UE 2 - Elbow, Forearm, Wrist and Hand 8/9/23

7. Radial fossa
(+) Annular Ligament - Prevents displacement of
Topic Outline Radial Head
- Nursemaid Elbow / Pulled Elbow
above the capitulum;
receives radial head when flexed
Elbow and Forearm Wrist and Hand
● Bone ● Bones 8. Coronoid Fossa
● Joint ● Joints above the trochlea
● Carrying Angle ● Soft Tissue receives coronoid process of ulna when flexed
● Cubital Fossa ○ Wrist
● Muscle ○ Fingers 9. Interosseous Membrane
● OINA ● Muscle Stability of the Radioulnar
Shock Absorber
Muscle Attachment

Elbow and Forearm

POSTERIOR

1. Lower half of Humerus

Medial Head of Triceps Brachii

Bones 2. Posterior of Lat. Epicondyle:

ANTERIOR O: Anconeus

1. Lateral supracondylar ridge 3. Olecranon Fossa

O: Brachioradialis and ECRL Location: above Trochlea
Articulates/Receives the Olecranon process of the
2. Medial Supracondylar Ridge ulna during elbow extension
Origin of Ligament of struthers → medial epicondyle Provides Stability
Thickening of Ligament of struthers → median nerve
palsy
Joints

3. Lateral Epicondyle
Attachment of LCL → olecranon process of ulna;
O: Supinator, common Wrist Extensors (ECRB, EDC,
EDM, ECU)

4. Medial Epicondyle
Ligament: MCL → Attachments: Coronoid and
olecranon process of ulna;
Muscles: Pronator teres & Common Wrist Flexors of
the wrist (FCR, Palmaris Longus, FCU (humeral hd),
FDS) Underneath (post) – Ulnar nn will pass

5. Capitulum
Rounded A. HUMERORADIAL
Articulates with head of Radius (FOVEA) T Hinge
Osteochondritis → PANNER’s DSE A (Capitulum of humerus (convex) & Head of Radius
(concave)
6. Trochlea & Trochlear Notch
L Lateral Collateral Ligament
hour-glass shaped;
- Restrict Excessive Varus
trochlear notch of ulna
K 1 Degree of Freedom
Flexion and Extension

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 UE 2 - Elbow, Forearm, Wrist and Hand 8/9/23

B. Humeroulnar Joint
T Hinge
A Trochlea of Humerus (convex) & Trochlear/Semilunar
Notch of Ulna (Concave)
L Medial Collateral Ligament
- Restrict Excessive Valgus
K
Flexion and Extension

Normal Values
Male 5° - 10°
Female 10° - 15°
Average 5° - 15°
Conditions
Cubitus Varus <5°
(Gunstock (+) Tear of MCL
Deformity)
C. Proximal Radioulnar Joint Cubitus Valgus >15°
T Pivot/Trochoid Tear of LCL
A Radial head (convex) & radial Notch of Ulna (concave)
L 1. Annular - Limits excessive Radial Head Cubital Fossa
Distraction
2. Oblique - Limits Supination
3. Quadrate - Limits Spinning of the Radial Head
K 1 Degree of Freedom
Supination and Pronation

D. Distal Radioulnar Joint

T Pivot/Trochoid
A Ulnar notch of Radius (concave) & Ulnar head (Convex)
L 1. Radioulnar Ligament
a. Anterior - Limits Posterior
Displacement of the RU
b. Posterior - Limits Anterior
Displacement of the RU
K 1 Degree of Freedom
Supination and Pronation

E. TFCC - Triangular Fibrocartilage Complex Borderaries

- Provides major stability to Distal Radioulnar Superior - Imaginary line between 2 epicondyle
joint Medial - Pronator Teres
Lateral - Brachioradialis
Floor
- Bracialis and Supinator
↑
Lateral
Be Bracioradialis
Right Radial Nerve
There Tendon of Biceps
Always Brachial Artery
My Median Nerve
PT Pronator Teres
Medial
↓

Cubital Tunnel
- Tunnel Formed between the Medial Epicondyle and
Carrying Angle Olecranon
- It is formed by the axis from the humeral shaft to ulnar - Ulnar Nerve

- Appear
- Elbow Extension
- Supination
-
- Disappear
- >30° Elbow Flexion
- Pronation

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 UE 2 - Elbow, Forearm, Wrist and Hand 8/9/23

Spurt vs Shunt Posterior Compartment

Muscles Origin Insertion Nerve Action
Triceps
Long head Infraglenoid Olecranon Radial nerve Extensor of
tubercle of process of elbow
scapula ulna joint
Lateral head Upper half of
posterior
surface of
shaft of
humerus
Medial head Lower half of
posterior
surface of
shaft of
humerus

Spurt Vs Shunt
Far Origin Near
Near Insertion Far
Mobility Purpose Stability
Brachialis Example Brachioradialis
Biceps Brachii
Triceps

