The Upper Extremity

Bones, Muscles, Vessels,

Bones 30 bones!!!! Appendicular skeleton Pectoral girdle

Scapula Clavicle

Allows for mobility Ball and socket attachments

Upper extremity: Arm

humerus Forearm

Radius, ulna (interosseous membrane)

Hand Carpals, metacarpals, phalanges

Review bones and landmarks studied in lab!!!

Glenoid cavity

Joints of Upper Extremity

Sternoclavicular Synovial-saddle Diarthrosis

Acromioclavicular Synovial-plane Diarthrosis

Glenohumeral joint Synovial-ball&socket Diarthrosis Many ligaments Muscle reinforcement Great Mobility

Joints of the Upper Extremity

Elbow Joint Synovial – hinge Diarthrosis

Articulations Humerus & Ulna Humerus & Radius

Many Ligaments

Joints of Upper Extremity

Proximal Radioulnar joint Synovial - pivot Diarthrosis

Distal Radioulnar joint Synovial – pivot Diarthrosis

Allows pronation and supination of forearm

Radiocarpal joint Synovial-condyloid Distal radius with proximal row of

carpals Intercarpal joints

Synovial-plane Carpal-metacarpal (2-5)

Synovial-plane Trapezium-metacarpal 1

Synovial-saddle Metacarpal-phalangeal

Synovial-condyloid Interphalangeal

Synovial-hinge ALL DIARTHROSES

Joints of the Upper Extremity

Review of Naming…..

What do the following names TELL you about the muscle? Naming

Flexor carpi ulnaris Flexor digitorum superficialis Flexor pollicis longus Pronator quadratus Extensor carpi radialis brevis

Scapula Muscles If the origin is on the

scapula – moves the arm Subscapularis Supraspinatus Infraspinatus Teres Minor Teres Major Latissimus Dorsi (partial

attachment) Coracobrachialis

RotatorCuff

Scapula Muscles

If the insertion is on the scapula – moves the scapula Rhomboids Trapezius Pectoralis Minor Serratus Ventralis Levator Scapulae

Use location of Insertion to determine movement!!

Scapula Innervation

Origin on scapula Subscapularis and

teres major Subscapular

Supraspinatus and Infraspinatus Suprascapular

Teres Minor Axillary

Latissimus Dorsi Thoracodorsal

Coracobrachialis Musculocutaneous

Insertion on scapula Rhomboids and Levator

Scapulae Dorsal scapular

Trapezius Accessory

Pectoralis Minor Medial and Lateral

Serratus Ventralis Long thoracic

Muscles of the Rotator CuffAll INSERT on the humerus

MuscleMuscle OriginOrigin ActionAction

SubscapularisSubscapularis Subscapular fossaSubscapular fossa Medial rotator of Medial rotator of the humerusthe humerus

infraspinatusinfraspinatus Infraspinous Infraspinous fossafossa

Lateral rotator of Lateral rotator of the humerusthe humerus

Teres minorTeres minor Lateral border of Lateral border of scapula (upper scapula (upper 2/3)2/3)

Lateral rotator of Lateral rotator of the humerusthe humerus

supraspinatussupraspinatus Supraspinous Supraspinous fossafossa

Abducts the Abducts the humerushumerus

Muscles of the Scapula *All these muscles INSERT on the scapula

MuscleMuscle OriginOrigin ActionActionTrapeziusTrapezius Ligamentum Ligamentum

nuchae and C7-T12nuchae and C7-T12Elevates, adducts, Elevates, adducts, rotates, and rotates, and depresses the depresses the scapulascapula

Levator Scapulae Levator Scapulae ventralisventralis

C1-C4C1-C4 Elevates the Elevates the scapula, flexes scapula, flexes neck laterallyneck laterally

RhomboidsRhomboids C7-T5C7-T5 Adduct, elevate, Adduct, elevate, and rotate the and rotate the scapulascapula

Pectoralis minorPectoralis minor Ribs 3-5Ribs 3-5 Depresses and Depresses and rotates the scapularotates the scapula

Serratus anteriorSerratus anterior Ribs 1-9Ribs 1-9 Protracts and Protracts and rotates the scapularotates the scapula

