M101 - Book

Anatomy of The
Upper Limb
CONTENTS
Page
The Bones of the Upper Limb 1
The Muscles of the Pectoral Region 27
The Muscles of the Scapular Region 30
The Muscles of the Arm 38
The Muscles of the Forearm 41
The Muscles of the Hand 52
The Anatomical Areas of the Upper Limb 59
The Brachial Plexus 67
The Nerves of the Upper Limb 74
The Arterial Supply of the Upper Limb 98
The Joints of the Upper Limb 106
I
Bones of The Upper Limb
(1) The Scapula

 It is a triangular, flat bone, which serves as a site for attachment for many
muscles.
 It articulates with the humerus at the glenohumeral joint (shoulder joint),
and with the clavicle at the
acromio-clavicular joint. In
doing so, the scapula
connects the upper limb to
the trunk.
 Surfaces of the scapula:

1. Costal Surface (Anterior)
o The costal (anterior)
surface of the scapula
faces the thoracic cage.
o Subscapular fossa: It is a
large concave depression.
It gives origin to the
subscapularis muscle
(rotator cuff muscle).
2. Posterior surface : faces backwards. It is a site of origin for the majority of

the rotator cuff muscles of the shoulder.
It is marked by:
 Spine: the most prominent feature of the posterior scapula. It runs
transversely across the scapula, dividing the surface into two fossae.
 Infraspinous fossa : the area below the spine of the scapula, it displays a
convex shape.
o The infraspinatus muscle originates from this area.
 Supraspinous fossa : the area above the spine of the scapula, it is much
smaller than the infraspinous fossa, and is more convex in shape.
o The supraspinatus muscle originates from this area.
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 Acromion : the lateral continuation of the spine. It has an oval facet for
articulation with the clavicle forming the acromio-clavicular joint.
 Borders of the Scapula:

1. Superior Border:
o The shortest border.
o Extends from the superior angle to the root of the coracoid process.
o Presents the supra-scapular notch near the root of the coracoid
process.
o The Coracoid process :
 It is a hook-like projection, which lies just underneath the clavicle.
 Three muscles attach to the coracoid process:
 The pectoralis minor muscle.
 The coracobrachialis muscle.
 The short head of the biceps brachii.
2. Medial Border:
o The longest border.
o Parallel to the vertebral spine.
o Extends from the superior angle to the inferior angle.
3. Lateral Border:
o The thickest border.
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o Extends from the glenoid cavity to the inferior angle.
 Angles of the Scapula:

1. Superior angle:
o It is nearly a right angle.
o It lies opposite the 2nd rib.
o It forms the junction between the
superior & the medial borders.
2. Inferior angle:
o It is an acute angle.
o It lies opposite the 7th rib.
o It forms the junction of the lateral
& the medial borders.
3. Lateral angle:
o It is enlarged to form the head &
the neck of scapula.
o It lies between the superior &
the lateral borders.
o The head carries a pear-shaped
concavity called the glenoid cavity for the articulation with the head of
humerus.
o The Glenoid fossa : has 2 tubercles
1. Supra-glenoid tubercle : a roughening immediately superior to the
glenoid fossa.
o The place of attachment of the long head of the biceps brachii.
2. Infra-glenoid tubercle: a roughening immediately inferior to the
glenoid fossa.
o The place of attachment of the long head of the triceps brachii.
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 Notches of the scapula:

1. Supra-scapular notch:
o It lies at the lateral end of the
superior border close to the root of
the coracoid process.
o It is transformed into foramen by
the suprascapular ligament.
o Through the foramen passes the
suprascapular nerve & above the
ligament passes the suprascapular
vessels.
2. Spino-glenoid notch:
o Lies lateral free border of the spine
& the glenoid cavity.
o It transmits the suprascapular nerve
& vessels from the spraspinatouos fossa to the infraspinatous fossa.
3. Circumflex scapular notch:

o It is a groove on the posterior aspect of the lateral border produced by the
circumflex scapular artery.
Articulations
The scapula has two main articulations:
1. Gleno-humeral joint (Shoulder joint): between the glenoid fossa of the
scapula and the head of the humerus.
2. Acromio-clavicular joint : between the acromion of the scapula and the
clavicle.
Identification of the side (Right or Left):
1. The glenoid cavity is directed laterally.
2. The posterior surface has a rough projection (spine).
3. The upper border is the shortest border.
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Muscles attached to the scapule:

 Anterior Surface:
1. Subscapularis muscle: origin from the subscapular fossa.
 Posterior surface:
1. Supraspinatus muscle: origin from the supraspinous fossa.
2. Infraspinatus muscle: origin from the infraspinous fossa.
 Glenoid cavity:
1. Long head of biceps: origin from supraglenoid tubercle.
2. Long head of triceps: origin from infraglenoid tubercle.
 Spine & Acromion:
1. Deltoid muscle: origin from the lower lip of the crest of the spin &
the lateral border of the acromion.
2. Trapezius muscle: insertion into the upper lip of the crest of the spin
& the medial border of the acromion.
 Medial border:
1. Serratus anterior muscle: insertion into the anterior lip of the medial
border.
2. Levator scapulae: insertion into the posterior lip of the medial border
above the root of the spine.
3. Rhomboideus minor: insertion into the posterior lip of the medial
border opposite the root of the spine.
4. Rhomboideus major: insertion into the posterior lip of the medial
border below the root of the spine.
 Lateral border:
1. Teres minor: origin from the upper 2/3 of the posterior aspect of the
lateral border.
2. Teres major: origin from the lower 1/3 of the posterior aspect of the
lateral border.
3. Latissimus dorsi: origin from the posterior aspect of the lateral
border at the inferior angle.
 Coracoid process:
1. Pectoralis minor: insertion into the coracoid process
2. Coracobrachialis: insertion into the tip of the coracoid process.
3. Short head of biceps: insertion into the tip of the coracoid process.
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6
(2) The Clavicle
The clavicle (collar bone) extends between the

manubrium of the sternum and the acromion of
the scapula.
It is classed as a long bone and can be palpated

along its length. In thin individuals, it is visible
under the skin. The clavicle has three main
functions:
 Attaches the upper limb to the trunk as

part of the ‘shoulder girdle’.
 Protects the underlying neurovascular
structures supplying the upper limb.
 Transmits force from the upper limb to
the axial skeleton.
Bony Landmarks and Articulations: It can be divided into a sternal end, a shaft
and an acromial end.
1. Sternal (medial) End

o The sternal end is large.
o It contains a smooth facet for articulation with the manubrium sterni
at the sterno-clavicular joint.
o The lower part of the facet extends slightly on the inferior surface of
the medial end for articulation with the 1st costal cartilage.
o The rough area above the articular facet gives attachment to the inter-
clavicular ligament.
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2. Acromial (lateral) End

o It is flattened
o It has a small facet for articulation with the acromion of the scapula at
the acromio-clavicular joint.
3. Shaft
o Presents a double curvature like the letter (S).
o Its medial 2/3 is convex forwards while its lateral 1/3 is convex
backwards.
o Upper surface is smooth.
o The lower surface : is rough.
o The lower surface of the medial 2/3:
 A rough impression: for the attachment of the costo-
clavicular ligament.
 A groove : for the insertion of the subclavius muscle.
 A nutrient foramen : lies in the groove of the subclavius.
o The lower surface of the lateral 1/3:

 Conoid tubercle: a prominent tubercle. It gives attachment to
the conoid part of the coraco-clavicular ligament.
 Trapezoid line : a rough line extending from the conoid
tubercle to the acromial end. It gives attachment to
the trapezoid part of the coraco-clavicular ligament.
o The coraco-clavicular ligament: is a very strong structure,

effectively suspending the weight of the upper limb from the clavicle.
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o The shaft of the clavicle acts a point of origin and attachment for
several muscles:
 The deltoid muscle.
 The trapezius muscle.
 The subclavius muscle.
 The pectoralis major muscle.
 The sternomastoid and sternohyoid muscles.
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1. The lateral (acromial) end is flattened .
2. The medial (sternal) end is thick & rounded.
3. The upper surface is almost smooth.
4. The lower surface is rough & shows a shallow groove in the intermediate
1/3.
5. The medial 2/3 of the shaft is convex forwards.
6. The lateral 1/3 of the shaft is convex backwards.
Muscles attached to the clavicle:

 Anterior aspect:
1. Pectoralis major muscle: origin from the medial 1/2 of it .
2. Deltoid muscle: origin from lateral 1/3 of it
 Posterior aspect:
1. Sternomastoid muscle: origin from the medial 1/3 of it.
2. Trapezius muscle: insertion into the lateral 1/3 of it.
 Inferior surface of the shaft:
1. Subclavius muscle: insertion into the middle 1/3 of the inferior
surface.
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The Humerus
 The humerus is a long bone of the upper limb, which
extends from the shoulder to the elbow.
 The proximal aspect of the humerus articulates with the

glenoid fossa of the scapula, forming the gleno-humeral joint
(shoulder joint).
 Distally, at the elbow joint, the humerus articulates with

the head of the radius and trochlear notch of the ulna.
The Proximal End:

1. The head: It faces medially, upwards and backwards.
2. The neck:
 It separates the head from the greater and lesser tuberosities.
 The surgical neck extends from just distal to the tuberosities to the shaft
of the humerus.
 The axillary nerve and circumflex humeral vessels is related to the
surgical neck.
3. The greater tuberosity:

 It is located laterally on the humerus.
 It has anterior and posterior surfaces.
 It serves as an attachment site for three of the rotator cuff muscles :
1. Supraspinatus muscle.
2. Infraspinatus muscle.
3. Teres minor muscle
 These 3 muscles attach to superior, middle and inferior facets
(respectively) on the greater tuberosity.
4. The lesser tuberosity:

 It is much smaller
 It located more medially located.
 It only has an anterior surface.
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 It provides attachment for the last rotator cuff muscle called the
subscapularis muscle.
5. The intertubercular sulcus (Bicipital groove):
 It separates the greater & the lesser tuberosities.

 The tendon of the long head of the biceps brachii emerges from the
shoulder joint and runs through this groove.
 The edges of the intertubercular sulcus are known as lips. It has a floor &
2 lips:
1. Medial lip: insertion of the teres major muscle.
2. Floor: insertion of the latissimus dorsi muscle.
3. Lateral lip: insertion of the pectoralis major muscle.
The Shaft:
 The shaft has 3 borders:
1. Anterior border:
 The upper part forms the lateral lip of the bicipital groove.
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 The lower part is smooth & rounded.

2. Medial border:
 It extends from the lesser tuberosity above to the medial
epicondyle below.
 The lower part is prominent and called the medial supra-condylar
ridge.
3. Lateral border
 It extends from the back of the greater tuberosity above to the
lateral epicondyle below.
 The lower part is prominent and called the lateral supra-condylar
ridge.
 The shaft has 3 surfaces:

1. Anteromedial surface:
 It lies between the anterior & the medial borders.
 The upper 1/2 presents the bicipital groove.
2. Anterolateral surface
 It lies between the anterior & lateral borders.
 Its middle part shows a V-shaped rough area called "deltoid
tuberosity" where the deltoid muscle attaches.
3. Posterior surface
 It lies between the medial & the lateral borders.
 Its middle 1/3 is crossed by a shallow depression that runs
downwards & laterally called the spiral (or radial) groove.
 The radial nerve and profunda brachii artery related to the spiral
groove.
 The following muscles attach to the humerus along its shaft:

 Anteriorly :
1. The coracobrachialis muscle.
2. The deltoid muscle.
3. The brachialis muscle .
4. The brachioradialis muscle.
 Posteriorly : medial and lateral heads of the triceps (the spiral groove
demarcates their respective origins).
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The Distal End

 Supra-condylar ridges: The lateral and medial borders of the distal
humerus form medial and lateral supra-condylar ridges . The lateral supra-
condylar ridge is more roughened, providing the site of common origin of
the forearm extensor muscles.
 lateral & Medial epicondyles:
 It is located immediately distal to the supra-condylar ridges

are extracapsular projections of bone.
 Both can be palpated at the elbow.
 The medial is the larger of the two and extends more distally.
 The ulnar nerve passes in a groove on the posterior aspect of the
medial epicondyle where it is palpable.
 The trochlea: distally, is located medially, and extends onto the posterior
aspect of the bone.
 The capitulum : lateral to the trochlea , it articulates with the radius.
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 There are three depressions, they accommodate the forearm bones during
flexion or extension at the elbow, known as
1. The coronoid: located anterior & medial.
2. The radial fossa: located anterior & lateral.
3. The olecranon fossa: located posterior above the trochlea.

