human-anatomy-synopsis-axilla-upper-limb.pdf

2
GERARD GORNIAK &
WILLIAM CONRAD
HUMAN ANATOMY
SYNOPSIS
AXILLA-UPPER LIMB

3
Human Anatomy Synopsis: Axilla-Upper limb
1st
edition
© 2018 Gerard Gorniak & William Conrad & bookboon.com
ISBN 978-87-403-2078-7
Peer review by Dr. Edward Kane, University of St. Augustine, USA

HUMAN ANATOMY SYNOPSIS:
AXILLA-UPPER LIMB Contents
4
4
CONTENTS
Preface 6
1 Axilla 7
1.1 Boundaries 7
1.2 Axillary artery 8
1.3 Brachial plexus 10
2 Shoulder complex 16
2.1 Osteology 16
2.2 Joints, ligaments, bursae 21
2.3 Glenohumeral muscles 29
3 Arm and elbow 40
3.1 Osteology 40
3.3 Anterior brachial compartment 46
3.4 Posterior brachial compartment 53
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AXILLA-UPPER LIMB Contents
5
4 Forearm and wrist 58
4.1 Osteology 58
4.3 Cubital fossa 65
4.4 Anteromedial muscular compartment 66
4.5 Posterolateral muscular compartment 76
5 The hand 89
5.1 Osteology 89
5.2 Joints, ligaments and bursae 90
5.3 Palm of the hand 96
5.4 Dorsum of the hand 114
6
Brachial plexus nerve injuries 117
Study question answers 132
References 142

AXILLA-UPPER LIMB PREFACE
6
PREFACE
This is one of a series of 4 Human Anatomy Synopses that are based on over 40 years of
Anatomy course notes used in the graduate education of health care professions. This series
started as a detailed content outline for a course developed for medical students back in
1983. Since that time, it has undergone many revisions and additions. In 2008 and 2014,
text and illustrations were reviewed and revised, and study sections were added throughout
the text. In 2017, the 4 Synopses were developed, and the text and illustrations formatted
to be used by students as a supplement to anatomy courses.
The 4 Human Anatomy Synopses in this series are: Spine and Neck, Axilla and Upper Limb,
Pelvic Girdle and Lower Limb, and Thorax, Abdomen, and Pelvis. There are numerous
illustrations and Tables. Many of the Tables have clinical relevance. This AXILLA AND
UPPER LIMB SYNOPSIS contains the brachial plexus and arteries in the axilla, the osteology,
joints and ligaments, nerves and muscles of the upper limb, and the tables of lesion of the
brachial plexus. In this Synopsis, major structures are CAPTILIZED. This feature allows
students to make a study outline by linking together these words under each title or subtitle.
After each content area, there are short answer Study Questions to help students relate and
apply the anatomy. The answers to these questions are included at the end of the Notes.
These Synopses are only possible because of the works of the many anatomists and other
basic scientists as well as numerous clinicians who have contributed to our knowledge and
understanding of the human body. I am most grateful to them for sharing what they learned.
I am also grateful to the many students who over the years, have made comments and
suggestions about the content of this work. I am also grateful to Drs. Hilmir Augustsson,
Jeff Rot, Ed Kane, Sue Curfman, Jim Viti, and Mrs. Jackie Nelson and to the University
of St Augustine for Health Sciences for help with this publication.
This book is dedicated to all those people who have so generously donated their body to
science so that we may learn. Thank you for the unselfish gift of yourself to others. May
God bless you for your contribution to mankind.
Unless otherwise indicated, all materials on these pages are copyrighted. All rights reserved.
No part of these pages, either text or image may be used for any purpose other than personal
use. Therefore, reproduction, modification, storage in a retrieval system or retransmission,
in any form or by any means, electronic, mechanical or otherwise, for reasons other than
personal use, is strictly prohibited without prior written permission.

AXILLA-UPPER LIMB AXILLA
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1 AXILLA
• The axilla lies inferior to the glenohumeral joint at the junction of the thorax and
the upper limb.
• It contains the major nerves and vascular channels for the upper limb.
1.1 BOUNDARIES
• The axilla is a pyramidal shaped region with the apex of the pyramid lying inferior
to the glenohumeral joint (Fig. 1-1)
• LATERAL BOUNDARY is formed by the intertubercular groove of the humerus
containing the tendon of the long head of the biceps.
• MEDIAL BOUNDARY consists of the upper 7 ribs, the intercostal muscles, and
the serratus anterior.
• ANTERIOR BOUNDARY is the clavicle, the pectoralis minor, and the pectoralis
major. The pectoralis major forms the ANTERIOR AXILLARY FOLD.
• POSTERIOR BOUNDARY consists of the costal surface of the scapula, the
subscapularis, the latissimus dorsi and the teres major. The latissimus dorsi and the
teres major muscle form the POSTERIOR AXILLARY FOLD.
Fig. 1-1. Axilla: Transverse section through the axillary region (right shoulder viewed from
below) showing its boundaries and contents: 1. pectoralis major, 2. pectoralis minor, 3. rib,
4. serratus anterior, 5. subscapularis, 6. scapula, 7. teres major, 8 latissimus dorsi, 9. humerus,
10. tendon of long head of biceps, 11. axillary artery, 12. axillary vein, 13. medial cord,
14. posterior cord, 15. laterally cord.

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1.2 AXILLARY ARTERY
• A continuation from the SUBCLAVIAN ARTERY of the thorax to the BRACHIAL
ARTERY of the upper limb (Fig. 1-2)
• PART I
○
○ Boundaries: lateral border of the first rib to the superior border of the
pectoralis minor.
○
○ Branch: SUPREME (superior) or HIGHEST THORACIC ARTERY to the first
and second intercostal spaces and the upper serratus anterior (Fig. 1-2)
• PART II
○
○ Boundaries: lies deep to the pectoralis minor muscle.
○
○ Branches: (Fig. 1-2)
ƒ
ƒ THORACOACROMIAL ARTERY to the pectoralis major; acromioclavicular
joint; the deltoid muscle; and sternoclavicular joint
ƒ
ƒ LATERAL THORACIC ARTERY to the serratus anterior, pectoralis major,
pectoralis minor and breast.
• PART III
○
○ Boundaries: inferior border of the pectoralis minor to the inferior border of the
teres major.
○
○ Branches: (Fig. 1-2)
ƒ
ƒ SUBSCAPULAR ARTERY which divides into a CIRCUMFLEX SCAPULAR
ARTERY to the posterior scapular muscles and the THORACODORSAL
ARTERY to the latissimus dorsi.
ƒ
ƒ ANTERIOR HUMERAL CIRCUMFLEX ARTERY to the deltoid and
anterior glenohumeral joint.
ƒ
ƒ POSTERIOR HUMERAL CIRCUMFLEX ARTERY to the deltoid, triceps,
and posterior and lateral glenohumeral joint; it anastomoses (communicates)
with the anterior humeral circumflex artery near of the surgical neck of
the humerus.

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Fig. 1-2. Axilla: 1. common carotid a., 2. vertebral a., 3.thyrocervical trunk, 4. suprascapular
a., 5. thoracoacromial a., 6. axillary a., 7. anterior and posterior circumflex humeral a.,
8. Brachial a., 9. profunda brachii a., 10. radial recurrent a., 11. radial a., 12. posterior
interosseous a., 13. proper digital a., 14. common digital a., 15. superficial palmar arch,
16. deep plamar arch, 17. ulnar a., 18. anterior interosseous a., 19. common interosseous
a., 20. anterior ulnar recurrent a., 21. posterior ulnar recurrent a., 22. inferior ulnar collateral
a., 23. superior ulnar collateral a., 24. thoracodorsal off subscapular a., 25. circumflex
scapular a. off subscapular a. 26. lateral thoracic a., 27. internal thoracic a., 28. subclavian
a., and 29. supreme thoracic a.

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1 – Study questions:
1) What are the boundaries of the axilla?
2) What are the boundaries of the axillary artery?
3) What two branches of part III of the axillary artery are most likely to supply the
glenohumeral joint?
1.3 BRACHIAL PLEXUS
• A nerve network to the upper limb
• SUPRACLAVICULARDIVISION begins superior to the clavicle in thePOSTERIOR
CERVICAL TRIANGLE and consists of VENTRAL RAMI AND TRUNKS
(Fig. 1-3; Table 1.1)
• INFRACLAVICULAR DIVISION lies inferior to the clavicle in the axilla and
consists of the three cords and multiple nerves arising from these cords. (Fig. 1-3;
Table 1.2)
Fig. 1-3. Axilla: Diagram of Brachial Plexus showings its components and nerves. 1. dorsal scapular, 2. long
thoracic, 3. suprascapular, 4. N. to subclavius, 5. lat. pectoral, 6. upper subscapular, 7. thoracodorsal, 8. lower
subscapular, 9. medial pectoral, 10. medial brachial cutaneous, 11. medial antebrachial cutaneous,
12. musculocutaneous, 13. radial, 14. axillary, 15. median, 16. ulnar.

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SUPRACLAVICULAR DIVISION
• The brachial plexus begins as a continuation of the VENTRAL RAMI from C5
through T1 spinal nerves (Figs. 1-3; 1-4)
• Ventral rami of C5 and C6 join to form the SUPERIOR (UPPER) TRUNK of
the plexus,
• Ventral ramus of C7 forms the MIDDLE TRUNK,
• Ventral rami of C8 and T1 join to form the INFERIOR (LOWER) TRUNK.
• Several nerves branch off these trunks (See TABLE 1-1)
• Each trunk divides into an ANTERIOR DIVISION and a POSTERIOR DIVISION
(Figs. 1-3; 1-4).
• Nerve fibers from the anterior divisions innervate the anterior regions of the upper
limb and those in the posterior divisions innervate the posterior regions.
Fig. 1-4. Axilla: 1. dorsal scapular N., 2. branch to join phrenic N. 3. suprascapular N., 4. N.
to subclavius, 5. lateral pectoral N., 6. musculocutaneous N., 7. axillary N., 8. median N., 9.
ulnar N., 10. medial antebrachial cutaneous N., 11. medial brachial cutaneous N., 12. radial
N., 13. lower subscapular N., 14. upper subscapular N., 15. medial pectoral N., 16. N. to
longus colli and scalenei, 17. long thoracic N. The unlabeled nerve between the upper (13)
and lower (14) subscapular nerves is the thoracodorsal N. (modified by Gray’s 1918)

