Arm

References
Black - Grey’s Anatomy Student’s, 4th edition
Blue - Vishram Singh’s upper limb and thorax
Green - Compilation of best educational platforms

Objectives:
To know about:
● Introduction

● Surface landmarks

● Compartment of arm with muscles

● Nerve supply

● Blood supply

● Clinical testing and correlations

● Injuries

Arm
Scapula Above (shoulder
● Humerus Joint)
articulates with

Radius & Ulna Below (elbow

joint)
● Primary neurovascular bundle of arm is located on the
medial side of the arm, hence protected by the limb.
It consists of: ● Brachial Artery
● Basilic vein
● Median
● Ulnar Nerves
● Radial
 Surface landmarks
1. In Humerus

Greater Shaft Medial Lateral Medial &

tubercle of epicondyle epicondyle lateral
of humerus of of epicondyle
humerus humerus humerus of humerus

Can be prominent prominent can be felt

felt below at the on the at lower
and medial side postero- 1/4th of the
lateral to of the lateral arm as the
acromion, elbow felt aspect of upward
deep to at slightly extended conti-
deltoid midflexed elbow nuation of
with the elbow medial &
arm. lateral
epocondyle
2. Muscles

Deltoid muscle Bicep muscle

prominent on abduction.
● conspicuous bulge on the
covers the upper 1/2 front of the arm
of humerus ● prominent on flexion of
● Arteriorly elbow.
● laterally is attached to lateral side of
● posteriorly middle of humerus.
& ● its apex.
● Artery - Brachial Artery
present in front of elbow.
● Nerves - Ulnar nerves
can be rolled by the middle finger in the groove
behind the medial epicondyle of humerus

● Head of radius

● depression on the posterolateral aspect of the

elbow just distal to the lateral epicondyle
● Rotation of head of radius can be felt by

Supination & pronation

of forearm.
● Olecranon process of Ulna (proximal part of Ulna)

readily palpable on the back of the elbow

between the medial & lateral epicondyles.

Compartments of Arm
● Deep fascia encloses the arm like a sleeve
● 2 fascial septa

one on medial side one on the lateral side

extends inwards extends inwards

gets attached gets attached

to the medial to the lateral
supracondylar ridge supracondylar ridge
 these facial sleeves for septa divide the arm into
2 compartments

Anterior compartments Posterior compartments

Contents Contents
● Muscles - 1. Biceps ● Muscles - Triceps
Brachii Brachii
2. Coraco- ● Nerves - Radial
brachialis Nerve
3. Brachialis
● Artery - Profunda
● Nerves - Musculocutaneous Brachii
nerve artery

In addition In addition to
these structures,
Median nerve also the following
Radial pass through structure also
Ulnar anterior passes through
compartment this
of arm compartments:
● Artery - Brachial Artery 1. Ulnar nerve
2. Ulnar collateral
arteries
Muscles of the anterior compartment of the arm (spinal segments
in bold are the major segments innervating the muscle)
Muscle Origin Insertion Innervation Function
Coraco- Apex of Linear Musculo- Flexor of
brachialis coracoid roughening cutaneous the arm at
process on midshaft nerve (C5, the gleno-
of humerus C6, C7) humeral
on medial joint
side
Biceps Long Radial Musculo- Powerful
brachii head — tuberosity cutaneous flexor of
supragle- nerve (C5, the
noid tu- C6) forearm at
bercle of the elbow
scapula; joint and
supinator
short
of the
head —
forearm;
apex of
accessory
coracoid
flexor of
process
the arm at
the
glenohu-
meral joint
Brachialis Anterior Tuberosity Musculo- Powerful
aspect of of the ulna cutaneous flexor of
humerus nerve (C5, the fore-
(medial C6); small arm at the
and contribu- elbow joint
lateral tion by the
surfaces) radial
and nerve (C7)
adjacent to lateral
intermus- part of
cular muscle
septae)
 Origin
1. Short head
from tip of
coracoid
process 2. Long head
from
supraglenoid
tubercle of
scapula

BICEPS
BRACHII

Bicipital
aponeurosis
Tendon of
biceps
Insertion
Posterior part of
radial tuberosity

Origin and insertion of the biceps brachii.

 Origin
Tip of coracoid
process in
common with
the short head
Short head of of biceps
biceps brachii brachii

CORACO-
BRACHIALIS Insertion
Middle (5 cm)
of the medial
border of
humerus

Origin and insertion of the coracobrachialis.

Origin
Lower half of
anterior surface
Deltoid of the humerus

BRACHIALIS

Insertion
Anterior surface
of the coronoid
process of ulna

Origin and insertion of the brachialis.

