1. The Upper Limb Ernest F. Talarico, Jr., Ph.D.
Associate Director of Medical Education
Associate Professor of Anatomy & Cell Biology
Associate Faculty, Radiologic Sciences
Indiana University School of Medicine – Northwest Campus

2. Objectives
To gain a comprehensive understanding of the osteology of the upper limb
To understand and be able to discuss the anatomy/anatomical relationships of the upper limb (i.e., veins, arteries, compartments, muscles)
To understand the brachial plexus
Apply the above to a case study of the brachial plexus and medical imaging.

3. Upper Limb Osteology Right Clavicle Brachium Antebrachium Carpus Manus
Phalanges
Right Clavicle

4. Fascia ☺ Compartment ☺ Lymphatics

5. Veins and Lymphatics of the Upper Limb

6. Muscles of the Brachiium
Posterior
Radial n.
What is the view?
What is the innervation?
(anterior)
(Musculocutaneous n.)

7. Muscles of the Antebrachium

8. Muscles of the Antebrachium

9. Muscles of the Antebrachium

10. Compartment & Muscles of the Manus

11. An Area of Concern!

12. Vessels

13. 1 2 3
Lateral boarder of R1 and medial border of pectoralis minor m.
Superior (supreme) Thoracic a.
Posterior to pectoralis minor m.
Thoracoacromial a. (Acromial, Clavicular, Pectoral, Deltoid)
Lateral Thoracic a. (**** BREAST ****)
Lateral border of pectoralis minor m. and the inferior border of teres major m.
Subscapular a. (largest)
Anterior & Posterior Circumflex Humeral aa. (P > A)

14. Anatomical Relationships - Vessels/Nerves

15. The Brachial Plexus Innervates all muscles of superior extremity
Sensory & motor nerves
Anterior division fibers supply flexors
Posterior division fibers supply extensors
Roots Trunks Divisions Cords Branches
Robert Taylor Drinks Cold Beer

17. IUSM-NW

18. Spinal Nerves (31 pairs) all are mixed nerves (sensory and motor)
4 fiber components
Sensory
GSA: general somatic afferent
GVA: general visceral afferent
Motor
GSE: skeletal
GVE: visceral
IUSM-NW

19. Typical Thoracic Spinal Nerve
31 pairs of spinal nerves:
8 cervical
12 thoracic
5 lumbar
5 sacral
1 coccygeal
IUSM-NW

22. Brachial Plexus: Major Branches
Musculocutaneous (C5-7)
Median Nerve (C6-T1)
Ulnar Nerve (C8-T1)
Axillary Nerve (C5-6)
Radial Nerve (C7-8)

23. Brachial Plexus: Major Branches
Musculocutaneous (C5-7)
Biceps Brachii (C5, C6)
Coracobrachialis (C5, C6, C7)
Brachialis (C5, C6)

24. Brachial Plexus: Major Branches
Median Nerve (C6-T1)
Pronator teres
Flexor carpi radialis
Palmaris longus
Flexor digitorum profundus (lateral)
Flexor digitorum superficialis
Flexor pollicus longus
Pronator quadratus
and hand mm.

25. Brachial Plexus: Major Branches
Ulnar Nerve (C8-T1, often C7)
 + 13 hand mm.
Flexor digitorum profundus (medial)
Flexor carpi ulnaris

26. Brachial Plexus: Major Branches
Axillary Nerve (C5-6)
Deltoid
Teres minor

27. Brachial Plexus: Major Branches
Radial Nerve (C5-T1)  12 + anconeus
Brachioradialis
Triceps brachii (C6, C7, C8)
Extensor carpi radialis longus
and brevis
Extensor digitorum
Extensor digiti minimi
Extensor carpi ulnaris
Supinator
Abductor pollicus longus
Extensor pollicus longus and brevis
Extensor indicus

28. Brachial Plexus: Other Nerves
Dorsal Scapular (C5)
Rhomboideus major and minor
Levator scapulae
Suprascapular (C5-6)
Supraspinatus
Infraspinatus
Shoulder joint
Subclavian (C5-6)
Subclavius
Lateral Pectoral (C5-C7)
Pectoralis major and minor

29. Upper Subscapular (C5-6)
Subcapularis
Thoracodorsal (C6-8)
Latissimus dorsi
Lower Subscapular (C5-6)
Teres major
Long Thoracic (C5-7)
Seratus anterior
Medial Pectoral (C8-T1)
Pectoralis minor and major
Medial Brachial Cutaneous
Medial Antebrachial Cutaneous

31. Brachial Plexus

32. Nerves of the Upper Limb

33. CLNICAL CORRELATION

34. Medical Imaging

35. Swan Neck Deformity
A swan neck deformity describes a finger with a hyperextended PIP joint and a flexed DIP joint.

36. How does this condition occur?
Conditions that loosen the PIP joint and allow it to hyperextend can produce a swan neck deformity of the finger.
Rheumatoid arthritis (RA) is the most common disease affecting the PIP joint.
The small (intrinsic) muscles of the hand and fingers can tighten up from hand trauma.
Various nerve disorders, such as cerebral palsy, Parkinson's disease, or stroke.

38. Mallet Finger

39. How do these injuries of the DIP joint occur?
A mallet finger results when the extensor tendon is cut or torn from the attachment on the bone. Sometimes, a small fragment of bone may be pulled, or avulsed, from the distal phalanx. The result is the same in both cases: the end of the finger droops down and cannot be straightened.