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INFRACLAVICULAR DIVISION (Figs 1-3; 1-4; 1-5; TABLE 1-2)
• Anterior divisions from the superior (C5, C6) and middle (C7) trunks join to form
the LATERAL CORD (C5, C6, C7).
• The anterior division from the inferior trunk (C8, T1) forms the MEDIAL CORD
(C8, T1).
• Posterior divisions from the superior (C5, C6), middle (C7) and inferior (C8, T1)
trunks unite to form the POSTERIOR CORD (C5, C6, C7, C8, T1). The nerve
cords are named because of their position relative to the axillary artery.
• TheLATERALCORD(C5,C6,C7)endsbydividingintotheMUSCULOCUTANEOUS
NERVE (C5, C6, C7) and the LATERAL ROOT OF THE MEDIAN NERVE
(C5, C6, C7).
• The MEDIAL CORD (C8, T1) ends by dividing into the ULNAR NERVE (C8,
T1) and the MEDIAL ROOT OF THE MEDIAN NERVE (C8, T1).
• The lateral (C5, C6, C7) and medial (C8, T1) roots of the median nerve join to
form the MEDIAN NERVE (C5 – T1).
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• The POSTERIOR CORD (C5 – T1) ends by dividing into the AXILLARY NERVE
(C5, C6) and the RADIAL NERVE (mainly C5–C8; small contribution from T;
Figs. 8-23, 8-24, 8-29). These terminal nerves and other nerve arising from the
rami, trunks and cords of the brachial plexus innervate the muscles and joints of
the entire upper limb.
• Several nerves branch off these cords before the cords end with terminal nerves
(See TABLE 1-2).
Fig. 1-5. Axilla. Dissection of brachial plexus in axilla. 1. Axillary artery, 2. Lateral pectoral nerve, 3. Lateral
cord, 4. Medial pectoral nerve, 5. Medial cord, 6. Thoracodorsal nerve, 7. Combined medial brachial and
antebrachial cutaneous nerves, 8. Ulnar nerve, 9. Median nerve, 10. Musculocutaneous nerve, Bs = Short
head of biceps, CB = Coracobrachialis, Pm = pectoralis minor, Pmj = Pectoralis major.
Nerve Spinal Level Structures Innervated
Dorsal scapular (C4)*, C5 Rhomboids major minor, levator scapulae
Lonq thoracic C5,6,7 Serratus anterior
Nerve to subclavius (C4), C5, (C6) Subclavius
Suprascapular N (C4), C5, 6 Supraspinatus, infraspinatus
* Spinal levels in parentheses are variable
TABLE 1-1 NERVES FROM THE SUPRACLAVICULAR DIVISION OF BRACHIAL PLEXUS

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LATERAL CORD
Lateral pectoral N. C5,6,7 pectoralis major
Musculocutaneous C5,6,7
Coracobrachialis; biceps
brachialis; skin of lateral forearm;
by lateral antebrachial N.
Lateral root of median N. C5,6,7
Muscles of forearm and
hand and skin of hand
MEDIAL CORD
Medial pectoral C8,T1 Pectoralis major and minor
Medial brachial cutaneous C8,T1
Medial skin of arm and
upper medial forearm
Medial antebrachial
cutaneous
C8,T1 Medial skin of forearm
Ulnar C8,T1
Muscles of forearm and
hand and skin of hand
Medial root of median N. C8,T1 Muscles of hand
POSTERIOR CORD
Upper subscapular C5,6,7 Subscapularis
Thoracodorsal C6,7,8 Latissimus dorsi
Lower subscapular C5,6,7 Subscapularis, teres major
Axillary C5,6
Deltoid, teres minor, skin
of the lateral upper arm by
lateral brachial cutaneous N.
Radial C5,6,7,8
Triceps; anconeus;
brachioradialis; extensors of wrist
and hand by deep radial N; skin
of posterior arm and forearm by
posterior antebrachial N; skin of
hand by superficial radial n.
TABLE 1-2 NERVES FROM CORDS OF THE INFRACLAVICULAR DIVISION OF THE BRACHIAL PLEXUS

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1) Which spinal nerves mainly contribute to the following:
a. Superior trunk?
b. Medial cord?
c. Posterior cord?
d. Lateral cord?
e. Inferior trunk?
2) What are the terminal branches and from what cords do each of these receive
their nerve fibers?
3) What are the branches off the:
a. Superior trunk?
b. Middle trunk?
c. Lateral cord?
d. Medial cord?
e. Posterior cord?
Above are diagrams of the brachial plexus. As we proceed through the different regions of
the arm, forearm and hand, these nerves will be described relative to that region. Following
the chapter on the hand, we will discuss the potential results of damage to the different
parts of the brachial plexus. Before you get there, all the muscles of the upper limb will have
been described, as well as the sensory distribution of the upper limb. With this information,
you will have a good overall picture of how damage to the brachial plexus affects the upper
limb. YOU WILL FIND IT VERY USEFUL IF CAN DRAW FIGURE 1-3 ACCURATELY.

AXILLA-UPPER LIMB SHOULDER COMPLEX
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2 SHOULDER COMPLEX
2.1 OSTEOLOGY
SCAPULA (Fig. 2-1)
• A triangular shaped bone in the upper posterior half of the thoracic region, just
under the trapezuis muscle.
• The SUPERIOR ANGLE of the scapula lies at the level of the second thoracic
vertebra (T2) and its INFERIOR ANGLE is at the level of T7.
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thinking.

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Fig. 2-1. Shoulder: Ventral A) and dorsal B) surfaces of the scapula. 1. Superior angle, 2. superior border,
3. suprascapular notch, 4. acromion, 5. coracoid process, 6. glenoid cavity, 7. neck, 8. lateral border, 9. subscapular
fossa, 10. inferior angle, 11. medial border, 12. infraspinous fossa, 13. Spine of the scapula, 14. supraspinous
fossa, and 15. lateral angle. (Modified from Gray 1918)
• SUBSCAPULAR FOSSA on the ventral (costal) surface where the SUBSCAPULARIS
MUSCLE attaches.
• SUPRASPINOUS FOSSA on the superior surface where the SUPRASPINATUS
MUSCLE attaches.
• INFRASPINOUS FOSSA on the dorsal surface where the INFRASPINATUS
MUSCLE attaches.
• SPINE OF THE SCAPULA separates the supraspinous and infraspinous fossae.
• ROOT OF THE SPINE is the flat medial end of the scapular spine.
• ACROMION PROCESS is the lateral end of the scapular spine.
• GLENOID FOSSA is inferior to the acromion process and articulates with the
head of the humerus forms the glenohumeral joint.
• CORACOID PROCESS projects anteriorly from the superior margin of the
glenoid fossa.

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CLAVICLE (Fig. 2-2)
• “S” shaped bone
• blunt, rounded medial end that articulates with the manubrium of the sternum
forming sternoclavicular joint
• flat lateral end that articulates with the acromion process of the scapula forming
the acromioclavicular joint.
Fig. 2-2. Shoulder: 1. Sternal end, 2. acromial end, 3. articular surface for sternum, 4. articular
surface for acromion. (Modified from Gray 1918)

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PROXIMAL HUMERUS (Fig. 2-3)
• The HUMERUS is divided into a proximal (upper) end, a shaft or body, and a
distal (lower) end.
• PROXIMAL END contains;
1) HUMERAL HEAD which articulates with the glenoid fossa of the humerus.
2) GREATER TUBERCLE where the supraspinatus, infraspinatus and teres minor
muscles attach.
3) LESSER TUBERCLE where the subscapularis muscle attaches.
4) INTERTUBERCULAR (Bicipital) GROOVE for the tendon of the long head
of the biceps and attachment for the pectoralis major, teres major and latissimus
dorsi muscles.
5) DELTOID TUBEROSITY for the attachment of the deltoid muscle.
6) GROOVE FOR THE RADIAL NERVE which is between the attachments of
the medial and lateral heads of the triceps.
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Fig. 2-3. Shoulder: Ventral A) and dorsal B) surfaces of the left humerus. 1. Head, 2. greater
tubercle, 3. anatomical neck, 4. lesser tubercle, 5. intertubercular groove, 6. crest of greater
tubercle extending to the lateral lip of the intertubercular groove, 7. surgical neck, 8. medial
lip of intertubercular groove, 9. deltoid tuberosity, 10. lateral supracondylar ridge, 11. medial
supracondylar ridge, 13. radial fossa, 14. lateral epicondyle, 15. olecranon fossa, 16. medial
epicondyle, 17. trochlea, 18. coronoid fossa, 19. capitulum. (Modified from Gray 1918)

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2.2 JOINTS, LIGAMENTS, BURSAE
2.2.1 JOINTS
• STERNOCLAVICULAR JOINT (Figs. 2-4; 2-6)
○
○ Saddle type joint
○
○ Medial CLAVICLE articulates with MANUBRIUM of the sternum
○
○ INTERARTICULAR DISC of fibrocartilage separating the joint cavity into an
upper and lower joint space.
Fig. 2-4. Shoulder: 1. Clavicle, 2. 1st rib, 3. sternum, 4. interclavicular ligament, 5. sternal notch,
6. articular disc, 7. costal cartilage, 8. sternocostal ligament, and 9. costoclavicular ligament. (Modified
from Gray 1918)
• ACROMIOCLAVICULAR JOINT (Figs. 2-5; 2-6; 2-7)
○
○ Plane type of joint
○
○ Lateral CLAVICLE articulates with ACROMION of the scapula
○
○ INTERARTICULAR DISC of fibrocartilage that divides the joint space.

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Fig. 2-5. Shoulder: 1. Clavicle, 2. scapula, 3. acromion, 4. capsule of
acromioclavicular joint, 5. trapezoid ligament, 6. conoid ligament, 7. transverse
scapular ligament, 8. coracoacromial ligament, 9. coracohumeral ligament,
10. superior glenohumeral (GH) ligament, 11. middle GH ligament, 12. inferior
GH ligament. 13. long head of biceps, 14. intertubercular groove, 15. coracoid
process. Attachment of: 16. pectoralis minor, 17. coracobrachialis, and 18. short
head of biceps. (Modified from Gray 1918)
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Fig. 2-6. Shoulder: (A) Sternoclavicular joint and (B) Acromioclavicular joint. 1. Costoclavicular lig.,
2. Interarticular disc, 3. Sternal head of sternocleidomastoid muscle, 4. Interclavicular lig. 5. Reflected
clavicular head of sternocleidomastoid muscle, 6. Acromioclavicular joint, 7. Trapezoid lig. of
coracoclavicular lig. 8. Conoid lig of coracoclavicular lig., 9. Coracoacromial lig., 10. Coracoid process,
11. Transverse humeral lig., 12. Deltoid burse continuous with subacromial bursa, 13. Long head of
biceps, C = Clavicle, H = Humerus, PM = Pectoralis major muscle
• GLENOHUMERAL JOINT (Figs. 2-5; 2-7)
○
○ ball and socket type joint
○
○ HUMERAL HEAD articulated with GLENOID FOSSA of scapula
○
○ GLENOID LABRUM is a fibrous rim that deepens the glenoid fossa
Fig. 2-7. Shoulder: Radiograph of the glenohumeral and acromioclavicular joints: (TOP) Frontal view and
(BOTTOM) Axillary view. 1. greater tubercle, 2. acromion, 3. clavicle, 4. medial border of scapula, 5. lateral
border of scapula, 6. glenoid fossa, 7. humeral head, and 8. coracoid process.

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• SCAPULOTHORACIC ARTICULATION (Fig. 2-8)
○
○ not a typical joint but a muscular area that allows multidirectional movement
of the scapula.
○
○ Two space the serratus anterior muscle:
○
○ 1) a COSTAL SPACE between the ribs and the serratus anterior muscle
○
○ 2) a SUBSCAPULAR SPACE between the subscapularis muscle and the serratus
anterior.
Fig. 2-8. Shoulder: Drawing of the scapula showing its position: A) at rest, B) with elevation and
depression, C) with adduction (retraction) and abduction (protraction), D) with upward (lateral) rotation,
and E) with downward (medial) rotation
2.2.2 LIGAMENTS
• STERNOCLAVICULAR JOINT LIGAMENTS (Figs. 2-4, 2-6)
1) ANTERIOR and thick POSTERIOR STERNOCLAVICULAR LIGAMENTS
connects the manubrium and medial end of clavicle;
2) INTERCLAVICULAR LIGAMENT connects the superior medial ends of the
clavicles and the sternal notch;
3) COSTOCLAVICULAR LIGAMENT connects the superior medial end of the
first rib and inferior medial end of the clavicle.