Articulations
1. The proximal region of the humerus articulates with the glenoid fossa of the
scapula to form the gleno-humeral joint (shoulder joint).
2. Distally, at the elbow joint, the capitulum of the humerus articulates with the
head of the radius and the trochlea of the humerus articulates with the trochlear
notch of the ulna.
1. The upper end is identified by the hemispherical head.
2. The lower end is identified by the trochlea & capitulum.
3. The medial side is identified by the head (directed medially).
4. The posterior surface is identified by the deep olecranon fossa in the lower
end.
Muscles attached to the humerus:

 Greater tuberosity:
1. Supraspinatous: insertion into the upper part of the greater
tuberosity.
2. Infraspinatous: insertion into the middle part of the greater
tuberosity.
3. Teres minor: insertion into the lower part of the greater tuberosity.
 Bicipital groove:
1. Teres major: insertion into the medial lip of the bicipital groove.
2. Latissimus dorsi: insertion into the floor of the bicipital groove.
3. Pectoralis major: insertion into lateral lip of the bicipital groove.
 Lesser tuberosity: insertion of the subscapularis muscle.
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 Shaft:
1. Brachialis: origin from the lower 1/2 of the anterior aspect of the
shaft.
2. Coracobrachialis: insertion into the middle of the medial border of
the humerus.
3. Deltoid muscle: insertion into the deltoid tuberosity.
 Supracondylar ridge:
1. Brachioradialis: origin from the upper 2/3 of the lateral
supracondylar ridge.
2. Extensor carpi radialis longus: origin from the lower 1/3 of the
supracondylar ridge.
3. Pronator teres: origin from lower part of the medial supracondylar
ridge.
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1. Lateral head of triceps: origin from the oblique ridge in the upper 1/3
of the posterior surface.
2. Medial head of triceps: origin from the whole posterior surface
below the spiral groove.
3. Anconeus: origin from the back of the lateral epicondyle.
 Front of the epicondyle:
1. Common flexor origin: origin from the front of the medial epicondyle.
2. Common extensor origin: origin from the lateral epicondyle.
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The Ulna
The ulna is a long bone in the forearm. It lies medially and parallel to the radius.
Proximally, the ulna articulates with the humerus at the elbow joint. Distally, the
ulna articulates with the radius, forming the distal radio-ulnar joint.
The bony landmarks:
The proximal end of the ulna articulates with the trochlea of the humerus.
Important landmarks of the proximal ulna are:
 Olecranon : a large projection of bone that extends proximally, forming part
of trochlear notch. It can be palpated as the ‘tip’ of the elbow. The triceps
brachii muscle attaches to its superior surface.
 Coronoid process : this ridge of bone projects outwards anteriorly, forming
part of the trochlear notch.
 Trochlear notch : formed by the olecranon and coronoid process. It is
wrench shaped, and articulates with the trochlea of the humerus.
 Radial notch : located on the lateral surface of the trochlear notch, this area
articulates with the head of the radius.
 Tuberosity of ulna : a roughening immediately distal to the coronoid
process. It gives insertion to the brachialis muscle.
 Supinator fossa & crest: depressed area lying below the radial notch. It is
bounded posteriorly by a sharp ridge called "supinator crest".
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Shaft of the Ulna

The ulnar shaft is triangular in shape, with three borders and three surfaces. As it
moves distally, it decreases in width.
 3 surfaces:
o Anterior : between the anterior & the interosseous borders.
o Posterior : between the interosseous border & the posterior border.
o Medial : between the anterior & the posterior borders.
 3 borders:
o Posterior : it is subcutaneous along the entire length of the forearm
posteriorly.
o Interosseous (lateral) : site of attachment for the interosseous
membrane, which connect between the ulna & the radius.
o Anterior : rounded.
Distal End of the Ulna
 The head: rounded directed laterally
 Styloid process: project downwards from the posteromedial part of the head
of ulna
Articulations
The distal end of the ulna is much smaller in diameter than the proximal end. It is
mostly unremarkable, terminating in a rounded head, with distal projection – the
ulnar styloid process.
The head articulates with the ulnar notch of the radius to form the distal radio-
ulnar joint.
1. The upper end is large & hook-like (trochlear notch).
2. The lower end is smaller & carries head & styloid process.
3. The concavity of the trochlear notch is directed forwards.
4. The lateral (interosseous) border is sharp.
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Muscles attached to the ulna:

 Upper End:
1. Triceps: insertion into the upper surface of the olecranon process.
2. Anconeus: insertion into the lateral surface of the olecranon process &
upper 1/4 of the posterior surface.
3. Brachialis: insertion into the ulnar tuberosity.
4. Supinator: origin from the supinator fossa & crest.
5. Flexor digitorum superficialis (ulnar head) & pronator teres (ulnar head):
origin from the medial border of the coronoid process.
 Anterior & Medial surfaces:

1. Flexor digitorum profundus: origin from the upper 3/4 of anterior &
medial surfaces.
2. Pronator quadratus: origin from the lower 1/4 of the anterior surface
of ulna.
 Posterior surface: the 3 muscles originate from above downwards from the
upper 2/3 of the posterior surface.
1. Abductor pollicis longus.
2. Extensor pollicis longus.
3. Extensor indicis.
 Posterior border: the 3 muscles originate from the ulnar aponeurosis from
the posterior border
1. Flexor carpi ulnaris (ulnar head).
2. Extensor carpi ulnaris.
3. Flexor digitorum profundus.
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(5) The Radius

The radius is a long bone in the forearm. It lies laterally and parallel to ulna, the
second of the forearm bones. The radius pivots around the ulna to
produce movement at the proximal and distal radio-ulnar joints.
The radius articulates in four places:
 Elbow joint : Partly formed by an articulation between the head of the
radius, and the capitulum of the humerus.
 Proximal radio-ulnar joint : An articulation between the radial head, and
the radial notch of the ulna.
 Wrist joint – An articulation between the distal end of the radius and the
carpal bones.
 Distal radio-ulnar joint : An
articulation between the ulnar
notch and the head of the ulna.
Proximal End of the Radius
The proximal end of the radius
articulates in both the elbow and
proximal radioulnar joints.
Important bony landmarks include
the head, neck and radial tuberosity:
 Head of radius : A disc-shaped
structure, with a concave
articulating surface. It is thicker
medially, where it takes part in the
proximal radio-ulnar joint.
 Neck : A narrow area of bone,
which lies between the radial head
and radial tuberosity.
 Radial tuberosity : A bony
projection, which recieves the
insertion of the biceps brachii
muscle.
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Shaft of the Radius

 It has 3 borders and 3 surfaces.
 In the middle of the lateral surface, there is a small roughening for the
attachment of the pronator teres muscle.
Distal End of the Radius

 Anterior surface: smooth
 Posterior surface: rough & has dorsal tubercle of Lister
 Lateral surface: forms styloid process
 Medial surface: forms the ulnar notch
 Inferior surface: smooth. Articulate with the scaphoid & lunate forming the
wrist joint.

1. The upper end carries a disc shaped head.
2. The lower end is expanded & carries the styloid process.
3. The anterior surface of the lower end is smooth & concave.
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Muscles attached to the radius:

 Radial tuberosity: insertion of the biceps tendon.
 Anterior aspect:
1. Flexor digitorum superficialis (radial head): origin from anterior
oblique line.
2. Flexor pollicis longus: origin from the upper 2/3 of the anterior
surface.
3. Pronator quadratus: insertion into the lower 1/4 of the anterior
surface of the radius.
 Lateral aspect:
1. supinator: insertion into the upper 1/3 of the shaft.
2. Pronator teres: insertion into the pronator tuberosity.
3. Brachioradialis: insertion into the lower end of the lateral surface.
1. Abductor pollicis longus: origin from the middle 1/3 of the posterior
surface.
2. Extensor pollicis brevis: origin from the lower 1/3 of the posterior
surface.
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(6) The bones of the Hand

The bones of the hand provide support and flexibility to the soft tissues. They can
be divided into three categories:
 Carpal bones (Proximal) : A set of eight irregularly shaped bones. These
are located in the wrist area.
 Metacarpals : There are five metacarpals, each one related to a digit
 Phalanges (Distal) : The bones of the fingers. Each finger has three
phalanges, except for the thumb, which has two.
Carpal Bones
The carpal bones are a group of eight, irregularly shaped bones. They are organised
into two rows: proximal and distal.
Proximal Row (lateral to medial) Distal Row (lateral to medial)
 Scaphoid  Trapezium
 Lunate  Trapezoid
 Triquetrum  Capitate
 Pisiform (a sesamoid bone,  Hamate (has a projection on
formed within the tendon of its palmar surface, known as
the flexor carpi ulnaris) the ‘hook of hamate’
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 Proximally, the scaphoid and lunate articulate with the radius to form the wrist
joint (also known as the ‘radio-carpal joint’).
 In the distal row, all of the carpal bones articulate with the metacarpals.
Metacarpal Bones
The metacarpal bones articulate proximally with the carpals, and distally with the
proximal phalanges. They are numbered, and each associated with a digit:
 Metacarpal I – Thumb.
 Metacarpal II – Index finger.
 Metacarpal III – Middle finger.
 Metacarpal IV – Ring finger.
 Metacarpal V – Little finger.
Each metacarpal consists of a base, shaft and a head. The medial and lateral
surfaces of the metacarpals are concave, allowing attachment of
the interossei muscles.
Phalanges
The phalanges are the bones of the fingers. The thumb has a proximal and distal
phalanx, while the rest of the digits have proximal, middle and distal phalanges.
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Muscles of The Pectoral Region
At the end of this chapter, we shall understand the anatomy of the muscles of the
pectoral region – their attachments, actions and innervation.
The pectoral region is located on the anterior chest wall. It contains four muscles
that exert a force on the upper limb:
1. The pectoralis major muscle.

2. The pectoralis minor muscle.
3. The serratus anterior muscle.
4. The subclavius muscle.
1. Pectoralis Major
The pectoralis major is the most superficial muscle in the pectoral region. It
is large and fan shaped, and is composed of a sternal head and a clavicular head:
 Origin:
o Clavicular head – originates from the anterior surface of the

medial clavicle.
o Sternocostal head – originates from the anterior surface of
the sternum, the superior 6 costal cartilages and the aponeurosis of
the external oblique muscle.
 Insertion: The distal attachment of both heads is into the lateral lip of the
intertubercular sulcus of the humerus.
 Action: Adducts and medially rotates the upper limb and draws the scapula
anteroinferiorly. The clavicular head also acts individually to flex the upper
limb.
 Nerve Supply: Lateral and medial pectoral nerves.
2. Pectoralis Minor
The pectoralis minor lies underneath its larger counterpart muscle, pectoralis
major. Both muscles form part of the anterior wall of the axilla region.
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 Origin: from the 3rd-5th ribs.
 Insertion: into the coracoid process of the scapula.
 Action: Stabilizes the scapula by drawing it anteroinferiorly against the

thoracic wall.
 Nerve Supply: Medial pectoral nerve.
3. Serratus Anterior
The serratus anterior is located more

laterally in the chest wall and forms
the medial border of the axilla
region.
 Origin: The muscle consists of

several strips, which originate
from the lateral aspects of the
upper 8 ribs.
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 Insertion: They attach to the costal surface of the medial border of the
scapula.
 Action:
1. Pulls the scapula forwards.

2. Allowing the arm to be raised above the head.
3. Fixation of the scapula against the chest wall.
 Nerve Supply: Long thoracic nerve. (nerve to serratus anterior).
4. Subclavius
The subclavius is small muscle, which is located directly underneath the clavicle,
running horizontally. It affords some minor protection to the underlying
neurovascular structures (e.g in cases of clavicular fracture or other trauma).
 Origin: Originates from the junction of the 1st rib and its costal cartilage.
 Insertion: It inserts into the subclavius groove in the inferior surface of the
middle 1/3 of the clavicle.
 Action: Steadies the clavicle at the sterno-clavicular.
 Nerve Supply: Nerve to subclavius.
29
Muscles of The Scapular Region
At the end of this chapter, we shall understand the anatomy of the extrinsic
muscles of the shoulder – their attachments, innervation, and actions.
The muscles of the shoulder are associated with movements of the upper limb.
They produce the characteristic shape of the shoulder, and can be divided into
two groups:
 Extrinsic – originate from the trunk, and attach to the bones of the
shoulder (clavicle, scapula or humerus).
 Intrinsic – originate from the scapula and/or clavicle, and attach to the
humerus.
Note: there are other muscles that act on the shoulder joint – the muscles of
the pectoral region, and the upper arm.
The extrinsic muscles of the shoulder originate from the trunk, and attach to the
bones of the shoulder – the clavicle, scapula, or humerus. They are located in the
back, and are also known as the superficial back muscles.
The muscles are organised into two layers – a superficial layer and a deep layer.
Superficial
There are two superficial extrinsic muscles – the trapezius and latissimus dorsi.
Trapezius
The trapezius is a broad, flat, and triangular muscle. The muscles on each side
form a trapezoid shape. It is the most superficial of all the back muscles.
 Origin: from back of the skull, nuchal ligament and the spinous processes of
C7-T12.
 Insertion: inserted into:
1. The posterior aspect of the lateral 1/3 of clavicle
2. Medial border of acromion.
3. Upper lip of the crest spine.
 Actions:
1. The upper fibres: elevate the scapula and rotates it during abduction
of the arm.
30
2. The middle fibres : retract the scapula.

3. The lower fibres : pull the scapula inferiorly.
 Nerve Supply: Motor innervation is from the spinal accessory nerve. It also
receives proprioceptor fibres from C3 and C4 spinal nerves.
Latissimus Dorsi
 Origin: Has a broad origin – arising from the spinous processes of T7-T12,
inferior angle of the scapula, iliac crest, thoracolumbar fascia and the
inferior three ribs.
 Insertion: The fibres converge into a tendon that inserted into the floor of
the intertubercular sulcus of the humerus.
 Actions: Extends, adducts, and
medially rotates the arm.
 Nerve Supply: Thoraco-dorsal
nerve (nerve to latissimus dorsi).
Deep
There are three muscles in this group –
the levator scapulae and the two
rhomboids. They are situated in the
upper back, underneath the trapezius.
Levator Scapulae
The levator scapulae is a small strap-like
muscle. It begins in the neck and
descends to attach to the scapula.
 Origin: Originates from the
transverse processes of the C1-C4
vertebrae.
 Insertion: to the medial border of the scapula above the roott of spine.
 Actions: Elevates the scapula.
 Nerve Supply: Dorsal scapular nerve (nerve to rhomboids) .
31
Rhomboids
There are two rhomboid muscles – major and minor. The rhomboid minor is
situated superiorly to the major.
 Rhomboideus Major
o Origin: from the spinous processes of T2-T5 vertebrae.
o Insertion: Attaches to the medial border of the scapula, below the
root of spin.
o Actions: Retracts and rotates the scapula.
o Nerve Supply: Dorsal scapular nerve (nerve to rhomboids) .
 Rhomboideus Minor
o Origin: from the spinous processes of C7-T1 vertebrae.
o Insertion: Attaches to the medial border of the scapula, at the level
of the root of spine.
o Actions: Retracts and rotates the scapula.
o Nerve Supply: Dorsal scapular nerve (nerve to rhomboids).
The intrinsic muscles (also known as the
scapula-humeral group) originate from the
scapula and/or clavicle, and attach to the
humerus.
There are six muscles in this group – the
deltoid, teres major, and the four rotator cuff
muscles (supraspinatus, infraspinatus,
subscapularis and teres minor).
Deltoid
The deltoid muscle is shaped like an inverted
triangle. It can be divided into an anterior,
middle and posterior part.
32
 Origin: Originates from:

