The upper limb

Muscles That Move the Pectoral Girdle

Originate on the axial skeleton and insert on the clavicle and scapula.

Stabilize the scapula and move it to increase the arm’s angle of movements.

Some of the superficial muscles of the thorax are grouped together according to the scapular movement they direct.

elevation, depression, protraction, or retraction

The muscles of back Superficial group

Trapezius

Latissimus dorsi

Levator scapulae

Rhomboideus

Deep group

Erector spinae

Splenius

Thoracolumbar fascia

The muscles of thorax Extrinsic muscles

Pectoralis major

Pectoralis minor

Serratus anterior

Intrinsic muscles

Intercostales externi

Intercostales interni

Intercostales intimi

The Muscles of Upper Limb

Muscles of shoulder

Deltoid

supraspinatus

Infraspinatus

Teres minor

Teres major

subscapularis

Major muscles of upper limb

Deltoid

Origin: lateral third of clavicle, acromion, and spine of scapula

Insertion: deltoid tuberosity of humerus

Action: abducts，flexes and medically rotates, extends, and laterally rotates arm

Teres major

Origin: dorsal surface of inferior angle of scapula

Insertion: crest of lesser tubercle of humerus

Action: medially rotates and adducts arm

Foramen axillare laterale et mediale

Arm Muscles That Move the Shoulder/Elbow Joint

(Flexor) compartment

Posterior (extensor) compartment

Anterior compartment

primarily contains shoulder/elbow flexors

Posterior compartment contains elbow extensors

the principal flexors biceps brachii, brachialis, and brachioradialis

muscles that extend the elbow joint triceps brachii and the anconeus

Muscles of arm

Antererior group

Biceps brachii

Coracobrachialis

Brachialis

Posterior group – triceps brachii

Biceps brachii Origin: long head,

supraglenoid tubercle; short head, coracoid process

Insertion: radical tuberosity Action: supinator of forearm,

flexor of elbow joint, weak flexor of should joint

Pronator teres Origin: medical epicondyle of

humerus and deep fascia of forearm

Insertion: middle of lateral surface of radius

Action: pronation of forearm and flexion of elbow

Triceps brachii

Origin: long head, infraglenoid tubercle; lateral head, above groove for radical n., medical head, below groove for radical n.

Insertion: olecranon of ulna

Action: extends elbow joint), long head can extend and adduct shoulder joint

Surface anatomy

M. triceps brachii

caput longum, medialis, lateralis

Surface elements

Skin thick and movable

Subcutaneous tissue well expressed

n. cutaneus brachii posterior

n. cutaneus brachii lateralis inferior

n. cutaneus antebrachii posterior

Posterior of the arm

Deep structures

А. Fascia brachialis

- Thick, thins distally

B. Neurovascular bundles

1. Upper - in canalis humero-muscularis, between:

- sulcus n. radialis

- medial and lateral head of m. triceps brachii

1.1. n. radialis – lies on the humerus

- n. cutaneus brachii lateralis inerior

- n. cutaneus antebrachii posterior

- rr. musculres

1.2. a. profunda brachii

- a. collateralis media

- collateralis radialis

Lower neurovascular bundle

behind medial epicondyle

n. ulnaris

a. collateralis ulnaris inferior

Elbow region

Anterior elbow

Surface anatomy

Three eminences

Two grooves

Elements

Lateral groove - v. cephalica, n. cutaneus

antebrachii lateralis

Medial groove – v. basilica, n. cutaneus

antebrachii medialis

V. mediana cubiti

Deep structures

А. Muscles

Flexors of forearm – medial eminence

Extensors of forearm – lateral eminence

Brachial muscles, mm. biceps, brachialis –

middle eminence

Deep structures

B. Vessels and nerves

Medial bundle - between m. biceps brachii and pronator

teres

- a.v. brachialis, n. medianus

Lateral bundle - between m. brachialis and

brachioradialis

- n. radialis, a. collateralis radialis, a. recurrens radialis

C. Cubital fossa

Boundaries

- m. brachioradialis (lateral), m. pronator teres (medial)