Arm Muscles

Cross elbow, move forearm

2 compartments Anterior

Flexors of forearm

Posterior Extensors of forearm

Arm Muscles

Anterior compartment Brachialis Biceps brachii Coracobrachialis Brachioradialis

Arm Muscles

Posterior compartment Triceps brachii Anconeus

Arm Muscle Innervation

Anterior compartment Radial nerve

Bracioradialis Musculocutaneous nerve

Coracobrachialis Brachialis Biceps brachii

Posterior compartment Radial nerve

Triceps brachii Anconeus

Forearm Muscles

Cross elbow, wrist and finger joints

Movement of hand and fingers Cross Wrist

flex, extend, abduct, adduct hand

Cross Fingers flex, extend fingers

Proximally are fleshy Distally have long tendons Flexor and extensor

retinacula “wristbands” Keep tendons from

jumping outwards when tensed

Forearm Muscles

Anterior flexor compartment Superficial and Deep Most flexors have

common tendon on medial epicondyle

Contains 2 pronators

Posterior extensor compartment Superficial and Deep

Anterior Compartment of Forearm

Muscles Nerves Superficial

Flexor digitorum superficialis Median Flexor carpi radialis Median Pronator teres Median Palmaris longus Median Flexor carpi ulnaris Radial

Deep Flexor pollicis longus Median Flexor digitorum profundus Ulnar (med

1/2) Median (lat 1/2)

Anterior Compartment Forearm

Posterior Compartment of Forearm

Muscles Nerves Superficial

Extensor carpi radialis longus Radial Extensor digitorum Radial Extensor carpi ulnaris Radial

Deep Supinator Radial Abductor pollicis longus Radial Extensor pollicis longus + brevis Radial Extensor indicus Radial

Posterior Compartment of Forearm

Hand Bones

Carpus (8) “True” wrist Distal to radius/ulna

Metacarpus (5) Distal to carpus

Phalanges (14) Distal to

metacarpus

Intrinsic Muscles of the Hand

Muscle Nerve Pinky (little finger)

All digiti minimi Ulnar(Flexor, Abductor, Opponens)

Thumb Abductor pollicis brevis Median Flexor pollicis brevis Median Opponens pollicis Median Adductor pollicis Ulnar

Other Intrinsic Muscles Palmar + Dorsal Interossei Ulnar Lumbricals Median, Ulnar

Muscles of the Upper Limb*All INSERT on the humerus (*)

MuscleMuscle OriginOrigin ActionAction

DeltoidDeltoid Lateral ½ of clavicle, acromion Lateral ½ of clavicle, acromion and spine of scapulaand spine of scapula

Prime flexor, abducts and Prime flexor, abducts and extends the humerus. Laterally extends the humerus. Laterally and medially rotates arm.and medially rotates arm.

Pectoralis majorPectoralis major Sternum and ribs 2-6Sternum and ribs 2-6 Adducts, flexes, and medially Adducts, flexes, and medially rotates humerusrotates humerus

Latissimus dorsiLatissimus dorsi Iliac crest, T7-T12 and lumbar Iliac crest, T7-T12 and lumbar fasciafascia

Extends, adducts, and medially Extends, adducts, and medially rotates the humerusrotates the humerus

Teres majorTeres major Lateral border of scapula Lateral border of scapula (lower 1/3)(lower 1/3)

Extends, adducts, and medially Extends, adducts, and medially rotates the humerusrotates the humerus

CoracobrachialisCoracobrachialis Coracoid processCoracoid process Flexes and adducts the Flexes and adducts the humerus.humerus.

Muscles Crossing the Elbow

MuscleMuscle OriginOrigin InsertionInsertion ActionActionTriceps BrachiiTriceps Brachii

(radial nerve)(radial nerve)Infraglenoid Infraglenoid tubuercle and tubuercle and shaft of shaft of humerushumerus

Olecranon Olecranon process of ulnaprocess of ulna

Forearm Forearm extensorextensor

AnconeusAnconeus

(radial nerve)(radial nerve)Lateral Lateral epicondyle of epicondyle of humerushumerus

Lateral aspect Lateral aspect of olecranon of olecranon process of ulnaprocess of ulna

Abducts ulna Abducts ulna during forearm during forearm pronationpronation

Biceps BrachiiBiceps Brachii

(musculocutane(musculocutaneous nerve)ous nerve)

