over tire pisiform and use the tip of the thumb to apply firm
pressure to the palm of the hand, in line with the space between the ring and lit-
tle finger.

7. Carpal bones: triquetrum

 Starting position: Sitting, with hand supported on table
 Location: Posterior to the pisiform
 Palpation process: Can be palpated with the wrist in radial deviation so that the
triquetral moves out from under the ulnar styloid process.

8. Carpal bones: lunate

 Starting position: Sitting, with hand supported on table
 Location: It is situated between scaphoid and triquetrum.
 Palpation process: Can be located about 1 cm proximal and slightly ulnar from
capitate.

9. Palpate the pulse of the radial artery

 Starting position: Sitting, with hand supported on table
 Palpation process: Can be palpated just proximal to the wrist between FCR
tendon medially, and lower part of the anterior border of radius laterally.

10. Palpate the pulse of the ulnar artery

 Starting position: Sitting, with hand supported on table
 Palpation Process: Can be palpated just proximal to the wrist lateral to the
flexor carpi ulnaris.

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Table 2: Forearm

Forearm

1. Ulna: head of ulna

 Starting position: Sitting, with forearm supported on table
 Location: Distal ulna
 Palpation process: With radio-ulnar joints in pronation and wrist joint in relaxed
position, the head of the ulna becomes fairly prominent in this position

2. Ulna: ulnar styloid process

 Starting position: Sitting
 Location: Just medial and distal to the ulnar head
 Palpation process: With your finger still on the head of ulna; supinate your
forearm. You can feel the head of ulna moving away and the styloid process
coming into place underneath your finger. Ulnar styloid process lies about 2 cm
proximal to the radial styloid process.

3. Ulna: olecranon
 Starting position: Sitting
 Location: Elbow
 Palpation process: The point of contact when you "lean on your elbow".

4. Radius: radial styloid process

 Starting position: Sitting, with forearm supported on table
 Location: Distal radius
 Palpation process: Can be felt in the floor of the anatomical snuff box, when the
wrist is adducted

5. Radius: dorsal tubercle

 Starting position: Sitting, with forearm supported on table
 Location: Approximately 1/3 of the way across the dorsum of the wrist from the
radial styloid process
 Palpation process: Locate the radial styloid process, and palpate dorsally across
the wrist.

6. Radius: head of radius

 Starting position: Sitting
 Location: Proximal radius
 Palpation process: With the elbow in full extension, shoulder joint in medial ro-
tation, note the depressed area of the posterior lateral elbow region. Palpate in
this depressed area will reveal 2 prominences with a groove between them. The
groove is radio-humeral joint line. The proximal prominence is the lateral epi-
condyle of the humerus. The distal prominence is the head of radius; confirm by
pronation and supination, the radial head moves.

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7. Palpate the medial collateral ligament
 Starting position: Sitting, with forearm supported on table
 Location: From medial epicondyle of humerus to proximal ulna.

8. Palpate the lateral collateral ligament

 Starting position: Sitting, with forearm supported on table
 Location: From lateral epicondyle of humerus to proximal radius.

9. Palpate the radio-humeral joint line

 Starting position: Sitting, with forearm supported on table
 Location: Between head of radius and capitulum of humerus
 Palpation process: Forearm pronated and palpate from the dorsolateral surface
of the lateral epicondyle distally.

10. Palpate the brachial artery

 Starting position: Sitting, with forearm supported on table
 Location: pulse can be palpated along the medial aspect of the arm or at the
cubital fossa medial to the biceps tendon.

11. Palpate the muscle: pronator teres

 Starting position: Sitting
 Location: Medial boundary of cubital fossa
 Palpation process: Place the palpating fingers just medial to the brachioradialis
and just distal to the tendons of the biceps brachii, with all of the muscles
relaxed by supporting the forearm on the table. The muscle can be palpated
when strong pronation is performed.

