SubGroup-3

ANATOMY OF
THE UPPER
LIMB
 BONES

2
Clavicle
• The clavicle (collar bone) connects the
upper limb to the trunk.
• The shaft of the clavicle has a double curve
in a horizontal plane.
Clavicle
▹ Its medial half is convex anteriorly, and its
sternal end is enlarged and triangular where
it articulates with the manubrium of the
sternum at the sternoclavicular (SC) joint.
▹ Its lateral half is concave anteriorly, and its
acromial end is flat where it articulates with
the acromion of the scapula at the
acromioclavicular (AC) joint.
The clavicle:
▹ Serves as a moveable, crane-like
strut (rigid support) from which the
scapula and free limb are suspended,
keeping them away from the trunk so
that the limb has maximum freedom
of motion.
▹Transmits shocks (traumatic
impacts) from the upper limb to the
axial skeleton.
 Scapula
▹ The scapula (shoulder blade) is a triangular flat bone that
lies on the posterolateral aspect of the thorax, overlying the
2nd–7th ribs.
▹ The convex posterior surface of the scapula is unevenly
divided by a thick projecting ridge of bone, the spine of the
scapula, into a small supraspinous fossa and a much larger
infraspinous fossa.
▹ The concave costal surface forms a large subscapular fossa.
 Scapula
▹ The spine continues laterally as the flat, expanded
acromion (G. akros, point), which forms the subcutaneous
point of the shoulder and articulates with the acromial end
of the clavicle.
▹ Superolaterally, the lateral surface of the scapula has a
glenoid cavity (G. socket), which receives and articulates
with the head of the humerus at the glenohumeral joint.
 Scapula
▹ The beak- like coracoid process is superior to the glenoid cavity, and projects
anterolaterally.
▹ The scapula has medial, lateral, and superior borders and superior, lateral, and
inferior angles.
▹ The scapula is capable of considerable movement on the thoracic wall at the
physiological scapulothoracic joint, providing the base from which the upper
limb operates.
Humerus
 Humerus
▹ largest bone in the upper limb
▹ articulates with the scapula at the glenohumeral
joint, and the radius and ulna at the elbow joint.
▹ The proximal end of the humerus has a head, surgical
and anatomical necks, and greater and lesser
tubercles.
 Humerus
▹ The shaft of the humerus has two prominent features:
▹ The deltoid tuberosity
▹ Radial groove (groove for radial nerve, spiral groove)
The inferior end of the humeral shaft widens as the sharp
medial and lateral supraepicondylar (supracondylar)
ridges form, and then end distally in the especially
prominent medial epicondyle and the lateral epicondyle,
providing for muscle attachment.
 Humerus
▹ The distal end of the humerus including the trochlea,
capitulum, olecranon, coronoid, and radial fossae makes
up the condyle of the humerus.
Humerus

▹ The condyle has two articular

surfaces:
▹ capitulum - articulation with the
head of the radius
▹ trochlea - for articulation with the
proximal end (trochlear notch) of the
ulna.
 Humerus
▹ Two hollows, or fossae, occur back to back superior to the trochlea,
▹ Anteriorly, the coronoid fossa receives the coronoid process of the
ulna during full flexion of the elbow.
▹ Posteriorly, the olecranon fossa accommodates the olecranon of the
ulna during full extension of the elbow.
▹ Superior to the capitulum anteriorly, a shallower radial fossa
accommodates the edge of the head of the radius when the forearm is
fully flexed.
 FOREARM
▹ Serve together to form the 2nd unit of an articulated mobile strut
(1st unit being the humerus) with a mobile base formed by the
shoulder that positions the hands.
▹ Formed by 2 parallel bones (RADIUS AND ULNA)

16
”
17 Radius
▹ Lateral and shorter of the forearm bones.
▹ It is the bone on side of the thumb.
▹ Rotates around the ulna, permitting the hand to rotate and be
flexible.
▹ Articulations:
▸ Proximally- smooth superior aspect of the head of the radius
with the capitulum of the humerus during flexion and
extension of the elbow joint
▸ Head also articulates peripherally with the radial notch of the
ulna
18 Radius
▹ The upper end consists of head, neck and radial
tuberosity.
▹ The shaft has 3 surface (anterior, posterior and lateral)
separated by 3 borders (anterior, posterior and medial)
▸ The medial border is sharp.
▹ It shares in 4 joints:
▸ Elbow joint
▸ Superior and Inferior radioulnar joints
▸ Wrist joint
19 Ulna
▹ Stabilizing bone of the forearm
▹ Medial and longer than radius.
▹ The shaft has 3 surfaces: (separated by 3 borders):
▸ Anterior, posterior and lateral
▸ Lateral (interosseous) border is sharp
▹ It shares in 3 joints:
▸ Elbow joint
▸ Superior and inferior radioulnar joints
20 Ulna