Supraglenoid Supraglenoid tubercle and tubercle and coracoid coracoid processprocess

Radial Radial tuberositytuberosity

Flex forearm Flex forearm and supinate and supinate handhand

BrachialisBrachialis

(musculocutane(musculocutaneous nerve)ous nerve)

Anterior surface Anterior surface of humerusof humerus

Coronoid Coronoid process of ulna process of ulna and capsule of and capsule of elbowelbow

Forearm flexor Forearm flexor and hand and hand supinatorsupinator

BrachioradialisBrachioradialis

(radial nerve)(radial nerve)**Supracondylar Supracondylar ridge of the ridge of the humerushumerus

Styloid process Styloid process of radiusof radius

Synergist in Synergist in forearm flexionforearm flexion*Exception: radial nerve usually serves extensor muscles

Muscles of the Forearm

MuscleMuscle OriginOrigin InsertioInsertionn

ActionAction

Pronator TeresPronator Teres

(median nerve)(median nerve)HumerusHumerus

Coronoid Coronoid process of ulnaprocess of ulna

Lateral raidusLateral raidus Pronate forearmPronate forearm

Weak flexor of Weak flexor of elbowelbow

Flexor Carpi Flexor Carpi RadialisRadialis

(median nerve)(median nerve)

Humerus-medial Humerus-medial epicondyleepicondyle

Base of 2Base of 2ndnd and and 33rdrd metacarpals metacarpals

Flexor of wrist, Flexor of wrist, abduct handabduct hand

Palmaris LongusPalmaris Longus

(median nerve)(median nerve)Humerus-medial Humerus-medial epicondyleepicondyle

Palmar fasciaPalmar fascia Weak wrist Weak wrist flexorflexor

Flexor Carpi Flexor Carpi UlnarisUlnaris

(ulnar nerve)(ulnar nerve)

Humerus-medial Humerus-medial epicondyleepicondyle

Olecranon Olecranon processprocess

Pisiform and Pisiform and hamate bones, hamate bones, base the 5base the 5thth metacarpalmetacarpal

Powerful flexor Powerful flexor of wrist, of wrist, adductor of handadductor of hand

Flexor Digitorum Flexor Digitorum SuperficialisSuperficialis

(median nerve)(median nerve)

Humerus-medial Humerus-medial epicondyle, epicondyle, coronoid process coronoid process of ulna, shaft of of ulna, shaft of radiusradius

Four tendons Four tendons into middle into middle phalange of phalange of fingers 2-5fingers 2-5

Flexes wristFlexes wrist

AN

TE

RIO

R

Sup

erfic

ial M

uscl

es

Muscles of the Forearm

MuscleMuscle OriginOrigin InsertionInsertion ActionAction

Flexor Pollucis Flexor Pollucis LongusLongus

(median nerve)(median nerve)

Radius and Radius and interosseous interosseous membranemembrane

Distal phalanx of Distal phalanx of thumbthumb

Flexes distal Flexes distal phalanx of thumbphalanx of thumb

Flexor Digitorum Flexor Digitorum ProfundusProfundus

(ulnar and median (ulnar and median nerves)nerves)

Ulna and Ulna and interosseous interosseous membranemembrane

Four tendons into Four tendons into distal phalanges of distal phalanges of fingers 2-5fingers 2-5

Flexor of the Flexor of the fingersfingers

Pronator QuadratusPronator Quadratus

(median nerve)(median nerve)

ulnaulna radusradus Forearm pronationForearm pronation

AN

TE

RIO

R D

eep

Mus

cles

Muscles of the ForearmMuscleMuscle OriginOrigin InsertionInsertion ActionActionExtensor Carpi Extensor Carpi Radialis LongusRadialis Longus

(radial nerve)(radial nerve)

Humerus-Humerus-lateral lateral epicondyleepicondyle

Base of 2Base of 2ndnd metacarpalmetacarpal

Extends and Extends and abducts wristabducts wrist

Extensor Carpi Extensor Carpi Radialis BrevisRadialis Brevis

(deep branch of (deep branch of radial nerve)radial nerve)

