The Upper Limb

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The Upper Limb

• Viroj Mitranonda

Department of Anatomy Faculty of Science Mahidol
University
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Parts of the upper limb

• Shoulder or Scapular region
• Arm
• Forearm
• Hand

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Bones

• Shoulder Scapula, Clavicle
• Arm Humerus
• Forearm Radius, Ulna
• Hand 8 carpal bones,
• 5 metacarpal bones,
• 14 phalanges
• carpal bones
• trapezium, trapezoid, capitate, hamate
• scaphoid, lunate, triquetrum, pisiform

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Superficial structures of the upper limb

• Cutaneous nerves
• Superficial veins
• Lymph vessels

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Cutaneous nerves of the upper limb

• Shoulder
• Lateral branches of the supraclavicular
  n.(c.3,4)
• Arm
• Upper lateral cutaneous nerve of arm (axillary
  n.)
• Lower lateral cutaneous nerve of arm (radial
  n.)
• Medial cutaneous nerve of arm (medial cord)
• Posterior cutaneous nerve of arm (radial n.)
• Intercosto-brachial nerve (T.2)

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Cutaneous nerves of the upper limb (continued)
Forearm

• Lateral cutaneous nerve of forearm (from
  musculocutaneous n.)
• Medial cutaneous nerve of forearm (from
  medial cord)
• Posterior cutaneous nerve of forearm (from
  radial n.)

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Cutaneous nerves of the upper limb (continued)
Hand

• Lateral 3 1/2
• of the palm Cutaneous branches of the median
  n.
• of the dorsum Cutaneous branches of the radial
  n
• Medial 1 1/2
• of the palm Cutaneous branches of the ulnar
  n.
• of the dorsum Cutaneous branches of the ulnar
  n.
• Distal part of the dorsum of the lateral 3 1/2
  fingers
• Cut. br. of the median n.

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Superficial veins of the upper limb

• Digital veins
• Dorsal venous arch
• Cephalic vein
• Basilic vein
• Median cubital vein
• Median veins of forearm
• (Median cephalic vein)
• (Median basilic vein)

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The lymph vessels

• Accompanied the superficial veins
• The medial side
• drains to the lateral group of the axillary node
• The lateral side
• drains to the delto-pectoral node

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Muscles found in the shoulder (scapular) region

• Axillary nerve
• Suprascapular nerve
• Suprascapular nerve
• Axillary nerve
• Upper and Lower subscapular nerves
• Lower subscapular nerve

• Deltoideus muscle
• Supraspinatus muscle
• Infraspinatus muscle
• Teres minor muscle
• Subscapularis muscle
• Teres major muscle

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The rotator cuff muscles
Consists of

• Supraspinatus m.
• Infraspinatus m.
• Teres minor m.
• Subscapularis m.

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Deltoideus muscle

• Origin Lateral 1/3 of clavicle,
• Acromion, Spine of scapula
• insertion Humerus, deltoid tuberosity
• Action Arm Flexion, medial rotation,
• Abduction, extension, lateral rotation
• nerve Axillary nerve

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Supraspinatus muscle

• Origin Scapula, supraspinous fossa
• Insertion Upper facet of greater tuberosity of
  Humerus
• Action Abduction
• Nerve Suprascapular nerve

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Infraspinatus muscle
Origin Scapula, infraspinous
fossa Insertion Middle facet of greater
tuberosity of the Humerus Action Lateral
rotation Nerve Suprascapular nerve
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Teres minor muscle
Origin Scapula, superior 2/3 Lateral
margin Insertion Lower facet of greater
tuberosity of the Humerus Action Lateral
rotate nerve Axillary nerve
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Subscapularis muscle

• Origin Scapula, subscapular fossa
• Insertion Lesser tuberosity of the Humerus
• Action Medial rotation
• Nerve Upper and lower subscapular nerve

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Teres major muscle

• Origin Inf. 1/3 lat. margin of scapula
• Insertion Humerus, crest of lesser tubercle
• Action Adduction,medial rotate, extension
• Nerve Lower subscapular nerve

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The arm
Flexor muscles of the arm

• Musculocutaneous n.
• Musculocutaneous n.
• Musculocutaneous radial nn.

