1. Anatomy of Arm Dr. Fadel Naim Orthopedic Surgeon Islamic University
Faculty of Medicine

2. Veins of the Arm
Two sets of veins, superficial and deep, anastomose freely with each other.
The superficial veins are in the subcutaneous tissue
The deep veins accompany the arteries.
Both sets of veins have valves
They are more numerous in the deep veins
The smooth muscles of the veins are innervated by sympathetic postganglionic nerve fibers

3. Superficial Veins The two main superficial veins of the arm:
The cephalic vein
The basilic vein

4. Superficial Veins The cephalic vein
Located in the subcutaneous tissue along the anterolateral surface of the proximal forearm and arm
Often visible through the skin
Passes superiorly between the deltoid and pectoralis major in the deltopectoral groove
It empties into the termination of the axillary vein in the deltopectoral triangle

5. Superficial Veins The basilic vein
located in the subcutaneous tissue and passes on the medial side of the inferior part of the arm
Often it is also visible through the skin.
Near the junction of the middle and inferior thirds of the arm, the basilic vein penetrates the brachial (deep) fascia and runs superiorly into the axilla
Where it merges with the accompanying veins of the brachial artery to form the axillary vein

6. Deep Veins of the Arm The brachial veins:
The paired veins accompanying the brachial artery
Their frequent connections encompass the artery, forming an anastomotic network within a common vascular sheath.
The pulsations of the brachial artery help move the blood through this venous network.
Begin at the elbow by union of the accompanying veins of the ulnar and radial arteries.
End by merging with the basilic vein to form the axillary vein.

7. Venipuncture of the Upper Limb
Because of the prominence and accessibility of the superficial veins of the upper limb, they are commonly used for venipuncture
These veins may be embedded with the subcutaneous tissue (fat), making them difficult to see
By applying a tourniquet to the arm, the venous return is occluded and the veins distend and are usually visible and/or palpable.

8. Venipuncture of the Upper Limb
The median cubital vein is commonly used for venipuncture for:
Drawing blood
Inserting a catheter for right cardiac catheterization
The dorsal venous network and the cephalic and basilic veins arising from it are commonly used for intravenous feeding

9. Lymphatic Drainage of the Upper Limb
Superficial lymphatic vessels
Arise from lymphatic plexuses in:
The digits
The palm
The dorsum of the hand
Ascend mostly with superficial veins
Deep lymphatic vessels:
Less numerous than superficial vessels
Accompany the major deep veins in the upper limb
Terminate in the humeral group of axillary nodes.

10. Lymphatic Drainage of the Upper Limb
Some vessels accompanying the basilic vein enter the cubital nodes, located:
proximal to the medial epicondyle
medial to the basilic vein.
Efferent vessels from these lymph nodes ascend in the arm and terminate in the humeral (lateral) axillary lymph nodes.
Most lymphatic vessels accompanying the cephalic vein cross the proximal part of the arm and anterior aspect of the shoulder to enter the apical group of axillary nodes; however, some vessels previously enter the deltopectoral nodes.

11. Lymphangitis, Lymphadenitis, and Lymphedema
The inflammation of lymphatic vessels
Lymphadenitis:
The inflammation of lymph nodes
These conditions may occur when the lymphatic system is involved in the spread (metastasis) of cancer cells or infection

12. Fascial compartments of the Upper Limb
The brachial fascia:
A sheath of deep fascia encloses the arm like a sleeve
It is continuous superiorly with the pectoral and axillary layers of fascia.
It is attached inferiorly to the epicondyles of the humerus and the olecranon of the ulna and is continuous with the antebrachial fascia
Intermuscular septa:
The medial and lateral intermuscular septa extend from the deep surface of the brachial fascia to the medial and lateral supracondylar ridges of the humerus
Dividing the arm into
Anterior (flexor) fascial compartment
Posterior (extensor) fascial compartment
Each of which contains muscles serving similar functions, nerves, and blood vessels that supply

14. Lateral head Long Triceps head brachii Posterior Medial compartment
of arm (extends
elbow); innervation:
radial nerve
Medial
head
Humerus
Extensors
Flexors
Brachialis
Others
Short head
Biceps brachii
Long head
(a)
(a) Muscles of the arm
Anterior compartment
of arm (flexes elbow);
innervation:
musculocutaneous
nerve

15. Muscles of the Arm 4 arm (brachial) muscles:
3 flexors in the anterior compartment
Supplied by the musculocutaneous nerve
Biceps brachii
Brachialis
Coracobrachialis
1 extensor in the posterior compartment
Triceps brachii
Supplied by the radial nerve.

16. BICEPS BRACHII ORIGIN INSERTION ACTION NERVE Long head: Short head:
supraglenoid tubercle of scapula.
Short head:
coracoid process of scapula with coracobrachialis
INSERTION
posterior border of bicipital tuberosity of radius (over bursa)
bicipital aponeurosis to deep fascia and subcutaneous ulna
ACTION
Supinator of the forearm
Flexion of the elbow
weakly flexes shoulder
NERVE
Musculocutaneous nerve (C5, 6) (from lateral cord)

17. The tendon of the long head of the biceps crosses the head of the humerus within the cavity of the glenohumeral joint
The tendon, surrounded by synovial membrane, descends in the intertubercular groove of the humerus

18. The bicipitoradial bursa separates the biceps tendon from--and reduces abrasion against--the anterior part of the radial tuberosity.