Humerus-Humerus-lateral lateral epicondyleepicondyle

Base of 3Base of 3rdrd metacarpalmetacarpal

Extends wristExtends wrist

Extensor Extensor DigitorumDigitorum

(radial nerve)(radial nerve)

humerushumerus Four tendons Four tendons into extensor into extensor expansions and expansions and distal distal phalanges of phalanges of fingers 2-5fingers 2-5

Prime mover of Prime mover of finger finger extension extension

Extensor Carpi Extensor Carpi UlnarisUlnaris

(posterior (posterior interosseous interosseous nerve)nerve)

Humerus-Humerus-lateral lateral epicondyle and epicondyle and ulnaulna

Base of fifth Base of fifth metacarpalmetacarpal

Extends wrist Extends wrist and adducts and adducts wristwrist

PO

ST

ER

IOR

Sup

erfic

ial

Mus

cles

Muscles That Move the ForearmMuscleMuscle OriginOrigin InsertionInsertion ActionActionSupinatorSupinator

(post. (post. Interosseous Interosseous nerve)nerve)

Humerus, ulnaHumerus, ulna Radius Radius proximal endproximal end

Supinate Supinate forearmforearm

Abductor Abductor Pollucis Pollucis LongusLongus

(post. Inter. (post. Inter. Nerve)Nerve)

Post. Radius Post. Radius and ulnaand ulna

Base of 1Base of 1stst metacarpal and metacarpal and trapeziumtrapezium

Abducts and Abducts and extends thumbextends thumb

Extensor Extensor Pollucis Brevis Pollucis Brevis and longusand longus

(post. Inter. (post. Inter. Nerve)Nerve)

Shaft of radius Shaft of radius and ulna, and ulna, interosseous interosseous membranemembrane

Base proximal Base proximal phalanx phalanx (brevis) and (brevis) and distal phalanx distal phalanx (longus) of (longus) of thumbthumb

Extends thumbExtends thumb

Extensor Extensor IndicisIndicis (post. (post. Inter. Nerve)Inter. Nerve)

Distal ulna, Distal ulna, interosseous interosseous membranemembrane

Extensor Extensor expansion of expansion of index fingerindex finger

Extends index Extends index fingerfinger

PO

ST

ER

IOR

Dee

p M

uscl

es

http://bio.bd.psu.edu/cat/Muscular_System/deep_muscles.htm# Upper Arm

1. Clavodeltoid

2. Biceps Brachii

3. Triceps Medial Head

4. Epitrochlearis

5.Triceps Long HeadUpper Arm –Medial View

1. Acromiotrapezius

2. Levator Scapulae Ventralis

3. Teres Major

4. Triceps Lateral Head (Reflected)

5. Triceps Long Head

6. Triceps Medial Head

7. Brachialis

8. Clavodeltoid

9. Anconeus

Upper Arm – Lateral View

1’ Long Head of Triceps 7.Extensor Digitorum Communis

2. Lateral Head of Triceps 8.Extensor Digitorum Lateralis

3. Brachialis 9. Extensor Carpi Ulnaris

4. Brachioradialis10.

Flexor Carpi Ulnaris

5.Extensor Carpi Radialis Longus

11.

Anconeus

6. Extensor Carpi Radialis Brevis

1. Brachioradialis 8. Clavodeltoid

2. Extensor Carpi Radialis Longus 9. Biceps Brachii

3. Extensor Carpi Radialis Brevis10.

Epitrochlearis

4. Pronator Teres11.

Long Head of Triceps

5. Flexor Carpi Radialis12.

Medial Head of Triceps

6. Palmaris Longus13.

Flexor Digitorum Superficialis

7. Flexor Carpi Ulnaris

Intrinsic Muscles of the HandThenar Eminence

MuscleMuscle OriginOrigin InsertionInsertion ActionActionAbductor Abductor Pollucis BrevisPollucis Brevis

(median nerve)(median nerve)

Flexor Flexor retinaculum,retinaculum,

Carpal bonesCarpal bones

Base of first Base of first proximal proximal phalanxphalanx

Abducts thumbAbducts thumb

Flexor Pollucis Flexor Pollucis BrevisBrevis

(median nerve)(median nerve)

Same as aboveSame as above Same as aboveSame as above Flex thumbFlex thumb

Opponens Opponens PollucisPollucis

(median nerve)(median nerve)