12. Palpate the muscle: palmaris longus tendon

 Starting position: Sitting, with forearm supported on table
 Location: Middle part of the anterior surface of the wrist
 Palpation process: During active wrist flexion, while at the same time, opposing
the tips of the thumb and the little finger.

13. Palpate the muscle: Flexor carpi radialis:

 Starting position: Sitting, with forearm supported on table
 Location: Lateral to the tendon of palmaris longus.
 Palpation process: The tendon crosses the wrist laterally during active wrist
flexion.

14. Palpate the muscle: Flexor carpi ulnaris

 Starting position: Sitting, with forearm supported on table
 Location: The muscle may be followed along the distal half of the forearm (
medial side), and the tendon can be felt as a cord-like tendon proximal to the
pisiform bone at the wrist.
 Palpation process: Subject performs active wrist flexion and adduction (ulnar
deviation), the tendon is prominent near the pisiform.
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15. Palpate the muscle: Flexor digitorum superficialis
 Starting position: Sitting, with forearm supported on table
 Location: The tendons lie between those of palmaris longus and flexor carpi
Ulnaris, and are at a slightly deeper level.
 Palpation process: The tendons can be more prominent if resistance is given to
finger flexion and wrist flexion, as the subject tries to close his fist tightly.

16. Palpate the muscle: Flexor digitorum profundus

 Starting position: Sitting, with forearm supported on table
 Location: Individual tendon can be palpated just proximal to its insertions.
 Palpation process: Stabilize the MCP and PIP joints of each finger, and apply
pressure to the palmar aspect of the fingertip in the direction of extension (as
the subject actively flex the DIP joint).

17. Palpate the muscle: Flexor pollicis longus

 Starting position: Sitting, with forearm supported on table
 Location: Palpate the fleshy portion along the anterior surface of the distal 1/2
of the radius, during active flexion of the IP and MCP joints of the thumb.
 Palpation process: Palpate the tendon along the palmar surface of the
metacarpal I just proximal to the sesamoid bones, and distal to the sesamoid
bones along the 1st phalanx as the same active flexion of IP & MCP joints are
performed.

18. Palpate the muscle: Brachioradialis

 Starting position: Sitting, with elbow 90° flexed and forearm in neutral position
 Location: Outline of the brachioradialis can be followed from the lateral border
of the humerus to about the distal half of the radius.
 Palpation process: Best observed and palpated when strong resistance is applied
at the wrist against elbow flexion at about 90°, in mid-position between
pronation and supination.

19. Palpate the muscle: Extensor digitorum

 Starting position: Sitting, with forearm supported on table
 Location: The tendons can be palpated as a group in the middle part of the
dorsal surface of the wrist.
 Palpation process: Instruct subject to extend the wrist and MCP joints of digits
II – V, with the inter-phalangeal joints in flexion.

20. Palpate the muscle: Extensor digiti minimi

 Starting position: Sitting, with forearm supported on table
 Location: Tendon may be palpated along the entire length of the 5th metacarpal
bone and on to the proximal phalanx.
 Palpation process: Active hyperextension of the metacarpo-phalangeal joint of
little digit helps to make the tendon prominent.

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21. Palpate the muscle: Extensor carpi ulnaris
 Starting position: Sitting, with forearm supported on table
 Location: The tendon is medial to the tendon of extensor digiti minimi.
 Palpation process: It can be palpated between the ulnar head and the base of
metacarpal V during active wrist extension and adduction (ulnar deviation).

22. Palpate the muscle: Extensor pollicis longus

 Starting position: Sitting, with forearm supported on table
 Location: The posterior boundary of the anatomical snuff-box.
 Palpation process: The tendon becomes prominent during strong extension of
the inter-phalangeal, metacarpo-phalangeal, and carpometacarpal joints of the
thumb.

23. Palpate the muscle: Extensor carpi radialis longus and brevis tendons
 Starting position: Sitting, with forearm supported on table
 Location: Tendons between EPL and ED at the dorsal aspect of wrist.
 Palpation process: Palpate ECRL by moving the finger laterally to the
anatomical snuffbox.