1. The anterior aspect of lateral 1/3 of clavicle.
2. Lateral border of acromion.
3. Lower lip of crest of spine of scapula.
 Insertion: It attaches to the deltoid tuberosity on the lateral aspect of

the humerus.
 Actions:
o Anterior fibres : flexion and medial rotation.
o Posterior fibres : extension and lateral rotation.
o Middle fibres : the major abductor of the arm (takes over from the
supraspinatus, which abducts the first 15 degrees).
 Nerve Supply: Axillary nerve.
Teres Major
The teres major forms the inferior border of the quadrangular space – the ‘gap’
that the axillary nerve and posterior circumflex humeral artery pass through to
reach the posterior scapular region.
 Origin: from the posterior surface of the inferior angle of the scapula.
 Insertion: to the medial lip of the intertubercular groove of the humerus.
 Actions: Adducts and extends at the shoulder, and medially rotates the
arm.
 Nerve Supply: Lower subscapular nerve.
Rotator Cuff Muscles
The rotator cuff muscles are a group of four muscles that originate from the
scapula and attach to the humeral head. Collectively, the resting tone of these
muscles acts to ‘pull’ the humeral head into the glenoid fossa. This
gives the glenohumeral joint a lot of additional stability.
In addition to their collective action, the rotator cuff muscles also have their own
individual actions.
33
Supraspinatus
 Origin: from the supraspinous fossa of the scapula.
 Insertion: attaches to the greater tuberosity of the humerus.
 Actions: Abducts the arm 0-15o, and assists deltoid for 15-90o
 Nerve Supply: Suprascapular nerve.
Infraspinatus
 Origin: Originates from the infraspinous fossa of the scapula.
 Insertion: attaches to the greater tuberosity of the humerus.
 Actions: Adduction & Laterally rotates the arm.
 Nerve Supply: Suprascapular nerve.
Subscapularis
 Origin: from the subscapular fossa, on the costal surface of the scapula.
 Insertion: to the lesser tuberosity of the humerus.
 Actions: Adduction & Medially rotates the arm.
 Nerve Supply: Upper and lower subscapular nerves.
34
Teres Minor
 Origin: Originates from the posterior surface of the scapula, adjacent to its
lateral border.
 Insertion: It attaches to the greater tuberosity of the humerus.
 Actions: Adduction & Laterally rotates the arm.
 Nerve Supply: Axillary nerve.
35
Muscle Origin Insertion Action Nerve Supply

upper fibres:
flexion of the
arm &
Anterior aspect
medially
of lateral 1/3 of
rotation of it.
clavicle +
Deltoid middle fibres :
Lateral border of
Deltoid tuberosity of abduction of Axillary nerve
acromion +
humerus the arm.
lower lip of crest
lower fibres :
of spine of
extension of
scapula
the arm &
laterally
rotation of it.
upper fibres:
elevate the
scapula and
Posterior
rotates it
aspect of the
back of the skull during
lateral 1/3 of spinal
+ nuchal abduction of
clavicle + accessory
ligament + the arm.
Trapezius Medial border nerve + C3
spinous middle fibres :
of acromion + and C4 spinal
processes of C7- retract the
Upper lip of nerves.
T12. scapula.
the crest spine.
lower fibres :
pull the
scapula
inferiorly.
spinous
processes of T7-
T12 + inferior Extension,
The floor of Thoraco-dorsal
angle of the adduction, and
Latissimus the bicipital nerve (nerve to
scapula + iliac medially
Dorsi groove of the latissimus
crest + rotation to the
humerus dorsi).
thoracolumbar arm.
fascia + inferior
3 ribs
36
Medial border Dorsal

Transverse
Levator of the scapula Elevates the scapular nerve
processes of the
scapulae above the root scapula (nerve to
C1-C4 vertebrae
of spine. rhomboids)
Medial border
Dorsal
Spinous of the scapula Retracts and
Rhomboideus scapular nerve
processes of C7- at the level of rotates the
minor (nerve to
T1 vertebrae the root of scapula
rhomboids)
spine
Spinous Medial border Dorsal
Retracts and
Rhomboideus processes of T2- of the scapula, scapular nerve
rotates the
major T5 vertebrae. below the root (nerve to
scapula
of spine rhomboids)
Adduction &
Greater
Lateral border of Lateral
Teres minor tuberosity of Axillary nerve
scapula rotation of the
humerus
arm
Adducts and
Medial lip of extends at the
Lateral border of Lower
Teres major bicipital shoulder, and
scapula scapular nerve
groove medially
rotates the arm
Greater
Supraspinous Abducts the Supra scapular
Suprespinatous tuberosity of
fossa arm 0-15o nerve
humerus
Adduction &
Infraspinous Greater
Lateral Supra scapular
Infraspinatous fossa tuberosity of
rotation of the nerve
humerus
arm
Adduction & Upper and
Lesser
Subscapular Medial Lower
Subscapularis tuberosity of
fossa rotation of the subscapular
humerus
arm nerve
37
Muscles of The Arm
At the end of this chapter, we understand the anatomy of the muscles of the
upper arm – their attachments, innervation and actions.
The upper arm is located between the shoulder joint and elbow joint. It contains
four muscles – three in the anterior compartment (biceps brachii, brachialis,
coracobrachialis), and one in the posterior compartment (triceps brachii).
Anterior Compartment
There are three muscles located in the anterior compartment of the upper arm:
1. The biceps brachii.
2. The coracobrachialis.
3. The brachialis.
They are all innervated by the musculocutaneous nerve.
Arterial supply to the anterior compartment of the upper arm is via muscular
branches of the brachial artery.
1. Biceps Brachii
 Origin: it is a two-headed muscle.
 Long head: from the supraglenoid tubercle of the scapula.
 Short head: from the tip of coracoid process of the scapula.
 Insertion: Both heads forms one tendon which insert distally into the radial
tuberosity and the fascia of the forearm via the bicipital aponeurosis.
 Action: Supination & flexion of the forearm. It also flexes the arm at the
elbow and at the shoulder.
 Nerve supply: Musculocutaneous nerve.
2. Coracobrachialis
The coracobrachialis muscle lies deep to the biceps brachii in the arm.
 Origin: from the tip of the coracoid process of the scapula.
 Insertion: The muscle passes through the axilla, and attaches to the middle
of the medial side of the humeral shaft (at the level of the deltoid
tuberosity).
38
Muscles of The Arm
 Action: Flexion of the arm at the shoulder, and weak adduction.

 Nerve supply: Musculocutaneous nerve.
3. Brachialis
The brachialis muscle lies deep to the biceps brachii, and is found more distally
than the other muscles of the arm. It forms the floor of the cubital fossa.
 Origin: from the medial and lateral surfaces of the humeral shaft.
 Insertion: inserts into the ulnar tuberosity, just distal to the elbow joint.
 Action: Flexion at the elbow.
 Nerve supply: Musculocutaneous nerve, with contributions from the radial
nerve.
Posterior Compartment
The posterior compartment of the upper arm contains the triceps brachii muscle,
which has three heads. The medial head lies deeper than the other two, which
cover it.
Arterial supply to the posterior compartment of the upper arm is via the profunda
brachii artery.
39
Muscles of The Arm
Triceps Brachii
 Origin:
 Long head: from the infraglenoid tubercle.
 Lateral head: from the posterior surface of the humerus, superior to
the radial groove.
 Medial head: from the posterior surface of the humerus, inferior to
the radial groove.
 Insertion: the 3 heads converge into one tendon and insert into the
olecranon of the ulna.
 Action: Extension of the arm at the elbow.
 Nerve supply: Radial nerve.
40
Muscles of The forearm
The anterior compartment of the forearm

The muscles in the anterior compartment of the forearm are organised into three
layers:
 Superficial: flexor carpi ulnaris, palmaris longus, flexor carpi radialis,
pronator teres.
 Intermediate: flexor digitorum superficialis.
 Deep: flexor pollicis longus, flexor digitorum profundus and pronator
quadratus.
This muscle group is associated with pronation of the forearm, flexion of the wrist
and flexion of the fingers.
They are mostly innervated by the median nerve (except for the flexor carpi
ulnaris and medial half of flexor digitorum profundus, which are innervated by the
ulnar nerve), and they receive arterial supply from the ulnar artery and radial
artery
Superficial Compartment
The superficial muscles in the anterior compartment are the flexor carpi ulnaris,
palmaris longus, flexor carpi radialis and pronator teres.
They all originate from a common origin called Common Flexor Origin , which
arises from the front of the medial epicondyle of the humerus.
1. Pronator Teres
The lateral border of the pronator teres forms the medial border of the cubital
fossa, an anatomical triangle located over the elbow.
 Origin: It has two origins:
1. The font of the medial epicondyle of the humerus.
2. The coronoid process of the ulna.
 Insertion: It attaches laterally to the mid-shaft of the radius.

 Actions: Pronation of the forearm.
 Nerve supply: Median nerve.
41
2. Flexor Carpi Radialis

 Origin: Originates from the front of medial epicondyle.
 Insertion: attaches to the base of metacarpals II and III.
 Actions: Flexion and abduction at the wrist.
3. Palmaris Longus
This muscle is absent in about 15% of
the population.
 Origin: from the front of the
medial epicondyle of humerus.
 Insertion: to the flexor
retinaculum of the wrist.
 Actions: Flexion at the wrist.
4. Flexor Carpi Ulnaris
 Origin: has two origins
 The humeral head : from
the front of medial
epicondyle of the
humerus with the other
superficial flexors.
 The ulnar head : from the
olecranon of the ulna.
 Insertion: The muscle tendon passes into the wrist and attaches to the
pisiform bone, hook of hamate, and base of the 5th metacarpal.
 Actions: Flexion and adduction at the wrist.
 Nerve supply: Ulnar nerve.
42
Intermediate Compartment
The flexor digitorum superficialis is the only muscle of the intermediate
compartment. It can sometimes be classed as a superficial muscle, but in most
individuals, it lies between the deep and superficial muscle layers.
The muscle is a good anatomical landmark in the forearm – the median
nerve and ulnar artery pass between its two heads, and then travel posteriorly.
 Origin: It has two heads:
 from the front of medial epicondyle of the humerus
 from the radius.
 Insertion: The muscle splits into four tendons at the wrist, which travel
through the carpal tunnel, and attach to the base of the middle phalanx of
the medial four fingers.
 Actions: Flexes the metacarpophalangeal joints and proximal
interphalangeal joints at the 4 fingers, and flexes at the wrist.
Deep Compartment
There are three muscles in the deep anterior forearm: flexor digitorum
profundus, flexor pollicis longus, and pronator quadratus.
1. Flexor Digitorum Profundus
 Origin: originates from:
1. The anterior & medial surfaces of ulna.
2. The coronoid process of the ulna.
43
3. The upper 3/4 of posterior border of ulna through ulnar aponeurosis.

4. The adjacent part of interosseous membrane.
 Insertion: At the wrist, it splits into four tendons, that pass through
the carpal tunnel and attach to the distal phalanges of the medial four
fingers.
 Actions: Flexion of all joints of the medial 4 fingers & flexion of the wrist.
 Nerve supply:
 The medial half (acts on the little and ring fingers) is innervated by
the ulnar nerve.
 The lateral half (acts on the middle and index fingers) is innervated by
the anterior interosseous branch of the median nerve.
2. Flexor Pollicis Longus

This muscle lies laterally to the flexor digitorum profundus
 Origin: from the anterior surface of the radius and surrounding
interosseous membrane (unipennate muscle).
 Insertion: to the base of the distal phalanx of the thumb.
 Actions: Flexion of all joints of the thumb.
 Nerve supply: Median nerve (anterior interosseous branch).
44
3. Pronator Quadratus
A square shaped muscle found deep to the tendons of the flexor digitorum
profundus and flexor pollicis longus.
 Origin: from the lower 1/4 of the anterior surface of the ulna and
 Insertion: attaches to the lower 1/4 of the anterior surface of the radius.
 Actions: Pronation the forearm.
 Nerve supply: Median nerve (anterior interosseous branch).
45
The Posterior Compartment of the Forearm

The muscles in the posterior compartment of the forearm are commonly known
as the extensor muscles. The general Action of these muscles is to produce
extension at the wrist and fingers. They are all innervated by the radial nerve.
The muscles in this compartment are organised into two
layers; deep and superficial. These two layers are separated by a layer of fascia.
Superficial Muscles
The superficial layer of the posterior forearm contains seven muscles. Four of
these muscles (extensor carpi radialis brevis, extensor digitorum, extensor carpi
ulnaris and extensor digiti minimi) share a common tendinous origin at the lateral
epicondyle.
1. Brachioradialis
The brachioradialis is a
paradoxical muscle. Its origin and
Nerve supply are characteristic of
an extensor muscle, but it is
actually a flexor at the elbow.
The muscle is most visible when
the forearm is half pronated, and
flexing at the elbow against
resistance.
In the distal forearm, the radial
artery and nerve are sandwiched
between the brachioradialis and
the deep flexor muscles.
 Origin: from the upper 2/3
of the lateral
supracondylar ridge of
humerus.
 Insertion: to the distal end
of the radius, just before
46
the radial styloid process.

 Actions:
1. Pronation & supination of the forearm.
2. Flexes at the elbow.