Flexor Flexor retinaculum retinaculum and trapeziumand trapezium

Anterior side of Anterior side of first metacarpalfirst metacarpal

OppostionOppostion

Adductor Adductor pollucispollucis (ulnar (ulnar nerve)nerve)

Capitate bone Capitate bone and bases of and bases of metacarpals 2-4metacarpals 2-4

Medial side of Medial side of base of first base of first proximal proximal phalanxphalanx

Adducts and Adducts and opposes the opposes the thumbthumb

Intrinsic Muscles of HandHypothenar Eminence

MuscleMuscle OriginOrigin InsertionInsertion ActionAction

Abductor Digiti Abductor Digiti MinimiMinimi

(ulnar nerve)(ulnar nerve)

pisiformpisiform Medial side of Medial side of proximal proximal phalanx of 5phalanx of 5thth fingerfinger

Abducts little Abducts little finger at MPJ.finger at MPJ.

Flexor digiti Flexor digiti minimi brevisminimi brevis

(ulnar nerve)(ulnar nerve)

Hamate and Hamate and flexor flexor retinaculumretinaculum

Same as aboveSame as above Flexes little Flexes little fingerfinger

Opponens digiti Opponens digiti minimiminimi

(ulnar nerve)(ulnar nerve)

Same as aboveSame as above Medial side of Medial side of metacarpal 5metacarpal 5

oppositionopposition

Muscles of the HandMidpalmar Muscles

MuscleMuscle OriginOrigin InsertionInsertion ActionActionLumbricalsLumbricals

(median and (median and ulnar nerve)ulnar nerve)

Lateral side of Lateral side of each tendon of each tendon of the deep flexorthe deep flexor

Lateral edge of Lateral edge of extensor extensor expansion of expansion of fingers 2-5fingers 2-5

Flex the MPJFlex the MPJ

Extend IPJ’sExtend IPJ’s

Palmar Palmar InterosseiInterossei

(ulnar nerve)(ulnar nerve)

Midaxial side of Midaxial side of each each metacarpal metacarpal except of met. except of met. #3#3

Extensor Extensor expansion expansion

Adduction of Adduction of fingersfingers

Dorsal Dorsal interosseiinterossei

(ulnar nerve)(ulnar nerve)

Sides of Sides of metacarpalsmetacarpals

Extensor Extensor expansionsexpansions

Abduct fingersAbduct fingers

Intrinsic Muscles of the Hand

Interossei Muscles Lumbrical Muscles

Blood Supply - Veins Deep veins

Deep palmar venous arches Radial - forearm Ulnar - forearm Brachial – arm/elbow Subclavian - neck Axillary – axilla

Superficial Veins Cephalic – arm/forearm Basilic – arm/forearm Median cubital – elbow

Blood draws!! Median - forearm Superficial palmar venous

arches Digital

Blood Supply - Arteries Subclavian (neck) Axillary (armpit)

Subscapular Circumflex humeral arteries

Brachial (arm) Deep brachial

Radial (forearm) Ulnar (forearm)

Common Interosseous Superficial & Deep Palmar

arches Digital

Axilla Between arms and chest Where axillary hair grow Boundaries

Ventral Pectoral muscles

Dorsal Latissimus dorsi, teres major,

subscapularis Medial

Serratus ventralis Lateral

Intertubercular (Bicipital) groove of humerus

Contents Axillary lymph nodes, Axillary

vessels, brachial Plexus

Surface Anatomy of Arm

Biceps brachii Triceps brachii Olecrenon

Process Medial Epicondyle Lateral Epicondyle

Surface Anatomy of Elbow Cephalic vein Cubital Fossa

Anterior surface elbow Contents

Median Cubital Vein Brachial Artery Median Nerve

Boundaries Medial= Pronator teres Lateral= Brachioradialis Superior= Line between epicondyles

Surface Anatomy of Hand

Carpal Tunnel Carpals concave anteriorly Carpal ligament covers it Contains: long tendons, Median

nerve Inflammation of tendons =

compression of Median nerve Anatomical Snuffbox

Lateral = E.pollicis brevis Medial = E. pollicis longus Floor = scaphoid, styloid of radius Contains Radial Artery (pulse)

Brachial Plexus Nerve plexus

Network of nerves formed by ventral rami

Lies partly in neck and partly in axilla

Gives rise to almost all nerves that supply upper limb

Formed by intermixing of ventral rami of spinal nerves C5-C8 and T1

Small contributions from C4 and T2

Ventral Rami

Brachial Plexus

Really Tired? Drink Coffee Buddy!

