Upper Limb Anatomy PDF

Anatomy of Musculoskeletal system- 1 Upper Limb 1- Bones, Blood vessels, Nerves, joints & Shoulder, Pectoral region Dr Suresh.,MBBS.,MD Assistant Professor, HSS. Objectives At the end of the lecture, students are able to, 1. name the bones of the upper limb and their important landmarks....

Anatomy of Musculoskeletal system- 1 Upper Limb 1- Bones, Blood vessels, Nerves, joints & Shoulder, Pectoral region Dr Suresh.,MBBS.,MD Assistant Professor, HSS. Objectives At the end of the lecture, students are able to, 1. name the bones of the upper limb and their important landmarks. 2. discuss the brachial plexus formation and major nerves supplying the upper limb. 3. describe the major arteries and veins their course in upper limb. 4. classify the joints and discuss the synovial joint structures. 5. describe the various movements that take place at joints. 6. describe the attachments, nerve supply and actions of various pectoral and scapulohumeral muscles  UPPER LIMB Consist of Four segments Shoulder Arm Forearm Hand BONES Most of upper limb bones are long bones, except the scapula & carpal bones SCAPULA HUMERUS Main nerves of upper limb Branches of brachial plexus Axillary nerve Radial nerve Musculocutaneous nerve Ulnar nerve Median nerve Brachial plexus Brachial plexus  Medial cord of brachial plexus Mulsculo cutaneous nerve (Arm muscles) Ulnar nerve Median nerve (forearm muscles) (forearm muscles) Axillary nerve (Arm muscles) Radial nerve (Upper limb- posterior muscles) Joints Joints are unions or junctions between two or more bones or rigid parts of the skeleton Type of Joints : 1. Synovial joints – freely mobile joints, covered by capsule. Ex. Shoulder joint, Knee joint 2. Fibrous joints- Less mobile joints, bone ends connected by fibrous tissue Ex- Sutures, 3. Cartilaginous joints- Bone ends are united by cartilages Primary – no movements Secondary – less movement Components of Synovial joint Bones Articular cartilage Synovial cavity Synovial fluid Synovial membrane Capsule  1.Sternoclavicular joint Joints of the Upper Limb 2. Acromioclavicular joint 3. Shoulder joint (Glenohumeral joint) 3. Elbow joint Humero-ulnar joint Humeroradial joint 4. Wrist joint (Radiocarpal joint ) Radius, Scaphoid, Lunate, Triquetrum 5. Carpometacarpal joint 6. Metacarpophalangeal joint 7. Proximal and distal interphalangeal joint Blood supply of upper limb Blood Supply: Arteries Subclavian (neck) Axillary (armpit) Brachial (arm) Radial (forearm) Ulnar (forearm) Superficial & Deep Palmar arches Blood Supply: Veins SUPERFICIAL Cephalic (arm-forearm) Basilic (arm-forearm) Median Cubital (elbow) SF. Palmar Venous Arch Digital Superficial veins drains skins and fascia of upper limb  Blood Supply: Veins DEEP Subclavian (neck) Axillary (axilla) Deep veins drains muscles and bones Brachial (arm-elbow) Radial (forearm) Ulnar (forearm) Deep Palmous Venous arch  Lymphatic drainage Lymphatics are lymph vessels which carry a clear interstitial fluid called lymph. The lymphatic system provides an alternative route for interstitial fluid to return to the Axillary group Cubital lymph venous system. nodes of lymph nodes Plays role in defense mechanism  BONES OF UPPER LIMB Acromial end Clavicle Transmits part of the weight of upper limb to the axial skeleton. The lateral or acromial end of the bone is flattened and articulates with the medial side of the acromion process of scapula Superior view Medial or sternal end is enlarged and articulates manubrium sternum Inferior view https://aclandanatomy-com.singaporetech.remotexs.co/MultimediaPlayer.aspx?multimediaId=10528033 SCAPULA HUMERUS Scapula Anterior view Posterior view Spine  Scapula Lateral view Coracoid process Acromian process Glenoid cavity