Upper limb I

Bones of the upper limb

Fracture of the clavicle
- clavicle: most frequently fractured bone (especially in children)
- common site: border between middle 1/3 & lateral 1/3
- signs
: elevation of medial fragment (by SCM muscle)
shoulder drop
medial dislocation of lateral fragment
(due to adductors of arm)
Fracture of the humerus
- fracture of the surgical neck
: common in elderly people with osteoporosis
- avulsion fracture of greater tubercle
: common in middle-aged & elderly people
arm is medially rotated
- transverse fracture of the shaft: abduction of proximal fragment
- intercondylar fracture
- supracondylar fracture: common in children
Fracture of the radius and ulna
- fracture of the distal end of radius
: common in elderly people (>50 years), especially in women
“Colles fracture” – complete transverse fracture of distal 2 cm
distal fragment is displaced dorsally  dinner fork deformity
Fracture of the scaphoid
- the most frequently fractured carpal bone
- symptoms
: pain on lateral side of wrist during dorsiflexion & abduction
 can be confused with wrist sprain
tenderness on the base of “anatomical snuff box”
- slow union of fracture or avascular necrosis
Surface anatomy of the upper limb bones
Compartments of the upper limb
Cutaneous nerves of the upper limb
Superficial veins of the upper limb
Lymphatic drainage of the upper limb
- superficial lymphatics
: lymphatic plexus in hands
 follows cephalic or basilic veins
 cubital LNs
 lateral (humeral) axillary LNs
deltopectoral LNs
 apical axillary LNs
- deep lymph vessel)
: follows deep veins to
lateral (humeral) axillary LNs
Anterior axioappendicular (or pectoral) muscles
- pectoralis major, pectoralis minor, subclavius, serratus anterior
Pectoralis major muscles
- two heads: clavicular head & sternocostal head
- adductor & medial rotator of arm
Pectoralis minor, subclavius & serratus anterior muscles
Paralysis of the serratus anterior muscle
- winged scapula
: injury to the long thoracic nerve
 lateral & posterior displacement of medial border of scapula
inability to abduct upper limb above the horizontal position
Posterior axioappendicular muscles
<three muscle groups>
- superficial posterior axioappendicular (extrinsic shoulder) muscles
: trapezius, latissimus dorsi
- deep posterior axioappendicular (extrinsic shoulder) muscles
: levator scapula, rhomboids
- scapulohumeral (intrinsic shoulder) muscles
: deltoid, teres major, rotator cuff muscles (supraspinatus,
infraspinatus, teres minor & subscapularis)
Superficial posterior axioappendicular (extrinsic shoulder) muscles
- trapezius
: connect clavicle & scapula to vertebral column
sup. fibers  elevates scapula / middle fibers  retracts scapula
inf. fibers  depresses scapula
- latissimus dorsi
Deep posterior axioappendicular (extrinsic shoulder) muscles
- levator scapulae
: upper cervical vertebra ~ superomedial border of scapula
elevates & rotates scapula
- rhomboids
: rhomboid major & minor mucsles
spinous process of vertebrae ~ medial border of scapula
retracts & rotates scapula
Triangle of auscultation
- place to examine posterior segments of the lungs with a stethoscope
- borders
: latissimus dorsi, trapezius, rhomboid major
Scapulohumeral (intrinsic shoulder) muscles
- deltoid
: clavicle, acromion & spine of scapula ~ deltoid tuberosity
abduction of arm (with supraspinatus)
innervated by axillary nerve
- injury to the axillary nerve
: fracture of surgical neck, dislocation of glenohumeral joint
 axillary nerve injury
 atrophy of deltoid
 loss of contour of shoulder
Scapulohumeral (intrinsic shoulder) muscles
- teres major
: adduction & medial rotation of arm
stabilizer of the glenohumeral joint
Scapulohumeral (intrinsic shoulder) muscles
- rotator cuff muscles
: musculotendinous rotator cuff around glenohumeral joint
supraspinatus, infraspinatus, teres minor, subscapularis
Axilla
- pyramidal space inferior to the glenohumeral joint & superior to
the axillary fascia
Axilla
- borders
: apex – cervicoaxillary canal (clavicle ~ scapula ~ 1ST rib)
base – skin, subcutaneous tissue, axillary fascia
ant. wall - pectoralis major, pectoralis minor, pectoral
& clavipectoral fascia
post. wall – scapula & subscapularis, teres major, lattissimus dorsi
med. wall – thoracic wall (ribs, intercostals & serratus anterior)