24. Palpate the muscle: Extensor indicis

 Starting position: Sitting, with forearm supported on table
 Location: The tendinous portion lies deep to the tendon of extensor digitorum,
as these 2 tendons are closely related to each other on the dorsum of the hand.
At the head of metacarpal II the tendon of extensor indicis is medial to the ten-
don of extensor digitorum to digit II.
 Palpation process: It may be difficult to distinguish individual tendons, and it
may be obtained by moving the proximal phalanx in several directions.

25. Palpate the muscle: Lumbricals

 Starting position: Sitting, with forearm supported on table
 Location: Between metacarpal bones
 Palpation process: These muscles extend IP joints and flex MCP
simultaneously. Combining the movement makes it more prominent.

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Table 3: Upper Arm

Upper Arm

1. Humerus: Medial and lateral humeral epicondyles

 Starting position: Sitting
 Location: Lateral side of distal humerus
 Palpation process: When the elbow is flexed, the 3 bony points form the angles
of an isosceles triangle. The lateral epicondyle is less prominent than the medial
epicondyle.

2. Humerus: greater tuberosity

 Starting position: Sitting
 Location: Just inferior and lateral to the anterior part of the acromion
 Palpation process: Arm lateral rotation helps to identify the bony landmark.

3. Humerus: lesser tuberosity

 Starting position: Sitting
 Location: Just anterior and medial to the greater tuberosity
 Palpation process: Arm lateral rotation helps to identify the bony landmark.

4. Humerus: bicipital groove (intertubercular sulcus)

 Starting position: Sitting
 Location: A groove running vertically, may be felt between the greater and
lesser tuberosities, represented by a line about 5 cm long, running downwards
from tire tip of the acromion, to the long axis of the humerus
 Palpation process: The long head of biceps brachii can be palpate in the groove
by asking the subject to isometrically contract the biceps brachii.

5. Humerus: head of humerus

 Starting position: Sitting
 Location: Head of the humerus articulates with the glenoid fossa of the scapula
 Palpation process: Subject abducts the shoulder to approximately 120°, elbow
flexed, and hand resting on the subject's head. Palpate the humeral head by
pushing your fingers into the axillary fossa (armpit).

6. Palpate the muscle: Biceps brachii tendon

 Starting position: Sitting
 Location: Cubital fossa
 Palpation process: 2 tendons can be identified in a position of 90° elbow flexion
with radioulnar joint supination. The medial aponeurotic portion (bicipital
aponeurosis) seems to end superficially in the deep fascia of the forearm. The
lateral portion forms a rounded tendon that goes deep into the cubital fossa
towards the radial tuberosity. A depressed area may be felt between the 2
tendons.

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7. Palpate the muscle: Triceps brachii tendon
 Starting position: Prone
 Location: Posterior humerus
 Palpation process: Shoulder abducted to 90° with the arm supported between
the shoulder and elbow by the table. Ask subject to extend the elbow joint. Re-
sistance can be given in the direction of elbow extension.

8. Palpate the muscle: Teres major

 Starting position: Prone with the humerus in a medially rotated position and
hand resting on the posterior iliac crest, head rotated to the same side
 Location: Between dorsal surface of inferior angle of scapula and intertubercu-
lar sulcus of humerus
 Palpation process: Subject performs extension and adduction of the humerus.
Resistance is given in the direction of abduction and flexion.

9. Palpate the muscle: Brachialis

 Starting position: Sitting with elbow placed in relaxed flexion (forearm
supported) and radioulnar joint in pronation.
 Location: Large part of the brachialis is covered by the biceps brachii. Palpation
can be accomplished near the elbow joint deep to the biceps by placing the
thumb on one side of the biceps tendon and index finger on the other side.
 Palpation process: Brachialis can be felt contracting as a small range of elbow
flexion is performed.