2. Extensor Carpi Radialis Longus
The extensor carpi radialis muscles are situated on the lateral aspect of the
posterior forearm. Due to their position, they are able to produce abduction as
well as extension at the wrist.
 Origin: from the lower 1/3 of the lateral supracondylar ridge of the
humerus.
 Insertion: to the base of 2nd metacarpal bone.
 Actions: Extension and abduction of the wrist.
3. Extensor Carpi Radialis Brevis
The extensor carpi radialis muscles are situated on the lateral aspect of the
posterior forearm. Due to their position, they are able to produce abduction as
well as extension at the wrist.
 Origin: from the lateral epicondyle of humerus (common extensor origin).
 Insertion: to the base of 3rd metacarpal bone.
 Actions: Extension and abduction of the wrist.
4. Extensor Digitorum:
The extensor digitorum is the main extensor of the fingers. To test the Action of
the muscle, the forearm is pronated, and the fingers extended against resistance.
 Origin: from the lateral epicondyle of humerus.
47
 Insertion: The tendon continues into in the distal part of the forearm,
where it splits into four, and inserts into the extensor expansion of each
finger. Each extensor expansion divides into 3 slips:
o Middle slip: inserted into the middle phalanx.
o 2 collateral slips: inserted into the distal phalanx.
 Actions: Extension of the interphalangeal and metacarpophalangeal joints

of the medial 4 fingers.
 Nerve supply: Posterior interosseous nerve (deep branch of radial nerve).
5. Extensor Digiti Minimi
The extensor digiti minimi is thought to originate from the extensor digitorum
muscle. In some people, these two muscles are fused together. Anatomically, the
extensor digiti minimi lies medially to the extensor digitorum.
 Origin: from the lateral epicondyle of the humerus.
 Insertion: It attaches, with the extensor digitorum tendon, into the
extensor expansion of the little finger.
 Actions: Extension of the joints of the little finger, and contributes to
extension at the wrist.
6. Extensor Carpi Ulnaris
The extensor carpi ulnaris is located on the medial aspect of the posterior
forearm. Due to its position, it is able to produce adduction as well as extension at
the wrist.
 Origin: Originates from the lateral epicondyle of the humerus.
 Insertion: attaches to the base of the 5th metacarpal bone.
 Actions: Extension and adduction of wrist.
48
7. Anconeus
The anconeus is situated medially and proximally in the extensor compartment of
the forearm. It is blended with the fibres of the triceps brachii, and the two
muscles can be indistinguishable.
 Origin: from the lateral epicondyle of humerus.
 Insertion: attaches to the posterior and lateral part of the olecranon.
 Actions: Extention and stabilises the elbow joint.
Deep Muscles
There are five muscles in the deep compartment of the posterior forearm – the
supinator, abductor pollicis longus, extensor pollicis brevis, extensor pollicis
longus and extensor indicis.
With the exception of the supinator, these muscles act on the thumb and the
index finger.
1. Supinator
The supinator lies in the floor of the cubital fossa. It has two heads, which the
deep branch of the radial nerve passes between.
 Origin: It has two heads of origin:
 from the lateral epicondyle of the humerus,
 from the supinator fossa &crest of the ulna.
 Insertion: They insert together into the upper 1/3 of lateral surface of
the radius.
 Actions: Supination the forearm.
49
2. Abductor Pollicis Longus

The abductor pollicis longus is situated immediately distal to the supinator
muscle. In the hand, its tendon contributes to the lateral border of the anatomical
snuffbox.
 Origin: from the interosseous membrane and the adjacent posterior
surfaces of the radius and ulna.
 Insertion: It attaches to the lateral side of the base of 1st metacarpal bone.
 Actions: Abduction of the thumb.
3. Extensor Pollicis Brevis
The extensor pollicis brevis can be found medially and deep to the abductor
pollicis longus. In the hand, its tendon contributes to the lateral border of
the anatomical snuffbox.
50
 Origin: from the posterior surface of the radius and interosseous

membrane.
 Insertion: It attaches to the base of the proximal phalanx of the thumb.
 Actions: Extension at the metacarpophalangeal and carpometacarpal joints
of the thumb.
4. Extensor Pollicis Longus
The extensor pollicis longus muscle has a larger muscle belly than the EPB. Its
tendon travels medially to the dorsal tubercle at the wrist, using the tubercle as a
‘pulley’ to increase the force exerted.
The tendon of the extensor pollicis longus forms the medial border of the
anatomical snuffbox in the hand.
 Origin: from the posterior surface of the ulna and interosseous membrane.
 Insertion: It attaches to the distal phalanx of the thumb.
 Actions: Extension all joints of the thumb: carpometacarpal,
metacarpophalangeal and interphalangeal.
5. Extensor Indicis
This muscle allows the index finger to be independent of the other fingers during
extension.
 Origin: from the posterior surface of the ulna and interosseous membrane,
distal to the extensor pollicis longus.
 Insertion: Attaches to the extensor expansion of the index finger.
 Actions: Extension the index finger.
51
Muscles of The Hand
At the end of this chapter, we shall understand the anatomy of the intrinsic
muscles of the hand – their Origin, Insertion, Actions and Nerve Supply.
I. Thenar Muscles (Lateral Compartment)
The thenar muscles are three short muscles located at the base of the thumb. The
muscle bellies produce a bulge, known as the thenar eminence. They are
responsible for the fine movements of the thumb.
The median nerve innervates all the thenar muscles.
1. Abductor Pollicis Brevis
The abductor pollicis brevis forms the anterolateral aspect of the thenar
eminence, overlying the opponens pollicis.
 Origin: from the tubercle of scaphoid and crest of trapezium, and from
the associated flexor retinaculum.
 Insertion: to lateral side of proximal phalanx of the thumb.
 Actions: Abducts the thumb.
 Nerve Supply: Median nerve (recurrent branch).
2. Flexor Pollicis Brevis
 Origin: from the tubercle of scaphoid & crest of trapezium and from the
associated flexor retinaculum.
 Insertion: to the base of the proximal phalanx of the thumb.
 Actions: Flexes the metacarpophalangeal joint of the thumb.
3. Opponens Pollicis
The opponens pollicis is the largest of the thenar muscles, and lies underneath
the other two.
 Origin: from the tubercle of scaphoid & crest of trapezium and the
associated flexor retinaculum.
 Insertion: to the lateral margin of the 1st metacarpal bone.
52
Muscles of The Hand
 Actions: Opposes the thumb against the other fingers.

II. Hypothenar Muscles (Medial Compartment):

The hypothenar muscles form the hypothenar eminence – a muscular protrusion
on the medial side of the palm, at the base of the little finger. These muscles are
similar to the thenar muscles in both name and organisation.
The ulnar nerve innervates the muscles of the hypothenar eminence.
1. Abductor Digiti Minimi
The abductor digiti minimi is the most superficial of the hypothenar muscle group.
 Origin: from the pisiform.
 Insertion: to the base of the proximal phalanx of the little finger.
 Actions: Abducts the little finger.
 Nerve Supply: Ulnar nerve.
53
Muscles of The Hand
2. Flexor Digiti Minimi Brevis

The flexor digiti minimi brevis lies laterally to the abductor digiti minimi in the
hand.
 Origin: from the hook of hamate and adjacent flexor retinaculum.
 Insertion: to the base of the proximal phalanx of the little finger.
 Actions: Flexes the metacarpophalangeal joint of the little finger.
3. Opponens Digiti Minimi
The opponens digit minimi lies deep to the other hypothenar muscles.
 Origin: from the hook of hamate and associated flexor retinaculum,
 Insertion: to the medial margin of 5th metacarpal bone.
 Actions: It rotates the metacarpal of the little finger towards the palm,
producing opposition.
54
Muscles of The Hand
III. Intermediate Compartment):

1. Lumbricals
There are four lumbricals in the hand, each associated with a finger. They are very
crucial to finger movement, linking the extensor tendons to the flexor tendons.
Denervation of these muscles is the basis for the ulnar claw and hand of
benediction.
 Origin: Each lumbrical originates from a tendon of the flexor digitorum
profundus.
 Insertion: They pass dorsally and laterally around each finger, and inserts
into the extensor expansion.
 Actions: Flexion at the MCP joint and extension at the interphalangeal (IP)
joints of each digit.
 Nerve Supply: The lateral two lumbricals (of the index and middle fingers)
are innervated by the median nerve. The medial two lumbricals (of the little
and ring fingers) are innervated by the ulnar nerve.
55
Muscles of The Hand
2. Interossei
The interossei muscles are located between the metacarpal bones of the hand.
They can be divided into two groups – dorsal and palmar.
In addition to their Actions of abduction (dorsal interossei) and adduction (palmar
interossei) of the fingers, the interossei also assist the lumbricals in flexion at the
MCP joints.
A. Dorsal Interossei
The most superficial of all dorsal muscles, these can be palpated on the dorsum of
the hand. There are four dorsal interossei muscles.
 Origin: Each interossei originates from the lateral and medial surfaces of
the metacarpals.
 Insertion: They attach into the extensor expansion and proximal phalanx of
each finger.
 Actions: Abduction of the digits. Assists in flexion at the
metacarpophalangeal joints.
B. Palmar Interossei
These are located anteriorly on the hand. There are three palmar interossei
muscles (although some texts describe a fourth muscle at the base of the
proximal phalanx of the thumb).
 Origin: Each interossei originates from a medial or lateral surface of a
metacarpal.
 Insertion: to the extensor expansion and proximal phalanx of same finger.
 Actions: Adduction of the digits. Assists in flexion at the
metacarpophalangeal joints.
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Muscles of The Hand
IV. Other Muscles in the Palm

There are two other muscles in the palm that are not lumbricals or interossei and
do not fit in the hypothenar or thenar compartments:
1. Palmaris Brevis
The palmaris brevis is a small, thin muscle, found superficially in the subcutaneous
tissue of the hypothenar eminence.
 Origin: from the palmar aponeurosis and flexor retinaculum, attaches to
the dermis of the skin on the medial margin of the hand.
 Actions: Wrinkles the skin of the hypothenar eminence and deepens the
curvature of the hand, improving grip.
2. Adductor Pollicis
The adductor pollicis large triangular muscle with two heads. The radial artery
passes anteriorly through the space between the two heads, forming the deep
palmar arch.
 Origin: has two heads which originate:
57
Muscles of The Hand
 Transverse head: from 3rd metacarpal bone.

 Oblique head: from the capitate and adjacent areas of 2nd & 3rd
metacarpal bones.
 Insertion: Both heads insert into the base of the proximal phalanx of the
thumb.
 Actions: Adductor of the thumb.
58
The Anatomical Areas of the Upper Limb
(1) The cubital fossa

 The cubital fossa is a triangular-shaped depression over the anterior aspect of
the elbow joint.
 It represents an area of transition between the anatomical arm and
the forearm, and conveys several important structures between these two
areas.
Borders
The cubital fossa is triangular in shape
and consists of three borders, a roof,
and a floor:
 Lateral border – medial border
of the brachioradialis muscle.
 Medial border – lateral border
of the pronator teres muscle.
 Superior border – horizontal line
drawn between the epicondyles
of the humerus.
 Roof – bicipital aponeurosis,
fascia, subcutaneous fat and
skin.
 Floor – brachialis (proximally)
and supinator (distally).
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Contents
The cubital fossa is a passageway for structures to pass between the upper arm
and forearm.
Its contents are (lateral to medial):
 Radial nerve – travels along the lateral border of the cubital fossa and
divides into superficial and deep branches.
o It has a motor and sensory function in the posterior forearm and
hand.
 Biceps tendon – passes centrally through the cubital fossa and attaches the
radial tuberosity (immediately distal to the radial neck).
o It gives rise to the bicipital aponeurosis which contributes to the roof
of the cubital fossa.
 Brachial artery – bifurcates into the radial and ulnar arteries at the apex of
the cubital fossa.
o The brachial pulse can be felt in the cubital fossa by palpating medial
to the biceps tendon
 Median nerve – travels medially through the cubital fossa, exiting by
passing between the two heads of the pronator teres.
o It has a motor and sensory function in the anterior forearm and
hand.
The roof of the cubital fossa also contains several superficial veins. Notably,
the median cubital vein, which connects the basilic and cephalic veins and can be
accessed easily – a common site for venepuncture.
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61
(2) The carpal tunnel

The carpal tunnel is a narrow canal infront of the wrist. It serves as the entrance
to the palm for several tendons and the median nerve.
Borders
The carpal tunnel is formed by two layers: a deep carpal arch and a superficial
flexor retinaculum. The deep carpal arch forms a concave surface, which is
converted into a tunnel by the overlying flexor retinaculum (transverse carpal
ligament).
Carpal Arch
 Concave on the palmar side, forming the base and sides of the carpal
tunnel.
 Formed laterally by the scaphoid and trapezium tubercles
 Formed medially by the hook of the hamate and the pisiform
Flexor Retinaculum
 Thick connective tissue which forms the roof of the carpal tunnel.
 Turns the carpal arch into the carpal tunnel by bridging the space between
the medial and lateral parts of the arch.
 Spans between the hook of hamate and pisiform (medially) to the scaphoid
and trapezium (laterally).
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Contents
The carpal tunnel contains a total of 9 tendons, surrounded by synovial sheaths,
and the median nerve. The palmar cutaneous branch of the median nerve is given
off prior to the carpal tunnel, travelling superficially to the flexor retinaculum.
Tendons
 The tendon of flexor pollicis longus
 Four tendons of flexor digitorum profundus
 Four tendons of flexor digitorum superficialis
The 8 tendons of the flexor digitorum profundus and flexor digitorum superficialis
are surrounded by a single synovial sheath. The tendon of flexor pollicis longus is
surrounded by its own synovial sheath. These sheaths allow free movement of
the tendons.
The muscular and tendinous components of the carpal tunnel

Median Nerve
Once it passes through the carpal tunnel, the median nerve divides into 2
branches: the recurrent branch and palmar digital nerves.
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The palmar digital nerves give sensory innervation to

the palmar skin and dorsal nail beds of the lateral three and a half digits. They
also provide motor innervation to the lateral two lumbricals. The recurrent
branch supplies the thenar muscle group.
Carpal Tunnel Syndrome
 Compression of the median nerve within the carpal tunnel can cause carpal
tunnel syndrome (CTS).
 It is the most common mononeuropathy.
 It can be caused by thickened ligaments and tendon sheaths. Its aetiology
is, however, most often idiopathic.
 If left untreated, it can cause weakness and atrophy of the thenar muscles.
 Clinical features include : numbness, tingling and pain in the distribution of
the median nerve. The pain will usually radiate to the forearm. Symptoms
are often associated with waking the patient from their sleep and being
worse in the mornings.
Tests for CTS can be performed during physical examination:
 Tapping the nerve in the carpal tunnel to elicit pain in median nerve
distribution (Tinel’s Sign)
 Holding the wrist in flexion for 60 seconds to elicit numbness/pain in
median nerve distribution (Phalen’s manoeuvre)
Thenar muscle wasting, secondary to carpal tunnel syndrome.
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(3) The extensor tendon compartments

The extensor tendon compartments of the wrist are six tunnels which transmit
the long extensor tendons from the forearm into the hand
They are located on the posterior aspect of the wrist. Each tunnel is lined
internally by a synovial sheath and separated from one another by fibrous septa.
The extensor tendon compartments of the wrist.
Compartment 1
The first extensor compartment is located on the lateral (radial) aspect of the
wrist. It transmits two tendons:
 Extensor pollicis brevis
 Abductor pollicis longus
These tendons form the lateral border of the anatomical snuffbox.
Compartment 2
The second extensor compartment contains the tendons of the extensor carpi
radialis longus and extensor carpi radialis brevis.
This compartment is separated from compartment 3 by Lister’s tubercle – a bony
prominence of the distal aspect of the radius.
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Compartment 3
Compartment three conducts the extensor pollicis longus tendon – this forms the
medial border of the anatomical snuffbox.
The posterior compartment of the forearm and