19. When right-handed persons drive a screw into hard wood
When the elbow is extended
The biceps is a simple flexor of the forearm
When the elbow is flexed and more power is needed against resistance
The biceps is the primary (most powerful) supinator of the forearm
When right-handed persons drive a screw into hard wood
Inserting a corkscrew and pulling the cork from bottle.
The biceps barely operates during flexion of the prone forearm.
To test the biceps:
The ebow joint is flexed against resistance when the forearm is supinated.
If acting normally, the muscle forms a prominent bulge on the anterior aspect of the arm that is easily palpated.

20. Biceps Tendinitis
The tendon of the long head of the biceps, enclosed by a synovial sheath, moves back and forth in the intertubercular groove of the humerus.
Wear and tear of this mechanism is a common cause of shoulder pain.
Inflammation of the tendon (biceps tendinitis), usually the result of repetitive microtrauma, is common in sports involving throwing and use of a racquet
A tight, narrow, and/or rough intertubercular groove may irritate and inflame the tendon, producing tenderness and crepitus

21. Rupture of the Tendon of the Long Head of the Biceps
Often as the result of prolonged tendinitis that weakens it.
May result from repetitive overhead motions, such as occurs in swimmers
May result from forceful flexion of the arm against excessive resistance, as occurs in weight lifters
Usually the tendon is torn from its attachment to the supraglenoid tubercle of the scapula.
Commonly dramatic and is associated with a snap or pop.
The detached muscle belly forms a ball near the center of the distal part of the anterior aspect of the arm ("popeye deformity")

22. BRACHIALIS ORIGIN INSERTION ACTION NERVE
Anterior lower half of humerus
medial and lateral intermuscular septa
INSERTION
Coronoid process and tuberosity of ulna
ACTION
Flexes elbow
NERVE
Musculocutaneous nerve (C5, 6) ( from lateral cord).
Also small supply from radial nerve (C7)

23. (picking up and put down a teacup carefully)
The brachialis is the main flexor of the forearm
Flexes the forearm in all positions and during slow and quick movements.
When the forearm is extended slowly, the brachialis steadies the movement by slowly relaxing
(picking up and put down a teacup carefully)
The brachialis always contracts during flexion of the elbow joint and is primarily responsible for maintaining flexion
Because of its many functions, it is regarded as the workhorse of the elbow flexors

24. CORACOBRACHIALIS ORIGIN INSERTION ACTION NERVE
Coracoid process of scapula with biceps brachii
INSERTION
Upper half medial border of humerus
ACTION
Flexes and weakly adducts arm
NERVE
Musculocutaneous nerve (C5, 6, 7) (from lateral cord)

25. Long head
Biceps brachii
Coracobrachialis
Short head
Biceps tendon
Aponeurosis of biceps brachii

26. Acromion process
Coracoid process
Humerus
Coracobrachialis
Musculocutaneous n.
Brachialis
Radius
Ulna

27. TRICEPS ORIGIN INSERTION ACTION NERVE Long head: lateral head:
infraglenoid tubercle of scapula.
lateral head:
upper half posterior humerus (linear origin).
medial head:
lies deep on lower half posterior humerus inferomedial to spiral groove and both intermuscular septa
INSERTION
Posterior part of upper surface of olecranon process of ulna and posterior capsule
ACTION
Extends elbow
Long head stabilizes shoulder joint
medial head retracts capsule of elbow joint on extension
NERVE
Radial nerve (C7, 8) (from posterior cord ), four branches

28. The triceps is the main extensor of the elbow joint.
Aids in extension and adduction of the arm.
Long head of the triceps helps stabilize the adducted glenohumeral joint by serving as a shunt muscle, resisting inferior displacement of the head of the humerus.
Just proximal to its distal attachment is a friction-reducing subtendinous olecranon bursa between the triceps tendon and the olecranon.
To test the triceps lesion
the arm is abducted 90 ° and then the flexed forearm is extended against resistance
If acting normally, the triceps can be seen and palpated.

29. Olecranon Deltoid (cut) Long head Triceps brachii Lateral head
Anconeus

30. Suprascapular nerve
Dorsal scapular nerve
Axillary nerve
Lateral head
Long head
Triceps brachii
Radial nerve
Medial head
Anconeus

31. Humeral Shaft Fracture
Fracture above the level of pectoralis major
proximal fragment abduct and rotate internally due to the action of the rotator cuff
Fracture above the deltoid and below pectoralis major
deltoid pulls the distal fragment laterally, pectoralis major pulls the proximal fragment medially
Fracture below deltoid
proximal fragment abducts due to deltoid, distal fragment pulled medially and proximally by biceps/ brachialis and coracobrachialis

32. Arteries of the arm Brachial Deep (profunda) brachial
Anterior branch
Posterior branch
Superior ulnar collateral
Inferior ulnar collateral
Recurrent branches from:
The radial artery
Ulnar artery
Interosseous artery
These arteries anastomose with descending articular branches of the deep artery of the arm and the ulnar collateral arteries