25
25
• ACROMIOCLAVICULAR JOINT LIGAMENTS (Figs. 2-5, 2-6, 2-9)
1) ACROMIOCLAVICULAR LIGAMENT connects the superior surfaces of the
clavicle and acromion,
2) CORACOCLAVICULAR LIGAMENT has 2 parts that connects the base of
the coracoid process of the scapula and lateral end of clavicle
○
○ a flat, rectangular-shaped TRAPEZOID LIGAMENT connects the trapezoid
line of the clavicle and coracoid process
○
○ a thick, cone-shaped CONOID LIGAMENT connects the conoid tubercle
of the clavicle and coracoid process.
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Fig. 2-9. Shoulder: Lateral A) and ventral B) views of the right glenohumeral joint. 1. acromion, 2. coracoacromial
ligament, 3. coracoid process, 4. coracohumeral ligament, 5. tendon of long head of biceps, 6. superior
glenohumeral (GH) ligaments, 7. subscapular bursa, 8. tendon of subscapularis, 9. middle GH ligament, 10. inferior
GH ligament, 11. labrum, 12. glenoid fossa, 13. tendon of teres minor, 14. capsule, 15. tendon of infraspinatus,
16. subacromial bursa, 17. tendon of supraspinatus, 18. subdeltoid bursa, 19. synovial lining of GH joint,
20. bicipital bursa, and 21. subcoracoid bursa.
• GLENOHUMERAL JOINT LIGAMENTS (Figs 2-9; 2-10)
1) SUPERIOR GLENOHUMERAL LIGAMENT connects the superior part of
the glenoid fossa near the origin of the coracoid process to the superior aspect
of the lesser tubercle.
2) MIDDLE GLENOHUMERAL LIGAMENT connects the middle of the anterior
margin of the glenoid to the inferior border of the lesser tubercle.
3) INFERIOR GLENOHUMERAL LIGAMENT connects the inferior margin of
the glenoid to the anatomical neck of the humerus.
4) CORACOHUMERAL LIGAMENT connects the lateral border of the coracoid
process, runs over the superior glenohumeral joint capsule, to the greater tubercle
of the humerus with the tendon of the supraspinatus muscle.
5) CORACOACROMIAL LIGAMENT connects the lateral aspect of the coracoid
process with the anterior margin of the acromion, and combined with the
acromion and coracoid processes form the CORACOACROMIAL ARCH.
6) TRANSVERSE HUMERAL LIGAMENT connects the greater and lesser
tubercles crossing the intertubercular groove and forming tunnel for long head
of the biceps.

27
Fig. 2-10. Shoulder: Dissection of a disarticulated glenohumeral joint showing an intracapsular
view of the ligaments. 1. Inferior glenohumeral lig., 2. Middle glenohumeral lig., 3. Superior
glenohumeral lig. 4. Coracohumeral lig., 5. Glenoid labrum, 6. Glenoid fossa, 7. Long head of
biceps, HH = Humeral head.
2.2.3 JOINT INNERVATION
• Joints are innervated by sensory nerves that provide proprioceptive and general
sensory information to the central nervous system.
• STERNOCLAVICULARJOINTisinnervatedbytheMIDDLESUPRACLAVICULAR
NERVE and the NERVE to the SUBCLAVIUS.
• ACROMIOCLAVICULAR JOINT is innervated by the LATERAL
SUPRACLAVICULAR NERVE, the MEDIAL and LATERAL PECTORAL
NERVES, the SUPRASCAPULAR NERVE and the AXILLARY NERVE.
• GLENOHUMERAL JOINT is innervated by the LATERAL PECTORAL NERVE,
the SUPRASCAPULAR NERVE, and the AXILLARY NERVE.

28
28
A general rule for the innervations of the joints of the upper and lower limbs is that nerves
innervating muscles that move the joints also innervate the joint being moved. Although
there are variations and maybe other cutaneous nerves innervate the joints, this rule usually
applies and is a good way to help you remember joint innervations.
2.2.4 BURSAE (FIG. 2-9)
• Sacks of synovial tissue found in areas to reduce high frictional forces.
• SUBACROMIAL BURSA lies between the acromion and the coracoacromial
ligament superiorly and the tendon of the supraspinatus muscle inferiorly.
• SUBDELTOID BURSA may be a lateral continuation of the subacromial bursa
or a separate distinct bursa. It lies between the middle deltoid and the capsule of
the glenohumeral joint.
• SUBSCAPULAR BURSA lies anteriorly between the tendon of the subscapularis
muscle and the middle glenohumeral ligament.
• INFRASCAPULAR BURSA lies between the posterior to the joint capsule and
the tendon of the infraspinatus muscle.
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29
• SUBCORACOID BURSA is inferior to the coracoid process between the anterior
joint capsule and the tendons of the coracobrachialis muscle and the short head
of the biceps.
• BICEPITAL BURSA lies in the intertubercular groove around the tendon of the
long head of the biceps.
1) Instability at the sternoclavicular joint may result from damage to which ligaments?
2) Instability at the acromioclavicular joint may result from damage to which ligaments?
3) What ligament lie anterior to the glenohumeral joint?
4) Where are the following bursae found?
a. Subscapular
b. Subacromial
c. Bicipital
d. Subcoracoid
2.3 GLENOHUMERAL MUSCLES
2.3.1 SCAPULAR GROUP
1) TRAPEZIUS (Figs. 2-11, 2-12).
• Medial Attachment (Origin): superior nuchal line of the occipital bone, external
occipital protuberance of the occipital bone, ligamentum nuchae, spinous processes
and supraspinous ligaments of C7 to T12
• Lateral Attachment (Insertion): posterior border of the lateral 1/3 of clavicle,
anterior border of the acromial process, anterior border of the entire spine of
the scapula
• Nerve: spinal accessory (CN. XI; motor innervations) and C3, C4 (sensory
innervations)
○
○ UPPER TRAPEZIUS: elevates and retracts the scapula, rotation of the glenoid
fossa upward, extends the head (both sides), laterally flexes the head (same side),
and rotates (opposite side) the head.
○
○ MIDDLE TRAPEZIUS: retracts (adducts) the scapula
○
○ LOWERTRAPEZIUS: depresses the scapula, rotation of the glenoid fossa upward

30
Fig. 2 -11. Shoulder. Drawing of the A) the superficial back muscles and a diagram B) showing the attachment
sites of these muscles. 1. trapezius, 1a. upper trapezius, 1b. middle trapezius, 1c. lower trapezius, 2. deltoid,
3. latissimus dorsi, 4. levator scapulae, 5. rhomboid minor, 6. rhomboid major, 7. post. Inf. serratus (Partly
modified from Gray 1918)
2) LEVATOR SCAPULAE (Figs. 2-11).
• Medial Attachment (Origin): transverse processes of C1 to C4
• Lateral Attachment (Insertion): medial border of the scapula from the superior
angle to the root of the spine of the scapula
• Nerve: dorsal scapular
• Actions: elevates the scapula, rotation of the glenoid fossa downward; extends
the neck (both sides), laterally flexes the neck (same side), and rotates the neck
(same side).

31
Fig. 2-12. Back Muscles: Photograph of the superficial back. 1a. Upper trapezius, 1b. Middle
Trapezius, 1c. Lower trapezius, 2. Deltoid, 3. Teres major, 4. Latissimus dorsi, 5. Thoracolumbar
fascia, 6. Infraspinatus, 7. Sternocleidomastoid, 8. Splenius capitis.
3) RHOMBOID MINOR (Fig. 2-11).
• Medial Attachment (Origin): lower ligamentum nuchae, spinous processes and
supraspinous ligament of C7-T1
• Lateral Attachment (Insertion): medial border of the root of the spine of the
scapula
• Actions: retracts the scapula, assists in elevation of the scapula
4) RHOMBOID MAJOR (Fig. 2-11).
• Medial Attachment (Origin): spinous processes and supraspinous ligament of
T2–T5
• Lateral Attachment (Insertion): lower medial border of the scapula from the root
of the spine to the inferior angle
• Actions: retracts the scapula, rotation of the glenoid fossa downward

32
32
5) SERRATUS ANTERIOR (Figs. 2-13, 2-14)
• Lateral attachment (Origin): muscular slips from the axillary border of ribs 1–9
• Medial attachment (Insertion): medial costal edge of the scapula
• Nerve: long thoracic
• Action: protraction of the scapula, upward rotation of the scapula which elevates
glenoid fossa
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33
Fig. 2-13. Shoulder: Drawing showing the serratus anterior under the cut pectoralis major
and intact pectoralis minor. Note the serratus anterior passes anterior to the subscapularis
to attach on the medial border of the scapula. 1. Tendon of short head of biceps,
2. Coracobrachialis, 3. Subscapularis, 4. Coracoid process, 5. Subclavius, 6. Clavicular and
sternal heads of the pectoralis major (cut), 7. Pectoralis minor, 8. Internal intercostal,
9. External intercostals, 10. Brachialis, 11. Radius, 12. Short head of biceps, 13. Serratus
anterior, 14. Latissimus dorsi, 15. Long head of biceps, 16. Pectoralis major tendon cut
andreflected.17.Tendonoflongheadofbiceps,18.Subacromial–deltoidbursa,19.Deltoid.
(Modified from Gray’s 1918)
Fig. 2-14. Shoulder: Diagram of the serratus anterior, pectoralis major, pectoralis minor and subclavius showing
their bony attachment sites. 1. anterior surface of scapula, 2. serratus anterior, 3. pectoralis major: a) clavicular
head, b) sternal head, and c) costal head. 4. Insertion of pectoralis major, 5. pectoralis minor, 6. subclavius.

34
2.3.2 ANTERIOR GLENOHUMERAL GROUP
1) PECTORALIS MAJOR ( Figs. 2-13, 2-14, 2-15)
• Medial attachment (Origin): medial half of the clavicle, manubrium and body
of the sternum; costal cartilage of upper 6 ribs.
• Lateral attachment (Insertion): lateral lip of the intertubercular groove of humerus
• Nerve: lateral pectoral nerve and medial pectoral nerve
• Action: adducts and internally rotates the humerus; flexes extended humerus;
extends flexed humerus.
2) PECTORALIS MINOR (Figs. 2-13, 2-14)
• Medial attachment (Origin): mid-clavicular region of ribs 2 through 5
• Lateral attachment (Insertion): medial surface of the coracoid process of scapula
• Nerve: medial pectoral nerve
• Action: depresses the scapula; downward scapular rotation
3) SUBCLAVIUS (Fig. 2-14)
• Medial attachment (Origin): superior surface of rib 1
• Lateral attachment (Insertion): subclavius groove on clavicle
• Nerve: nerve to subclavius
• Action: depresses and stabilize clavicle
4) CORACOBRACHIALIS (Figs. 2-13, 3-11, 3-12, 3-13; SEE ARM AND ELBOW
FOR DETAILS)
5) SHORT HEAD of BICEPS (Figs. 2-13, 2-15, 3-11, 3-12, 3-13; SEE ARM AND
ELBOW FOR DETAILS)
6) LONG HEAD of BICEPS (Figs. 2-13, 2-15, 3-11, 3-12, 3-13 SEE ARM AND
ELBOW FOR DETAILS)
2.3.3 POSTERIOR GLENOHUMERAL GROUP
1) TERES MAJOR (Figs 2-15, 2-16, 2-17, 3-11, 3-15, 3-16, 3-16)
• Medial attachment (Origin): dorsal lateral edge of the inferior 1/3 of the scapula
• Lateral attachment (Insertion): medial lip of the intertubercular groove of
the humerus
• Nerve: lower subscapular nerve
• Action: adducts and internally rotates the humerus