R = RAMI (ventral) (5) T = TRUNKS (3) D = DIVISIONS (2) C = CORDS (3) B = BRANCHES (Many!!)

Rami join to form Trunks! (in neck)

Ventral Rami Trunks

C5 Upper Trunk C6

C7 Middle Trunk

C8 T1 Lower Trunk

Trunks Split to form Divisions! (in neck)

Trunks Divisions

Upper AnteriorPosterior

Middle AnteriorPosterior

Lower Anterior Posterior

Divisions Join to form Cords! (in axilla)

Trunks Division Cords

U A LateralP

M A MedialP

L A PosteriorP

Cords Give off Branches!! (in axilla) Lateral Musculocutaneous

Median

Medial Ulnar

Posterior RadialAxillary

Thoracodorsal

Subscapular

1. Vagus Nerve

2. Brachial Plexus

3. Radial Nerve

4. Axillary Nerve

5. Median Nerve

6. Ulnar Nerve

Brachial Plexus – Cords and Branches

Lateral Musculocutaneous Median

Medial Ulnar

Posterior Radial Axillary Thoracodorsal Subscapular

Lateral Cord Musculocutaneous nerve

Off lateral cord Course:

Anterior arm Becomes cutaneous and gives skin sensation to lateral forearm

Innervates: Corocobrachialis (motor) Biceps brachii (motor) Brachialis (motor) Skin distal to the elbow (sensory)

Medial Cord Ulnar nerve

Course: Comes off medial cord Descends along medial side of arm Passes posterior to medial epicondyle Follows the ulna Superficial to carpal tunnel into hand Branches to supply intrinsics and skin

Innervates: Flexor carpi ulnaris (motor) Flexor digitorum profundus (motor) Most intrinsic hand muscles (motor) Dorsal branch supplies skin of medial 2/3 of hand (sensory)

Both Medial and Lateral Cords

Median nerve Course:

Middle of brachial plexus (from lateral and medial cords) Does not branch in arm Distal to elbow provides many branches to most forearm flexors Passes through carpal tunnel to hand

Innervates: Anterior forearm (motor)

Most flexors, some intrinsics (thumb)

2/3 Lateral palm (sensory) Dorsum of fingers 2 and 3 (sensory)

Posterior Cords Radial nerve

Largest branch of brachial plexus Comes from posterior cord Course:

Through arm Around humerus Around lateral epicondyle (then divides)

Innervates: Posterior muscles of arm and forearm

Triceps brachii, anconeus, supinator, brachioradialis Divides in forearm:

Superficial Skin of arm and dorsolateral surface of hand

Deep Extensor muscles of forearm (eg E. carpi radialis L + B)

Posterior Cord Axillary nerve

Branches off posterior cord Course:

Runs posterior to humerus Runs with caudal humeral circumflex artery

Innervates: Deltoid and teres minor (motor) Capsule of shoulder, skin of shoulder (sensory)

Subscapular nerve Innervates:

Subscaplaris, Teres major Thoracodorsal nerve

Course: Runs with thoracodorsal artery and nerve

Innervates: Latissimus dorsi

Cutaneous Innervation to Hand

Nerve Damage

Ulnar nerve “Claw hand”

Inability to extend fingers at interphalangeal joints, results in permanent flexion = claw

Median nerve “Ape hand”

Inability to oppose thumb

Radial nerve “Wrist drop” Inability to extend the hand,

inability to fully extend forearm

Carpal Tunnel Syndrome At A Glance

•Carpal tunnel syndrome is caused by irritation of the median nerve at the wrist. •Any condition that exerts pressure on the median nerve can cause carpal tunnel syndrome. •Symptoms of carpal tunnel syndrome include numbness and tingling of the hand. •Diagnosis of carpal tunnel syndrome is suspected based on symptoms, supported by physical examination signs, and confirmed by nerve conduction testing. •Treatment of carpal tunnel syndrome depends on the severity of symptoms and the underlying cause.