▹ For articulation with the humerus, it has two projections:

▸ Olecranon (forming the point of the elbow)
▸ Coronoid process
▹ Articulation to humerus allows only flexion and extension of the
elbow joint although a small amount of abduction-adduction
occurs during pronation and supination of the forearm.
 HAND
8 Carpal bones
5 Metacarpal bones
14 phalanges

22
”
 Carpal

▹ Eight small bones that make up the wrist (or carpus) that connects the
hand to the forearm.
▹ Allows the wrist to move and rotate vertically.
▹ Divided into 2 rows: Proximal and Distal
▹ Proximal row (radial to ulnar):
• Scaphoid (boat-shaped): most commonly fractured carpal bone
• Lunate (moon-shaped)
• Triquetral (pyramid-shaped)
• Pisiform (pea-shaped): smallest carpal bone (also classified as
sesamoid)
▹ Distal row (radial to ulnar):
• Trapezium (Irregular quadrilateral with one side parallel)
• Trapezoid (Irregular quadrilateral with no sides parallel): smallest
carpal bone in distal row
• Capitate (head-shaped): largest carpal bone
• Hamate (having hook/hamulus)
Carpal ▹ Useful
MNEMONICs:
▸ “Sally Left The Party
To Take Cathy Home”

▸ “She Looks Too Pretty,

Try To Catch Her”

▸ “Some Lovers Try

Positions That They
Cannot Handle”
 Metacarpals
▹ Forms the skeleton of the palm of the hand
between carpal and the phalanges.
▹ Articulations:
▸ Proximal base- carpal bones
▸ Distal heads- proximal phalanges, forms the
knuckles
▹ 5 metacarpal bones.
▹ Each consists of a base, shaft and head.
 Phalanges

▹ The thumb contains only 2

phalanges: proximal and distal.
▹ All other fingers contain 3
phalanges: proximal, middle and
distal
▹ Each phalanx has a base proximally,
shaft and head, distally.
FASCIA AND
MUSCLES
Fascia of the shoulder
Pectoralis fascia
Axillary fascia
Clavipectoral fascia
Supraspinous,Infraspinous and Subscapular fascia
Deltoid Fascia
Fascia and compartments of the shoulder
Fascia and compartments of the shoulder
Muscles of the pectoral and scapular regions

▹ ANTERIOR AXIOAPPENDICULAR MUSCLES – 4

muscles which move the pectoral girdle
▹ POSTERIOR AXIOAPPENDICULAR MUSCLES –
4 muscles which attach the upper limb to the skeleton of
the trunk
▹ SCAPULOHUMERAL MUSCLES – 6 muscles which
act on the glenohumeral joint
Anterior Axioappendicular Muscles of the Shoulder
Posterior Axio-appendicular and Scapulohumeral
Muscles

▸ Superficial (extrinsic shoulder) – trapezius, latissimus

dorsi
▸ Deep (extrinsic shoulder) – levator scapulae,
rhomboids
▸ Scapulohumeral (intrinsic shoulder) – deltoid, teres
major, rotator cuff muscles (supraspinatus,
infraspinatus, teres minor, subscapularis)
SUPERFICIAL POSTERIOR AXIO-
APPENDICULAR MUSCLES
DEEP POSTERIOR AXIO-APPENDICULAR
MUSCLES
38
SCAPULOHUMERAL MUSCLES
41
Muscles of arm
43
Flexor muscles of
forearm
45
46
Extensor muscles of forearm
48
49
Muscles of hand
51
52
53
 Compartments of
54 forearm
55 Compartments of wrist
 Compartments, spaces,
56 and fascia of palm
Superficial
Veins
Deep Veins
▹ Lymphatic
drainage
 BRACHIAL PLEXUS