• Coracobrachialis m.
• Biceps brachii m.
• Brachialis m.

Extensor muscle of the arm

• Triceps brachii m.

• Radial n.

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Biceps brachii muscle

• Origin Short head Coracoid process
• Long head Supraglenoid tubercle
• Insertion Radial tuberosity, bicipital
  aponeurosis
• Action Supination, flexes elbow
• Nerve Musculocutaneous nerve

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Coracobrachialis muscle

• Origin Coracoid process
• Insertion Humerus, middle of body,medial
• Action Flexion (flexes shoulder)
• Nerve Musculocutaneous nerve

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Brachialis muscle

• Origin Humerus, ant. surface distal 1/2
• Insertion Ulna, coronoid process,
• ulnar tuberosity
• Action Flexes elbow
• Nerve Musculocutaneuos n. radial n.

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Cubital fossa
Boundaries

• Base Imaginary line between the condyles
  of the humerus
• Laterally Brachioradialis muscle
• Medially Pronator teres muscle
• Apex Brachioradialis m. overlapped
  Pronator teres m.
• Roof Skin, superficial fascia veins,
  bicipital aponeurosis
• Floor Brachialis m.,Supinator m.
• Contents Tendon of Biceps brachii m. Brachial
  a. and its
• terminal branches(radial a. and
  ulnar a.) Median n., fat

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Triceps brachii muscle

• Origin Long headScapula, infraglenoid
  tubercle
• Lateral head Humerus, post.
  surface
• above groove for radial
  nerve
• Medial head below groove for
  radial n.
• Insertion Ulna,olecranon process
• Action Extends elbow
• Nerve Radial nerve

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The forearm
Flexor muscles of forearm
Superficial layer

• Pronator teres muscle
• Flexor carpi radialis muscle
• Palmaris longus muscle
• Flexor carpi ulnaris muscle

Median nerve Median nerve Median nerve Ulnar
nerve
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Flexor muscles of forearm (continued)
Intermediate layer

• Flexor digitorum superficialis (sublimis) muscle

Median nerve
Deep layer

• Flexor pollicis longus muscle
• Flexor digitorum profundus muscle
• Pronator quadratus muscle

Median nerve MedianUlnar nn. Median nerve
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Pronator teres muscle

• Origin Medial epicondyle of humerus,
• Coronoid process of ulna
• Insertion Midlateral surface of radius
• Action Pronation
• Nerve Median nerve

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Flexor carpi radialis muscle

• Origin Medial epicondyle of humerus
• Insertion Base of 2nd and 3rd metacarpal bones
• Action Flexes and abducts wrist (hand)
• Nerve Median nerve

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Palmaris longus muscle

• Origin Medial epicondyle of humerus
• Insertion Palmar aponeurosis
• Action Flexes wrist
• Nerve Median nerve

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Flexor carpi ulnaris muscle

• Origin Medial epicondyle of humerus,
• Upper dorsal border of ulna
• Insertion Pisiform bone
• ( base of 5th metacarpal bone)
• Action Flexes wrist, adduct wrist (hand)
• Nerve Ulnar nerve

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Flexor digitorum superficialis muscle

• Origin Medial epicondyle of humerus,
• Coronoid process of ulna,
• Oblique line of radius
• Insertion Middle phalanges of medial four
  fingers
• Action Flexes middle phalanges of each
  finger,
• Flexion of MP PIP joints
• Nerve Median nerve

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Flexor pollicis longus muscle

• Origin Radius, ant. surface middle 1/2
• Insertion Distal phalanx of thumb
• Action Flexes thumb
• Nerve median nerve

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Flexor digitorum profundus muscle

• Origin Ulna, prox. 2/3 ant. and medial
  surfaces
• Insertion Bases of distal phalanges of medial
  four fingers
• Action Flexes distal phalanges of each
  finger (DIP joints)
• Flexes MP IP joints (PIP joints)
• Nerve Median and ulnar nerves
• (lateral 1/2 median nerve, medial 1/2
  ulnar nerve)

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Pronator quadratus muscle

• Origin Ulna, ant. surface distal 1/4
• Insertion Radius, ant. surface distal 1/4
• Action Pronation. Holds radius to ulna
• Nerve Median nerve

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THE HAND
Viroj Mitranonda
Department of Anatomy Faculty of Science Mahidol
University
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Muscles of the hand
3 Thenar muscles

• Abductor pollicis brevis m.
• Flexor pollicis brevis m.
• Opponens pollicis m.