Content

- tendo m. brachialis, m. biceps brachii, bursa bicipitoradialis

Layers of the elbow

Venous

1 v. cephalica

2 v. basilica

3 v. mediana cubiti

Apponeurotic

1 aponeurosis bicipis

2 tendo m. biceps brachii

Neurovascular

1 a. brachialis

2 n. medianus

Muscle

1 m. supinator

2 m. brachialis

3 tendo m. biceps brachii

Bone

1 humerus

2 radius

3 ulna

Anterior elbow

Arteries of upper limb Axillary artery

Continuation of subclavian artery at lateral border of first rib

Becomes brachial artery at lower border of teres major

Divided into three parts by overlying pectoralis minor First portion, above muscle－gives rise

to thoracoacromial a.

Second portion, behind muscle－gives rise to lateral thoracic a.

Third portion, below muscle－gives rise to subscapular a. divides into throcodorsal a.

and circumflex scapular a.

anterior and posterior humeral circumflex a.;

Brachial artery

Continuation of axillary artery

Divides into radial and ulnar arteries at level of neck of radius

Branches Deep brachial a. accompanies

radial nerve

Superior ulnar collaeral a. accompanies ulnar nerve

Inferior ulnar collateral a.

Radial artery and branches

Radial recurrent a.

Superfical palmar branch

Principal artery of thumb

Ulnar artery and branches

Ulnar recurrent a.

Common interosseous artery

Anterior interossous a.

Posterior interosseous a.

Deep palmar branch

Basilic vein

Arises from the medial side of the dorsal venous rete of hand

Ascends on the ulnar side of forearm to the elbow and then in the medial bicepital brachii furrow to middle of the arm where it pierces the deep fascia and joins the brachial vein or axillary vein

Median cubital vein

links cephalic vein and basilic vein in the cubital fossa. It is a frequent site for venipuncture to remove a sample of blood or add fluid to the blood

The lymphatic drainage of upper limb Lymphatic vessels

Superficial－follow the superficial veins, drain into supratrochlear and axillary lymph nodes

Deep－accompany main vessels, end in axillary lymph nodes

Lymph nodes

Cubital lymph node: lies above medial epicondyle of humerus

Axillary lymph node－arranged in five groups

Axillary lymph nodes Arranged in five groups

Lateral lymph nodes lie around the distal end of axillary vein , receiving drainage from the arm, forearm, and hand

Pectoral lymph nodes lie along lateral thoracic vessels, receive afferents from anterior thoracic wall including central and lateral portion of mamma

Subscapular lymph node along subscapular vessels, receive lymph from nape and scapular region

Efferents above three groups pass to central lymph node

Brachial plexus Formation: Five roots: anterior rami of C5-C8

and T1 spinal nerves, roots C5-C7give rise to long thoracic n.

Three trunks Upper trunk formed by the joining of

roots C4,C5,C6. Middle trunk continuation of root C7. Lower trunk formed by the joining of

roots C8 and T1.

Six divisions: above clavicle, trunks form anterior and posterior divisions

Three cords: below clavicle, divisions form three cords that surround the second portion of axillary a.

Position:

passes through the scalene fissure to posterosuperior of subclavian artery, then enters the axilla to form lateral, medial and posterior cords

Main branches Lateral cord

Musculocutaneous n.

Lateral root to median n.

Medial cord

Medial root to median n.

Ulnar n.

Medial brachial cutaneous n.

Medial antebrachial cutaneous n.

Posterior cord

radial n.

axillary n.

thoracodorsal n.