35
35
Fig 2-15. Shoulder: Dissections of anterior shoulder region (Left) and posterior shoulder region
(Right). 1. Long head of biceps, 2. Short head of biceps, 3. Brachioradialis, 4. Biceps tendon,
5. Brachialis, 6. Ulnar nerve, 7. Brachial artery, 8. Axillary artery, 9. Sternal head of pectoralis
major, 10. Clavicular head of pectoralis major, 11. Supraspinatus, 12. Teres minor, 13. Axillary
nerve, 14. Radial nerve, D = Deltoid, IS = Infraspinatus, LD = Latissimus dorsi, LT = Long head
of triceps, RMj = Rhomboid major, TMj = Teres major.
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2) LATISSIMUS DORSI (Figs. 2-11, 2-12; 2-15; 2-16).
• Medial Attachment (Origin): spinous processes of T6 to T12, L1–L5 by
thoracolumbar fascia, base of the sacrum, iliac crest, and ribs 8–12, inferior
angle of the scapula.
• Lateral Attachment (Insertion): floor of the intertubercular groove of the humerus.
• Nerve: thoracodorsal
• Actions: humeral adduction, humeral internal (medial) rotation, assists in humeral
extension and flexion depending on humeral position
3) LONG HEAD of the TRICEPS (Figs. 2-15, 2-16, 3-11, 3-14, 3-15, 3-16, 3-17;
SEE ARM AND ELBOW FOR DETAILS)
Fig. 2-16. Shoulder: (Left) Posterior glenohumeral group. 1.Teres minor, 2. Greater tubercle of humerus,
3. Quadrangular space, 4. Teres major, 5. Lateral head of triceps, 6. Olecranon process, 7. Long head of
triceps, 8. Latissimus dorsi, 9. Triangular space, 10. Infraspinatus, 11. Supraspinatus, 12. Spine of scapula.
(Modified from Gray’s 1918) (Right) Superior glenohumeral group 1a. Posterior deltoid, 1b.middle deltoid,
1c. anterior deltoid, 2. triceps, 3. biceps, 4. brachialis, 6. brachioradialis, 7. deltoid tuberosity, 8. acromion,
and 9. clavicle.
2.3.4 SUPERIOR GLENOHUMERAL GROUP
1) ANTERIOR DELTOID (Figs. 2-15, 2-16)
• Medial attachment (Origin): lateral one-third of clavicle
• Lateral attachment (Insertion): deltoid tuberosity of humerus
• Nerve: axillary nerve
• Action: flexion, abduction and internal rotation of humerus

37
2) MIDDLE DELTOID (Fig. 2-11, 2-16)
• Medial attachment (Origin): lateral acromion process of scapula
• Lateral attachment (Insertion): middle of deltoid tuberosity of humerus
• Action: abduction of the humerus
3) POSTERIOR DELTOID (Fig. 2-11, 2-12, 2-15, 2-16)
• Medial attachment (Origin): lateral one-third of the spine of the scapula
• Lateral attachment (Insertion): posterior deltoid tuberosity of humerus
• Action: extension, abduction and externally rotates humerus
2.3.5 ROTATOR CUFF GROUP
Fig. 2-17. Shoulder: Diagram showing the bony attachment sites of the 1. Supraspinatus, 2. Teres
minor, 3. Teres major. 4. Infraspinatus. and 5. Subscapularis.
1) SUPRASPINATUS (Figs. 2-15, 2-16, 2-17)
• Medial attachment (Origin): supraspinous fossa of scapula
• Lateral attachment (Insertion): cranial most facet of the greater tubercle of
the humerus;
• Nerve: suprascapular nerve
• Action: abducts humerus, internal and external rotator of the glenohumeral joint
depending on humeral position.
2) INFRASPINATUS (Figs. 2-15, 2-16, 2-17)
• Medial attachment (Origin): infraspinous fossa of scapula
• Lateral attachment (Insertion): middle facet of the greater tubercle of the humerus
• Nerve: suprascapular nerve
• Action: externally rotates humerus, depresses humeral head, superior part assists
in humeral abduction, inferior part assists in humeral adduction.

38
38
3) TERES MINOR (Figs. 2-15, 2-16, 2-17)
• Medial attachment (Origin): middle 1/2 of the axillary border of the scapula
• Lateral attachment (Insertion): caudal most facet of the greater tubercle of
the humerus
• Action:externallyrotatesandstabilizeshumerus,weakadductorofglenohumeraljoint
4) SUBSCAPULARIS (Figs. 2-13, 2-17)
• Medial attachment (Origin): subscapular fossa of scapula
• Lateral attachment (Insertion): lesser tubercle of humerus
• Nerve: upper and lower subscapular nerves
• Action:internallyrotateshumerus,depresseshumeralhead,assistsinhumeraladduction

39
1) Name the muscles that produce the following movement:
a. Scapular retraction
b. Scapular elevation
c. Scapular protraction
d. Scapular upward rotation
e. Scapular downward rotation
f. Glenohumeral flexion
g. Glenohumeral abduction
h. Glenohumeral external rotation
i. Glenohumeral internal rotation
2) Name the muscles that produce both of the following movements:
a. Glenohumeral adduction and internal rotation
b. Glenohumeral joint extension and external rotation
c. Glenohumeral joint flexion and internal rotation
3) Name the muscle(s) and movement that would be affected with damage to each
of the following nerves:
a. Dorsal scapular nerve
b. Axillary nerve
c. Medial pectoral nerve
d. Suprascapular nerve
e. Spinal accessory nerve

AXILLA-UPPER LIMB ARM AND ELBOW
40
40
3 ARM AND ELBOW
3.1 OSTEOLOGY
• The arm contains a single bone, the HUMERUS that articulates proximally with
the glenoid fossa of the scapula and distally with the RADIUS and ULNA.
• DISTAL HUMERAL SHAFT (Figs. 2-3, 3-1)
○
○ MEDIALSUPRACONDYLARRIDGE ends at a large MEDIALEPICONDYLE.
○
○ LATERAL SUPRACONDYLAR RIDGE ends at the LATERAL EPICONDYLE
• DISTAL HUMERAL END (Figs. 3-1, 3-3)
○
○ round CAPITULUM for the head of the radius
○
○ RADIAL FOSSA is anterior above the capitulum
○
○ hourglass shaped TROCHLEA with its TROCHEAR GROOVE
○
○ deep CORONOID FOSSA is anterior above the trochlea for the coronoid
process of the ulnar
○
○ large and deep OLECRANON FOSSA is posterior above the trochlea for the
olecranon process of the ulnar
○
○ GROOVE FOR THE ULNAR NERVE is inferior to the medial epicondyle

41
Fig. 3-1. Arm: Ventral A) and dorsal B) surfaces
of the left humerus. 1. Head, 2. greater
tubercle, 3. anatomical neck, 4. lesser tubercle,
5. intertubercular groove, 6. crest of greater
tubercle extending to the lateral lip of the
intertubercular groove, 7. surgical neck, 8.
medial lip of intertubercular groove, 9. deltoid
tuberosity, 10. lateral supracondylar ridge, 11.
medial supracondylar ridge, 13. radial fossa,
14. lateral epicondyle, 15. olecranon fossa, 16.
medial epicondyle, 17. trochlea, 18. coronoid
fossa,19.Capitulum.(ModifiedfromGray1918)
Fig. 3-2. Arm: Ventral and dorsal views of the radius
and ulna. 1. olecranon, 2. trochlear fossa, 3. radial
notch, 4. head of radius, 5. ulnar tuberosity, 6.
anconeus, 7. radial tuberosity, 8. flexor digitorum
profundus, 9. supinator, 10. flexor pollicis longus,
11. pronator quadrates, 12. ulnar head, 13. groove
for extensor pollicis brevis and abductor pollicis
longus, 14. ulnar styloid, 15. radial styloid, 16.
groove for extensor carpi radialis longus and brevis,
17. Lister’s (dorsal radial ) tubercle, 18. groove for
the extensor pollicis longus, 19. groove for extensor
carpi ulnaris. (Modified from Gray 1918)
• PROXIMAL RADIUS (Figs. 3-2; 3-3)
○
○ RADIAL HEAD articulates with the capitulum of the humerus and RADIAL
NOTCH on the ulna.
○
○ RADIAL TUBEROSITY for the insertion of the biceps tendon.
• PROXIMAL ULNA (Figs. 3-2; 3-3)
○
○ OLECRANON is the C – shaped socket
○
○ TROCHLEAR NOTCH is the concavity of the olecranon
○
○ OLECRANON PROCESS is the top of the olecranon
○
○ CORONOID PROCESS is the bottom of the olecranon
○
○ TROCHLEAR RIDGE is in the middle of the trochlea notch
○
○ RADIAL NOTCH is lateral to the coronoid process

42
42
JOINTS (Fig. 3-3)
1) HUMERORADIAL JOINT between the head of the radius and the capitulum
of the humerus
2) HUMEROULNAR JOINT between the trochlear notch of the ulna and the
trochlea of the humerus
3) PROXIMAL RADIOULNAR JOINT between the head of the radius and the
radial notch on the ulna.
LIGAMENTS (Figs. 3-4, 3-5)
1) Thin RADIAL (lateral) COLLATERAL LIGAMENT extends from the lateral
epicondyle to the radial side of the annular ligament.
2) Thick ULNAR (medial) COLLATERAL LIGAMENT extends from the medial
epicondyle to the coronoid process and the medial aspect of the trochlear notch
of the olecranon.
3) Thick ANNULAR LIGAMENT attaches to the anterior and posterior edges of the
radial notch of the ulna and envelops the head of the radius.
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43
Fig. 3-3. Arm: Elbow Joint Radiographs and MRI: A) AP radiograph, B) lateral radiograph, and C) coronal
plane T1 MRI. The numbers in the radiographs indicate: 1. lateral epicondyle, 2. medial epicondyle,
3. capitulum, 4. head of radius, 5. olecranon, 6. coronoid process of ulna, and 7. radial tuberosity.

44
Fig. 3-4. Arm: A) medial, B) lateral, and C) anterior views of the elbow: 1. medial collateral
ligamentanteriorband,2.medialcollateralposteriorband,3.anteriorjointcapsule,4.annular
ligament of radius, 5. lateral collateral ligament, 6. capsule, 7. oblique cord, and 8. synovial
membrane. (Modified from Gray 1918)

45
Fig. 3-5. Arm. Dissection of the Medial elbow (Left) and Lateral elbow (Right) ligaments. 1. Anterior band of
medial collateral lig., 2. Ulnar nerve, 3. Posterior band of medial collateral lig., 4. Transverse band of medial
collateral lig., 5. Cubital tunnel, 6. Ulnar nerve, 7. Lateral epicondyle, 8. Lateral collateral lig., 9. Annular lig.,
10. Radius, 11. Ulna.
BURSAE
1) SUBCUTANEOUS OLECRANON BURSA lies between the skin and the olecranon
2) SUBTENDINOUS OLECRANON BURSA lies between the tendon of the triceps
and the superior aspect of the olecranon
3) BICIPITAL BURSA that lies between the biceps tendon and the radial tuberosity
4) RADIOULNAR BURSA that lies between the extensor digitorum muscle of the
forearm and the underlying humeroradial joint and supinator muscle
1) Which of the joints of the elbow involve articulation with the radius?
2) Which of the joints of the elbow involve articulation with the ulna?
3) What joints do the following ligaments mainly stabilize:
a. Medial collateral?
b. Lateral collateral?
c. Annular?