Compartment 4
The 4th extensor compartment of the wrist transmits the tendons of the extensor
digitorum and extensor indicis. It also transmits anterior interosseous artery &
posterior interosseous nerve.
Compartment 5
Compartment five contains the extensor digiti minimi tendon, which travels into
the little finger.
Compartment 6
The sixth compartment is the located on the medial (ulnar) aspect of the wrist. It
conducts the tendon of the extensor carpi ulnaris.
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The Brachial plexus
At the end of this chapter, we shall understand the anatomy of the brachial
plexus – its formation and anatomical course through the body.
The brachial plexus is a network of nerve fibres that supplies the skin and
musculature of the upper limb. It begins in the root of the neck, passes through
the axilla, and runs through the entire upper extremity.
The plexus is formed by the anterior rami (divisions) of cervical spinal nerves C5,
C6, C7 and C8, and the first thoracic spinal nerve, T1.
The brachial plexus is divided into five parts; roots, trunks, divisions, cords and
branches . There are no functional differences between these divisions – they are
simply used to aid explanation of the brachial plexus.
Roots
The ‘roots’ refer the anterior rami of the spinal nerves that comprise the brachial
plexus. These are the anterior rami of spinal nerves C5, C6, C7, C8, and T1.
At each vertebral level, paired spinal nerves arise. They leave the spinal cord via
the intervertebral foramina of the vertebral column.
Each spinal nerve then divides into an anterior and a posterior ramus. The roots
of the brachial plexus are formed by the anterior rami of spinal nerves C5-T1 (the
posterior divisions innervate the skin and musculature of the intrinsic back
muscles).
After their formation, these nerves pass between
the anterior and medial scalene muscles to enter the base of the neck.
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The Brachial plexus
II. Trunks
At the base of the neck, the roots of the brachial plexus converge to form 3
trunks. These structures are named by their relative anatomical location:
 Superior trunk : a combination of C5 and C6 roots.
 Middle trunk : continuation of C7.
 Inferior trunk : combination of C8 and T1 roots.
The trunks traverse laterally, crossing the posterior triangle of the neck.
III. Divisions
 Each trunk divides into two branches within the posterior triangle of the
neck. One division moves anteriorly (toward the front of the body) and the
other posteriorly (towards the back of the body). Thus, they are known as
the anterior and posterior divisions.
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The Brachial plexus
 We now have three anterior and three posterior nerve fibres. These
divisions leave the posterior triangle and pass into the axilla.
They recombine into the cords of the brachial plexus.
IV. Cords
Once the anterior and posterior divisions have entered the axilla, they combine
together to form three cords, named by their position relative to the axillary
artery.
 The lateral cord is formed by:
 The anterior division of the superior trunk.
 The anterior division of the middle trunk.
 The posterior cord is formed by:

 The posterior division of the superior trunk.
 The posterior division of the middle trunk.
 The posterior division of the inferior trunk
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The Brachial plexus
 The medial cord is formed by:

 The anterior division of the inferior trunk.
The cords give rise to the major branches of the brachial plexus.
V. Major Branches
In the axilla and the proximal aspect of the upper limb, the three cords give rise to
5 major branches. These nerves continue into the upper limb to provide
innervation to the muscles and skin present.
1. Musculocutaneous Nerve
 Roots: C5, C6, C7.
 Motor Functions: Innervates the brachialis, biceps brachii and
coracobrachialis muscles.
 Sensory Functions: Gives off the lateral cutaneous branch of the
forearm, which innervates the lateral half of the anterior forearm, and a
small lateral portion of the posterior forearm.
2. Axillary Nerve
 Roots: C5 and C6.
 Motor Functions: Innervates the teres minor and deltoid muscles.
 Sensory Functions: Gives off the superior lateral cutaneous nerve of
arm, which innervates the inferior region of the deltoid (“regimental
badge area”).
3. Median Nerve
 Roots: C6 – T1. (Also contains fibres from C5 in some individuals).
 Motor Functions: Innervates most of the flexor muscles in the forearm,
the thenar muscles, and the two lateral lumbricals associated with the
index and middle fingers.
 Sensory Functions: Gives off the palmar cutaneous branch, which
innervates the lateral part of the palm, and the digital cutaneous
branch, which innervates the lateral three and a half fingers on the
anterior (palmar) surface of the hand.
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The Brachial plexus
4. Radial Nerve
 Roots: C5 – T1.
 Motor Functions: Innervates the triceps brachii, and the muscles in the
posterior compartment of the forearm (which are primarily, but not
exclusively, extensors of the wrist and fingers).
 Sensory Functions: Innervates the posterior aspect of the arm and
forearm, and the posterolateral aspect of the hand.
5. Ulnar Nerve
 Roots: C8 and T1.
 Motor Functions: Innervates the muscles of the hand (apart from the
thenar muscles and two lateral lumbricals), flexor carpi ulnaris and
medial half of flexor digitorum profundus.
 Sensory Functions: Innervates the anterior and posterior surfaces of the
medial one and half fingers, and associated palm area.
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The Brachial plexus
VI. Minor Branches

In addition to the five major branches of the brachial plexus, there are a number
of smaller nerves that arise. They do so from all five parts of the brachial plexus,
and are listed below:
Roots Trunks Lateral cord Medial cord Posterior cord
Dorsal Suprascapular Lateral Medial pectoral Superior

scapular nerve pectoral nerve subscapular nerve
nerve nerve
Medial cutaneous Thoracodorsal

Long nerve of arm nerve
Nerve to
thoracic
subclavius
nerve
Medial cutaneous Inferior
nerve of forearm subscapular nerve
Injury of the Brachial Plexus:

I. Upper Brachial Plexus Injury (Erb’s Palsy)
Erb’s palsy refers to an injury to the upper roots of the brachial plexus (typically
C5-6). It most commonly occurs as a result of a stretching injury during a difficult
vaginal delivery.
 Nerves affected – the peripheral nerves derived
from C5-6 roots are most affected. This includes
the musculocutaneous, axillary, suprascapular,
and nerve to subclavius.
 Muscles affected – supraspinatus, infraspinatus,
subclavius, biceps brachii, brachialis,
coracobrachialis, deltoid and teres minor.
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The Brachial plexus
 Motor functions affected – abduction at shoulder, lateral rotation of arm,

supination of forearm, and flexion at shoulder.
 Sensory functions affected – sensation over the lateral aspect of upper
limb (C5-6 dermatomes).
The affected limb hangs limply, medially rotated by the unopposed action of
pectoralis major. The forearm is pronated due to the loss of biceps brachii. The
wrist is weakly flexed due to the normal tone of the wrist flexors relative to the
weakened wrist extensors. This is position is known as ‘waiter’s tip’ and is
characteristic of Erb’s palsy.
II. Lower Brachial Plexus Injury (Klumpke’s Palsy)

Klumpke’s palsy is an injury of the lower roots of the brachial plexus (C8-T1). It is
also most commonly associated with a difficult vaginal delivery but has a much
lower incidence than Erb’s palsy.
 Nerves affected – the peripheral nerves derived from T1 root are most
affected; the ulnar and median nerves
 Muscles affected – the intrinsic hand muscles
 Sensory functions affected – sensation along medial side of upper limb (C8-
T1 dermatomes).
The primary feature of Klumpke’s palsy is a clawed hand. This occurs due to
paralysis of the lumbrical muscles, which normally act to flex the
metacarpophalangeal joints (MCPJs) and extend the interphalangeal joints (IPJs).
When paralysed, the fingers subsequently become extended at the MCPJs and
flexed at the IPJs, producing a clawed appearance.
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The Nerves of the Upper Limb
(1) The Axillary Nerve

The axillary nerve is a major peripheral nerve of the upper limb.
 Roots: C5 and C6.
 Sensory functions: Gives rise to the upper lateral cutaneous nerve of arm,
which innervates the skin over the lower deltoid (‘regimental badge area’).
 Motor functions: Innervates the teres minor and deltoid muscles.
Anatomical Course
 The axillary nerve is formed
within the axilla area of the upper
limb.
 It is a direct continuation of the
posterior cord from the brachial
plexus – and therefore contains
fibres from the C5 and C6 nerve
roots.
 In the axilla, the axillary nerve is
located posterior to the axillary
artery and anterior to the
subscapularis muscle.
 It exits the axilla at the inferior
border of subscapularis via
the quadrangular space,
often accompanied by the posterior circumflex humeral artery and vein.
 The axillary nerve then passes medially to the surgical neck of the humerus,
where it divides into three terminal branches:
 Posterior terminal branch – provides motor innervation to the posterior
aspect of the deltoid muscle and teres minor. It also innervates the skin
over the inferior part of the deltoid as the upper lateral cutaneous nerve of
the arm.
 Anterior terminal branch – winds around the surgical neck of the humerus
and provides motor innervation to the anterior aspect of the deltoid
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muscle. It terminates with cutaneous branches to the anterior and

anterolateral shoulder.
 Articular branch – supplies the glenohumeral joint
The Quadrangular Space

The quadrangular space is a gap in the muscles of the posterior scapular region. It
is a pathway for neurovascular structures to move from the axilla anteriorly to the
posterior shoulder and arm. It is bounded by:
 Superior – inferior aspect of teres minor
 Inferior – superior aspect of teres major
 Lateral – surgical neck of humerus.
 Medial – long head of triceps brachii
 Anterior – subscapularis
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The axillary nerve and posterior circumflex humeral artery and vein pass through
the quadrangular space. These structures can be compressed as a result of
trauma, muscle hypertrophy or space occupying lesion; resulting in weakness of
the deltoid and teres minor. This is particularly common in athletes who perform
overhead activities.
Motor Functions
The axillary nerve innervates teres minor and deltoid muscles.
 Teres minor – part of the rotator cuff muscles which act to stabilise
the glenohumeral joint. It acts to externally rotate the shoulder joint and is
innervated by the posterior terminal branch of the axillary nerve.
 Deltoid – situated at the superior aspect of the shoulder. It
performs abduction of the upper limb at the glenohumeral joint and is
innervated by the anterior terminal branch of the axillary nerve.
NB: There is some evidence from research on cadavers that the axillary nerve can
also innervate the lateral head of triceps brachii muscle.
Sensory Functions
The sensory component of the axillary nerve is delivered via its posterior terminal
branch.
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After the posterior terminal branch of the axillary nerve has innervated the teres
minor, it continues as the upper lateral cutaneous nerve of the arm. It innervates
the skin over the inferior portion of the deltoid (the ‘regimental badge area’).
In a patient with axillary nerve damage,
sensation at the regimental badge area may
be impaired or absent. The patient may also
report paraesthesia (pins and needles) in the
distribution of the axillary nerve.
Injury to the Axillary Nerve

The axillary nerve can be damaged through
trauma to the proximal humerus or shoulder
girdle. It often presents with other brachial
plexus injuries.
Common mechanisms of injury include
fracture of the humeral surgical neck,
shoulder dislocation or iatrogenic injury
during shoulder surgery.
 Motor functions – the deltoid and teres minor muscles will be affected,
rendering the patient unable to abduct the affected limb beyond 15
degrees.
 Sensory functions – the upper lateral cutaneous nerve of arm will be
affected, resulting in loss of sensation over the inferior deltoid (‘regimental
badge area’).
Clinical tests include deltoid extension lag and external rotation lag. Chronic
lesions of the axillary nerve can result in permanent numbness at the lateral
shoulder region, muscle atrophy, and neuropathic pain.
Erb’s palsy is a condition resulting from damage to the C5 and C6 roots of the
brachial plexus. The axillary nerve is therefore affected, and the individual is
usually unable to abduct or externally rotate at the shoulder.
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(2) The musculocutaneous nerve

The musculocutaneous nerve is a major peripheral nerve of the upper limb.
In this article, we shall look at the anatomy of the musculocutaneous nerve – its
anatomical course, motor and sensory functions, and its clinical correlations.
 Roots : C5-C7.
 Motor functions – muscles in the anterior compartment of the arm
(coracobrachialis, biceps brachii and the brachialis).
 Sensory functions – gives rise to the
lateral cutaneous nerve of forearm,
which innervates the lateral aspect of
the forearm.
Anatomical Course
 The musculocutaneous nerve is the

terminal branch of the lateral cord of
the brachial plexus (C5, C6 and C7) and
emerges at the inferior border of
pectoralis minor muscle.
 It leaves the axilla and pierces

the coracobrachialis muscle near its point
of insertion on the humerus.
 It then passes down the flexor

compartment of the upper arm, superficial
to brachialis but deep to the biceps brachii
muscle.
 The nerve then pierces the deep fascia

lateral to biceps brachii to
emerge lateral to the biceps tendon and
brachioradialis. It continues into the
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forearm as the lateral cutaneous nerve and provides sensory innervation to

the lateral aspect of the forearm.
Motor Functions
The musculocutaneous nerve innervates the muscles in the anterior compartment
of the arm:
 Biceps brachii
 Brachialis
 Coracobrachialis
These muscles flex the upper arm at the shoulder and the elbow. In addition, the
biceps brachii also supinates the forearm.
Sensory Functions
The musculocutaneous nerve gives rise to the lateral cutaneous nerve of
forearm.
This nerve initially enters the deep forearm, but then pierces the deep fascia to
become subcutaneous. In this region, it can be found close to the cephalic vein.
The lateral cutaneous nerve of forearm innervates the skin of the anterolateral
aspect of the forearm.
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Injury to the Musculocutaneous Nerve

The musculocutaneous nerve is well protected within the axilla and injury is
relatively uncommon. Characteristic mechanisms of injury include penetrating
trauma to the axilla (e.g. stabbing), and iatrogenic injury resulting from heavy
retraction during the deltopectoral approach to the shoulder.
 Motor functions – coracobrachialis, biceps brachii and brachialis muscles
are affected:
o Flexion at the shoulder and elbow are weakened but can still be
performed by the pectoralis major and brachioradialis respectively.
o Supination of the forearm is weak, but can still be performed by the
brachioradialis.
 Sensory functions – loss of sensation over the lateral side of the forearm.
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(3) The median nerve