Muscles of the posterior compartment of the arm (spinal segment
indicated in bold is the major segment innervating the muscle)

Muscle Origin Insertion Innervation Function

Triceps long Olecranon Radial Extension
brachii head — nerve (C6, of the
infragle- C7, C8) forearm
noid at the
tubercle of elbow
scapula; joint;
medial long head
head — can also
posterior extend
surface of and
humerus; adduct
the arm
lateral at the
head — shoulder
posterior joint
surface of
humerus
 Profunda
brachii artery
Origin of long and radial nerve
head from:
Origin of lateral
Infraglenoid
head from:
tubercle of
scapula Oblique ridge
on the posterior
aspect of
humerus

TRICEPS Origin of medial

head from:
Posterior
Insertion surface of
humerus below
Posterior part
the radial
of the
groove
superior
surface of the
olecranon
process

Origin and insertion of the triceps brachii.

Clinical testing of Bicep Brachii

Bicep brachii is tested by asking the patient to flex
the elbow against resistance & when forearm is
supinated

In this, the muscle forms a prominent bulge on the

front of arm.
● Clinical Correlation

Bicep Reflex: tapping the tendon of Bicep Brachii

by Reflex hammer with forearm pronated &
partially extended at elbow

Normal Reflex brief jerk like flexion of the elbow

confirms normal integrity of

musculocutaneous nerve C5 &
C6 spinal segment

Rupture of Biceps Tendon

Most common tendon to Rupture is long head of

biceps brachii muscle

flexing the elbow

Causes Deformity in
causes extremely
prominent bulge of muscle
belly as its unrestrained
fibres contract

Called “Popeyes sign”

Important features of Coracobrachialis

Coracobrachialis is muscle of medial compartment
of forelimb of quadrupeds.
● It is not well developed in human beings.
● In some animals this muscle consist of 3 heads.
In Humans

● upper 2 heads are fused & musculocutaneous

nerve passes between the 2 heads.
● lower 3rd head has disappeared in humans
But occasionally the lower head persists as a
fibrous band ligament of Struthers

this band may calcify and

compresses median nerve
● Median Nerve and Brachial Artery

then passes deep to the ligament and may

be compressed.

Anatomical Events at the insertion

of Coracobrachialis:
becomes triangular
1. Circular shaft of humerus below this level.

2. Brachial Artery passes from medial side of the arm

to

its anterior aspect

3. Basilic vein pierces deep fascia

 4. Median nerve crosses in front of brachial
to
artery from Lateral Medial side

5. Radial nerve pierces lateral

intermuscular septum & passess
from Posterior compartment
to

Anterior Compartment
Median nerve

Brachial
Anterior Deltoid artery

Lateral Medial Ulnar

nerve

Posterior

Radial nerve
Coracobrachialis

6. Ulnar nerve pierces medial intermuscular

septum and passes from Anterior
Compartment
to

Posterior compartment

7. Medial cutaneous nerve of the arm and forearm

pierces the deep fascia.

8. Nutrient artery pierces the humerus.

 Musculocutaneous Nerve
Bicep Brachii
arise from
Short head
long head
Coracoid
process Lateral cord of
brachial plexus

Musculocutaneous
nerve

Pierces
coracobrachialis muscle
also supplies it:

Passes between the

biceps & brachialis
muscles
Brachialis

Biceps
brachii It appears at the lateral
margin of tendon of
biceps brachii
Tendon
of biceps
brachii It pierces the deep
fascia just above
the elbow

& continues to form

Lateral cutaneous lateral cutaneous nerve
nerve of forearm of forearm
 Branches & Distribution

Muscular Cutaneous Articular

Branch Branch Branch
Supplies Supplies Supplies
to to to

● Bicep brachii ● Skin on the ● elbow joint

● Coracobrachialis front & lateral through its
● Brachialis aspect of branch to
forearm brachialis
muscle
Injury to musculocutaneous nerve
It is rare but can lead to following signs & symptoms
1. Loss of strong flexion & supination.
2. Loss of biceps tendon reflex.
3. Loss of sensation along the lateral aspect
of forearm

Brachial Artery
● Main artery of the arm.
● Begins at the lower border of Teres major as a
continuation of axillary artery
● Terminates in front of elbow at the level of neck of
Radius - by dividing into

Radial artery Ulnar artery

 Axillary
artery

Teres major
Deltoid/ muscle
ascending
branch
(anastomotic Profunda
branch) brachii artery

Brachial
artery
Nutrient artery

Muscular branch Superior

ulnar
Posterior
collateral
descending
artery
branch (radial
collateral artery)
Anterior Inferior ulnar
descending collateral
branch (middle artery
collateral artery)