46
46
3.3 ANTERIOR BRACHIAL COMPARTMENT
3.3.1 NERVES OF ANTERIOR COMPARTMENT
• MUSCULOCUTANEOUS NERVE (Figs. 3-6, 3-10)
○
○ passes through the coracobrachialis muscle
○
○ ends as the LATERAL ANTEBRACHIAL NERVE which is sensory to the skin
of the lateral lower arm and the lateral forearm.
• MEDIAN NERVE (Figs. 3-7, 3-9, 3-10)
○
○ follows the brachial artery
○
○ rests on the brachialis muscle
○
○ enters the cubital fossa and passes deep to the bicipital aponeurosis.
• ULNAR NERVE (Figs. 3-8, 3-9, 3-10)
○
○ runs along the medial side of the biceps
○
○ crosses into the posterior compartment of the arm
○
○ passes through the CUBITAL TUNNEL that lies in the ulnar groove between
the medial epicondyle and the trochlea of the humerus
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Fig. 3-6. Shoulder: Musculocutaneous Nerve to 1.
coracobrachialis, 2. biceps, 3. Brachialis, 4. posterior
and 5. anterior branches of the lateral antebrachial
cutaneous N.
Fig. 3-7. Shoulder: Median Nerve to 1. flexor carpi
rad. 2. palmaris longus, 3. flexor dig. profundus,
4. pronator teres, 5. flexor digitorum sublimes, 6.
flexorpollicislongus,7.flexordigitorumprofundus,
8. pronator quadratus 9. abductor pollicis brevis,
10. opponens pollicis, 11. superficial head of flexor
pollicis, and 12. 1st and 2nd lumbricals.

48
Fig. 3-8. Shoulder: Ulnar Nerve to 1. and 2. flexor carpi
ulnaris. 3. flexor digitorum profundus. 4. abductor digiti
minimi, 5. opponens digiti minmi, 6. flexor digiti minimi
brevis. 7. 3rd and 4th lumbricals. 8. palmar and dorsal
interossei, 9. adductor digiti minimi.

49
Fig. 3-9. Arm: Drawing of the ventral fore-
arm with the superficial muscles removed:
1. Biceps, 2. brachialis, 3. brachioradialis, 4.
deep radial N., 5. superficial radial N., 6.
radial artery, 7. flexor pollicis longus, 8. ra-
dial artery, superficial palmar branch of ra-
dial, 9. recurrent branch of median N., 10.
median N., 11. flexor retinaculum, 12. su-
perficial ulnar N., 13. superficial ulnar artery,
14. ulnar N., 15. ulnar artery, 16. flexor
carpi ulnaris, 17. flexor digitorum superfi-
cialis, and 18. brachial artery.
Fig. 3-10. Arm: Drawing of the ventral fore-
arm – deep muscles, arteries, and nerves in
this region: 1. Musculocutaneous N., 2. bra-
chialis, 3. radial N., 4. lateral epicondyle, 5.
deep radial N., 6. supinator, 7. superficial
radial N., 8. posterior interosseous artery,
9. radial artery, 10. pronator quadratus, 11.
superficial palmar branch of radial artery,
12. superficial ulnar N., 13. deep ulnar N.,
14. flexor digitorum profundus, 15. anterior
interosseous A+N, 16. ulnar artery, 17. ulnar
N., 18. common interosseous artery, 19.
brachial artery, 20. medial epicondyle, and
21. median N.

50
50
3.3.2 BRACHIAL ARTERY (FIGS. 1-2, 3-9, 3-10)
• the main artery to the arm.
• begins at the inferior border of the teres major muscle as a continuation of the
axillary artery
• runs with the median nerve in anterior brachial compartment
• gives off the PROFUNDA BRACHII ARTERY which travels with the radial nerve
into the posterior brachial compartment.
• ends near the cubital fossa by dividing into ULNAR and RADIAL ARTERIES
3.3.3 MUSCLES OF THE ANTERIOR COMPARTMENT
1) CORACOBRACHIALIS (Figs. 3-11, 3-12, 3-13)
• Proximal attachment (Origin): tip of the coracoid process of the scapula
• Distal attachment (Insertion): middle one-third of the shaft of the humerus
• Nerve: musculocutaneous
• Action: flexion of the glenohumeral joint
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51
2) BICEPS BRACHII (Figs. 3-9, 3-11, 3-12, 3-13)
• Proximal attachment (Origin): long head: the supraglenoid tubercle of the scapula
and glenoid labrum; short head: tip of the coracoid process of the scapular
• Distal attachment (Insertion): bicipital (radial) tuberosity of radius
• Action: flexion of the humeroradial and humeroulnar joints; supination of the
radioulnar joint; flexion of the glenohumeral joint
3) BRACHIALIS (Figs. 3-10, 3-13)
• Proximal attachment (Origin): distal half of the humerus
• Distal attachment (Insertion): coronoid process and tuberosity of the ulna
• Action: flexion of the humeroradial and humeroulnar joints
Fig 3-11. Arm: (Left) Anterior view of the upper limb. (Right) Posterior viewof the upper
limb. 1. Deltoid, 2. biceps, 3. brachioradialis, 4. flexor digitorum profundus, 5. flexor pollicis
longus, 6. flexor digitorum superficialis, 7. flexor carpi radialis, 8. palmaris longus, 9. medial
head of triceps, 10 long head of triceps. 11. coracobrachialis, 12. rhomboid major, 13.
subscapularis, 14. rhomboid minor, 15. levator scapulae, 16. trapezius, 17. infraspinatus,
18. teres minor, 19. teres major, 21. medial head of triceps, 22. flexor carpi ulnaris, 23.
extensor digitorum, 24. extensor carpi ulnaris, 25. anconeus, and 26. lateral head of triceps.

52
Fig. 3-12. Arm: Dissection of the anterior compartment of the arm. 1, Pectoralis major (reflected),
2. Deltoid (reflected), 3. Brachialis, 4. Brachioradialis, 5. Lateral antibrachial cutaneous nerve,
6. Tendon of biceps, 7. Long head of biceps, 8. Short head of biceps, 9. Subscapularis, 10.
Conjoint tendon of short head of the biceps and coracobrachialis from coracoid process, 11.
Pectoral minor (reflected).

53
Fig. 3-13. Arm: A) Picture of the biceps and coracobrachialis. 1. Tendon of short head of biceps, 2.
Coracobrachialis, 3. Subscapularis, 4. Coracoid process, 5. Pectoralis minor, 6. Serratus anterior, 7.
Latissimus dorsi, 8. Short head of biceps, 9. Brachialis, 10. Radius, 11. Long head of biceps, 12.
Tendon of long head of biceps, 13. Subacromial – deltoid bursa, 14. Deltoid. (Modified from Gray’s
1918); B) Diagram of biceps and C) Coracobrachialis and brachialis showing the attachment sites.
3.4 POSTERIOR BRACHIAL COMPARTMENT
3.4.1 RADIAL NERVE (FIGS. 3-14, 3-16, 3-17)
• terminal end of the posterior cord of the brachial plexus.
• run with the profunda brachii artery in the RADIAL GROOVE which lies between
the medial and lateral heads of the triceps muscle.
• divides near the lateral epicondyle of the humerus into a DEEP RADIAL NERVE
(posterior interosseous nerve) to the extensor forearm muscles and a SUPERFICIAL
RADIAL NERVE for sensation of the dorsum of the hand

54
54
3.4.2 PROFUNDA (DEEP) BRACHII ARTERY (FIGS. 1-2, 3-16, 3-17)
• branch of the brachial artery arises just distal to the teres major muscle
• runs with the radial nerve to supply the triceps muscle
3.4.3 MUSCLES OF THE POSTERIOR COMPARTMENT
1) TRICEPS (Figs. 3-11, 3-14, 3-15, 3-16, 3-17)
• Proximal attachment (Origin): long head: the infraglenoid tubercle of the scapula;
lateral head: the upper posterior humerus proximal to the radial groove; medial
head: the posterior humerus distal to the radial groove
• Distal attachment (Insertion): posterior and superior aspects of the olecranon
• Nerve: radial
• Action: extends the humeroradial and humeroulnar joints; long head assists in
extension of the glenohumeral joint

55
2) ANCONEUS (Fig. 3-11, 3-14)
• Proximal attachment (Origin): posterior lateral epicondyle of the humerus
• Distal attachment (Insertion): lateral aspect of the olecranon
• Nerve: radial
• Action: extends the humeroradial and humeroulnar joints
Fig. 3-14. Arm: Drawing showing the attachments of the Triceps and anconeus
3.4.4 QUADRANGULAR AND TRIANGULAR SPACES (FIGS. 3-15, 3-16, 3-17)
• QUADRANGULAR SPACE
○
○ formed by the long head of the triceps medially, the humerus laterally, the teres
minor superiorly and the teres major interiorly.
○
○ POSTERIOR HUMERAL CIRCUMFLEX ARTERY from the axillary artery
and the AXILLARY NERVE pass through it.
• TRIANGULAR SPACE
○
○ formed by the long head of the triceps laterally, the teres minor superiorly, the
teres major inferiorly and the meeting point of the teres minor and major medially.
○
○ CIRCUMFLEX SCAPULAR ARTERY off the subscapular artery passes through it.
• TRIANGULAR INTERVAL
○
○ formed by the long head of the triceps medially, the lateral head of the triceps
laterally, the teres major superiorly and the meeting point of the long and lateral
heads of the triceps inferiorly.
○
○ RADIAL NERVE and PROFUNDA (deep) BRACHII ARTERY pass through
this space

56
Fig. 3-15. Arm: Posterior Muscles and Spaces: 1.
spine of scapula, 2. supraspinatus, 3. acromion, 4.
quadrangular space, 5. triangular interval, 6. lat-
eral head of triceps, 7. long head of triceps, 8.
triangular space, 9. teres major, 10. teres minor,
and 11. infraspinatus.
Fig. 3-16. Arm: Posterior Nerves and Arteries: 1.
supraspinatus fossa, 2. suprascapular N., 3. supras-
capular A., 4. transverse scapular ligament, 5. acro-
mion, 6. teres minor, 7. posterior hum. circumflex
A., 8. axillary N., 9. profunda brachii, 10. radial N.,
11. long head of triceps, 12. teres major, 13. scap-
ular circumflex A., 14. infraspinous fossa, and 15.
spine of scapula.

57
Fig. 3-17. Arm. Dissection of the quadrangualar space and triangular interval. 1. Radial nerve, 2.
Profunda brachii artery, 3. Long head of triceps, 4. Lateral head of triceps, 5. Posterioir humeral circumflex
artery, 6. Axillary nerve, 7. Teres minor, 8. Supraspinatus. D = Deltoid, IS = Infraspinatus, LD = Latissimis
dorsi, RMj = Rhomboid major, TMj = Teres major.
1) Damage to the musculocutaneous nerve will affect what muscles and actions?
2) What terminal branches of the brachial plexus do not innervate muscles in the arm?
3) Damage to the radial nerve in the triangular interval will affect what motions at
the glenohumeral joint?
4) Trauma to the area of the quadrangular space will affect what muscles and movements?
5) Blockage or damage to the profunda brachii artery will affect which muscles?

