BONES OF THE UPPER

LIMB
L.FRANCIS MBBS,FRCS,FACS
 Bones of upper limb
Whereas the lower limb is
specialized for support and
locomotion the upper limb is the
organ of manual activity
Stability has been sacrificed to
gain mobility
The fingers are the most mobile,
but other parts are still more mobile
than comparable parts of the lower
limb
For example the range of movement
of the scapula provides fully one-
thirds of the range of movement of
the humerus relative to the body
Clavicle is the first bone to ossify in the embryo and it does so by
intramembranous rather than endochondral ossification. Because
of this the lining cartilage at the ends is fibrocartilage rather than
hyaline cartilage.
Describe the clavicle: medial 2/3 rounded and convex forward,
lateral 1/3 flat, it lies horizontal and subcutaneous.
Clavicle: its upper surface is smoother than the
lower surface. The muscle origins and insertions
wont be discussed today, but I would be pointing
the ligaments that hold the bones together
This is the important sternoclavicular joint. It is
the only bony connection of the upper limb to
the axial skeleton. It is an atypical, complex
synovial joint
This is the acromioclavicular joint, also atypical
and complex. Discuss ligaments and disruption of
this joint occurs in contact sports. Point injury
Because the clavicle is the only bony contact of the upper extremity to
the axial skeleton fractures of the clavicle are relatively common and
caused by falls on the shoulder or the outstretched arm.
The break is almost always between the costoclavicular and
coracoclavicular ligaments, each of which is stronger than the clavicle
itself. At this site there rarely is any damage to underlying structures
SCAPULA: This flattened triangular bone lies on the posterolateral
aspect of the thorax, covering parts of 2nd to 7th ribs.
It connect the clavicle to the humerus. The crest of the spine of the
scapula, the acromion process and the inferior angle are easily
palpated. The inferior angle is a good guide to the 7th ICS when the
arm is in the anatomical position.
Scapula has two surfaces: anterior surface: subscapular fossa
dorsal surface: spine of scapla acromion, supraspinous fossa
infraspinous fossa . It has 3 borders: superior, lateral and medial.
It has 3 angles: superior, inferior and lateral. The lateral angle is
glenoid cavity and inferior angle is at 7th rib.
Costal or anterior surface: point out muscles of origin and
insertion.
Discuss subscapularis. Its multipennate origin from a large area
creates 3-4 ridges converging towards the lateral angle with a bare
area protected b a bursa. Tendon fuses with anterior capsule of
shoulder joint. Insertion. Prime medial rotator.
Dorsal or posterior surface: point out muscle origins and
insertions. Today we will discuss 3 of these.
Supraspinatus and infraspinatus muscles arise from the
medial two-thirds of their respective fossae and the
adjacent area of the spine
Teres minor arises from an elongated narrower area dorsal
to the lateral border. The origin of teres minor is commonly
bisected by a groove for the circumflex scapular vessels.
Discuss the insertions of these four rotator cuff muscles
and their importance in stability of the shoulder joint
Anterior
humerus

Discuss features
on the anterior
surface of the
hmerus
Anterior
humerus

Discuss muscle
attachments
and insertions
Posterior
humerus

Discuss features
Posterior
humerus

Discuss muscle
attachments
Bony features of radius and ulna
Attachments of muscles
More details at the elbow
Articular surfaces, synovial membrane and joint capsule.
Rounded capitulum and grooved trochlea articulate with upper
surface of the head of humerus and trochlear notch of the ulna.
Superior radioulnar joint is between the circumference of the
radial head and fibroosseous ring of annular ligament and radial
notch of ulna.
Expand on synovial membrane and joint capsule
 Superior radioulnar joint
Joint surface between
circumferential hyaline
cartilage of head of radius,
radial notch of ulna and
annular ligament
Uniaxial pivot synovial
joint
Shares same nerve supply
as elbow joint
Allows pronation and
supination of radius on
ulna
May get discolated in
children
This demonstrates the uniaxial pivot action of the
superior and inferior radioulnar joints
 Lower ends of
radius and ulna