Muscle Trivia
1. Biceps Brachii
Wrist and Hand
a. Maximized in Supination
b. Strongest Supinator
2. Brachialis
a. Maximized in Pronation
b. Workhorse of the Elbow Flexors (Pure
Elbow)
3. Brachioradialis
a. Maximized in Neutral or Mid Position
4. Triceps Brachii
a. Long head - Prone to Insufficiency
b. Medial Head - Always Active
c. Lateral Head - More muscular “Prominent”
5. Anconeus
a. Initiate Elbow Extension
b. Stabilize Elbow Extension
MOINA
Anterior Compartment

Muscles Origin Insertion Nerve Action

Biceps Brachii
Long head Supraglenoid Tuberosity of Musculocutaneous Supinator of
tubercle of radius and nerve forearm and Bones
scapula bicipital flexor of elbow
Short head Coracoid aponeurosis into joint; weak flexor
process of deep fascia of of shoulder joint
scapula forearm How many bones in Wrist and
Coracobrachiali Coracoid Medial aspect of Musculocutaneous Flexes arm and Hand?
s process of shaft of nerve also weak - 29 (U/L)
scapula humerus adductor
Brachialis Front of lower Coronoid Musculocutaneous Flexor of elbow How many bones are in the Hand?
half of humerus process of ulna nerve joint - 27 (U/L)
- Excluding Ulna and
radius

Carpal Bones

“Stop Letting Those People”

“Touch The Cadavers Hand”

Proximal Row

A. Scaphoid (Navicular)
a. Boat Shape
b. Most Mobile
c. Largest in
proximal row

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B. Lunate (Semilunar) Metacarpal Bones

a. How to Palpate?
i. From Lister’s Tubercle > Forward - Composed of:
ii. Separates the ECRL to ECRB a. Head
b. Ask the pt to Flex the Wrist b. Shaft
C. Triquetrum c. Base
a. 3 Cornered Bone - Long type of Bone
b. Lies below the pisiform - Held by the deep transverse metacarpal
c. Not a Platform!
D. Pisiform
a. Peashape
b. Characteristics
i. Smallest
ii. 1 Articulation (Triquetrum)
iii. Last to Ossify
iv. Only sesamoid in the carpals
v. No Other Name

Distal Row

E. Trapezium (Greater multangular)

a. 4 sided without side parallel
F. Trapezoid (Lesser Multangular)
a. 4 sided with 2 side parallel
b. 2nd Smallest
G. Capitate (Os Magnum)
a. Shape: Head
Conditions
b. Largest
A. Fracture
H. Hamate (Unciform)
a. 1st MC = BEnnet/Rolando
a. Hooked Shape
b. 5th MC = Boxers/Street Fighter
Proximal Row Phalanges
Scaphoid Lunate Triquetrum Pisiform
“Battle Line”
Lateral Trapezium Trapezoid Capitate Hamate Medial - 1st - Pollex
Distal Row
Joints

Number of Articulation
1. Capitate = 7 A. RadioCarpal
2. Scaphoid = 5
T Ellipsoidal
3. The Rest = 4
4. Pisiform = 1 A Distal Radius and Proximal Carpals
L Radiocarpal
Carpal Conditions - Anterior \
- - Prevents Posterior Displacement
A. Most commonly Fractured - Stronger = Wrist Extension
a. 1st - Scaphoid - (+) Tenderness in - Posterior
Anatomical Snuff box - Prevents Anterior Displacement
b. 2nd - Lunate K 2 DOF
c. 3rd - Triquetrum - Supination and Pronation
- UD / RD
B. Most Commonly Dislocated
a. Lunate ROM
Motion Normal Values Needed
C. Avascular Necrosis Wrist Flexion 80° 40°
a. Scaphoid - Pressers Wrist Extension 70° 40°
b. Lunate - Kienbock Radial Deviation 20° 10°
c. Distal Lunate - Burns Ulnar Deviation 30° 30°

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B. TFCC -
a. Triangular Fibrocartilage Soft Tissue (Wrist)
b. Ulnocollateral ligament
c. Palmar Ulnocarpal Ligament A. Flexor Retinaculum (Transverse Carpal Ligament)
d. Meniscus Homologue
i. Common - Inflammation

C. Midcarpal
T Plane
A Proximal and Distal Carpal
L Scapholunate Ligament
- “DISI”
- Dorsal Intercalated Segment Instability
Lunotriquetral Ligament
- “VISI”
- Ventral intercalated Segment Instability
K 2 DOF
- Supination and Pronation
- UD / RD

Attachment
- Lateral - Scaphoid and Trapezium
- Medial - Pisiform and Hook of Hamate

Pass Thru (10) Underneath (11)

● 4 Tendons of FPS
● 4 Tendons of FDP
● 1 Tendon of FPL
● 1 Median Nerve
● 4 Tendons of FPS
● 4 Tendons of FDP
● 1 Tendon of FPL
● 1 Median Nerve
● + 1 Tendon of FCR