AXILLA-UPPER LIMB FOREARM AND WRIST
58
58
4 FOREARM AND WRIST
4.1 OSTEOLOGY
RADIUS (Fig. 4-1)
• RADIAL HEAD articulates with the capitulum of the humerus and the radial
notch of the ulna.
• RADIAL TUBEROSITY for the insertion of the biceps tendon.
• RADIALSHAFT with a sharp medial edge for the attachment of the INTEROSSEOUS
MEMBRANE
• RADIAL STYLOID PROCESS on distal lateral border
• ULNAR NOTCH on distal medial border for articulation of the ulnar head
• SCAPHOID FOSSA on the inferior border for the articulation of the scaphoid
carpal bone
• LUNATE FOSSA for articulation of lunate carpal bones

59
Fig. 4-1. Forearm: Ventral and dorsal views of the radius and ulna. 1. olecranon, 2.
trochlear fossa, 3. radial notch, 4. head of radius, 5. ulnar tuberosity, 6. anconeus, 7.
radial tuberosity, 8. flexor digitorum profundus, 9. supinator, 10. flexor pollicis longus,
11. pronator quadrates, 12. ulnar head, 13. groove for extensor pollicis brevis and
abductor pollicis longus, 14. ulnar styloid, 15. radial styloid, 16. groove for extensor
carpi radialis longus and brevis, 17. Lister’s (dorsal radial) tubercle, 18. groove for the
extensor pollicis longus, 19. groove for extensor carpi ulnaris. (Modified from
Gray’s 1918)
ULNA (Fig. 4-1)
• TROCHLEAR NOTCH articulates with the trochlea of the humerus, forming the
humeroulnar joint.
• RADIAL NOTCH articulates with the head of the radius, forming the proximal
radioulnar joint
• OLECRANON for attachment of triceps
• CORONOID PROCESS for attachment of the brachialis muscle
• ULNAR TUBEROSITY for attachment of the brachialis muscle

60
• ULNAR SHAFT with a sharp lateral edge for the attachment of the interosseous
membrane.
• ULNAR HEAD distal end of ulna
• UNLAR STYLOID PROCESS off ulnar head
CARPAL BONES (Figs. 4-2, 4-3)
• PROXIMAL ROW of carpal bones
○
○ SCAPHOID (navicular)
○
○ LUNATE
○
○ TRIQUETRUM
○
○ PISIFORM
• DISTAL ROW of carpal bones
○
○ TRAPEZIUM (greater multangular)
○
○ TRAPEZOID (lesser multangular)
○
○ CAPITATE
○
○ HAMATE
Fig. 4-2. Forearm: Palmar view of the wrist and hand showing the carpal bones: 1. Scaphoid, 2. lunate,
3. triquetrum, 4. pisiform, 5. hamate, 6. capitate, 7. trapezoid, and 8. trapezium. (Modified from
Gray’s 1918)

61
61
Fig 4- 3. Forearm: Bones forming the joints of the wrist. 1. Radius, 2. Scaphoid, 3. Trapezoid, 4.
Trapezium, 5. Capitate, 6. Hamate, 7. Triquetrum, 8. Pisiform, 9. Lunate, 10. Ulna. (Modified from
Gray 1819)
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4.2.1 JOINTS
JOINTS OF THE WRIST (Fig. 4-3)
• DISTAL RADIOULNAR
○
○ articulation between the head of the ulna and the ulnar notch of the radius
• RADIOCARPAL JOINT
○
○ articulation between the distal radius and the scaphoid and lunate bone
• ULNOCARPAL JOINT
○
○ articulation between the head of the ulna and an interarticular disc and between
the disc and the triquetrum
• MIDCARPAL JOINT
○
○ articulation between the proximal carpal row and the distal carpal row
• INTERCARPAL JOINTS
○
○ articulation between adjacent carpal bones
• CARPOMETACARPAL JOINTS
○
○ articulation between distal carpal and metacarpals of the hand
4.2.2 LIGAMENTS (FIGS. 4-3, 4-4, 4-5)
1. PALMAR RADIOCARPAL LIGAMENT extends from the palmar surface of the
distal radius and the styloid process of the radius to the palmar surface of the
scaphoid, lunate, and capitate.
2. DORSAL RADIOCARPAL LIGAMENT is narrower, thinner, and weaker than the
palmar radiocarpal ligament. It extends from the dorsal surface of the distal medial
half of the radius to the dorsal surface of the scaphoid, lunate and triquetrum.
3. PALMAR ULNOCARPAL LIGAMENT extends from the palmar surface of the
lateral head of the ulna and the lateral interarticular disc to the palmar surface of
the proximal triquetrum.
4. The RADIAL COLLATERAL LIGAMENT extends from the distal aspect of the
styloid of the radius to the radial (lateral) surface of the scaphoid, trapezium, and
flexor retinaculum.
5. ULNAR COLLATERAL LIGAMENT extends from the styloid process of the ulna
to the ulnar (medial) surface of the triquetrum, pisiform and flexor retinaculum.
6. DORSAL and PALMAR INTERCARPAL LIGAMENTS interconnect the carpal
bones to each other.

63
Fig. 4-4. Forearm: The picture shows the palmar ligaments of the wrist and distal
radioulnar joints: 1. Interosseous membrane, 2. palmar radioulnar lig., 3. ulnar collateral
lig., 4. ulnolunate lig. of ulnocarpal lig. 5. ulnotriquetrial lig. of ulnocarpal lig. 6.
pisometacarpal lig. 7. pisohamate lig. 8. carpometacarpal lig. 9. palmar metacarpal ligs.,
10. trapezoid, 11. capsule of 1st carpometacarpal joint., 12. trapezium, 13. radial
collateral lig., 14. tubercle of scaphoid, 15. radiocapitate lig.of radiocarpal lig., 16.
radiolunate lig. of radiocarpal lig., 17. pisiform, and 18. hamate. (Modified from
Gray’s 1918)

64
64
Fig. 4-5. Forearm: The picture shows the dorsal ligaments of the wrist and distal
radioulnar joints: 1. Trapezoid, 2. capitate, 3. hamate., 4. pisohamate lig, 5. dorsal
radiocarpal lig., 6. ulnar collateral lig., 7. dorsal radioulnar lig., 8. interosseous
membrane, 9. radial collateral lig., 10. dorsal intercarpal ligs., 11. carpometacarpal
ligs., and 12. dorsal metacarpal ligs. (Modified from Gray 1918)
.

65
4.2.3 BURSAE (FIG. 5-6)
• RADIAL BURSA surrounds the tendon of the flexor pollicis longus muscle at
the wrist
• ULNAR BURSA surrounds the tendons of the flexor digitorum superficialis and
profundus muscles in the carpal tunnel.
1) What carpals form the proximal carpal row?
2) What are the joints of the wrist?
3) What ligaments are on the radial side of the wrist?
4) What are the ligaments on the ulnar side of the wrist?
4.3 CUBITAL FOSSA (FIGS. 4-6, 4-7, 4-8, 4-9)
• Area anterior to the elbow joint, continuation of arm into forearm
• BOUNDARIES
○
○ Medial: by the pronator teres muscle
○
○ Lateral: by the brachioradialis muscle
○
○ Inferior: meeting point of the pronator teres and brachioradialis
○
○ Superior: line interconnecting the medial and lateral epicondyles of the humerus
○
○ Floor: supinator and brachialis muscles
○
○ Roof: bicipital aponeurosis and skin
• CONTENTS
1) biceps tendon and bicipital aponeurosis
2) median nerve (See anteromedial muscular compartment)
3) radial nerve (See posterior lateral muscular compartment)
4) deep radial nerve (See posterior lateral muscular compartment)
5) superficial radial nerve (See posterior lateral muscular compartment)
6) radial artery (See anteromedial muscular compartment)
7) ulnar artery (See anteromedial muscular compartment)
8) common interosseous artery off the ulnar artery (See anteromedial muscular
compartment)
9) median cubital vein connecting cephalic and basilic veins

66
Fig. 4-6. Forearm: Boundaries of the cubital fossa.
1) Which muscles would be physically damaged (bruised) by a trauma to the cubital fossa?
2) Which nerves could be damaged by a trauma to the cubital fossa?
3) Which terminal nerves of the brachial plexus do not lie in the cubital fossa?
MUSCLES OF THE FOREARM
4.4 ANTEROMEDIAL MUSCULAR COMPARTMENT
4.4.1 CONTENTS
1) median nerve
2) ulnar nerve
3) radial artery
4) ulnar artery
5) common interosseous artery
6) anterior interosseous artery
7) SUPERFICIAL GROUP from the medial epicondyle by a common tendon of origin
8) DEEP GROUP from the ulna, radius and interosseous membrane

67
67
• MEDIAN NERVE (Figs. 4-7, 4-8, 4-9, 4-12).
○
○ lies in the middle of the cubital fossa and on the anterior surface of the brachialis
muscle
○
○ median nerve gives off the ANTERIOR INTEROSSEOUS NERVE to the deep
forearm flexors
○
○ enters the CARPAL TUNNEL with tendons of digitorum superficialis and
profundus
• ULNAR NERVE (Figs. 4-7, 4-8, 4-9, 4-11, 4-12)
○
○ passes through the cubital tunnel behind the medial epicondyle
○
○ ulnar nerve then runs with the ulnar artery.
○
○ enters GUYON’S TUNNEL at wrist with the ulnar artery
○
○ divides into a SUPERFICIAL ULNAR NERVE and a DEEP ULNAR NERVE
to the hand
• RADIAL ARTERY (Figs. 4-7, 4-8, 4-9, 4-12)
○
○ off the brachial artery with ulnar artery
○
○ runs on anterior brachialis muscle and then deep to the brachioradialis muscle
○
○ gives off a superficial palmar artery at wrist which may join the superficial ulnar
artery to complete the superficial palmar arch of the hand
○
○ enters the ANATOMICAL SNUFF BOX on the dorsum of the thumb
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68
• ULNAR ARTERY (Figs. 4-7, 4-8, 4-9, 4-12)
○
○ off the brachial artery with radial artery
○
○ between the median and ulnar nerves
○
○ gives off the short COMMON INTEROSSEOUS ARTERY which divides into
an ANTERIOR and a POSTERIOR INTEROSSEOUS ARTERY.
○
○ enters Guyon’s tunnel with the ulnar nerve at the wrist
○
○ divides into a SUPERFICIAL ULNAR ARTERY to the superficial palmar arch
and a DEEP PALMAR ARTERY to the deep palmar arch
• ANTERIOR INTEROSSEOUS ARTERY (Figs. 4-9, 4-12)
○
○ runs along the anterior surface of the interosseous membrane
○
○ joins an arterial network on the palmar surface of the carpal bones
Fig. 4-7. Forearm: Drawing of the ventral forearm showing the superficial
muscles: 1. Brachial artery, 2. median N., 3. pronator teres, 4. flexor carpi
radialis, 5. palmaris longus, 6. flexor carpi ulnaris, 7. flexor digit. superficialis,
8. ulnar artery, 9. ulnar N, 10. flexor retinaculum, 11. palmar aponeurosis,
12. median N., 13. radial artery, 14. flexor pollicis longus, 15. extensor carpi
radialis brevis and 16. longus, 17. brachioradialis, 18. brachialis, and
19. biceps

