The Upper Limb

Viroj Mitranonda

Department of AnatomyFaculty of ScienceMahidol University

Parts of the upper limb

•Shoulder or Scapular region

•Arm

•Forearm

•Hand

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

Superficial structures of the upper limb

•Cutaneous nerves

•Superficial veins

•Lymph vessels

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)

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.)

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.

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)

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

Muscles found in the shoulder (scapular)

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

•Axillary nerve

•Suprascapular nerve

•Suprascapular nerve

•Axillary nerve

•Upper and Lower subscapular nerves

•Lower subscapular nerve

The rotator cuff muscles

Consists of :•Supraspi

natus m.•Infraspinatus m.•Teres minor m.•Subscapularis m.

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

Supraspinatus muscle

•Origin : Scapula, supraspinous fossa

•Insertion : Upper facet of greater tuberosity of Humerus

•Action : Abduction

•Nerve : Suprascapular nerve

Infraspinatus muscle

Origin : Scapula, infraspinous fossa

Insertion : Middle facet of greater tuberosity of the Humerus

Action : Lateral rotation

Nerve : Suprascapular nerve

Teres minor muscleOrigin : Scapula, superior 2/3 Lateral margin

Insertion : Lower facet of greater tuberosity of the Humerus

Action : Lateral rotate

nerve : Axillary nerve

Subscapularis muscle

•Origin : Scapula, subscapular fossa

•Insertion : Lesser tuberosity of the Humerus

•Action : Medial rotation

•Nerve : Upper and lower subscapular nerve

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

The arm

Flexor muscles of the arm•Coracobrachialis m.•Biceps brachii m.•Brachialis m.

•Musculocutaneous n.

•Musculocutaneous n.

•Musculocutaneous & radial nn.Extensor muscle of the arm

•Triceps brachii m. •Radial n.

Biceps brachii muscle•Origin : Short head; Coracoid process

: Long head; Supraglenoid tubercle•Insertion : Radial tuberosity, bicipital aponeurosis•Action : Supination, flexes elbow•Nerve : Musculocutaneous nerve

Coracobrachialis muscle

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

Brachialis muscle

•Origin : Humerus, ant. surface distal 1/2•Insertion : Ulna, coronoid process,

ulnar tuberosity•Action : Flexes elbow•Nerve : Musculocutaneuos n. & radial n.

Cubital fossaBoundaries

•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

Triceps brachii muscle•Origin : Long head;Scapula, 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

Flexor muscles of forearmSuperficial layer

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

The forearm

Median nerve

Median nerve

Median nerve

Ulnar nerve

Flexor muscles of forearm (continued)

Intermediate layer•Flexor digitorum superficialis (sublimis) muscle

Deep layer•Flexor pollicis longus muscle

•Flexor digitorum profundus muscle•Pronator quadratus muscle

Median nerve

Median nerve

Median&Ulnar nn.

Median nerve

Pronator teres

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

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

Palmaris longus muscle•Origin : Medial epicondyle of humerus

•Insertion : Palmar aponeurosis•Action : Flexes wrist•Nerve : Median nerve

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

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

Flexor pollicis longus muscle

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

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)

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

THE HAND

Viroj Mitranonda

Department of AnatomyFaculty of ScienceMahidol University

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.

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.

Extensor muscles of forearm

Superficial group

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

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

* = Radial nerve ** = deep branch of radial nerve

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

Brachioradialis muscle

•Origin : Humerus, lateral supracondylar line

•Insertion : Radius, base of styloid process

•Action : Flexes elbow

•Nerve : Radial nerve

Extensor carpi radialis longus muscle

•Origin : Humerus, lateral supracondylar line

•Insertion : Base of second metacarpal bone

•Action : Extends wrist, abduct hand

•Nerve : Radial nerve

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

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

Extensor digitorum

muscle•Origin : Humerus,

lateral epicondyle

•Insertion : Middle

and distal phalanges,

extensor

expansion

•Action : Extends

phalanges

•Nerve : Deep

branch of radial nerve

Extensor digiti minimi muscle

•Origin : Humerus, lateral epicondyle

•Insertion : Extensor expansion of fifth digit

•Action : Extends fifth digit

•Nerve : Deep branch of radial nerve

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

Supinator muscle

•Origin :

Humerus, lateral

epicondyle

: Ulna,

supinator crest

•Insertion :

Proximal 1/3 of radius

•Action :

Supination

•Nerve : Deep

branch of radial nerve

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)

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)

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)

Extensor indicis muscle•Origin : Ulna, posterior surface

•Insertion : Extensor expansion

•Action : Extends index

•Nerve : Deep branch of radial nerve

(Posterior interosseous nerve)

Out cropping muscles

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

: Bounded the anatomical snuff

box

•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

Tendon of the muscles in the fascial tunnels

Arthrology (Study of joint)

1. According to the movement

1.1 Immovable or synarthrosis

eg. suture

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

1.3 Freely movable (diarthrosis)

• have joint cavity, joint capsule

eg. Shoulder joint, elbow joint

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

2.3. Synovial joint

General patterns of synovial joint

•There are at least 2 bones

•It’s 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

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

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

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

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

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

5. Plane or gliding type

•For example : intercarpal joints

•Bones : carpal bones

•Movement : gliding

•Ligaments : interosseous ligaments

6. Saddle type

•For example :1st carpometacarpal joint

•Bones : 1st metacarpal bone and

trapezium

•Movement : flex, extend, adduct,

abduct and circumduct

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

Joints of the upper limb

• Sternno-clavicular joint

• Coraco-acromial joint

• Coraco-clavicular joint

• Acromio-clavicular joint

• Shoulder joint

• Elbow joint

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)

NERVE LESIONS OF UPPER LIMBS

BY

VIROJ MITRANONDADepartment of AnatomyFaculty of Science, Mahidol University