Musculocutaneous nerve

Supplies:

Muscles -‘BBC nerve’

Biceps brachii,

Brachalis

Coracobrachialis;

skin on the anterior aspect of forearm

Median nerve Supplies:

Flexors of forearm except brachioradialis,

Flexor carpi ulnaris

flexor digitorum profundus - ulnar half

Thenar except adductor pollicis, two lateral lumbricals;

Skin of thenar, central part of palm, palmar aspect of radial three and one-half fingers, including middle and

distal fingers on dorsum

Injury: Ape hand

produces sign of benediction, the index and middle fingers cannot be flexed and the thumb cannot be opposed

Ulnar nerve

Supplies:

flexor carpi ulnaris,

ulnar half of flexor digitorum profundus,

hypothenar muscles, interossei,

3rd and 4th lumbricals and adductor pollicis;

skin of hypothenar, palmar surface of ulnar one and one-half fingers, ulnar half of dorsum of hand, posterior aspect of ulnar two and one-half fingers

Injury: claw hand

Radial

Supplies:

Extensor muscles of arm and forearm,

Brachioradialis;

skin on back of arm, forearm, and radial side of dorsum of hand and radial two and one-half fingers

Injury: Wrist drop

Axillary nerve

Supplies:

Deltoid and teres minor muscle;

skin over deltoid and upper posterior aspect of arm

Injury:

deltoid and teres minor paralysis (loss of shoulder abdution and wheel external rotation)

loss of sensation over the deltoid

Forearm Muscles

Supinate and Pronate Supinator muscle supinates the forearm. Biceps brachii supinates the forearm. Pronator teres and pronator quadratus pronate the forearm.

Move the Wrist Joint, Hand, and Fingers

Muscles in the forearm move the hand at the wrist and/or the fingers.

Extrinsic muscles of the wrist and hand originate on the forearm, not the wrist or hand.

Tendons of forearm muscles typically are surrounded by tendon (synovial) sheaths and held adjacent to the skeletal elements by strong fascial structures.

At the wrist, the deep fascia of the forearm forms thickened, fibrous bands termed retinacula.

The forearm extends

from elbow to wrist.

It posses two bones

radius laterally & Ulna

medially.

The two bones are

connected together

by the interosseous

membrane.

This membrane

allows movement of

Pronation and

Supination while the two bones are

connected together.

Also it gives origin for the deep muscles.

Sheath of deep fascia attached to the posterior border of the ulna .

The fascial sheath, interosseous membrane & fibrous intermuscular septa, divide the forearm into 3 compartments, each having its own muscles, nerves, and blood supply.

Fascial Compartments of the Forearm

I-Superficial: 4

Pronator teres

Flexor carpi radialis

Palmaris longus

Flexor carpi ulnaris

II-Intermediate: 1

Flexor digitorum superficialis

These muscles: 8 Act on the elbow & wrist joints and those of the fingers. Form fleshy masses in the proximal part and become tendinous in the distal part of the forearm. •Arranged in three groups:

III- Deep: 3

Flexor digitorum profundus

Flexor pollicis longus

Pronator quadratus

FLEXOR GROUP

Superficial Flexors:

They arise - more or less- from the common flexor origin (front of medial epicondyle).

All are supplied by median nerve except one, flexor carpi ulnaris, FCU (ulnar).

All cross the wrist joint except one, pronator teres, (PT).

Muscles of forearm Superficial layer

Brachioradialis

Pronator teres

Flexor carpi radialis

Palmaris longus

Flexor carpi ulnaris

common flexor origin (front of medial epicondyle)

supplied by median nerve except flexor carpi ulnaris

All cross the wrist joint except pronator teres

Second layer

Flexor digitorum superficials

Origin:

Common flexor origin,

Coronoid process of ulna;

Anterior surface of radius

Insertion:

Base of middle phalanges of 2nd to 5th fingers.

Action:

Flexes middle and proximal phalanges of 2nd to 5th fingers, and the hand

Third layer

Flexor digitorum profundus

Flexor pollicis longus

Fourth layer Pronator quadratus

Action: flex radiocarpal joint and fingers, pronate forearm

Lateral compartment (3) Brachioradialis

Extensor carpi radialis longus

Extensor carpi radialis brevis

Common extensor origin, (front of lateral epicondyle of the humerus), EXCEPT, 2 (BR & ECRL).