https://aclandanatomy- com.singaporetech.remotexs.co/Multimedia Player.aspx?multimediaId=10528033 Humerus Anterior aspect Posterior aspect Olecranon fossa Humerus upper end https://aclandanatomy- com.singaporetech.remotexs.co/MultimediaPlayer.aspx?multimediaId=10528065 Humerus lower end  Muscles of upper limb Pectoral region Three muscles: Pectoralis major Pectoralis minor Serratus anterior  Pectoralis major Origin: (Proximal attachments) Medial half of clavicle and anterior surface of sternum, first seven costal cartilages, Insertion: (Distal attachments) Proximal part of humerus (lateral lip of intertubercular groove) Innervation: Medial and lateral pectoral nerves Action: Adduction, medial rotation, and flexion of the humerus at the shoulder joint Proximal attachments (Origin): Pectoralis minor Anterior surfaces of the third, fourth and fifth ribs, and deep fascia overlying the related intercostal spaces Distal attachments (Insertion) Coracoid process Innervation: Medial pectoral nerve Action: Depresses tip of shoulder; protracts scapula Proximal attachment: Serratus anterior External surfaces of lateral parts of 1st–8th ribs Distal attachments: Medial border of scapula Innervation: Long thoracic nerve (C5, C6, C7) Action: Protracts scapula and holds it against thoracic https://sketchfab.com/3d-models/muscles-of-back-and-shoulder-region- wall; rotates scapula d0a6c51ec91e45c88a2d0f7337feb3be  PROXIMAL attachment from scapula DISTAL attachment in humerus = Move humerus Muscles of Scapula (INTRINSIC SHOULDER MUSCLES) Scapulohumeral muscles Subscapularis Supraspinatus Rotator Infraspinatus Cuff Teres Minor Teres Major Deltoid Latissimus Dorsi (partial) Coracobrachialis https://aclandanatomy.com.singaporetech.remotexs.co/Multimedia Player.aspx?multimediaId=10528045 Muscles of Scapula: If DISTAL ATTACHMENT (INSERTION) on scapula = Move scapula EXTRINSIC SHOULDER MUSCLES Rhomboids Trapezius Pectoralis Minor Serratus anterior Levator Scapulae https://aclandanatomy.com.singaporetech.remotexs.co/Multim ediaPlayer.aspx?multimediaId=10528049 Muscles of Scapula Subscapularis Muscles of Scapula- Rotator cuff Muscles of Scapula- Rotator cuff  Muscles of Scapula- Muscle Proximal Distal Attachment Nerve supply Action Attachment (Insertion) (Origin) Subscapularis Subscapular fossa Lesser tubercle of Upper and lower Medially rotates humerus subscapular arm, helps to hold nerves head of humerus in glenoid cavity Supraspinatus Supraspinous fossa Greater tubercle Suprascapular Abduction of of humerus nerve of arm along with scapula Deltoid Infraspinatus Infraspinous fossa Greater Suprascapular Laterally rotates of tubercle of nerve arm scapula humerus Teres minor Middle part of Greater Axillary nerve Adducts and lateral lateral tubercle of rotation of arm border of scapula humerus  Deltoid Origin: Lateral third of clavicle; acromion and spine of scapula Insertion: Deltoid tuberosity of humerus Nerve supply: Axillary nerve (C5, C6) Action: Clavicular (anterior) part: flexes and medially rotates arm Acromial (middle) part: abducts arm Spinal (posterior) part: extends and laterally rotates arm Axillary nerve Branch of posterior cord Supply Deltoid and teres minor  Trapezius Origin: Medial third of superior nuchal line; External occipital protuberance; nuchal ligament; Spinous processes of C7–T12 vertebrae Insertion: Lateral third of clavicle; acromion and spine of scapula Nerve supply: Spinal accessory nerve Action: Descending part elevates scapula Ascending part depresses scapula Middle part - retracts scapula  Muscles of Scapula = Move scapula Muscle Proximal Distal Attachment Nerve supply Action attachments (Insertion) (Origin) Levator scapulae Transverse Posterior surface of Dorsal scapular Elevates the scapula processes of C1 –C4 medial border of nerve vertebrae scapula Rhomboid minor Lower end of Posterior surface of Dorsal scapular nerve Elevates and retracts ligamentum nuchae medial border of the scapula and spinous scapula processes of C7 and T1 vertebrae Rhomboid major Spinous processes of Posterior surface of Dorsal scapular nerve Retract scapula and TII-TV vertebrae medial border of rotate scapula from the root its glenoid cavity of the spine of the inferiorly; fix scapula to the scapula to thoracic inferior angle wall Muscles of Scapula = Move scapula Levator scapulae Rhomboid minor Rhomboid major Joints of the Upper Limb 1.Sternoclavicular joint 2. Acromioclavicular joint 3. Shoulder joint (Glenohumeral joint)  Glenohumeral (shoulder) joint Ball-and-socket type of synovial joint Multi axial joint, permits a wide range of movement The large, round humeral head shallow glenoid cavity of the scapula Glenoid cavity is deepened and expanded peripherally by a fibrocartilaginous collar- glenoid labrum  LIGAMENTS i. Fibrous capsule ii. Gleno – humeral ligaments – superior, middle and inferior iii. Glenoidal labrum iv. Coraco – humeral ligament v. Transverse humeral ligament Movements ❖ FLEXION: - Pectoralis major, anterior fibres of deltoid, assisted by coracobrachialis and biceps brachii ❖ EXTENSION: - posterior fibres of deltoid and teres major - From full flexion, extension is by latissimus dorsi ABDUCTION: Supraspinatus, Deltoid ❖ ADDUCTION: - anterior and posterior fibres of the deltoid, pectoralis major, teres major, latissimus dorsi, coracobrachialis and long head of triceps ❖ MEDIAL ROTATION Subscapularis Pectoralis major; deltoid (clavicular part); latissimus dorsi; teres major ❖ LATERAL ROTATION Infraspinatus, Teres minor; deltoid (spinal part)  Applied anatomy Dislocation of shoulder joint: - due to laxity of the ligaments and disproportionate articular surfaces. - axillary nerve is affected Rotator Cuff Injuries During repetitive use of the upper limb above the horizontal line Recurrent inflammation of the rotator cuff, especially the relatively avascular area of the supraspinatus tendon Common cause of shoulder pain and results in tears of the musculotendinous rotator cuff. FROZEN SHOULDER (adhesive capsulitis) (Periarthritis shoulder) Adhesive fibrosis and scarring between the inflamed joint capsule of the glenohumeral joint, rotator cuff, subacromial bursa, and deltoid References Richard Drake A. Wayne Vogl Adam 2011. Gray's Anatomy for Students, 3rd edition Churchill Livingstone Standring, 2015 Gray’s Anatomy: The Anatomical Basis of Clinical Practice, 42nd Edition,, Churchill Livingstone Moore, K.L., Dalle,A.F. & Agur, A.M. 2013. Clinically Oriented Anatomy. 7th edition. Philadelphia: Lippincott Williams & Wilkins. Snell, R.S. 2011. Clinical Anatomy by Regions. 9th edition. Philadelphia: Lippincott Williams & Wilkins. Frederic H. Martini. Fundamentals of Anatomy & Physiology, Global Edition, 11th Edition: Pearson (instructor resources) Visible body applications http://anatomediaonline.com/amedia/index.html Anatomy of Musculoskeletal system 2- Upper Limb - Muscles and joints of arm, forearm and Hand Dr Suresh MBBS MD Objectives At the end of the lecture, students are able to, 1. Describe the proximal and distal attachments, innervation and actions of front and back of arm muscles 2. Describe boundaries and clinical importance of cubital fossa. 