The median nerve is a major peripheral nerve of the upper limb.
 Roots: C6 – T1 (also contains fibres from C5 in some individuals).
 Motor functions: Innervates the flexor and pronator muscles in
the anterior compartment of the forearm (except the flexor carpi ulnaris
and part of the flexor digitorum profundus, innervated by the ulnar nerve).
Also supplies innervation to the thenar muscles and lateral two lumbricals
in the hand.
 Sensory functions: Gives rise to the
palmar cutaneous branch, which
innervates the lateral aspect of the
palm, and the digital cutaneous branch,
which innervates the lateral three and a
half fingers on the anterior (palmar)
surface of the hand.
Anatomical Course
 The median nerve is derived from
the medial and lateral cords of
the brachial plexus. It contains fibres from
roots C6-T1 and can contain fibres from C5
in some individuals.
 After originating from the brachial plexus

in the axilla, the median nerve descends
down the arm, initially lateral to
the brachial artery.
 Halfway down the arm, the nerve crosses

over the brachial artery, and becomes
situated medially.
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 The median nerve enters the anterior compartment of the forearm via
the cubital fossa.
 In the forearm, the nerve travels between the flexor digitorum profundus and
flexor digitorum superficialis muscles.
 The median nerve gives off two major branches in the forearm:
 Anterior interosseous nerve – supplies the deep muscles in the anterior
forearm.
 Palmar cutaneous nerve – innervates the skin of the lateral palm.
(The functions of these nerves are explored in more detail later in the
article).
After giving off the anterior interosseous and palmar cutaneous branches,
the median nerve enters the hand via the carpal tunnel – where it
terminates by dividing into two branches:
 Recurrent branch – innervates the thenar muscles.
 Palmar digital branch – innervates the palmar surface and fingertips of the
lateral three and half digits. Also innervates the lateral two lumbrical
muscles.
Motor Functions
The median nerve innervates the majority of the muscles in the anterior forearm,
and some intrinsic hand muscles.
Anterior Forearm
In the forearm, the median nerve directly innervates muscles in the superficial
and intermediate layers:
 Superficial layer – pronator teres, flexor carpi radialis and palmaris longus.
 Intermediate layer – flexor digitorum superficialis.
The median nerve also gives rise to the anterior interosseous nerve, which
supplies the deep flexors:
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 Deep layer – flexor pollicis longus, pronator quadratus, and the lateral half
of the flexor digitorum profundus (the medial half of the muscle is
innervated by the ulnar nerve).
In general, these muscles perform pronation of the forearm, flexion of the
wrist and flexion of the digits of the hand.
Hand
The median nerve innervates some of the muscles in the hand via two branches.
1. The recurrent branch of the median nerve: innervates the thenar muscles
– muscles associated with movements of the thumb.
2. The palmar digital branch innervates the lateral two lumbricals – these
muscles perform flexion at the metacarpophalangeal joints and extension
at the interphalangeal joints of the index and middle fingers
Sensory Functions
The median nerve is responsible for the cutaneous innervation of part of the
hand. This is achieved via two branches:
 Palmar cutaneous branch – arises in the forearm and travels into the hand.
It innervates the lateral aspect of the palm. This nerve does not pass
through the carpal tunnel, and is spared in carpal tunnel syndrome.
 Palmar digital cutaneous branch – arises in the hand. Innervates the
palmar surface and fingertips of the lateral three and half digits.
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Injury of the Median Nerve

I. Injury at the Elbow
 Mechanism of injury: Supracondylar fracture of the humerus.
 Motor functions: The flexors and pronators in the forearm are paralysed,
with the exception of the flexor carpi ulnaris and medial half of flexor
digitorum profundus. The forearm constantly supinated, and wrist flexion
is weak (often accompanied by adduction, because of the pull of the flexor
carpi ulnaris).
o Flexion at the thumb is also prevented, as both the longus and brevis
muscles are paralysed.
o The lateral two lumbricals are affected, and the patient will not be
able to flex at the MCP joints or extend at IP joints of the index and
middle fingers.
 Sensory functions: Lack of sensation over the areas that the median nerve
innervates.
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 Characteristic signs: The thenar eminence is wasted, due to atrophy of the

thenar muscles. If patient tries to make a fist, only the little and ring fingers
can flex completely. This results in a characteristic shape of the hand,
known as hand of benediction.
II. Injury at the Wrist
 Mechanism of injury: Lacerations just proximal to the flexor retinaculum.
 Motor functions: Thenar muscles paralysed, as are the lateral two
lumbricals. This affects opposition of the thumb and flexion of the index
and middle fingers.
 Sensory functions: Same as an injury at the elbow.
 Characteristic signs: The hand is held in the same position as damage at the
elbow, but the forearm is unaffected (not supinated or adducted, wrist
flexion likely unaffected, depending on the location of the lesion).
III. Carpal Tunnel Syndrome
Compression of the median nerve within the carpal tunnel can cause carpal
tunnel syndrome (CTS).
It is the most common mononeuropathy and is caused by an increased
tissue pressure within the carpal tunnel. Whilst risk factors for CTS have
been identified (such as diabetes, pregnancy and acromegaly), the exact
underlying aetiology is not well understood.
Clinical features include numbness, tingling, and pain in the distribution of
the median nerve. Importantly, the palm is usually spared – as the palmar
cutaneous branch does not travel through the carpal tunnel. Symptoms can
wake the patient from sleep and are usually worse in the morning. If left
untreated, chronic CTS can cause weakness and atrophy of the thenar
muscles.
Tests for carpal tunnel syndrome can be performed during physical
examination:
 Tinel’s sign – tapping the nerve in the carpal tunnel to elicit pain in median
nerve distribution.
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 Phalen’s manoeuvre – holding the wrist in flexion for 60 seconds to elicit

numbness/pain in median nerve distribution.
Treatment involves the use of a splint, holding the wrist in extension
overnight to relieve symptoms. If this is unsuccessful, corticosteroid
injections into the carpal tunnel can be trialled. Surgical decompression of
the carpal tunnel may be required in severe cases.
Thenar muscle wasting, secondary to carpal tunnel syndrome.
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(4) The Radial Nerve

The radial nerve is a major peripheral nerve of the upper limb.
 Roots : C5-T1.
 Sensory: Innervates most of the skin of the posterior forearm, the lateral
aspect of the dorsum of the hand, and the dorsal surface of the lateral
three and a half digits.
 Motor : Innervates the triceps brachii and the extensor muscles in the
forearm.
Anatomical Course
 The radial nerve is the terminal
continuation of the posterior
cord of the brachial plexus. It
therefore contains fibres from
nerve roots C5 – T1.
 The nerve arises in

the axilla region, where it is
situated posteriorly to
the axillary artery. It exits the
axilla inferiorly (via the
triangular interval), and
supplies branches to the long
and lateral heads of the triceps
brachii.
 The radial nerve then descends

down the arm, travelling in a
shallow depression within the
surface of the humerus, known
as the radial groove.
 As it descends, the radial nerve

wraps around the humerus
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laterally, and supplies a branch to the medial head of the triceps brachii.
During much of its course within the arm, it is accompanied by the deep
branch of the brachial artery.
 To enter the forearm, the radial nerve travels anterior to the lateral
epicondyle of the humerus, through the cubital fossa.
 The nerve then terminates by dividing into two branches:
 Deep branch (motor) : innervates the muscles in the posterior
compartment of the forearm.
 Superficial branch (sensory) : contributes to the cutaneous innervation
of the dorsal hand and fingers.
Motor Functions
The radial nerve innervates the muscles located in the posterior arm
and posterior forearm.
 It innervates:
 The three heads of the triceps brachii.
 Branch that supply the brachioradialis muscle.
 Branch that supply the extensor carpi radialis longus.
A terminal branch of the radial nerve, the deep branch of the radial
nerve, innervates the remaining muscles of the posterior forearm.
Note: When the deep branch of the radial nerve penetrates the supinator muscle
of the forearm, it is termed the posterior interosseous nerve for the remainder of
its course.
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Sensory Functions
There are four branches of the radial nerve that provide cutaneous innervation to
the skin of the upper limb. Three of these branches arise in the upper arm:
 Lower lateral cutaneous nerve of arm : Innervates the lateral aspect of the
arm, inferior to the insertion of the deltoid muscle.
I. Posterior cutaneous nerve of arm : Innervates the posterior surface of the
arm.
 Posterior cutaneous nerve of forearm : Innervates a strip of skin down the
middle of the posterior forearm.
 The superficial branch of the radial nerve: is a terminal division of the
radial nerve. It innervates the dorsal surface of the lateral three and half
digits and the associated area on the dorsum of the hand.
The cutaneous innervation of the radial nerve.
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Injury to the Radial Nerve

Injury to the radial nerve can be broadly categorised into four groups –
depending on where the damage has occurred (and thus which components of
the nerve have been affected).
I. In the Axilla
The radial nerve can be damaged in the axilla region by a dislocation at the
shoulder joint, or a fracture of the proximal humerus. Occasionally, it is injured
via excessive pressure on the nerve within the axilla (e.g. a badly fitting crutch).
 Motor functions : the triceps brachii and muscles in posterior compartment
are affected. The patient is unable to extend at the forearm, wrist and
fingers. Unopposed flexion of wrist occurs, known as wrist-drop.
 Sensory functions : all four cutaneous branches of the radial nerve are
affected. There will be a loss of sensation over the lateral and posterior
arm, posterior forearm, and dorsal surface of the lateral three and a half
digits.
Wristdrop of the left forearm, as a result of radial nerve palsy.
II. In the Radial Groove

The radial nerve is tightly bound within the spiral groove of the humerus. Thus, it
is most susceptible to damage with a fracture of the humeral shaft.
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 Motor functions
o The triceps brachii may be weakened, but is not paralysed (branches
to the long and lateral heads of the triceps arise proximal to the
radial groove).
o Muscles of the posterior forearm are affected. The patient is unable
to extend at the wrist and fingers. Unopposed flexion of wrist occurs,
known as wrist-drop.
 Sensory functions – the cutaneous branches to the arm and forearm have
already arisen. The superficial branch of the radial nerve will be damaged,
resulting in sensory loss to the dorsal surface of the lateral three and half
digits and the associated area on the dorsum of the hand.
III. In the Forearm
There are two terminal branches of the radial nerve located within the forearm.
The typical mechanism of injury and effect of their injury differs:
Superficial Branch Deep Branch
Mechanism Stabbing or laceration Fracture of radial head, or
of forearm posterior dislocation of radius
Motor None Majority of the muscles in

functions posterior forearm are affected.
Wrist-drop does not occur, as the
extensor carpi radialis longus
is unaffected, and maintains some
extension at the wrist
Sensory Sensory loss affecting None

functions the lateral 3 ½ digits,
and associated the
associated area on the
dorsum of the hand.
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(5) The Ulnar Nerve

The ulnar nerve is a major peripheral nerve of the upper limb.
 Roots: C8-T1.
 Motor functions:
o Two muscles of the anterior forearm – flexor carpi ulnaris and medial
half of flexor digitorum profundus
o Intrinsic muscles of the hand (apart
from the thenar muscles and two
lateral lumbricals)
 Sensory functions: Medial one and half
fingers and the associated palm area.
Anatomical Course
 The ulnar nerve arises from the brachial
plexus within the axilla region. It is a
continuation of the medial cord and
contains fibres from spinal roots C8 and
T1.
 After arising from the brachial plexus, the

ulnar nerve descends in a plane between
the axillary artery (lateral) and the axillary
vein (medial).
 It proceeds down the medial aspect of the

arm with the brachial artery located
lateral.
 At the mid-point of the arm, the ulnar

nerve penetrates the medial fascial
septum to enter the posterior
compartment of the arm.
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 It passes posterior to the elbow through the ulnar tunnel (small space
between the medial epicondyle and olecranon). Here, it also gives arise to
an articular branch which supplies the elbow joint.
 In the forearm, the ulnar nerve pierces the two heads of the flexor carpi
ulnaris, and travels deep to the muscle, alongside the ulna. Three main
branches arise in the forearm:
 Muscular branch – innervates two muscles in the anterior
compartment of the forearm.
 Palmar cutaneous branch – innervates the medial half of the palm.
 Dorsal cutaneous branch – innervates the dorsal surface of the
medial one and a half fingers, and the associated dorsal hand area.
 At the wrist, the ulnar nerve travels superficially to the flexor retinaculum,
and is medial to the ulnar artery.
 It enters the hand via the ulnar canal (Guyon’s canal). In the hand, the
nerve terminates by giving rise to superficial and deep branches.
Motor Functions
The ulnar nerve innervates muscles in the anterior compartment of the forearm,
and in the hand.
I. Anterior Forearm
In the anterior forearm, the muscular branch of the ulnar nerve supplies two
muscles:
 Flexor carpi ulnaris – flexes and adducts the hand at the wrist.
 Flexor digitorum profundus (medial half) – flexes the ring and little fingers
at the distal interphalangeal joint
The remaining muscles in the anterior forearm are innervated by the median
nerve.
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II. Hand
The majority of the intrinsic hand muscles are innervated by the deep branch of
the ulnar nerve:
 Hypothenar muscles (flexor digiti minimi brevis, abductor digiti minimi,
opponens digiti minimi)
 Medial two lumbricals
 Adductor pollicis
 Palmar and dorsal interossei of the hand
The palmaris brevis is an exception to this rule and is innervated by the
superficial branch of the ulnar nerve. The other muscles of the hand (lateral two
lumbricals and the thenar eminence) are innervated by the median nerve.
Superficial and deep layers of the hypothenar muscles

Sensory Functions
There are three branches of the ulnar nerve that are responsible for its sensory
innervation.
Two of these branches arise in the forearm, and travel into the hand:
 Palmar cutaneous branch: innervates the medial half of the palm.
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 Dorsal cutaneous branch : innervates the dorsal surface of the medial one
and a half fingers, and the associated dorsal hand area.
The last branch arises in the hand itself:
 Superficial branch : innervates the palmar surface of the medial one and a
half fingers.
Cutaneous innervation of the ulnar nerve