lat. wall – intertubercular groove of humerus

Axilla
- contents
: axillary vessels, lymphatic vessels & axillary LNs, brachial plexus
axillary sheath encloses neurovascular structures
Axillary artery
- lateral border of 1st rib ~ inferior border of teres major
- three parts are divided by pectoralis minor
- branches
: 1st part – highest (superior) thoracic a.
2nd part - thoracoacromial a.
(pectoral, acromial, clavicular, deltoid branches)
lateral thoracic a.
3rd part - subscapular a. (circumflex scapular a. & thoracodorsal a.)
ant. & post. humeral circumflex A.
Arterial anastomoses around the scapula
- suprascapular a., dorsal scapular a. (from transverse cervical a.),
subscapular a. (through circumflex scapular a.), intercostal a.
 collateral circulation
Axillary vein
- brachial v. + basilic v.  axillary v.
- axillary v. (+ cephalic v.)  subclavian v.
The role of axillary vein in subclavian vein puncture
- subclavian vein puncture
: insertion of a catheter through the terminal part of axillary vein
axillary vein is located ant. & inf. to axillary a. & brachial plexus
Axillary lymph nodes
- five groups
: apical, humeral, central, pectoral & subscapular LNs
Brachial plexus
- supplies most nerves in the upper limb
: ant. rami of C5 ~ T1 spinal nerves
 three trunks (sup., middle & inf.)
 ant. & post. division of each trunk (supply each compartment)
 three cords (lat., med. & post.) surround 2nd part of axillary a.
Brachial plexus
- branches of the supraclavicular part
: dorsal scapular n. ( rhomboids), long thoracic n. ( serratus ant.)
n. to subclavius, suprascapular n. ( supraspinatus &
infraspinatus)
Brachial plexus
- branches of the infraclavicular part
: lat. cord  lat. pectoral n.
med. cord  med. pectoral n., med. brachial cut. n.,
med. antebrachial cut. n.
post. cord  upper & lower subscapular nerves, thoracodorsal n.
Five terminal branches of brachial plexus
- lat. cord  musculocutaneous n. & lat. root of median n.
- med. cord  ulnar n. & med. root of median n.
- post. cord  axillary n. & radial n.
Bachial plexus injury
- injuries to the sup. parts of brachial plexus
: injury to the sup. trunk  “Erb-Duchenne palsy”
paralysis of deltoid, biceps, brachialis, brachioradialis
 adducted shoulder, medially rotated arm, extended elbow
“ waiter’s tip position”
loss of sensation  lat. aspect of upper limb
- chronic microtrauma to the sup. trunk
: motor & sensory deficits of musculocutaneous & radial nerves
 “backpacker’s palsy”
Bachial plexus injury
- acute brachial plexus neuritis (brachial plexus neuropathy)
: sudden onset of severe pain  muscle weakness & atrophy
fibers derived from sup. trunk are usually involved
- injuries to the inf. parts of brachial plexus
: injury to the inferior trunk  “Klumpke’s paralysis”
paralysis of short muscles of the hands
 claw hand
Bachial plexus injury
- compression of cords
: prolonged hyperabduction of arm
 pain radiating down the arm, paresthesia, erythema
- crutch palsy
: too long crutch  compression of post. cord
paralysis of triceps, anconeus, extensors of wrist  “wrist-drop”
deficits of movements of elbow, wrist & extension of fingers
Muscles of the arm
- three flexors & one extensor
: biceps brachii, brachialis, coracobrachialis ( musculocutaneous n.)
triceps ( radial n.)
Biceps brachii
- long head: supraglenoid tubercle ~ radial tuberosity
- short head: coracoid process ~ radial tuberosity
- functions
: flexion of forearm – when elbow is extended
flexion of forearm
– elbow is flexed close to 900
& forearm is supinated
supination of forearm
– elbow is flexed close to 900
& forearm is pronated
Bicipital myotactic reflex
- biceps reflex
: DTR to confirm integrity of musculocutaneous nerve (C5 ~ C6)

Biceps tendinitis
- tendinitis of biceps long head tendon
: repetitive microtrauma in the intertubercular groove
Brachialis
- main flexor of forearm
- distal half of the ant. surface of humerus
~ coronoid process & tuberosity of ulna
Coracobrachialis
- coracoid process ~ middle 1/3 of body of humerus
- flexion & abduction of arm, stabilization of shoulder joint
Triceps brachii
- long head, lateral head, medial head
- main extensor of forearm, extension & adduction of arm
Anconeus
- small triangular muscle on the posterolat. aspect of elbow
- usually partially blended with triceps & assists triceps
Brachial artery
- inf. border of teres major ~ radial & ulnar arteries
- branches
: deep artery of arm, humeral nutrient a.
sup. & inf. ulnar collateral arteries

Deep artery of the arm

- accompanies radial nerve
along the radial groove
- branches
: radial collateral a. &
middle collateral a.
Veins of the arm
- superficial veins: cephalic & basilic veins
- deep veins
: brachial vein accompanies brachial a. within a common sheath
Nerves of the arm
- musculocutaneous nerve
: origin - lat. cord of brachial plexus
supplies brachialis, coracobrachialis & biceps brachii in the arm
lateral antebrachial cut. n. of forearm
- injury to the musculocutaneous nerve
: paralysis of brachialis, coracobrachialis & biceps brachii
weakness of flexion of elbow & supination of forearm
loss of sensation on the lat. surface of forearm
Nerves of the arm
- radial nerve
: origin - post. cord of brachial plexus
supplies triceps brachii in the arm
superficial branch  sensation of the dorsum of hand & fingers
deep branch  muscles & joints
Nerves of the arm
- median nerve
: med. & lat. cords of brachial plexus
no branch in the arm, articular branch to elbow joint
- ulnar nerve
: medial cord of brachial plexus
no branch in the arm, articular branch to elbow joint
- injury to the radial nerve
: paralysis of triceps, brachioradialis, supinator,
extensors of wrist & fingers  “wrist drop”
loss of sensation
Cubital fossa
- borders
: line connecting med. & lat. epicondyles (sup.)
pronator teres (med.)
brachioradialis (lat.)
brachialis & supinator (floor)
- contents
: median n, brachial a. & terminal br.,
biceps tendon, radial n.