3. Describe the proximal and distal attachments, innervation and actions of front and back of forearm muscles 4. Anatomy of elbow, wrist and radio ulnar joints 5. Describe intrinsic muscles of hand and thumb. Muscles of Scapula- Rotator cuff Muscles of Arm: Cross elbow, Move forearm Anterior Compartment Biceps brachii Brachialis Coraco brachialis Posterior Compartment (Extensors of forearm) Triceps brachii Anconeus  Biceps brachii Origin: Long head-supraglenoid tubercle of scapula; Short head-apex of coracoid process Insertion: Radial tuberosity of radius Nerve supply: Musculocutaneous nerve Action: Flexor of the forearm at the elbow joint Supinator of the forearm Accessory flexor of the arm at shoulder joint Brachialis Origin: Anterior aspect of humerus Insertion: Tuberosity of the ulna Nerve supply: Musculocutaneous nerve Action: Flexor of the forearm at the elbow joint Coracobrachialis Origin: coracoid process of scapula Insertion: mid-shaft of humerus Nerve supply: Musculocutaneous nerve Action: Flexor of the arm at the shoulder joint Nerves – musculocutaneous nerve Branch of lateral cord of brachial plexus Pierces coracobarchialis muscle Supplies: (BBC) Biceps brachii, Brachialis Coraco brachialis  Triceps brachii Origin: Long head- Infraglenoid tubercle of scapula Medial head-posterior surface of humerus lateral head-posterior surface of humerus Insertion: Olecranon process of ulna Nerve supply: Radial nerve Action: Extension of the forearm at the elbow joint. Long head - extend and adduct the arm at the shoulder joint Nerves – radial nerve Branch of posterior cord of brachial plexus Supplies muscles of back of arm and forearm Nerves Median nerve Ulnar nerve Arteries Axillary artery ▪ Commences at the outer border of the first rib ▪ Continuation of the subclavian artery ▪ Divided into three parts by pectoralis minor ▪ Continue as Brachial artery from the lower border of teres major Brachial. artery ▪ Commences at the lower border of teres major ▪ Divided into radial and ulnar artery below the elbow joint Elbow joint- (Hing joint) Articular surfaces Capsule & ligaments Movements Arterial supply Nerve supply Brachial, - Musculocutaneous nerve. Profunda brachii, - Radial nerve. Radial, and ulnar arteries. - Ulnar nerve - Median nerve Cubital fossa Situated in anterior aspect of the elbow Boundaries: 1. Superiorly- an imaginary line connecting the medial and lateral epicondyles. 2. Medially- pronator teres & the mass of flexor muscles of the forearm 3. Laterally- brachioradialis ,mass of extensor muscles Cubital fossa Contents (lateral to medial) tendon of the biceps brachii muscle brachial artery median nerve Muscles of forearm: Cross Wrist : flex, extend, abduct, adduct hand Cross Fingers : flex, extend fingers Anterior Flexor Compartment (Superficial + Deep layers) Most flexors have common tendon on medial epicondyle Contains 2 pronators Innervated by *Median, Ulnar nerves Posterior Extensor Compartment (Superficial + Deep layers) Innervated by Radial nerve Lateral epicondyle origin Flexor & Extensor Retinaculam Collagenous bands keep tendons from bowing thick, deep fascia FOREARM Olecranon Olecranon Trochlear notch Coronoid process Proximal Head of radius Radial notch radio-ulnar Neck of joint radius Ulnar tuberosity Radial tuberosity Ulna Ulna Radius Ulna c Lateral view of ulna, showing Interosseous trochlear notch membrane https://aclandanatomy- com.singaporetech.rem Ulnar notch Distal radio-ulnar joint of radius otexs.co/MultimediaPla Head of ulna yer.aspx?multimediaId= Head of ulna Ulnar styloid process Radial styloid 10528065 process a Posterior view b Anterior © 2018 Pearson Education, Ltd. view  HAND She – Scaphoid Looks– Lunate Too – Triquetral Pretty – Pisiform Try – Trapezium To – Trapezoid Catch – Capitate Her – Hamate https://aclandanatomy- com.singaporetech.remotexs.co/MultimediaPlayer.aspx?multimediaId=10528093  Innervation of Anterior Compartment- Forearm Muscles Muscle Nerve Superficial Muscles Pronator teres Median Flexor carpi radialis Median Palmaris longus Median Flexor carpi ulnaris Ulnar (Intermediate layer) Flexor digitorum