69
4.4.2 SUPERFICIAL MUSCLE GROUP
1) PRONATOR TERES (Figs. 4-6, 4-7, 4-10, 4-11)
○
○ Proximal attachment (Origin): Humeral Head: medial epicondyle via a common
flexor tendon; Ulnar Head: coronoid process of the ulna
○
○ Distal attachment (Insertion): middle lateral shaft of the radius
○
○ Nerve: median
○
○ Action: pronation of the proximal and distal radioulnar joint; flexion of the
humeroulnar and humeroradial joints
2) FLEXOR CARPI RADIALIS (Figs. 4-7, 4-10, 4-11)
○
○ Proximal attachment (Origin): medial epicondyle via a common flexor tendon
○
○ Distal attachment (Insertion): palmar metacarpal base of the index and middle fingers
○
○ Nerve: median
○
○ Action: flexion of the radial side of the wrist; radial deviation of the hand at the
midcarpal joint; flexion of the humeroulnar and humeroradial joints
3) PALMARIS LONGUS (Figs. 4-7, 4-10, 4-11)
○
○ Proximal attachment (Origin): medial epicondyle via a common flexor tendon
○
○ Distal attachment (Insertion): palmar aponeurosis in the hand and flexor retinaculum
○
○ Nerve: median
○
○ Action: flexion of the radiocarpal joint; tenses the palmar aponeurosis in the hand
4) FLEXOR CARPI ULNARIS (Figs. 4-7, 4-8, 4-10, 4-11)
○
○ Proximal attachment (Origin): Humeral head: medial epicondyle via a common
flexor tendon. Ulnar head: olecranon process, posterior proximal ulna
○
○ Distal attachment (Insertion): hook of hamate, pisiform and the palmar base of
the metacarpal of the little finger
○
○ Nerve: ulnar
○
○ Action: flexion of the ulnar side of the wrist; ulnar deviation of the hand at the
midcarpal joint; flexion of the humeroulnar and humeroradial joints
5) FLEXOR DIGITORUM SUPERFICIALIS (Figs. 4-7, 4-8, 4-9, 4-10, 4-11)
○
○ Proximal attachment (Origin): Humeral head: medial epicondyle via a common
flexor tendon; coronoid process of the ulna. Radial head: central anterior shaft
of the radius
○
○ Distal attachment (Insertion): sides of the middle phalanx of the little, ring,
middle and index fingers
○
○ Nerve: median
○
○ Action: flexion of the metacarpal joints, proximal interphalangeal joints of the
fingers; flexion of the wrist; flexion of the humeroulnar and humeroradial joints

70
Fig. 4-8. Forearm: Drawing of the ventral
forearm with the superficial muscles re-
moved: 1. Biceps, 2. brachialis, 3. brachio-
radialis, 4. deep radial N., 5. superficial ra-
dial N., 6. radial artery, 7. flexor pollicis
longus, 8. radial artery, superficial palmar
branch of radial, 9. recurrent branch of me-
dian N., 10. median N., 11. flexor retinacu-
lum, 12. superficial ulnar N., 13. superficial
ulnar artery, 14. ulnar N., 15. ulnar artery,
16. flexor carpi ulnaris, 17. flexor digitorum
superficialis, and 18. brachial artery.
Fig. 4-9. Forearm: Drawing of the ventral
forearm – deep muscles, arteries, and
nerves in this region: 1. musculocutaneous
N., 2. brachialis, 3. radial N., 4. lateral epi-
condyle, 5. deep radial N., 6. supinator, 7.
superficial radial N., 8. posterior interosse-
ous artery, 9. radial artery, 10. pronator
quadratus, 11. superficial palmar branch of
radial artery, 12. superficial ulnar N., 13.
deep ulnar N., 14. flexor digitorum profun-
dus, 15. anterior interosseous A+N, 16.
ulnar artery, 17. ulnar N., 18. common in-
terosseous artery, 19. Brachial artery, 20.
medial epicondyle, and 21. median N.

71
Fig. 4-10. Forearm: Diagram of the superficial and deep anteromedial muscles
showing their attachment sites: 1. Palmaris longus, 2. flexor carpi ulnaris, 3.
pronator teres, 4. flexor carpi radialis, 5. flexor digitorum superficialis and 6.
profundus, 7. flexor pollicis longus, and 8. pronator quadratus.
4.4.3 DEEP MUSCLE GROUP
1) FLEXOR DIGITORUM PROFUNDUS (Figs. 4-8, 4-9, 4-10, 4-11)
○
○ Proximal attachment (Origin): proximal shaft of the ulna; medial coronoid
process of the ulna and the interosseous membrane

72
72
○
○ Distal attachment (Insertion): palmar base of distal phalanx of the little, ring,
middle, and index fingers
○
○ Nerve: median nerve for the radial 1/2 of muscle; ulnar nerve for ulnar 1/2
of muscle
○
○ Action: flexion of the metacarpal joints, proximal and distal interphalangeal
joints of the fingers.
2) FLEXOR POLLICIS LONGUS (Figs. 4-7, 4-8, 4-10)
○
○ Proximal attachment (Origin): anterior shaft of the radius and interosseous
membrane
○
○ Distal attachment (Insertion): palmar base of the distal phalanx of the thumb
○
○ Nerve: median
○
○ Action: flexion of the carpometacarpal, metacarpal and interphalangeal joints
of the thumb
3) PRONATOR QUADRATUS (Figs. 4-9, 4-10)
○
○ Medial attachment (Origin): distal anterior shaft of the ulna
○
○ Lateral attachment (Insertion): distal anterior shaft of the radius
○
○ Nerve: median
○
○ Action: pronation at the proximal and distal radioulnar joint

73
Fig. 4-11. Forearm. Dissection of the muscles of the anterior forearm. 1. Flexor carpi ulnaris, 2. Palmaris
longus, 3. Pronator teres, 4. Flexor carpi radialis, 5. Palmaris longus tendon, 6. Flexor digitorum
superficialis, 7. Flexor retinaculum, 8. Abductor pollicis brevis, 9. Flexor pollicis brevis, 10. palmar
aponeurosis, 11. Abductor digiti minimi, 12. Palmaris brevis, 13. Flexor digitorum profundus, 14.
Ulnar nerve.
1) With damage to the medial nerve, what muscles and which actions would be
impaired?
2) Which of the anteromedial forearm muscles flex the elbow?
3) How does the flexor digitorum superficialis differ from the flexor digitorum profundus?
4) Which of the anteromedial forearm arise from the medial epicondyle by a
common tendon?
5) What movements would most likely increase pain at the medial epicondyle?

74
4.4.4 FLEXOR RETINACULUM (FIGS. 4-7, 4-8, 4-11, 4-12)
• Flexor retinaculum bridges the distal and proximal rows of carpal bone ulnar
• Flexor retinaculum provides attachment sites for some of the intrinsic muscles of
the thumb and little finger
CARPAL TUNNEL (Figs. 4-8, 4-11, 4-12)
• CARPAL TUNNEL between the flexor retinaculum palmarly and the carpal
bones dorsally
• CONTENTS:
1) median nerve,
2) tendons of the flexor digitorum superficialis and profundus
3) tendon of the flexor pollicis longus
4) radial and ulnar bursae
GUYON’S TUNNEL (Fig. 4-12)
• located on the ulnar side of the wrist, lateral to the pisiform bone and palmar to
the flexor retinaculum
• contains ulnar nerve and ulnar artery

75
Fig. 4-12. Forearm: Diagram showing a cross section through the wrist A) at the level
of the distal radioulnar joint, and B) through the carpal tunnel region: 1. Median N., 2.
pronator quadratus, 3. palmaris longus, 4. flexor digitorum superficialis, 5. ulnar A., 6.
ulnar N., 7. flexor carpi ulnaris, 8. hypothenar muscles, 9. flexor digitorum profundus,
10. extensor carpi ulnaris, 11. distal radioulnar joint, 12. extensor digiti minimi, 13.
extensor digitorum, 14. extensor indicis, 15. extensor pollicis longus, 16. extensor carpi
radialis brevis and 17. longus, 18. extensor pollicis brevis, 19. abductor pollicis longus,
20. radial artery, 21. flexor carpi radialis, and 22. flexor pollicis longus. (Modified from
Gray 1918)

76
76
1) What nerves running in the forearm would not be affected by decreasing the size
of the carpal tunnel?
2) Would the blood flow to the hand, by the way of the radial and ulnar arteries, be
reduced if the size of the carpal tunnel were reduced? Why or why not?
3) What structures are common to both the carpal tunnel and Guyon’s tunnel?
4.5 POSTEROLATERAL MUSCULAR COMPARTMENT
4.5.1 CONTENTS
1) radial nerve
2) superficial radial nerve
3) the deep radial nerve (posterior interosseous nerve) to all the deep muscles of
this compartment
4) the posterior interosseous artery
5) SUPERFICIAL LATERAL MUSCLE GROUP
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77
6) SUPERFICIAL POSTERIOR MUSCLE GROUP
7) DEEP MUSCLE GROUP
• RADIAL NERVE (Figs. 4-8, 4-9)
○
○ divides into a SUPERFICIAL and DEEP RADIAL NERVE
○
○ the superficial radial nerve runs downward along the lateral forearm to innervate
the dorsum of the hand
○
○ The deep radial nerve innervates the extensors of the wrist, fingers and thumb
and the abductor longus of the thumb
• POSTERIOR INTEROSSEOUS ARTERY
○
○ runs along the posterior surface of the interosseous membrane
○
○ connects with the anterior interosseous artery at the wrist
4.5.2 SUPERFICIAL LATERAL MUSCLE GROUP
1) BRACHIORADIALIS (Figs. 4-13, 4-14)
○
○ Proximal attachment (Origin): lateral supracondylar ridge of humerus
○
○ Distal attachment (Insertion): lateral base and styloid process of the radius
○
○ Nerve: radial
○
○ Action: flexion of the humeroradial and humeroulnar joints
2) EXTENSOR CARPI RADIALIS LONGUS (Figs. 4-13, 4-14, 4-16)
○
○ Proximal attachment (Origin): lateral supracondylar ridge of humerus
○
○ Distal attachment (Insertion): base of the metacarpal of the index finger
○
○ Nerve: radial
○
○ Action: extension of the radial side of the wrist; radial deviation of the hand
3) EXTENSOR CARPI RADIALIS BREVIS (Figs. 4-13, 4-14, 4-16)
○
○ Proximal attachment (Origin): lateral humeral epicondyle via a common
extensor tendon; radial collateral ligament
○
○ Distal attachment (Insertion): base of the metacarpal of the middle finger
○
○ Nerve: deep radial
○
○ Action: extension of the wrist joint
4.5.3 SUPERFICIAL POSTERIOR MUSCLE GROUP
1) EXTENSOR DIGITORUM (Figs. 4-13, 4-14, 4-16)
○
extensor tendon

78
78
○
○ Distal attachment (Insertion): extensor assembly of the little, ring, middle
and index fingers
○
○
○ Action: extension of the metacarpophalangeal, proximal and distal interphalangeal
joints; extension of the wrist joint
2) EXTENSOR DIGITI MINIMI (Figs. 4-13, 4-14, 4-16)
○
extensor tendon
○
○ Distal attachment (Insertion): extensor assembly of the little finger
○
○
○ Action: extension of the metacarpophalangeal, proximal and distal interphalangeal
joints of the little finger
3) EXTENSOR CARPI ULNARIS (Figs. 4-13, 4-14, 4-16)
○
extensor tendon; posterior ulna
○
○ Distal attachment (Insertion): dorsal base of the metacarpal of the little finger
○
○
○ Action: extension of the ulnar side of the wrist; ulnar deviation of the hand
at the wrist joint
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79
Fig. 4-13. Forearm: Drawing of the posterior forearm showing muscles of the
superficial lateral and superficial posterior muscle groups: 1. tendon of triceps,
2. ulnar N., 3. medial epicondyle, 4. ulnar collateral A., 5. flexor and 6. extensor
carpi ulnaris 7. extensor digiti minimi, 8. extensor retinaculum with tunnels, 9.
branch of the superficial ulnar N., 10. tendon of extensor pollicis longus and
11. brevis, 12. radial A., 13. tendon of abductor pollicis longus, 14. and 15.
tendons of extensor carpi radialis longus and brevis, 16. extensor digitorum,
17. anconeus, and 18. brachioradialis.