34. Brachial Artery
The brachial artery provides the main arterial supply to the arm
The brachial artery, the continuation of the axillary artery
Begins at the inferior border of the teres major and ends in the cubital fossa opposite the neck of the radius
Under cover of the bicipital aponeurosis, the brachial artery divides into the radial and ulnar arteries

35. The brachial artery, superficial and palpable throughout its course
Lies anterior to the triceps and brachialis.
At first it lies medial to the humerus, and then anterior to it.
As it passes inferolaterally, the brachial artery accompanies the median nerve, which crosses anterior to the artery
During its course through the arm, the brachial artery gives rise to:
Many unnamed muscular branches
Humeral nutrient arteries, which arise from its lateral aspect

36. Deep Artery of the Arm The largest branch of the brachial artery
Most superior origin
Accompanies the radial nerve through the radial groove and passes around the body of the humerus
Divides into anterior and posterior descending branches that participate in the arterial anastomoses around the elbow.

37. Nutrient Humeral Artery
Arises from the brachial artery around the middle of the arm and enters the nutrient canal on the anteromedial surface of the humerus.
The artery runs distally in the canal toward the elbow

38. Superior Ulnar Collateral Artery
This artery arises from the medial aspect of the brachial artery near the middle of the arm and accompanies the ulnar nerve posterior to the medial epicondyle of the humerus
It anastomoses with the :
posterior ulnar recurrent artery
inferior ulnar collateral artery

39. Inferior Ulnar Collateral Artery
Arises from the brachial artery approximately 5 cm proximal to the elbow crease
Passes inferomedially anterior to the medial epicondyle of the humerus
Joins the anastomoses of the elbow region by anastomosing with the anterior ulnar recurrent artery

41. Measuring Blood Pressure
Arterial blood pressure measurement using sphygmomanometer.
A cuff is placed around the arm and inflated with air until it compresses the brachial artery against the humerus and occludes it.
A stethoscope is placed over the artery in the cubital fossa, the pressure in the cuff is gradually released
The examiner detects the sound of blood beginning to spurt through the artery.
The first audible spurt indicates systolic blood pressure.
As the pressure is completely released, the point at which the pulse can no longer be heard is the diastolic blaod pressure.

42. Compressing the Brachial Artery
The best place to compress the brachial artery to control hemorrhage is near the middle of the arm
The brachial artery may be clamped distal to the deep artery of the arm without producing tissue damage
The anatomical basis for this is that the ulnar and radial arteries still receive sufficient blood through the anastomoses around the elbow
Ischemia of the elbow and forearm results from clamping of the brachial artery proximal to the deep artery of the arm for an extended period

43. Nerves of the Arm 4 main nerves pass through the arm:
Median
Ulnar
Musculocutaneous
Radial
The median and ulnar nerves supply no branches to the arm.

45. Musculocutaneous Nerve
One of the terminal branches of the lateral cord
Supplies all the muscles in the anterior (flexor) compartment of the arm.
Begins opposite the inferior border of the pectoralis minor, pierces the coracobrachialis, and continues distally between the biceps and brachialis
After supplying all three of these muscles, it becomes the lateral cutaneous nerve of the forearm

46. Radial Nerve The direct continuation of the posterior cord
Supplies all the muscles in the posterior compartment of the arm.
It enters the arm
Posterior to the brachial artery
Medial to the humerus
Anterior to the long head of the triceps
The radial nerve descends inferolaterally with the deep brachial artery and passes around the humeral body in the radial groove
Before entering the groove, it gives branches to the long and lateral heads of the triceps.

47. Radial Nerve
At the lateral border of the humerus, it pierces the lateral intermuscular septum and continues inferiorly in the anterior compartment of the arm between the brachialis and brachioradialis to the level of the lateral epicondyle of the humerus.
It then divides into deep and superficial branches
The deep branch is entirely muscular and articular in its distribution.
The superficial branch is entirely cutaneous in its distribution, supplying sensation to the dorsum of the hand and digits.

48. Median Nerve
Formed in the axilla by the union of a lateral root from the lateral cord and a medial root from the medial cord
It runs distally in the arm, initially on the lateral side of the brachial artery until it reaches the middle of the arm ,where it crosses to the medial side and contacts the brachialis.
The median nerve then descends to the cubital fossa, where it lies deep to the bicipital aponeurosis and medial to cubital vein.
The median nerve has no branches in the axilla or the arm, but it supplies articular branches to the elbow joint.

49. Ulnar Nerve
This is the larger of the two terminal branches of the medial cord
It passes distally, anterior to the triceps, on the medial side of the brachial artery
Around the middle of the arm it pierces the medial intermuscular septum with the superior ulnar collateral artery and descends between the septum and the medial head of the triceps.
The ulnar nerve passes posterior to the medial epicondyle and medial to the olecranon to enter the forearm
Posterior to the medial epicondyle where the ulnar nerve is referred to in lay terms as the “funny bone“
The ulnar nerve has no branches in the arm, but it supplies articular branches to the elbow joint.