superficialis Median Deep Muscles Pronator quadratus Median Flexor pollicis longus Median Flexor digitorum profundus Ulnar (med 1/2) Median (lat 1/2) Anterior Compartment Forearm- Superficial layer Medial Epicondyle Pronator Teres Flexor Carpi Radialis Palmaris longus Flexor Carpi Ulnaris Flexor Digitorum Superficialis is deep to other flexors Anterior Compartment Forearm-Deep layer Flexor dig. profundus Flexor pollicis longus Pronator quadratus Pronator teres Origin: medial epicondyle of humerus Ulnar head-coronoid process Insertion: mid-shaft, of radius Nerve supply: median nerve Action: Pronate and flexes forearm Flexor carpi radialis Origin: medial epicondyle of humerus Insertion: Base of metacarpals II and III Nerve supply: median nerve Action: Flexion and abduction of wrist  Palmaris longus Origin: Medial epicondyle of humerus Insertion: Palmar aponeurosis of hand Nerve supply: median nerve Action: Flexion of wrist joint  Flexor carpi ulnaris Origin: medial epicondyle of humerus Ulnar head: olecranon and posterior border of ulna Insertion: Pisiform bone, hamate and base of metacarpal V Nerve supply: Ulnar nerve Action: Flexion and adduction of wrist  Flexor digitorum superficialis Origin: Medial epicondyle of humerus, coronoid process of ulna head of radius Insertion: Four tendons, which attach to the palmar surfaces of the middle phalanges of the index, middle, ring, and little fingers Nerve supply: median nerve Action: Flexes proximal interphalangeal joints of the index, middle, ring, and little fingers; can also flex metacarpophalangeal joints of the same fingers and the wrist joint  Flexor digitorum profundus Origin: Ulna and interosseous membrane Insertion: Four tendons, which attach to the palmar surfaces of the distal phalanges of the index, middle, ring, and little fingers Nerve supply: Lateral half by median nerve , medial half by ulnar nerve Action: Flexes distal interphalangeal joints of the index, middle, ring, and little fingers; flex metacarpophalangeal joints of the same fingers and the wrist joint Flexor pollicis longus Origin: Anterior surfaces of radius and interosseous membrane Insertion: base of distal phalanx of thumb Nerve supply: median nerve Action: Flexes interphalangeal and metacarpo- phalangeal joint of the thumb Pronator quadratus Origin: Distal anterior surface of ulna Insertion: Distal anterior surface of radius Nerve supply: median nerve Action: pronation Posterior Compartment of Forearm  Forearm Muscles- Posterior Compartment Superficial Brachioradialis Extensor carpi radialis longus Extensor carpi radialis brevis Extensor digitorum Extensor carpi ulnaris Extensor digiti minimi Radial nerve Anconeus Deep Supinator Abductor pollicis longus Extensor pollicis longus + brevis Extensor indicis Brachioradialis Origin: supracondylar ridge of humerus Insertion: Distal end of radius Nerve supply: radial nerve Action: flexor of elbow joint  Muscle Origin Insertion Action Extensor carpi radialis supracondylar ridge of humerus Dorsal surface of base of Extends and abducts longus metacarpal II the wrist Extensor carpi radialis Lateral epicondyle of humerus Dorsal surface of base of Extends and abducts brevis metacarpals II and III the wrist Extensor digitorum Lateral epicondyle of humerus bases of the middle and Extends the index, distal phalanges of the middle, ring, and index, middle, ring, and little fingers; can little fingers also extend the ‘Extensor Hoods' wrist Extensor digiti minimi Lateral epicondyle of humerus Dorsal hood of the little Extends the little finger finger Extensor carpi ulnaris Lateral epicondyle of humerus base of metacarpal V Extends and adducts and ulna the wrist  Deep muscles of Posterior Compartment Muscle Origin Insertion Action Supinator