Injury of the Ulnar Nerve:
I. Injury at the Elbow
 Mechanism of injury: Trauma at the level of the medial epicondyle (e.g.
isolated medial epicondyle fracture, supracondylar fracture). It can also be
compressed in the cubital tunnel.
o All the muscles of innervated by the ulnar nerve are affected.
o Flexion of the wrist can still occur, but is accompanied by abduction
(due to paralysis of flexor carpi ulnaris and medial half of flexor
digitorum profundus).
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o Abduction and adduction of the fingers cannot occur (due to

paralysis of the interossei).
o Movement of the 4th and 5th digits is impaired (due to paralysis of
the medial two lumbricals and hypothenar muscles).
o Adduction of the thumb is impaired, and the patient will have a
positive Froment’s sign (due to paralysis of adductor pollicis).
 Sensory functions: All sensory branches are affected, so there will be a loss
of sensation over the areas that the ulnar nerve innervates.
 Characteristic signs: Patient cannot grip paper placed between fingers,
positive Froment’s sign, wasting of hypothenar eminence.
 Mechanism of injury: Lacerations to the anterior wrist.
o Only the intrinsic muscles of the hand are affected.
o Abduction and adduction of the fingers cannot occur (due to
paralysis of the interossei).
o Movement of the 4th and 5th digits is impaired (due to paralysis of
the medial two lumbricals and hypothenar muscles).
o Adduction of the thumb is impaired, and the patient will have a
positive Froment’s sign (due to paralysis of adductor pollicis).
 Sensory functions: The palmar branch and superficial branch are usually
severed, but the dorsal branch is unaffected. This results in sensory loss
over palmar side of medial one and a half fingers only.
 Characteristic signs: Patient cannot grip paper placed between fingers,
positive Froment’s sign, wasting of hypothenar eminence.
 Froment’s Sign
Froment’s sign is a test for ulnar nerve palsy – specifically paralysis of
the adductor pollicis:
 The patient is asked to hold a piece of paper between the thumb and index
finger, as the paper is pulled away.
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 They should be able to hold the paper there with no difficulty (via
adduction of the thumb).
 A positive test is when the patient is unable to adduct the thumb. Instead,
they flex the thumb at the interphalangeal joint to try to maintain a hold
on the paper.
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The Blood Supply of the Upper Limb
The arterial supply to the upper limb is delivered via five main vessels (proximal
to distal):
 Subclavian artery
 Axillary artery
 Brachial artery
 Radial artery
 Ulnar artery
Schematic demonstrating the arterial supply to the upper limb.
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Subclavian Artery
The arterial supply to the upper limb begins as the subclavian artery. On the
right, the subclavian artery arises from the brachiocephalic trunk. On the left, it
branches directly from the arch of aorta.
The subclavian artery travels laterally towards the axilla. It can be divided into
three parts based on its position relative to the anterior scalene muscle:
 First part – origin of the subclavian artery to the medial border of the
anterior scalene.
 Second part – posterior to the anterior scalene.
 Third part – lateral border of anterior scalene to the lateral border of the
first rib.
At the lateral border of the first rib, the subclavian artery enters the axilla – and is
renamed the axillary artery.
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Axilla: Axillary Artery

The axillary artery lies deep to the pectoralis minor and is enclosed in the axillary
sheath (a fibrous layer that covers the artery and the three cords of the brachial
plexus).
Importantly, the artery can be divided into three parts based on its position
relative to the pectoralis minor muscle:
 First part – proximal to pectoralis minor
 Second part – posterior to pectoralis minor
 Third part – distal to pectoralis minor
The main branches of the axillary artery include:
First Part Second Part Third Part
Superior thoracic artery Thoracoacromial artery Subscapular artery
Lateral thoracic artery Anterior and posterior
circumflex arteries
The anterior and posterior circumflex humeral arteries form an anastomotic
network around the surgical neck of the humerus and can be damaged in cases of
fracture.
At the lower border of the teres major muscle, the axillary artery is renamed
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Upper Arm: Brachial Artery

The brachial artery is a continuation of the axillary artery past the lower border of
the teres major. It is the main supply of blood for the arm.
Immediately distal to the teres major, the brachial artery gives rise to
the profunda brachii (deep artery), which travels with the radial nerve in the
radial groove of the humerus and supplies structures in the posterior aspect of
the upper arm (e.g. triceps brachii). The profunda brachii terminates by
contributing to an anastomotic network around the elbow joint.
The brachial artery proper descends down the arm. As it moves through
the cubital fossa, underneath the bicipital aponeurosis, the brachial
artery terminates by bifurcating into the radial and ulnar arteries.
Forearm: Radial and Ulnar Arteries

The radial and ulnar arteries are formed by the bifurcation of the brachial artery
within the cubital fossa:
 Radial artery – supplies the posterolateral aspect of the forearm. It
contributes to anastomotic networks surrounding the elbow joint and
carpal bones.
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o The radial pulse can be palpated in the distal forearm, immediately

lateral to the prominent tendon of the flexor carpi radialis muscle.
 Ulnar artery – supplies the anteromedial aspect of the forearm. It
contributes to an anastomotic network surrounding the elbow joint.
o Also gives rise to the anterior and posterior interosseous arteries,
which supply deeper structures in the forearm.
These two arteries anastomose in the hand by forming two arches – the
superficial palmar arch, and the deep palmar arch.
Hand: Superficial and Deep
Palmar Arches
The hand has a rich arterial
supply with many anastomoses
between vessels. This allows
the hand to be perfused even
when under high resistance to
flow (such as when grasping or
applying pressure).
Arterial supply to the hand
begins with the ulnar and
radial arteries. The ulnar
artery enters the hand
anteriorly to the flexor
retinaculum and laterally to the
ulnar nerve. It gives rise to the
deep palmar branch and
continues laterally across the
palm as the superficial palmar
arch.
The radial artery enters the
hand dorsally, crossing the
floor of the anatomical
snuffbox. It then turns medially
and travels between the heads of the adductor pollicis muscle. The radial artery
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supplies a branch to the thumb, the index finger and to the superficial palmar
arch – it then continues as the deep palmar arch.
As a result, two arterial arches are formed:
 Superficial palmar arch – located anteriorly to the flexor tendons in the
hand and deep to the palmar aponeurosis. It gives rise to the digital
arteries, which supply the four fingers.
 Deep palmar arch – located deep to the flexor tendons of the hand. It
contributes to the blood supply to the digits and to the wrist joint.
Arterial supply to the hand, via the superficial and deep palmar arches
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The Venous Supply

The venous system of the upper limb drains deoxygenated blood from the arm,
forearm and hand. It can be subdivided into the superficial system and the deep
system.
In this article, we shall look at the anatomy of the upper limb veins – their
anatomical course, structure, and their clinical relevance.
Superficial Veins
The major superficial veins of the upper
limb are the cephalic and basilic veins.
They are located within the
subcutaneous tissue of the upper limb.
Basilic Vein
The basilic vein originates from the
dorsal venous network of the hand and
ascends the medial aspect of the upper
limb.
At the border of the teres major, the
vein moves deep into the arm. Here, it
combines with the brachial veins from
the deep venous system to form
the axillary vein.
Cephalic Vein
The cephalic vein also arises from the
dorsal venous network of the hand. It
ascends the antero-lateral aspect of the
upper limb, passing anteriorly at the
elbow.
At the shoulder, the cephalic vein
travels between the deltoid and
pectoralis major muscles (known as the
deltopectoral groove), and enters
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the axilla region via the clavipectoral triangle. Within the axilla, the cephalic vein
empties into axillary vein.
The cephalic and basilic veins are connected at the elbow by the median cubital
vein.
Deep Veins
The deep venous system of the upper limb is situated underneath the deep
fascia. It is formed by paired veins, which accompany and lie either side of an
artery. In the upper extremity, the deep veins share the name of the artery they
accompany.
The brachial veins are the largest in size, and are situated either side of the
brachial artery. The pulsations of the brachial artery assist the venous return.
Veins that are structured in this way are known as vena comitantes.
Perforating veins run between the deep and superficial veins of the upper limb,
connecting the two systems.
The major deep veins of the upper limb.
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The Joints of the Upper Limb
The Acromio-clavicular Joint

The acromio-clavicular joint is an articulation in the shoulder region between the
clavicle and the acromion of the
scapula.
Type: It is a plane type synovial
joint.
Articulating Surfaces
The acromio-clavicular joint
consists of an articulation between
the lateral end of the clavicle and
the acromion of the scapula.
It has two atypical features:
 Articular surfaces of the
joint are lined with
fibrocartilage – as opposed
to hyaline cartilage.
 Joint cavity is partially divided by an articular disc – a wedge of
fibrocartilage suspended from the upper part of the capsule.
Joint Capsule
The joint capsule of the acromio-clavicular joint encloses the two articular
surfaces. It consists of a loose layer of fibrous tissue, which is lined internally by a
synovial membrane.
The posterior aspect of the joint capsule is reinforced by fibres from
the trapezius muscle.
Ligaments
There are three main ligaments that strengthen and stabilise the
acromioclavicular joint:
 Acromio-clavicular ligament : runs horizontally from the acromion to the
lateral clavicle. It covers the joint capsule, reinforcing its superior aspect.
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 Conoid ligament : runs vertically from the coracoid process of the scapula
to the conoid tubercle of the clavicle.
 Trapezoid ligament : runs from the coracoid process of the scapula to the
trapezoid line of the clavicle.
The conoid and trapezoid ligaments are collectively known as the coraco-
clavicular ligament. It is a very strong structure, effectively suspending the weight
of the upper limb from the clavicle.
Movements
The acromioclavicular joint allows a gliding movement in the superior/inferior
and anteroposterior planes, along with a small amount of axial rotation.
As no muscle acts directly on the joint, all movements are passive, and are
initiated by movement at other joints
Blood Supply
The arterial supply to the acromioclavicular joint is via the:
 Suprascapular artery – arises from the subclavian artery at the
thyrocervical trunk.
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 Thoracoacromial artery – arises from the axillary artery.

The venous drainage accompanies the major arteries.
Innervation
The acromioclavicular joint is innervated by articular branches of
the suprascapular and lateral pectoral nerves. They both arise directly from the
brachial plexus.
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The Sterno-clavicular Joint

The sternoclavicular joint is an articulation between the clavicle and the
manubrium of the sternum.
It is a saddle-type synovial joint which acts to link the upper limb with the trunk.
In this article, we will examine the anatomy of the sternoclavicular joint – its
structure, neurovascular supply, and clinical considerations.
The sternoclavicular joint is formed by an articulation between three structures:
 Sternal end of the clavicle
 Manubrium of the sternum
 First costal cartilage (cartilage associated with the first rib)
The articular surfaces are covered with fibrocartilage (as opposed to hyaline
cartilage, present in the majority of synovial joints). The joint is separated into
two compartments by a fibrocartilaginous articular disc.
Joint Capsule
The joint capsule of the sternoclavicular joint extends to the borders of the
articular surfaces.
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It is lined internally by a synovial membrane, which produces synovial fluid to

reduce friction between the articulating structures.
Ligaments
The ligaments of the sternoclavicular joint provide much of its stability. There are
four main ligaments:
 Sternoclavicular ligaments (anterior and posterior) : reinforces the joint
capsule anteriorly and posteriorly.
 Interclavicular ligament : attaches to the sternal end of both clavicles and
reinforces the joint capsule superiorly.
 Costoclavicular ligament : attaches the first rib and costal cartilage to the
inferior surface of the clavicle.
o It is the main stabilising force for the joint, resisting elevation of the
pectoral girdle.
Movements
The sternoclavicular joint has a large degree of mobility, with several movements
possible:
 Elevation of the shoulders – shrugging the shoulders or abducting the arm
over 90º
 Depression of the shoulders – drooping shoulders or extending the arm at
the shoulder behind the body
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 Protraction of the shoulders – moving the shoulder girdle anteriorly

 Retraction of the shoulders – moving the shoulder girdle posteriorly
 Rotation – when the arm is raised over the head, the clavicle rotates
passively as the scapula rotates.
Mobility:
 Type of joint : being a saddle joint it can move in two axes.
 Articular disc : this allows the clavicle and the manubrium to slide over
each other more freely, allowing for rotation and movement in a third axis.
Stability:
 Joint capsule : thick and strong.
 Ligaments : particularly the costoclavicular ligament, which transfers forces
from the clavicle to the manubrium (via the costal cartilage).
Blood Supply
The arterial supply to the sternoclavicular joint is from the internal thoracic artery
and the suprascapular artery.
Innervation
The sternoclavicular joint is supplied by the medial supraclavicular nerve (C3 and
C4) and the nerve to subclavius (C5 and C6).
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The Shoulder Joint

The shoulder joint (gleno-humeral joint) is an articulation between the glenoid
cavity of the scapula and the head of the humerus.
Type: Ball and socket synovial joint, and one of the most mobile joints in the
human body.
The shoulder joint is formed by an articulation between the head of the humerus
and the glenoid cavity (or fossa) of the scapula.
Like most synovial joints, the articulating surfaces are covered with hyaline
cartilage.
The head of the humerus is much larger than the glenoid fossa, giving the joint a
wide range of movement at the cost of instability. To reduce the disproportion in
surfaces, the glenoid fossa is deepened by a fibrocartilage rim – called
the glenoid labrum.
Joint Capsule
 The joint capsule is thin & lax (permitting greater mobility).
 Attachments: It extends from the anatomical neck of the humerus to the
border or ‘rim’ of the glenoid fossa.
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The synovial membrane lines the inner surface of the joint capsule and produces
synovial fluid to reduce friction between the articular surfaces.
Ligaments
Ligaments play an important role in stabilising the shoulder joint:
 Gleno-humeral ligaments (superior, middle and inferior) : extend from the
humerus to the glenoid fossa, reinforcing the joint capsule. They act to
stabilise the anterior aspect of the joint.
 Coraco-humeral ligament : extends from the base of the coracoid process
to the greater tuberosity of the humerus. It supports the superior part of
the joint capsule.
 Transverse humeral ligament : extends between the two tubercles of the
humerus ( over the upper part of the bicipital groove). It holds the tendon
of the long head of the biceps in the intertubercular groove.
 Coraco-acromial ligament : extends between the acromion and coracoid
process of the scapula, forming an arch-like structure over the shoulder
joint (coracoacromial arch). This resists superior displacement of the
humeral head.
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Bursae
A bursa is a synovial fluid filled sac, which acts as a cushion between tendons and
other joint structures. There are several bursae present in the shoulder joint:
 Subacromial :between coracoacromial ligament & acromion above and the
supraspinatous muscle tendon below. and
 Subscapular : between the the subscapularis muscle tendon & the front of
the shoulder joint capsule.
 Infraspinatous: between the tendon of the infraspinatous muscle & the
back of the capsule of the shoulder joint
 Subcutaneous: between the upper surface of acromion & the skin.
Movements
The shoulder joint is an extremely mobile joint, with a wide range of movement
possible:
 Extension (upper limb backwards in sagittal plane) : posterior deltoid,
latissimus dorsi and teres major.
 Flexion (upper limb forwards in sagittal plane) : pectoralis major, anterior
deltoid and coracobrachialis. Biceps brachii weakly assists in forward
flexion.
 Abduction (upper limb away from midline in coronal plane):
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o The first 0-15 degrees of abduction is produced by the supraspinatus.

