The Upper Limb Viroj Mitranonda Department of Anatomy Faculty of Science Mahidol University

Shoulder or Scapular region Arm Forearm Hand 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 Axillary nerve Suprascapular nerve Upper and Lower subscapular nerves Lower subscapular nerve Deltoideus muscle Supraspinatus muscle Infraspinatus muscle Teres minor muscle Subscapularis muscle Teres major muscle

The rotator cuff muscles Consists of : Supraspinatus 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 muscle Origin : 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

Flexor muscles of the arm Musculocutaneous n. Musculocutaneous & radial nn. Coracobrachialis m. Biceps brachii m. Brachialis m. 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 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

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 forearm 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 Ulnar nerve

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 Median&Ulnar nn.

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 Anatomy Faculty of Science Mahidol University

Muscles of the hand 3 Thenar muscles : Abductor pollicis brevis m. Flexor pollicis brevis m. Opponens pollicis m. 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. 3 Palmar interossei mm. 4 Dorsal interossei mm. 4 Lumbricales mm. Ulnar n. 1st and 2nd Median n. 3rd and 4th Ulnar n. Palmaris brevis m. Ulnar n.

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

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)

: Bounded the anatomical snuff box Out cropping muscles Abductor pollicis longus m. Extensor pollicis brevis m. Extensor pollicis longus m. : Bounded the anatomical snuff box

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

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 MITRANONDA Department of Anatomy Faculty of Science, Mahidol University