70
 Remember To Drink Cold Bear
Root Trunk Division Cord Branches
▹ Anterior divisions of the trunks supply
anterior (flexor) compartments of the
upper limb
▹ Posterior divisions of the trunks
supply posterior (extensor)
compartments.
The divisions of the trunks form three cords
of the brachial plexus
1. Anterior divisions of the superior and
middle trunks unite to form the lateral cord.
2. Anterior division of the inferior trunk
continues as the medial cord.
3. Posterior divisions of all three trunks unite
to form the posterior cord.
The roots of the
plexus usually
pass through the
gap between the
anterior and the
middle scalene
(L. scalenus
anterior and
medius) muscles
with the
subclavian artery
 Brachial Plexus

▹ Each trunk of the brachial plexus divides into anterior and posterior
divisions as the plexus passes through the cervico-axillary canal
posterior to the clavicle
CLINICAL CORELATION
 Colles fracture
▹ The Colles fracture of distal radius fracture
with dorsal angulation, dorsal
displacement, radial shortening, and an
associated fracture of the ulnar styloid.

▹ Most commonly caused by fall, landing on

an outstretched hand with wrist in
dorsiflexion.

▹ This leads to classic DINNER FORK

DEFORMITY of wrist

▹ Risk factor

▹ Complication: Median N. inj, malunion

▹ Diagnosis: Mainstay is X-Ray

 Smith Fracture
▹ Smith fracture is extraarticular fracture of distal radius featuring a volar
displacement or angulation of the distal fragement.

▹ Occurs either as fall onto a flexed wrist or as a direct blow to dorsal aspect of
the wrist.

▹ Aka reverse colles’ fracture or garden spade deformity diagnosed with X-ray

▹ Treatment is similar to colle’s fracture

 Chauffeur fracture
▹ Chauffeur fractures (also known
as Hutchinson
fractures or backfire
fractures) are intra-articular
fractures of the radial
styloid process. 

▹ These injuries are sustained

either from direct trauma
typically a blow to the back of
the wrist or from forced
dorsiflexion and abduction.
 TREATMENT
1. Analgesia.
2. Surgery:
▸ Non-displaced fractures can be managed with a
Colles type plaster.

▸ Displaced fractures will require ORIF.

 SCAPHOID Fracture
▹ Hx: Trauma (usually fall), pain and swelling

▹ PE: “Snuffbox” tenderness, Ulner deviation

▹ High index of suspicion

▹ X-ray may be normal initial so repeat x-ray after 2 weeks

▹ Nondisplaced: 1. Casting average 10-12wk; 2. Percutaneous

screw •
▹ Displaced: ORIF / bone graft •
▹ Nonunion: ORIF with tricortical bone graft or vascularized bone
graft
 Monteggia fracture
▹ Praximal 1/3 of ulna fracture, shortening forces result in radal
head disiocation

▹ Mechanism: direct blow or fall on outstretched hand.

▹ Complication : Radial nerve injury

 Classification
▹ Bado classification
▹ 1: anterior
▹ 2: posterior
▹ 3: lateral
▹ 4: anterior with associated both-bone
fracture
 Evaluation
▹ Hx: Fall, pain and sweling
▹ PE: Tendemess, deformity.
▹ Check compartments and do neurovascular exam
▹ XR: AP-lateral

TREATMENT
▹ Ulna: ORIF (plate'screws)
▹ Radial head: closed reduction (open it irreducible or
unstable)
▹ Peds: closed reduction and cast
 Galezzi fracture
▹ Distal radial shaft fracture, shortening
forces result in distal ra- doulnar dislocation

Evaluation
▹ Same with Monteggia fracture
 TREATMENT

▹ Radius: ORIF

▹ DRJ: closed reduction, +-

percutanecus pins in
supination if unstable
(open it unstable)

▹ Cast for 4-6wk • Peds:

reduce & cast
 Barton’s fracture
▹ It is a fracture of the distal radius which
extends through the dorsal aspect of the
articular surface with dislocation of the
radiocarpal joint

▹ There is usually no disruption of the

radiocarpal ligaments so the articular
surface of the fractured distal radius
remains in contact with the proximal carpal
row.

▹ Initial radiographic evaluation begins with

X-ray of the wrist, consisting of at least
frontal and lateral views.
▹ CT can be used to better evaluate anatomic detail, and if both
are unclear, MRI may be utilized to evaluate associated
ligament or soft tissue injuries.