Neck of radius Ulnar artery

(large
terminal
branch)
Radial artery
(small terminal
branch)

Brachial artery
 Relations of Brachial Arteries

Anteriorly Posteriorly

upper medial lower brachial artery lies

part part part successively on
related is
to from above
medial crossed In cubital long head
cutaneous by fossa it is of triceps
nerve of median crossed by
medial head
forearm nerve Bicipital
of triceps
from aponeurosis
lateral Coraco-
to brachialis
medial
side Brachialis
muscle

downwards

Medially Laterally
● Ulnar nerve ● Median nerve
● Basilic vein ● Coracobrachialis
● Biceps

in upper part of the arm

in upper part
● Median nerve in
● tendon of Biceps
lower part of arm
in lower part
 Branches of Brachial Artery

1. Profunda Brachii Artery 2. Nutrient Artery

to humerus

● Largest and
● first branch of brachial enters nutrient
artery. foramen of
humerus located
Arise from near the
posteromedial aspect of insertion of
brachial artery just below coracobrachialis
the lower border of
teres major
it accompanies
radial nerve
which leaves lower
triangular intermuscular
space to enter spiral groove

3. Superior 4. Superior ulnar 5. Terminates in

ulnar collateral
collateral
arise near the lower Ulnar Radial
arise near the end of humerus & Arteries
middle of the divides into anterior
arm & & posterior
branches which Terminal
accompanies
takes part in Branches
the ulnar
nerve formation of arterial
anastomosis around
the elbow
Clinical Correlation
Brachial artery is superficial throughout its course
being covered only by the skin & fascia, hence
easily accessible.

● Brachial Pulse It is commonly felt in Cubital Fossa

● Medial to the It’s auscultated for

tendon of biceps recording the blood
pressure

Biceps tendon is
easily palpable on
flexing the elbows

Axillary artery

Humerus

Teres major

Brachial artery

Insertion of Site of
coracobrachialis compression of
brachial artery

Radial artery Ulnar artery

Compression of the brachial artery against humerus.

● Compression of Brachial Artery
Brachial artery can be compressed against
the humerus at the level of insertion of
coracobrachialis.

To stop the hemorrhages in the upper limb occuring

from any artery distal to the brachial artery
Eg: Bleeding wound of the palmar arterial arches

● Rupture of the brachial artery in supracondylar

fracture of humerus
may lead to

Volkmann’s ischemic contracture

Brachial artery
Humerus

Supracondylar
Rupture of fracture of
brachial artery humerus

Ulna

Rupture of the brachial artery in supracondylar fracture of

the humerus.
 Arterial Anastomosis around Elbow

Medial epicondyle Above olecranon

fossa
In front Behind
Middle collateral
of medial the medial
artery
epicondyle epicondyle (Branch of profunda
Inferior ulnar Superior ulnar brachii artery)
collateral artery collateral artery Anastomose with
and branch and a branch of
from superior inferior ulnar
ulnar collateral collateral artery Transverse branch
artery (Branches of from the posterior
(Branches of brachial artery) division of the
brachial artery inferior ulnar
Anastomose
with collateral artery
Anastomose
with
Posterior ulnar
Anterior ulnar recurrent artery
recurrent artery (Branch of ulnar
(Branch of ulnar artery)
artery)
Lateral epicondyle

In front of lateral Behind the lateral epicondyle

epicondyle
Posterior descending artery
Radial collateral artery (Branch of profunda brachii artery)
(Branch of profunda
Anastomose with
brachii artery)

Anastomose with ● Interosseuos recurrent artery

Radial recurrent artery
(Branch of radial artery)
(Branch of common interosseous
artery) &
● Branch of common
interosseous artery
(Branch of ulnar artery)
 Profunda
brachii artery

Brachial artery

Superior
Posterior
ulnar collateral
descending
artery
branch
L M
Inferior
ulnar
Anterior collateral
descending artery
branch
(or radial Posterior
collateral) ulnar
recurrent
Radial artery
recurrent
artery Anterior
ulnar
recurrent
artery
Interosseous Common
recurrent interosseous
artery artery

Ulnar artery

Radial artery Anterior

Interosseous
Posterior artery
interosseous artery

Arterial anastomosis around the elbow joint (L - lateral epicondyle,

M - medial epicondyle).
 Large nerves passing
through the arm
Median Ulnar Radial
arise from arise from arise from