B. Extensor Retinaculum
Contributions to Motion
Motion Radiocarpal Midcarpal
Wrist Flexion 50° 30°
Wrist Extension 20° 50°
Radial Deviation ⅔ - 20° ⅓ -10°
Ulnar Deviation 10° 10°

D. Carpometacarpal Joint (CMC)

a. Primary function - Palmar Arch (Grasping)
1. 1st CMC
T Saddle/Sellar
A Trapezium and 1st Metacarpal
K Concave: Sagittal (Abd,Add)
Convex: Frontal (flex and Ext)
2. 2nd - 5th CMC
T Plane Joint

E. Metacarpophalangeal Joint
a. T - Condyloid
b. 2 DOF
i. Flexion/Extension
ii. Abd/Add

F. Interphalangeal Joint
1. DIP - Hinge
2. PIP - Hinge
3. 1 DOF = Flexion and Extension

Fingers Attachment
- Medial - Pisiform and Hook of Hamate
1. Most Mobile - 4th and 5th - Lateral - Distal Radius
2. Less Mobile - 2nd and 3rd
3. Strongest - 2nd 6 Dorsal Tunnel
4. Weakest - 5th I. APL & EPB
II. ECRL & ECRB
III. EPL
IV. ED & EI
V. EDM
VI. ECU

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C. Tunnel of Guyon
a. Between Pisiform and Hamate Flexor Zone
b. “Pisohamate Ligament”
I. Insertion of FDP
c. Ulnar Nerve Pass thru this tunnel
II. Insertion of FDS
III. Neck of Metacarpals
IV. Carpal Tunnel
V. Proximal to Wrist Joint

B. Extensor Mechanism

D. Anatomic Snuff Box

a. “Fovea Radialis”

C. Annular and Cruciate Pulleys

Annular Cruciate
Soft Tissue (Hand) A1 - MCP / Metacarpal C1– A2-A3
A2 - Midaspect of PP C2– A3-A4
A. Flexor Zone of the Hand A3 - Distal PP C3– A4-A5
A4 - Midascpect of MP
A5 - Proximal of DP

Muscle (Forearm)
Anterior Compartment
Muscle Innervation Action
Pronator Teres Median Nerve Pronation and flexion
of forearm
Pronator Quadratus Median Nerve Pronates forearm
Palmaris Longus Median Nerve Flexes hand
Flexor Carpi Radialis Median Nerve Flexes and abducts
hand at wrist joint
Flexor Pollicis Median Nerve Flexes distal phalanx
Longus of thumb
Flexor Digitorum Median Nerve Flexes middle
Superficialis phalanx of fingers and
assists in flexing
proximal phalanx and
hand

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 UE 2 - Elbow, Forearm, Wrist and Hand 8/9/23

Flexor Digitorum Lateral Half Flexes distal phalanx Muscle (Hand)

Profundus -Median Nerve of fingers; then
Medial Half assists in flexion of
Medial Nerve Ulnar Nerve
-Ulnar Nerve middle and proximal
(Thenar Eminence - AFO) (Hypothenar Eminence)
phalanges and wrist
● Abductor Pollicis ● Abductor Digiti
Brevis Minimi
Flexor Carpi Ulnaris Ulnar Nerve Flexes and adducts
● Flexor Pollicis Brevis ● Flexor Digiti Minimi
hand at wrist joint
● Opponens Pollicis ● Opponens Digiti
Minimi
Note! ADD
1. Strong Clench - FPS - Abductor Pollicis
2. Light Hand Closure - FDP Lumbricals Lumbricals
- 1st and 2nd - 3rd and 4th
Lateral Compartment - Lateral Half - Medial Half
- MCP Flex & IP Extend - MCP Flex & IP Extend
Interossei (PADAB)
Muscle Innervation Action - Palmar - ADD
Extensor Carpi Radial Nerve Extends and - Dorsal - ABD
Radialis Longus abducts hand at
wrist joint Flexor Pollicis Brevis
Bracioradialis Radial Nerve Flexes forearm at -Dual Innervation
elbow joint; rotates
forearm to the
midprone position

Posterior Compartment

Muscle Innervation Action

Anconeus Deep branch of Extends elbow joint
radial nerve
Abductor Pollicis Deep branch of Extends and abducts
Longus radial nerve thumb
Extensor Pollicis Deep branch of Extends
Brevis radial nerve metacarpophalangeal
joint of thumb
Extensor Carpi Deep branch of Extends and abducts
Radialis Brevis radial nerve hand at wrist joint
Extensor Pollicis Deep branch of Extends distal
Longus radial nerve phalanx of thumb
Extensor Digitorum Deep branch of Extends
radial nerve metacarpophalangeal
joint of little finger

Extensor Indicis Deep branch of Extends fingers and

radial nerve hand
Extensor Digiti Deep branch of Extends
Minimi radial nerve metacarpophalangeal
joint of index finger
Extensor Carpi Deep branch of Extends and adducts
Ulnaris radial nerve hand at wrist joint
Supinator Deep branch of Supination of
radial nerve forearm

Abanto. PTRP