TREATMENT
▹ Traditionally, the treatment of distal radius fractures is by
closed reduction and immobilization in a splint or cast,
Diaphyseal Radius
and
Ulna Fractures
 Radial and
ulnar shaft
fractures
occurring at
same level,
implying no
significant
rotation.
 Mechanism of Injury
▹ The primary mechanism is a fall on an outstretched hand that transmits
force to the bones of the forearm.

▹ Biomechanical studies have suggested that the junction of the middle and
distal thirds of the radius and a substantial portion of the shaft of the ulna
have an increased vulnerability to fracture.

▹ A direct force to the arm (such as being hit by a baseball bat) can fracture a
single bone (especially the ulna) without injury to the adjacent distal or
PRUJs. Isolated ulnar shaft fractures have been referred to as “nightstick
fractures.”

Signs and Symptoms of Diaphyseal Radius and Ulna Fractures 

▹ Classic findings are deformity, swelling and exquisite pain in that region.
▹ Decreased range of motion.
 Classification
Descriptive
Closed versus open
Location
Comminuted, segmental, multifragmented
Displacement

OTA (Orthopaedic Trauma Association) Classification

Type A (simple)
Simple fracture that is spiral (A1), oblique (A2), or transverse (A3)
Type B (wedge)
Wedge fracture that is intact (B2) or fragmentary (B3)
Type C (multifragmentary)
Multifragmentary fracture that is intact segmental (C2) or
fragmentary segmental (C3)
 Associated Injuries with Diaphyseal
Radius and Ulna Fractures
▹ Most fractures of the shafts of the radius and ulna occur as
isolated injuries, but other injuries can occur like :

▹ Wrist and elbow fractures.

▹ Compartment syndrome

▹ Vascular injury (Capillary refil)

▹ Nerve injury
 Treatment
Nonoperative
▹ Brace if isolated nondisplaced or distal 2/3 ulna shaft
fx(nightstick)

Operative
▹ ORIF without bone grafting if it is either a displaced distal 2/3
isolated ulna fxs, proximal 1/3 isolated ulna fxs, all radial shaft
fxs (even if nondisplaced), both bone fxs or Gustillo I, II, and IIIa
open fractures may be treated with primary ORIF

▹ ORIF with bone grafting if cancellous autograft is indicated in

radial and ulnar fractures with bone loss, bone loss that is
segmental or associated with open injury or nonunions of the
forearm
Physical Examination
 SHOULDER

▹Inspection (from all angles and with Shoulder

fully exposed)
A. Swelling and Bruising in recent Trauma
B. Scars suggesting old Trauma
C. Observable deformity
1. Sternoclavicular Joint
2. Clavicle
3. Acromioclavicular joint
4. Glenohumeral joint (in acute
dislocations)
 SHOULDER

▹Inspection (from all angles and with Shoulder

fully exposed)

D. Asymmetry
1. Disuse atrophy of the supraspinatus muscle
a. Chronic Rotator Cuff Tear or Shoulder Impingement
b. Efficacy of atrophy as test for Rotator Cuff Syndrome
i. Test Sensitivity: 56%
ii. Test Specificity: 73%
2. Shoulder sag
a. Cranial Nerve 11 disorder
3. Sulcus at glenohumeral joint
a. Seen with acute Shoulder Dislocation
 SHOULDER

▹Palpation
A. Grading of pain
1. No pain: 0
2. Mild pain: 1
3. Moderate: 2
4. Severe: 3
 SHOULDER

▹Palpation
A. Technique
1. Both Shoulders exposed
2. Palpate for atrophy or swelling
3. Assess contour of Shoulder
4. Palpate for tenderness in both Shoulders
5. Deformity and focal tenderness: Palpate landmarks in
order (anterior, medial to lateral, then to Scapular and
spine)
6. Palpate fibromyalgia Tender Points at occiput and medial
trapezius muscle
a) Assess for comorbid myofascial pain
 SHOULDER

▹Specific Shoulder Tests

A. Shoulder Range of Motion
1. Shoulder Range of Motion (forward flexion,
abduction)
2. Apley Scratch Test (internal and external
Shoulder rotation)
3. Evaluate passive and active range of
motion
 SHOULDER