41. Boutonniere Injury
Boutonnière deformity (buttonhole deformity) is a deformity in which the middle finger joint is bent in a fixed position inward (toward the palm) and the outermost finger joint is bent excessively outward (away from the palm).
This disorder most often results from rheumatoid arthritis but can also occur from injury (such as deep cuts, joint dislocation, or fractures) or osteoarthritis

43. A 34-year-old, African-American male, falls from the roof of a new home under construction and lands on a cement boulder with impact on the right, proximal one-third of the humeral diaphysis. Medical history is significant for HTN, diabetes, and hypercholesterolemia. Examination in the ER is remarkable for BP 168/90; T 99.9; P 90; R 28. Bone is evident topographically near the deltoid tuberosity, and there is bleeding. Inflammatory response is active and there is decreased ROM; flexor and extensor reflexes are intact. CT reveals shattered humeral diaphysis with displacement. Surgical intervention is consistent with internal fixation and bone grafting using osseous tissue from the ilium ground and mixed with sea coral. The anterior and posterior circumflex humeral arteries were noted to be intact, and were clamped during surgery to facilitate repair. Three weeks post-surgery, the patient complains of significant pain near the site of injury. MRI reveals AVN of the proximal humeral diaphysis. Which of the
following selections best explains the patient’s condition?
A. nonunion of bone fragments
B. malpractice on the part of the surgeon
C. diabetes
D. muscle injury
E. neuropathy

44. A 34-year-old, African-American male, falls from the roof of a new home under construction and lands on a cement boulder with impact on the right, proximal one-third of the humeral diaphysis. Medical history is significant for HTN, diabetes, and hypercholesterolemia. Examination in the ER is remarkable for BP 168/90; T 99.9; P 90; R 28. Bone is evident topographically near the deltoid tuberosity, and there is bleeding. Inflammatory response is active and there is decreased ROM; flexor and extensor reflexes are intact. CT reveals shattered humeral diaphysis with displacement. Surgical intervention is consistent with internal fixation and bone grafting using osseous tissue from the ilium ground and mixed with sea coral. The anterior and posterior circumflex humeral arteries were noted to be intact, and were clamped during surgery to facilitate repair. Three weeks post-surgery, the patient complains of significant pain near the site of injury. MRI reveals AVN of the proximal humeral diaphysis. Which of the
following selections best explains the patient’s condition?
A. nonunion of bone fragments
B. malpractice on the part of the surgeon
C. diabetes
D. muscle injury
E. neuropathy
Based on your knowledge of anatomy of the upper limb, what is the
most likely cause of the AVN and the patient’s pain?
Question

45. A 34-year-old, African-American male, falls from the roof of a new home under construction and lands on a cement bolder with impact on the right, proximal one-third of the humeral diaphysis. Medial history is significant for HTN, diabetes, and hypercholesterolemia. Examination in the ER is remarkable for BP 168/90; T 99.9; P 90; R 28. Bone is evident topographically near the deltoid tuberosity, and there is bleeding. Inflammatory response is active and there is decreased ROM; flexor and extensor reflexes are intact. CT reveals shattered humeral diaphysis with displacement. Surgical intervention is consistent with internal fixation and bone grafting using osseous tissue from the ilium ground and mixed with sea coral. The anterior and posterior circumflex humeral arteries were noted to be intact, and were clamped during surgery to facilitate repair. Three weeks post-surgery, the patient complains of significant pain near the site of injury. MRI reveals AVN of the proximal humeral diaphysis. Which of the
following selections best explains the patient’s condition?
A. nonunion of bone fragments
B. malpractice on the part of the surgeon
C. diabetes
D. muscle injury
E. neuropathy
Based on your knowledge of anatomy of the upper limb, what is the
most likely cause of the AVN and the patient’s pain?
Question
Objective: Is to test the student doctor’s understanding of anatomical and vascular relationships of the upper limb.

46. A 34-year-old, African-American male, falls from the roof of a new home under construction and lands on a cement boulder with impact on the right, proximal one-third of the humeral diaphysis. Medical history is significant for HTN, diabetes, and hypercholesterolemia. Examination in the ER is remarkable for BP 168/90; T 99.9; P 90; R 28. Bone is evident topographically near the deltoid tuberosity, and there is bleeding. Inflammatory response is active and there is decreased ROM; flexor and extensor reflexes are intact. CT reveals shattered humeral diaphysis with displacement. Surgical intervention is consistent with internal fixation and bone grafting using osseous tissue from the ilium ground and mixed with sea coral. The anterior and posterior circumflex humeral arteries were noted to be intact, and were clamped during surgery to facilitate repair. Three weeks post-surgery, the patient complains of significant pain near the site of injury. MRI reveals AVN of the proximal humeral diaphysis. Which of the
following selections explains the patients condition?
A. nonunion of bone fragments
B. malpractice on the part of the surgeon
C. diabetes
D. muscle injury
E. neuropathy
Based on you knowledge of anatomy of the upper limb, what is the
most likely cause of the AVN and the patient’s pain?
Question
Objective: Is to test the student doctor’s understanding of anatomical and vascular relationships of the upper limb.
Confirmation
Reasoning
Elimination