• Median n.
• Median n.
• Median n.

• Adductor pollicis m.

• Ulnar n.

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Muscles of the hand (continued)
3 Hypothenar muscles

• Abductor digiti minimi m.
• Flexor digiti minimi m.
• Opponens digiti minimi m.

• Ulnar n.
• Ulnar n.
• Ulnar n.

• 3 Palmar interossei mm.
• 4 Dorsal interossei mm.
• 4 Lumbricales mm.

• Ulnar n.
• Ulnar n.
• 1st and 2nd Median n.
• 3rd and 4th Ulnar n.

Palmaris brevis m.
Ulnar n.
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Extensor muscles of forearm
Superficial group

• Brachioradialis m.
• Extensor carpi radialis longus m.
• Extensor carpi radialis brevis m.

Laterally
Posteriorly

• Extensor digitorum m.
• Extensor digiti minimi m.
• Extensor carpi ulnaris m.
• Anconeus m.

Radial nerve deep branch of
radial nerve
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Extensor muscles of forearm (continued)
Deep group

• Supinator m.
• Abductor pollicis longus m.
• Extensor pollicis brevis m.
• Extensor pollicis longus m.
• Extensor indicis m.

Nerve supply Deep branch of radial nerve
or posterior interosseous nerve
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Brachioradialis muscle

• Origin Humerus, lateral supracondylar line
• Insertion Radius, base of styloid process
• Action Flexes elbow
• Nerve Radial nerve

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Extensor carpi radialis longus muscle

• Origin Humerus, lateral supracondylar line
• Insertion Base of second metacarpal bone
• Action Extends wrist, abduct hand
• Nerve Radial nerve

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Extensor carpi radialis brevis muscle

• Origin Humerus, lateral epicondyle
• Insertion Base of third metacarpal bone
• Action Extends wrist, abduct hand
• Nerve Deep branch of the radial nerve

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Extensor carpi ulnaris muscle

• Origin Lateral epicondyle of humerus,
• posterior border of ulna
• Insertion Base of fifth metacarpal bone
• Action Extends wrist, adduct hand
• Nerve Deep branch of radial nerve

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Extensor digitorum muscle

• Origin Humerus, lateral epicondyle
• Insertion Middle and distal phalanges,
• extensor expansion
• Action Extends phalanges
• Nerve Deep branch of radial nerve

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Extensor digiti minimi muscle

• Origin Humerus, lateral epicondyle
• Insertion Extensor expansion of fifth digit
• Action Extends fifth digit
• Nerve Deep branch of radial nerve

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Anconeus muscle

• Origin Lateral epicondyle of humerus
• Insertion Proximal 1/3 lat. surface of ulna
• Action Holds ulna to radius, extends
  elbow
• Nerve Radial nerve

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Supinator muscle

• Origin Humerus, lateral epicondyle
• Ulna, supinator crest
• Insertion Proximal 1/3 of radius
• Action Supination
• Nerve Deep branch of radial nerve

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Abductor pollicis longus muscle

• Origin Radius and ulna distal to supinator
  m.
• Insertion Base of first metacarpal bone
• Action Abducts thumb
• Nerve Deep branch of radial nerve
• (Posterior interosseous nerve)

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Extensor pollicis brevis muscle

• Origin Radius, posterior surface
• Insertion Base of proximal phalanx of thumb
• Action Extends thumb
• Nerve Deep branch of radial nerve
• (Posterior interosseous nerve)

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Extensor pollicis longus muscle

• Origin Middle 1/3 post. surface of ulna
• Insertion Distal phalanx of thumb
• Action Extends thumb
• Nerve Deep branch of radial nerve
• (Posterior interosseous nerve)

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Extensor indicis muscle

• Origin Ulna, posterior surface
• Insertion Extensor expansion
• Action Extends index
• Nerve Deep branch of radial nerve
• (Posterior interosseous nerve)

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Out cropping muscles

• Abductor pollicis longus m.
• Extensor pollicis brevis m.
• Extensor pollicis longus m.