● Lateral ● Medial cord ● Posterior cord of

cord of brachial brachial plexus in axilla
● medial plexus in axilla● In Arm
cord of
● Runs 1. Nerve 1st lies
brachial
downward in the posterior to brachial
plexus in
medial side of the artery
axilla.
arm to the
brachial artery
● It is closely 2. Then it winds
upto insertion of around the back of the
related to
coracobrachialis arm & to enter
brachial
artery radial/spiral groove of
throughout ● At the humerus (where it is
the course in insertion of accompanied
arm coracobrachialis by profunda brachial
It pierces the artery)
● It is intermuscular
superficially septum & enters
located 3. At the lower end
to posterior
except at the compartment of spiral groove
elbow where it pierces lateral
it is crossed At Elbow joint intermuscular septum
by the & enters the anterior
bicipital compartment of arms
it passes behind
aponeurosis. medial epicondyle
of humerus 4. It then continues till
where it can be the cubital fossa
easily palpated

* Ulnar nerve do not give any branch in the arm

 Relationship of median nerve

Upper part Middle part Lower part

lateral to It crossed in front of the medial to the

artery artery from lateral to artery upto
medial side elbow

Branches of median nerves

Nerve to Vasomotor nerve Articular branch

pronator teres to brachial artery to the elbow joint

Teres major
Median nerve
Ulnar nerve
Brachial artery

Medial
Radial nerve
Intermuscular
septum
Lateral
intermuscular
septum
Bicipital
aponeurosis
Radial artery
Ulnar artery

Relations of the median nerve with the brachial artery in arm. The
course of the radial and ulnar nerves in the arm is also shown.
 Radial nerve
Nerve to
long head
of triceps
Lateral head
Long head of triceps
of triceps
Nerve to
Posterior lateral head of
cutaneous triceps
nerve of arm
Nerves to Lower lateral
medial head of cutaneous
triceps nerve of arm

Posterior
Nerves to cutaneous
anconeus nerve of
forearm

Anconeus

Course, relations and branches of the radial nerve in the arm.

● Radial Nerve
Brachialis
In Cubital Fossa it lies between
Brachioradialis
muscle

It divides in 2 terminal branches

Sensory branch Motor branch

called Superficial radial nerve the deep radial nerve

 Branches

In Axilla In Spiral Groove In Anterior

1. Nerves to lateral compartment of
1. Nerve to
& medial head of Arm
long & medial
head of triceps 1. Nerves to
triceps 2. Nerve to ● Brachialis
2. Posterior anconeus ● Brachioradialis
cutaneous ● Extensor carpi
3. Lower lateral
nerve radialis longus
cutaneous nerve
of arm of arm 2. Articular branch
of elbow joint
4. Posterior
cutaneous nerve 3.Deep radial nerve
of forearm 4. Superficial radial
nerve

Triangular
interval

Profunda
brachii artery
Radial nerve
(in radial
Branch to groove)
medial head of
triceps brachii Inferior
lateral
Medial cutaneous
epicondyle nerve of arm
Ulnar nerve
Posterior
cutaneous
nerve of
forearm
Radial nerve in the arm.
 Radial nerve injury in the arm:
Radial nerve is tightly bound with
Profunda brachii artery between

medial lateral head of triceps brachii

in the Radial Groove

● If there is fracture of humerus

Radial nerve may become stretched or

transected in this region

leading to permanent damage & lost of function

● Symptoms ● wrist drop (due to denervation of

extensor muscles)
● Sensory changes over
dorsum of hand

Humerus

Radiograph of the humerus demonstrating a midshaft fracture,

which may disrupt the radial nerve.
 Median nerve injury in Arm
usually not injured by trauma because
relatively deeply placed
● Commonest neurological problem associated
with median nerve compression

Beneath the flexor reticulum at the wrist

(carpal tunnel syndrome).

● On a very rare occasion - fibrous band may

arise from the anterior aspect of humerus
beneath which the median nerve passes.

This is embryological remnant of coracobrachialis

called ligament of struther

● It occasionaly calcifies that compresses median

nerve

Resulting weakness of flexor muscles &

thenar muscles.
 Summary:

- Humerus articulates with scapula at proximal end and

ulna, radius at distal end
- Muscles- deltoid muscle and bicep muscle
- Anterior compartment muscles include Biceps
brachii, coracobrachialis, brachialis.
- Posterior compartment muscles include triceps
brachii
- Biceps reflex performed in a pronated forearm by
tapping on the biceps tendon,brief jerk-like flexion of
elbow, when tapped at the tendon of bicep brachii
using a knee hammer.
- Musculocutaneous nerve branches: muscular branch,
cutaneous branch, articular branch
- Brachial artery terminates in front of elbow at the
level of neck of radius into radial and ulnar artery.
- Brachial pulse felt in cubital fossa, medial to the
tendon of biceps brachii
• Volkmann’s ischemic contracture is rupture of
brachial artery in supracondylar fracture of humerus