Superficial part-lateral Lateral surface of supination epicondyle of humerus, radius ulna Extensor indicis Ulna Extensor hood of Extends index index finger finger  Deep muscles of Posterior Compartment Muscle Origin Insertion Action Abductor pollicis Posterior surfaces of ulna Lateral side of base of Abducts carpometacarpal longus and radius metacarpal I joint of thumb Extensor pollicis brevis Posterior surface of base of proximal phalanx of Extends radius the thumb metacarpophalangeal and carpometacarpal joint of the thumb Extensor pollicis longus Posterior surface of ulna Dorsal surface of base of Extends interphalangeal distal phalanx of thumb joint of the thumb; can also extend carpometacarpal and metacarpophalangeal joints of the thumb Hand  Intrinsic Muscles of Hand Muscle Nerve little finger All digiti minimi Ulnar (Flexor, Abductor, Opponens) Thumb Abductor pollicis brevis Median Flexor pollicis brevis Median Opponens pollicis Median Adductor pollicis Ulnar Other Intrinsic Muscles Palmar + Dorsal Interossei Ulnar Lumbricals Median, Ulnar  Muscles of Hand Muscle Origin Insertion Nerve supply Action Thenar muscles Opponens Tubercle of Lateral margin and median nerve Medially rotates thumb pollicis trapezium and adjacent palmar flexor surface of retinaculum metacarpal I Abductor Tubercles of Proximal phalanx median nerve Abducts thumb at pollicis brevis scaphoid and and extensor metacarpophalangeal joint trapezium and hood of thumb adjacent flexor Flexor pollicis Tubercle of the Proximal phalanx median nerve flexes the metacarpophalangeal joint brevis trapezium and of the thumb of the thumb flexor retinaculum  Muscles of Hand Muscle Origin Insertion Nerve supply Action Hypothenar muscles Opponens digiti Hook of hamate Medial aspect of Deep branch of ulnar Laterally rotates minimi and flexor metacarpal V nerve [C8,T1] metacarpal V retinaculum Abductor digiti Pisiform, the Proximal phalanx of Deep branch of ulnar Abducts little finger at minimi pisohamate little finger nerve [C8,T1] metacarpophalangeal ligament, and joint tendon of flexor carpi ulnaris Flexor digiti minimi Hook of the Proximal phalanx of Deep branch of ulnar Flexes little finger at brevis hamate and flexor little finger nerve [C8,T1] metacarpophalangeal retinaculum joint Lumbricals 1ST Dorsal interossei Adductor pollicis Flexor pollicis brevis Opponens pollicis Abductor pollicis brevis Palmar interosseus Abductor digiti minimi Flexor digiti minimi brevis Opponens digiti minimi Intrinsic Muscles of Hand Lumbricals Palmar Dorsal Interossei Interossei 3rd ADDuction ABduction 2nd 4th 1st Interossei help the lumbricals to extend IP joints and flex MC-P joints BLOOD SUPPLY Wrist joint synovial joint ARTICULAR SURFACES: Distal end of radius & scaphoid, lunate, triquetral LIGAMENTS: Fibrous capsule with synovial membrane Dorsal & palmar radio-carpal ligaments Radial & ulnar collateral ligaments Movements: adduction- abduction flexion – extension Radio-ulnar joints APPLIED ANATOMY Subluxation or pulled elbow. Preschool children. eg., lifting a child into bus. Nerves Median nerve Ulnar nerve Radial nerve Carpal tunnel syndrome References Richard Drake A. Wayne Vogl Adam 2011. Gray's Anatomy for Students, 3rd edition Churchill Livingstone Standring, 2020 Gray’s Anatomy: The Anatomical Basis of Clinical Practice, 42nd Edition,, Churchill Livingstone Moore, K.L., Dalle,A.F. & Agur, A.M. 2017. Clinically Oriented Anatomy. 8th edition. Philadelphia: Lippincott Williams & Wilkins. Snell, R.S. 2018. Clinical Anatomy by Regions. 10th edition. Philadelphia: Lippincott Williams & Wilkins. Frederic H. Martini. Fundamentals of Anatomy & Physiology, Global Edition, 11th Edition: Pearson (instructor resources) http://anatomediaonline.com/amedia/index.html