Discuss lower ends of

radius and ulna, the
triangular
fibrocartilage or
articular disc and
distal radiolnar joint.
Inferior radioulnar joint
Uniaxial synovial pivot
joint between convex head
of ulna and concave radial
notch of radius and the
triagular fibrocartilage or
articular disc( read up)
The proximal surface of
this articular disc
articulates with the ulna
head
Allows for pronation and
supination
Nerve supply by posterior
and anterior interosseus
nerves
Extensor retinaculum is attached to the anterolateral border
above the radial styloid and runs obliquely to it’s attachment on
the ulna. Septae from this pass down to the distal radius and ulna
to give rise to six compartments for the extensor tendons as we’ll
see in one slide. Dorsal tubercle of Lister
Extensor compartments of forearm with synovial
sheaths
First row: Scaphoid, lunate, triquetrium, pisiform.
Second row: trapezium, trapezoid, capitate, hamate
Some lovers try positions that they can’t handle
She likes to play, try to catch her
 Wrist joint or radiocarpal joint
Biaxial synovial joint
Concave ellipsoid surface of
radius and articular disc
articulate with proximal
surface of scaphoid, lunate
and triquetral bones.
The radius articulates with
the scaphoid and lunate.
The triqetrum only
articulates in extreme of
ulnar deviation
Movements are flexion,
extension, also abduction
and adduction
Carpal bones
Scaphoid means boat-shaped and it articulates with
radius proximally, lunate medially, trapezium, trapezoid and
capitate distally. The tubercle is a blunt prominence that
forms a part of the lateral wall of the carpal tunnel.
The narrow middle one-third of the bone is non articular
and this is the site of the bone that occasionally fractures
during a fall.
The blood flow to the proximal part of the bone is
retrograde from distal foramina and because of this a
fracture may lead to avascular necrosis.
Lunate is semilunar in shape and is the most commonly
dislocated carpal bone and when this occurs comppession
of the medial nerve in the carpal tunnel is a complication
Palmar and dorsal views of carpal bones
Carpal bones
Triquetral articulates with the pisiform on it’s palmar
surface
Pisiform is pea-shaped and is really a sesamoid bone
in the tendon of the FCU. It forms a part of the lateral
wall of the carpal tunnel
Trapezium (bone by the thumb) has a saddle shaped
articular surface for the thumb. There is a prominent
ridge (tubercle) on its palmar surface that forms one
of the walls of the carpal tunnel. On this tubercle
there is a groove on the medial side for the flexor carpi
radialis
Trapezoid is the bone besides it.
Hamate. Mention hook and groove for ulnar nerve
Dorsal and palmar views of hand bones
Flexor retinaculum- Try to visualize the hook of the
hamate and the pisiform forming the medial wall of the
carpal tunnel and the tubercle of the scaphoid and the
tuberosity of the trapezium forming the lateral wall.
Metacarpals & phalanges
Metatarsal bones have
expanded bases which
articulate with the carpal
bones a and with each other at
their bases.
CMC joints 2-5 are completely
different from that of thumb.
They are also held together
by deep transverse
metacarpal ligament,thus
very little movement of the
CMCs 2-5, the most being at
the 5th which helps with
cupping of the palm
CMC joint of thumb deserves special mention.
It sits in front of others and at an angle to them
Because of this the thumb and its MC lie in front of the fingers
and the thumb faces not forward, as the fingers do, but
sideways, across the palm of the hand

Sellar
carpometa-
carpal joint of
thumb and
planar joints of
metacarpals 2-5.
Discuss
movements.
Metacarpals and phalanges- Condylar shape of MCPJ of
2-5 allowing movement in 2 planes
Trochlea or hinge-like shape of IPJs of fingers and MCPJ
of thumb allowing movements only in one plane.
Discuss ligaments at MCPJs and IPJs. Knuckles
Proximal and middle
phalanges flattened on
palmar surfaces.
Sesamoid bones of
thumb for FPB and
AP. Others occasionally
found at other
metacarpal heads.
Ossification
centres- elbow
Order of
appearances of
secondary ossificat-
ion centres should
be known so as not to
confuse with fractures
in children
On the next slide is a
mnemonic for order
of appearance
Girls tend to appear
before boys.
Mnemoic is CRITOE: capitulum, radial head, internal epi-
condyle, trochlea, olecranon and external epicondle. Age of
appearance: 1,3,5, 7, 9& 11 years. Much variation.
Secondary ossification centres for wrist bones
At birth, there is no calcification
in the carpal bones.
Ossification of the carpal bones
occurs in a predictable sequence,
starting with the capitate and
ending with the pisiform.
Capitate&hamate: 1-3 & 4-6 mths.
Triquetral- 2-3 yrs,lunate-2-4yrs
Scaphoid, trapezium and
trapezoid- 4-6 years
Pisiform-8-12 years
Distal radius- 1 year, distal ulna is
5-6 years
Colles fracture with dinner fork deformity