Bounded the anatomical snuff box
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Tendon of the muscles in the fascial tunnels

• 2 Abductor pollicis longus and extensor
  pollicis brevis
• 3 Extensor carpi radialis longus and brevis
• 1 Extensor pollicis longus
• 5 Extensor digitorum and extensor indicis
• 6 Extensor digiti minimi
• 4 Extensor carpi ulnaris

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Arthrology (Study of joint)
1. According to the movement
1.1 Immovable or synarthrosis eg. suture
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• 1.2 Slightly movable or amphi(ar)throsis
• Fibrous tissue lies between the bones
  (syndesmosis) eg. Intermediate
  radio-ulnar jt.
• Cartilage joins the bones (synchondrosis) eg.
  Pubic symphysis, intervertebral disc,
  sterno-costal joint

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• 1.3 Freely movable (diarthrosis)
• have joint cavity, joint capsule eg.
  Shoulder joint, elbow joint

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2.According to the structures found in the joint

• 2.1. Fibrous joint
• there are fibrous tissue in the joint eg.
  Suture, radio-ulnar joint, tibio-fibular joint

• 2.2. Cartilagenous joint
• there are cartilage in the joint eg. Pubic
  symphysis, sterno-costal joint

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2.3. Synovial joint
General patterns of synovial joint

• There are at least 2 bones
• Its articular surfaces lied with hyaline
  cartilage (articular cartilage)
• It has articular or joint capsule
• It has joint cavity
• Inner surface of the joint capsule lied with
  synovial membrane which secrete the synovial
  fluid or synovia

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Classification of the synovial joint
Classified into 7 types
1. The ball and socket type

• For example shoulder joint
• Bones humerus and scapula
• Ball the head of the humerus
• Socket primary socket is the glenoid
  cavity of the scapula
  secondary socket is the coraco-acromial
  ligament

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The ball and socket type (continue)

• Movement multiaxial - flex, extend,
  adduct,abduct and circumduct
• Joint capsule thin fibrous membrane
• Ligaments coraco-humeral, superior, middle
  and inferior gleno-humeral ligaments

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2. Hinge type

• For example the elbow joint
• Bones humerus, ulna and radius
• Movement around horizontal axis flex and
  extend
• Joint capsule thin at the anterior and
  posterior sides thicken at medial and lateral
  sides
• Ligaments medial or ulnar collateral
  ligament lateral or radial collateral ligament

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3. Pivot type

• For example proximal radio-ulnar joint
• Bones radius and ulna
• Movement around the vertical axis
  medial and lateral rotation
• Ligament annular ligament

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4. Ellipsoidal type

• For example wrist or radio-carpal joint
• Bones distal end of radius, scaphoid,
  lunate and triquetrum
• Movement modified hinge type flex,
  extend, adduct and abduct
• Ligaments medial or ulnar collateral
  ligament lateral or radial collateral ligament

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5. Plane or gliding type

• For example intercarpal joints
• Bones carpal bones
• Movement gliding
• Ligaments interosseous ligaments

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6. Saddle type

• For example 1st carpometacarpal joint
• Bones 1st metacarpal bone and
  trapezium
• Movement flex, extend, adduct, abduct
  and circumduct

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7. Condyloid type

• For example metacarpophalangeal joint
  (MP) interphalangeal joint (IP)
• Bones metacarpal bone, phalanges
• Movement flex and extend, (adduct,
  abduct)
• Ligaments medial and lateral collateral
  ligaments

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Joints of the upper limb

• Sternno-clavicular joint
• Coraco-acromial joint
• Coraco-clavicular joint
• Acromio-clavicular joint
• Shoulder joint
• Elbow joint

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Joints of the upper limb (continue)

• Radio-ulnar joints (prox.,middle and distal)
• Wrist or radio-carpal joint
• Intercarpal joints
• Carpometacarpal joints
• Intermetacarpal joints
• Metacarpophalangeal joints (MP joint)
• Interphalangeal joints (IP joint)

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NERVE LESIONS OF UPPER LIMBS
BY
VIROJ MITRANONDA Department of Anatomy Faculty
of Science, Mahidol University
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