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Table 4: Scapula and Clavicle

Scapula and Clavicle

1. Scapula: Medial and lateral borders

 Starting position: Prone with back muscle relaxed, arms adducted
 Palpation process: Outline the whole scapula, the medial border and lateral
border can often be seen.
2. Scapula: Inferior angle
 Starting position: Prone with back muscle relaxed, arms adducted
 Location: At the junction of the medial and lateral borders
 Palpation process: Can be palpated opposite the 7th thoracic vertebra.

3. Scapula: Acromial angle

 Starting position: Prone with back muscle relaxed, arms adducted
 Location: At the junction of the lateral border of the acromion and the spine of
Scapula. Note: the acromion angle is a point
 Palpation process: Palpate along the lateral border until the most lateral point.

4. Scapula: Acromial process

 Starting position: Prone with back muscle relaxed, arms adducted
 Location: Most lateral part of scapula
 Palpation process: Palpate it lateral to the acromio-clavicular joint and follow it
to the acromion angle.

5. Scapula: spine of scapula

 Starting position: Prone with back muscle relaxed, arms adducted
 Location: At the level of the spinous process of the 3rd thoracic vertebra,
 Palpation process: Palpate this from the acromial angle to the medial border.
Note that the spine is narrow at about its centre, broadening out towards the
medial border of the scapula and forming a smooth triangular surface.
6. Scapula: coracoid process
 Starting position: Sitting
 Location: 1.25 cm below and lateral to the junction of the middle and outer 1/3
of the clavicle
 Palpation process: Easily palpated by putting the fingers in the infraclavicular
fossa and pushing laterally.
7. Scapular muscle: supraspinatus
 Starting position: Prone with the arm hanging over the edge of the plinth
 Location: Deep in the supraspinous fossa
 Palpation process: May be difficult to palpate because it is and covered by
trapezius. Palpate the scapular spine, and palpating fingers placed above the
spine, relax the trapezius by rotating the face toward the opposite side. Instruct
the subject to slowly perform small range of abduction (initial few degrees of
abduction), momentary contraction of the supraspinatus can be felt.

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8. Scapular muscle: infraspinatus and teres minor
 Starting position: Prone with the arm hanging over the edge of the plinth
 Location: Infraspinous fossa
 Palpation process: Place palpating fingers on the lateral border of the scapula
below the deltoid.

9. Scapular muscle: teres major

 Starting position: Prone with the humerus in a medially rotated position and
hand resting on the posterior iliac crest, head rotated to the same side
 Location: Below teres minor
 Palpation process: Subject performs extension and adduction of the humerus.
Resistance is given in the direction of abduction and flexion.

10. Palpate the muscle: Deltoid

 Starting position: Sitting with shoulder abducted
 Location: Lateral to acromial angle
 Palpation process:
o Anterior fibers
 Instruct the subject to push the humerus obliquely upwards (horizontal
adduction to 45°), anterior fibers becomes more distinct especially if
resistance is given in the opposite direction.
o Middle fibers
 Instruct the subject to hold the shoulder in the abducted position, while the
resistance is applied.
o Posterior fibers
 Instruct the subject to pull the humerus obliquely backwards (extend and
horizontal abduction to 45°), the posterior fibers becomes more distinct as
resistance is given.

References:

Anatomy Team: Functional Anatomy Laboratory Handbook 2018-2019. Department of Rehabili-

tation Sciences, The Hong Kong Polytechnic University; 2019

Kendall FP, McCreary EK, Provance PG. Muscles, Testing and Function: With Posture and Pain.
5th edition. Lippincott Williams & Wikins; 2005

Clarkson HM. Musculoskeletal Assessment: Joint Motion and Muscle Testing. 3rd edition. Lip-
pincott Williams & Wilkins; 2013

MAGEE, David J. Orthopedic physical assessment.6th edition. Elsevier Health Sciences; 2014.

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