▹Normal range of motion

1. Abduction: 150 degrees
2. Adduction: 30 degrees
3. Forward flexion: 150-180 degrees
4. Extension: 45-60 degrees
5. Rotation (test with elbow flexed to 90
degrees)
 SHOULDER

▹Exam:
A. Test Active and Passive Range of Motion
B. Test Apley Scratch Test
C. Shoulder Strength Exam
D. Shoulder Instability Exam
E. Shoulder Impingement Signs
F. Cervical Spine Test (cervical radicular pain radiating
to Shoulder)
 ELBOW

▹Inspection
1. Olecranon Tip and the 2 Epicondyles
2. Olecranon Tip, Lateral Epicondyle, and Radial head
3. Carrying Angle

▹ Exam: Range of motion

Normal elbow range of motion
▸ Extension: 180 degrees
▸ Flexion: 150 degrees
▸ Pronation: 160-180 degrees
▸ Supination: 90 degrees
 ELBOW

▹Strength (resisted Isometric) Mnemonic

A. MFP: medial (epicondyle) flexors and pronators
B. LES: lateral (epicondyle) extensors and supinators

▹Stability Testing
A.Varus or Valgus stress
⬩ Flex elbow to 30 degrees to unlock olecranon
B.Ulnar Collateral Ligament Injury most
common
⬩ Very significant injury for pitchers
 ELBOW

▹Palpation C. Medial
▸ Medial epicondyle
A. Anterior ▸ Forearm flexor and pronator
▸ Biceps tendon tendons
▸ Median Nerve ▸ Medial collateral ligament
▸ Ulnar Nerve
▸ Anterior capsule D. Lateral
B. Posterior ▸ Lateral epicondyle
▸ Triceps tendon ▸ Radiocapitellar joint
▸ Radial head
▸ Olecranon fossa ▸ Radial Nerve
▸ Ulnar collateral ligament
 WRIST
▹Normal Range of Motion
▹Abduction: 150 degrees
1. Wrist flexion: 70 degrees
2. Wrist extension: 70 degrees
3. Ulnar deviation: 40 degrees
4. Radial deviation: 20 degrees
5. Forearm supination: 80 degrees
6. Forearm pronation: 80 degrees
 WRIST
▹Triangular Fibrocartilage Complex (TFCC)
A. Locate depression between Pisiform and ulnar
styloid
⬩ Tenderness distal to this point suggests TFCC
Injury
B. Patient and examiner shaking hands
⬩ Patient tries to supinate or pronate wrist
⬩ Pain or decreased ROM suggests TFCC
Injury
 WRIST
▹Bony Landmarks on Volar Surface
▸ Pisiform
1. Ulnar side of palm just proximal to palmar crease
2. Flexor carpi ulnaris inserts on Pisiform
a.Identify by opposing thumb and fifth finger
3.Assess for tenderness at bony prominence
▸ Hook of Hamate
▸ Scaphoid tubercle
 WRIST
▹Bony Landmarks on Dorsal Surface
▸ Anatomic Snuff box
1. Radial border
2. Ulnar border
▹Scaphoid distal pole
▹Carpal Bones on radial side of wrist
▹Triscaphe Joint
▹Lister's Tubercle (Radial Tubercle)
▹Scapholunate joint or interval
▹Lunate
 WRIST
▹Specific to Wrist Overuse syndromes
A. Carpal Tunnel Syndrome (Phalen's Test, Tinel's
Test)
B. De Quervain's Tenosynovitis (Finkelstein Test)
C. Intersection Syndrome (tender at dorsal distal
radius)
 HAND
▹Observation:
A. Hand Position of Function
B. Fixed digital flexion or extension
1. Fixed single finger extension: Flexor
Tendon Injury
2. Fixed single finger flexion: Extensor Tendon
Injury
C. Finger rotational deformity
D. Skin changes (Capiliary refill)
 HAND
▹Brief tendon evaluation
▹Brief Neurologic Examination
A. Ulnar Nerve
B. Median Nerve
C. Radial Nerve
▹Neurovascular exam
A. Radial Pulses and distal Capillary Refill
B. Sensory Exam (C6, C7, C8)
C. Motor Exam (Wrist drop, Cannot make “ok” sign, Claw
Hand)
THE END