o The middle fibres of the deltoid are responsible for the next 15-90
degrees.
o Past 90 degrees, the scapula needs to be rotated to achieve
abduction – that is carried out by the trapezius and serratus anterior.
 Adduction (upper limb towards midline in coronal plane) – pectoralis
major, latissimus dorsi and teres major.
 Internal rotation (rotation towards the midline, so that the thumb is
pointing medially) – subscapularis, pectoralis major, latissimus dorsi, teres
major and anterior deltoid.
 External rotation (rotation away from the midline, so that the thumb is
pointing laterally) – infraspinatus and teres minor.
 Circumduction (moving the upper limb in a circle) – produced by a
combination of the movements described above.
Mobility: The shoulder joint is one of the most mobile in the body
 Type of joint : ball and socket joint.
 Bony surfaces : shallow glenoid cavity and large humeral head – there is a
1:4 disproportion in surfaces. A commonly used analogy is the golf ball and
tee.
 Joint capsule : lax
Stability: The shoulder joint is unstable joint
 Rotator cuff muscles : surround the shoulder joint, attaching to the
tuberosities of the humerus, whilst also fusing with the joint capsule. The
resting tone of these muscles act to compress the humeral head into the
glenoid cavity.
 Glenoid labrum : a fibrocartilaginous ridge surrounding the glenoid cavity.
It deepens the cavity and creates a seal with the head of humerus, reducing
the risk of dislocation.
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 Ligaments : act to reinforce the joint capsule and form the coracoacromial
arch.
 Biceps tendon : it acts as a minor humeral head depressor, thereby
contributing to stability.
Blood Suppy: supplied by

1. The anterior and posterior circumflex humeral arteries (branches of the
axillary artery).
2. The suprascapular artery (branch of the thyrocervical trunk).
3. The subscapular artery.
Innervation: supplied by
1. The axillary nerve.
2. The musculocutaneous nerve.
3. The suprascapular nerve.
4. The lateral pectoral nerve.
116
The Elbow Joint

Type: hinge-type synovial joint.
The elbow joint consists of two separate articulations:
 Trochlear notch of the ulna and the trochlea of the humerus
 Head of the radius and the capitulum of the humerus
Joint Capsule and Bursae

Like all synovial joints, the elbow joint has a capsule enclosing the joint. This in
itself is strong and fibrous, strengthening the joint. The joint capsule is thickened
medially and laterally to form collateral ligaments, which stabilise the flexing and
extending motion of the arm.
A bursa is a membranous sac filled with synovial fluid. It acts as a cushion to
reduce friction between the moving parts of a joint, limiting degenerative
damage. There are many bursae in the elbow, but only a few have clinical
importance:
117
 Intratendinous olecranon : located within the tendon of the triceps brachii.

 Subtendinous olecranon : between the olecranon and the tendon of the
triceps brachii, reducing friction between the two structures during
extension and flexion of the arm.
 Subcutaneous olecranon bursa : between the olecranon and the overlying
connective tissue (implicated in olecranon bursitis).
Ligaments
The joint capsule of the elbow is strengthened by ligaments medially and laterally.
 The radial collateral ligament : on the lateral side of the joint, extending
from the lateral epicondyle, and blending with the annular ligament of the
radius (a ligament from the proximal radioulnar joint).
 The ulnar collateral ligament: originates from the medial epicondyle, and
attaches to the coronoid process and olecranon of the ulna.
Blood Supply
The elbow joint receives a rich arterial supply from a surrounding network of
vessels (anastomosis around the elbow joint), which is formed by branches of
118
Innervation: The elbow joint is innervated by branches of:

1. The musculocutaneous nerve.
2. The radial nerve.
3. The ulnar nerve.
Movements
The orientation of the bones forming the elbow joint produces a hinge type
synovial joint, which allows for extension and flexion of the forearm:
 Extension : triceps brachii and anconeus
 Flexion : brachialis, biceps brachii, brachioradialis
119
The Wrist Joint

The wrist joint is an articulation between the radius and the carpal bones of the
hand.
Type: It is ellipsoid-type synovial joint
The wrist joint is formed by an articulation between:
 Distal end of the radius and the articular disk below the head of the ulna
(Concave).
 Proximal row of the carpal bones except the pisiform (Convex).
Together, the carpal bones form a convex surface, which fits into the concave
shape of the radius and articular disk.
The ulna is prevented from articulating with the carpal bones by the presence of a
fibrocartilaginous ligament, the articular disk. Instead, the ulna articulates with
the radius just proximal to the wrist – at the distal radioulnar joint.
120
Joint Capsule
The joint capsule of the wrist joint attaches to the lower end of radius, ulna and
the proximal row of the carpal bones.
It is lined internally by a synovial membrane, which produces synovial fluid to
reduce friction between the articulating structures.
Ligaments
There are four main ligaments located at the wrist joint:
 Palmar radio-carpal : on the palmar (anterior) surface of the joint. It passes
from the radius to both rows of carpal bones. It increases the stability of
the wrist joint.
 Dorsal radio-carpal : on the dorsum (posterior) surface of the hand. It

passes from the radius to both rows of carpal bones. It contributes to the
stability of the wrist.
 Ulnar (medial) collateral : from the ulnar styloid process to the triquetrum
and pisiform. It acts to prevent excessive radial (lateral) deviation of the
hand.
 Radial (lateral) collateral : from the radial styloid process to the scaphoid.
It acts to prevent excessive ulnar (medial) deviation of the hand.
121
Movements
The wrist is an ellipsoidal (condyloid) type synovial joint, allowing for movement
along two axes. This means that flexion, extension, adduction and abduction can
all occur at the wrist joint.
All the movements of the wrist are performed by the muscles of the forearm.
 Flexion : Produced mainly by the flexor carpi ulnaris, flexor carpi radialis,
with assistance from the flexor digitorum superficialis.
 Extension : Produced mainly by the extensor carpi radialis longus and
brevis, and extensor carpi ulnaris, with assistance from the extensor
digitorum.
 Adduction : Produced by the extensor carpi ulnaris and flexor carpi ulnaris
 Abduction : Produced by flexor carpi radialis, extensor carpi radialis longus
and brevis, the abductor pollicis longus, extensor pollicis brevis.
Mobility and Stability
 The wrist joint is a highly mobile joint to allow the hand to move in several
directions. Because of this, the wrist joint is prone to injury.
 The extrinsic ligaments: include

1. The palmar & dorsal radio-carpal ligaments.
2. The radial and ulnar collateral ligaments.
Blood Supply
The wrist joint receives blood from branches of the dorsal and palmar carpal
arches, which are derived from the ulnar and radial arteries.
Innervation: by branches of:
1. Median nerve : Anterior interosseous branch.
2. Radial nerve : Posterior interosseous branch.
122
The Joints of the Hand

The meta-carpo-phalangeal joint
The metacarpophalangeal joint is an articulation between the metacarpal head
and the base of the proximal phalanx.
There are five joints located in each hand – one for each
digit.
Type: a condyloid synovial joint.
The metacarpophalangeal joint consists of an articulation
between two bones of the hand:
 Metacarpal head : large articulating surface, convex
shape.
 Base of proximal phalanx : smaller articulating
surface, concave shape.
Both the metacarpal and phalangeal articular surfaces are lined by hyaline
cartilage.
Joint Capsule
Each metacarpophalangeal joint is covered by a loose fibrous joint capsule that
attaches close to the margins of the articulating surfaces.
The joint capsule is thicker on the medial and lateral aspects – where it is
reinforced by collateral ligaments.
Ligaments
The metacarpophalangeal joint capsule is reinforced by several ligaments and
adjacent musculoskeletal structures.
 The collateral metacarpophalangeal ligaments (medial & lateral): on the
medial & lateral aspects of the joint capsule.
 The palmar ligament: at the anterior aspect of the joint capsule.
123
 The deep transverse metacarpal ligaments: are strong band which extend
transversely between the palmar ligaments of 2nd-5th
metacacarpophalangeal joints.
The posterior aspect of the joint capsule receives fibres from the overlying
tendons of the extensor muscles of the forearm (extensor pollicis longus,
extensor indicis, extensor digitorum, and extensor digiti minimi).
Movements
Each metacarpophalangeal joint has two planes of motion. It allows for flexion,
extension, abduction, adduction, circumduction and limited rotation of the digit.
All of the movements at the joint are produced by muscles of the forearm and
hand.
Thumb
 Flexion – produced by flexor pollicis brevis and longus.
 Extension – produced by extensor pollicis brevis and longus.
 Adduction – produced by adductor pollicis.
 Abduction – produced by abductor pollicis longus and brevis.
 Axial rotation – produced by simultaneous contraction of the flexor pollicis
brevis and abductor pollicis brevis.
124
Medial 4 fingers:
 Flexion – produced by flexor digitorum superficialis, flexor digitorum
profundus, lumbricals, flexor digiti minimi (little finger).
 Extension – produced by extensor digitorum, extensor indicis (index), and
extensor digiti minimi (little finger).
 Adduction – produced by palmar interossei muscles.
 Abduction – produced by the dorsal interossei muscles. Abduction of the
fifth digit is also produced by the abductor digiti minimi.
Mobility and Stability

The major stabilisers of the metacarpophalangeal joint are the collateral
ligaments. The proper collateral ligaments primarily limit hyperflexion, while the
accessory collateral ligaments limit hyperextension.
The main function of the palmar ligament is to prevent hyperextension. The deep
transverse metacarpal ligaments contribute to MCPJ stability during grip
functions.
125
The Interphalangeal Joints

The proximal interphalangeal joint (PIPJ) refers to the articulation between the
proximal and middle phalanx in the hand. It is present in all digits except the
thumb.
It is a synovial hinge joint which permits flexion
and extension in center of the fingers,
contributing to fine motor control.
The proximal interphalangeal joint is formed
by the articulation between the head of the
proximal phalanx and the base of the middle
phalanx:
 Head of the proximal phalanx – formed
by two curved condylar processes, which
form a shallow groove in the middle.
 Base of the middle phalanx – formed by
two opposing concave sections which
form a raised ridge. This ridge fits neatly
into the proximal groove and provides great intraarticular stability.
Joint Capsule
Each proximal interphalangeal joint is surrounded by a small fibrous capsule. It is
lined by a synovial membrane and filled with synovial fluid.
Ligaments
The proximal interphalangeal joint capsule
is strengthened by surrounding ligaments:
o The collateral ligaments are located on the
radial and ulnar aspect of the joint. They
prevent excessive adduction and abduction
at the PIPJ.
o The palmar ligaments
126
Movements
Given the nature of hinge joints and the stability of the proximal interphalangeal
joint, it only moves in one plane: flexion and extension.
 Flexion:
o The primary muscle that drives PIPJ flexion is flexor digitorum
superficialis.
o The secondary driver of PIPJ flexion is flexor digitorum profundus (it
primarily flexes the distal interphalangeal joint).
 Extension:
o It is achieved by the extensor digitorum, lumbricals, and interossei
muscle
o The index finger PIPJ gets further assistance from extensor indicis.
Blood Supply
Arterial supply to the proximal interphalangeal joint is via the palmar digital
arteries.
Innervation
Sensory innervation to the proximal interphalangeal joint is from the palmar
digital nerves. They arise from branches of the median and ulnar nerves within
the hand.
127

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Anatomy of The

The Muscles of the Pectoral Region 27

The Muscles of the Scapular Region 30

The Muscles of the Arm 38

The Muscles of the Forearm 41

The Muscles of the Hand 52

The Anatomical Areas of the Upper Limb 59

The Brachial Plexus 67

The Nerves of the Upper Limb 74

The Arterial Supply of the Upper Limb 98

The Joints of the Upper Limb 106

(1) The Scapula

 Surfaces of the scapula:

2. Posterior surface : faces backwards. It is a site of origin for the majority of

 Borders of the Scapula:

o Extends from the glenoid cavity to the inferior angle.

 Angles of the Scapula:

 Notches of the scapula:

3. Circumflex scapular notch:

Muscles attached to the scapule:

(2) The Clavicle

The clavicle (collar bone) extends between the

It is classed as a long bone and can be palpated

 Attaches the upper limb to the trunk as

1. Sternal (medial) End

2. Acromial (lateral) End

o The lower surface of the lateral 1/3:

o The coraco-clavicular ligament: is a very strong structure,

Identification of the side (Right or Left):

Muscles attached to the clavicle:

 The proximal aspect of the humerus articulates with the

 Distally, at the elbow joint, the humerus articulates with

The Proximal End:

3. The greater tuberosity:

4. The lesser tuberosity:

5. The intertubercular sulcus (Bicipital groove):

 It separates the greater & the lesser tuberosities.

 The lower part is smooth & rounded.

 The shaft has 3 surfaces:

 The following muscles attach to the humerus along its shaft:

The Distal End

 lateral & Medial epicondyles:

 It is located immediately distal to the supra-condylar ridges

 The capitulum : lateral to the trochlea , it articulates with the radius.

1. The coronoid: located anterior & medial.

2. The radial fossa: located anterior & lateral.

3. The olecranon fossa: located posterior above the trochlea.

Muscles attached to the humerus:

Shaft of the Ulna

Muscles attached to the ulna:

 Anterior & Medial surfaces:

(5) The Radius

Shaft of the Radius

Distal End of the Radius

Identification of the side (Right or Left):

Muscles attached to the radius:

(6) The bones of the Hand

1. The pectoralis major muscle.

o Clavicular head – originates from the anterior surface of the

 Nerve Supply: Lateral and medial pectoral nerves.