Cross the wrist EXCEPT brachioradialis.

Supplied by deep branch of radial nerve

Posterior compartment (8)

Superficial layer (3)

Extensor digitorum

Extensor digiti minimi

Extensor carpi ulnaris

Common extensor origin, (front of lateral epicondyle of the humerus),

Cross the wrist.

Supplied by deep branch of radial nerve

Deep layer (5)

Supinator

Abductor pollicis longus

Extensor pollicis brevis

Extensor pollicis longus

Extensor indicis

Action: extend radiocapral joint and fingers, and supinate forearm

Extensor carpi radialis brevis:

base of 3rd metacarpal bone.

Extensor digitorum:

Extensor expansion of the

medial 4 fingers.

Extensor digiti minimi:

Extensor expansion of the

little finger.

Extensor carpi ulnaris:

Base of the 5th metacarpal

bone.

INSERTION

Supination

and

pronation

It occurs in the superior

and inferior radioulnar

joints;

Muscles produce

supination

Biceps brachii.

Supinator.

Muscles produce

pronation

Pronator teres.

Pronator quadratus.

NB. Brachioradialis put

the forearm in midprone-

position.

Human hand – masterpiece of art

Muscles of hand (palm)

Lateral group thenar (4) Abductor pollicis brevis

Flexor pollicis brevis

Opponens pollicis

Adductor pollicis

Action: flex, abduct, adduct and oppose thumb

Medial group hypothenar (3) Abductor digiti minimi

Flexor digiti minimi brevis

Opponens digiti minimi

Action: flex, abduct , and oppose little finger

Intermedial group

Lumbricals (4) flex fingers at MP joints; extend fingers at IP joints

Palmar interossei (3) adduct fingers towards middle finger at MP joints

Dorsal interossei (3) abduct fingers away from middle finger at MP joints

Arteries of upper limb Axillary artery

Continuation of subclavian artery at lateral border of first rib

Becomes brachial artery at lower border of teres major

Divided into three parts by overlying pectoralis minor First portion, above muscle－gives rise

to thoracoacromial a.

Second portion, behind muscle－gives rise to lateral thoracic a.

Third portion, below muscle－gives rise to subscapular a. divides into throcodorsal a.

and circumflex scapular a.

anterior and posterior humeral circumflex a.;

Brachial artery

Continuation of axillary artery

Divides into radial and ulnar arteries at level of neck of radius

Branches Deep brachial a. accompanies

radial nerve

Superior ulnar collaeral a. accompanies ulnar nerve

Inferior ulnar collateral a.

Radial artery and branches

Radial recurrent a.

Superfical palmar branch

Principal artery of thumb

Ulnar artery and branches

Ulnar recurrent a.

Common interosseous artery

Anterior interossous a.

Posterior interosseous a.

Deep palmar branch

Superficial palmar arch

Formed by ulnar artery and superficial palmar branch of radial artery

Curve of arch lies across the palm, level with the distal border of fully extended thumb

Gives rise to three common palmar digital arteries each then divides into two proper palmar digital arteries

Deep palmar arch

Formed by radial artery and deep palmar branch of ulnar artery

Curve of arch lies across upper part of palmar at level with proximal border of extended thumb

Gives rise to three palmar

metacarpal arteries

Veins of the upper limb Deep veins: accompany the arteries of

the same region and bear similar names

Superficial veins

Cephalic vein Arises from the lateral side of the

dorsal venous rete of hand

Ascends on radial side of the forearm to the elbow and then in the lateral side of biceps brachii furrow, continues up the arm in the deltopectoral groove and then to the infraclavicular fossa, where it pierces clavipectoral fascia to drain into axillary vein