80
Fig. 4-14. Forearm: Diagrams of muscles showing attachments sites of superficial lateral and
posterior extensor muscles.
4.5.4 DEEP POSTEROLATERAL MUSCLES
1) SUPINATOR (Figs. 4-15, 4-17)
○
○ Proximal attachment (Origin): supinator fossa and crest of the ulna; lateral
humeral epicondyle; radial collateral and annular ligaments of the elbow
○
○ Distal attachment (Insertion): dorsal, lateral and palmar surfaces of proximal radius
○
○
○ Action: supination of the proximal and distal radioulnar joint; stabilizes
proximal radioulnar joint

81
81
2) ABDUCTOR POLLICIS LONGUS (Figs. 4-13, 4-15, 4-16, 4-17)
○
○ Proximal attachment (Origin): posterior middle shaft of the ulna and radius;
interosseous membrane
○
○ Distal attachment (Insertion): dorsal base of the metacarpal of the thumb
○
○
○ Action: abduction of the carpometacarpal joint of the thumb; radial deviation
of the wrist
3) EXTENSOR POLLICIS LONGUS (Figs. 4-13, 4-15, 4-17)
○
○ Proximal attachment (Origin): posterior middle shaft of the ulna; interosseous
membrane
○
○ Distal attachment (Insertion): dorsal base of the distal phalanx of the thumb
○
○
○ Action:extensionofthecarpometacarpal,metacarpophalangealandinterphalangeal
joints of the thumb; radial deviation of the wrist

82
4) EXTENSOR POLLICIS BREVIS (Fig. 4-13, 4-15, 4-16, 4-17)
○
○ Proximal attachment (Origin): distal posterior radius; interosseous membrane
○
○ Distal attachment (Insertion): dorsal base of the proximal phalanx of the thumb
○
○
○ Action: extension of the carpometacarpal, metacarpophalangeal joint of the
thumb; radial deviation of the wrist
5) EXTENSOR INDICIS (Fig. 4-15)
○
○ Proximal attachment (Origin): distal posterior ulna and interosseous membrane
○
○ Distal attachment (Insertion): extensor assembly of the index finger
○
○
○ Action: extension of the carpometacarpal, metacarpophalangeal, proximal and
distal interphalangeal joints of the index finger; extension of the wrist.
Fig. 4-15. Forearm: Diagrams of muscles showing attachments sites of the deep extensor muscles.

83
Fig. 4-16. Forearm. Dissection of the extensor muscles of the forearm. 1. Brachialis, 2. Biceps, 3.
Brachioradialis, 4. Extensor carpi radialis brevis, 5. Abductor pollicis longus, 6. Extensor pollicis brevis,
7. Extensor carpi radialis longus and brevis tendons, 8. Extensor retinaculum, 9. Extensor Digiti Minimi,
10. Extensor carpi ulnaris, 11. Extensor digitorum, 12. Common extensor tendon, 13. Extensor carpi
radialis longus.

84
Fig. 4-17. Forearm. Dissection of the deep extensor forearm. 1.Extensor pollicis longus, 2. Abductor
pollicis longus, 3. Extensor pollicis brevis, 4. Supinator 5. Superficial radial N., 6. Radial N., 7. Deep radial
nerve going deep to supinator, 8. Extensor digitorum (cut), 9. Deep radial nerve emerging from under
supinator, 10. Extensor carpi ulnaris, 11. Extensor digitorum (cut).
4.5.5 EXTENSOR TUNNELS (FIGS. 4-18, 4-19, TABLE 4-1).
• tendons of nine of extensor muscles cross the distal radius and ulna
• tendons pass through six fibro-osseous tunnels formed by the EXTENSOR
RETINACULUM
• each tendon passing through these tunnels is surrounded by a synovial sheath.

85
85
Tunnel Contents (tendons of) Location
A = #1
Abductor pollicis longus
Extensor pollicis brevis
Lateral margin (radial side) of distal radius
B = #2 Extensors carpi radialis longus and brevis
Posterolateral surface of distal radius
medial to tunnel A
C = #3 Extensor pollicis longus Middle posterior surface of distal radius
D = #4
Extensor digitorum
Extensor indicis
Medial margin (Ulnar side) of the distal
radius
E = #5 Extensor digiti minimi
Between medial edge (Ulnar side) of the
distal radius and the head of the ulna
F = #6 Extensor carpi ulnaris
Lateral (radial side) of the styloid process
of the ulna
TABLE 4-1
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86
Fig. 4-18. Forearm: Extensor tunnels: Drawing of the dorsal wrist showing the extensor
retinaculum, extensor tunnels, and the tendons passing through these tunnels. See Table 4-1
for the contents of the tunnels labeled A-F. 1. Tendon of extensor indicis, 2. tendons of extensor
digitorum, 3. tendon of extensor digiti minimi, 4. tendon of extensor carpi ulnaris, 5. tendon
of extensor pollicis brevis, 6. tendon of abductor pollicis longus, 7. tendon of extensor carpi
radialis brevis and 8. longus, 9. extensor retinaculum, 10. tendon of extensor pollicis longus,
and 11. lumbrical and 1st dorsal interosseous. (Modified from Gray 1918)

87
Fig. 4-19. Forearm. Dissection of the extersor tunnels of the forearm. 1. Extensor pollicis longus
tendon and third tunnel, 2. Second tunnel with extensor carpi radialis longus and brevis tendons,
3. Extensor pollicis brevis, 4. Abductor pollicis longus, 5. Extensor carpi ulnaris, 6. Extensor digiti
minimi 7. Fourth tunnel with extensor digitorum tendons, 8. Sixth tunnel for extensor carpi
ulnaris tendon, 9. Fifth tunnel for the extensor digiti minimi tendon.
4.5.6 ANATOMICAL SNUFF BOX (FIGS. 4-13, 4-20)
• located on the radial side of the dorsal wrist
• borders
○
○ lateral (radial): the tendons of the abductor pollicis longus and extensor pollicis
brevis (first extensor tunnel)
○
○ medial (ulnar): the tendon of the extensor pollicis longus (third extensor tunnel)
○
○ floor (base): the tendons of the extensor carpi radialis longus and brevis (second
tunnel)
• radial artery crosses through the snuff box
• superficial radial nerve runs over this area to innervate the skin on dorsum of hand

88
Fig. 4-20. Forearm: Drawing of the Anatomical snuff box. 1, extensor digiti minimi,
2. extensor retinaculum with tunnels, 3. branch of the superficial ulnar N., 4. tendon
of abductor pollicis longus, 5. tendon of extensor pollicis brevis, 6. tendon of
extensor pollicis longus, 7. tendons of extensor carpi radialis longus and brevis, 8.,
tendon of abductor pollicis longus, 9. radial A., 10. tendon of extensor pollicis
brevis, 11. tendon of extensor pollicis longus
11 – Study Questions:
1) What posterior forearm muscles attach to the lateral epicondyle?
2) If the area of the lateral epicondyle is inflamed, what movements are most likely
to increase inflammation?
3) Damage to the radial nerve will result in what movements being impaired?
4) If the first extensor tunnel were inflamed, which movements would tend to increase
pain? What if the second extensor tunnel were inflamed? How about the fourth tunnel?
5) Other than tendons, what structures would be damaged with trauma to the
anatomical snuff box?

AXILLA-UPPER LIMB THE HAND
89
89
5 THE HAND
5.1 OSTEOLOGY (FIG. 5-1)
• METACARPAL
○
○ BASE articulates with the distal row of carpal bones
○
○ SHAFT or BODY
○
○ HEAD articulates with the proximal phalanx
• PHALANX
○
○ PROXIMAL, MIDDLE, DISTAL phalanges in fingers
○
○ PROXIMAL and DISTAL phalanges in thumb
○
○ BASE, SHAFT or BODY and HEAD subdivisions
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90
Fig. 5-1. Hand. Drawing showing the bones and joints of the hand. CMC – Carpometacarpal
joint, DCR – Distal carpal row, DIP – Distal interphalangeal joint, DP – Distal phalanx, IP –
Interphalangeal joint, MC – metacarpal, MCP – metacarpophalangeal joint, MP – Middle
phalanx,PCR–Proximalcarpalrow,PIP–Proximalinterphalangealjoint,PP–Proximalphalanx.
5.2 JOINTS, LIGAMENTS AND BURSAE
JOINTS (Fig. 5-1)
• CARPOMETACARPAL JOINT (CMC) between metacarpal base a carpal bone
• METACARPOPHALANGEAL JOINT (MCP) between metacarpal head the base
of a proximal phalanx
• PROXIMAL INTERPHALANGEAL JOINT (PIP) between the head of proximal
phalanx and base of middle phalanx
• DISTAL INTERPHALANGEAL JOINT (DIP) between the head of the middle
phalanx and the base of the distal phalanx

91
LIGAMENTS (Figs. 4-4, 4-5, 5-2, 5-4)
• DORSALandPALMARCARPOMETACARPALLIGAMENTSatthecarpometacarpal
joints
• METACARPAL (intermetacarpal) LIGAMENTS
• LATERAL (radial) and MEDIAL (ulnar) COLLATERAL LIGAMENT located at
the sides of MCP, PIP, DIP
• PALMAR (volar) PLATE on the palmar side of MCP, PIP
• EXTENSOR ASSEMBLY distally
BURSAE (Fig. 5-6)
• RADIAL BURSA extending from wrist to surround the tendon of the flexor pollicis
longus muscle in the palm of the hand
• ULNAR BURSA extending from wrist to surrounds the tendons of the flexor
digitorum superficialis and profundus muscles in the palm of the hand
5.2.1 COMMON FLEXOR TENDON SHEATH (FIGS. 5-2, 5-3, 5-6)
• fibrous tunnel on the palmar surface of the fingers
• attaches to the palmar plate
• five ANNULAR LIGAMENTS
• three CRUCIATE pulley-like LIGAMENTS
• ligaments form tunnel to guide the tendons of the flexor digitorum superficialis
and profundus

92
Fig. 5-2. Hand: (A) Lateral view showing the metacarpophalangeal and interphalangeal joints
of a finger. (B) Lateral view of a finger showing the dorsal extensor assembly and palmar
common flexor sheath. (C) Cross section at the metacarpophalangeal joint. 1. terminal tendon
of extensor assembly, 2. central slip of extensor assembly, 3. extensor expansion (hood), 4.
tendon of ext. digitorum, 5. palmar plates, 6. accessory collateral ligaments, 7. tendon of
flex. digitorum superficialis and 8. profundus, 9. collateral ligaments, 10 extensor assembly,
and 11. transverse metacarpal ligaments. A1–A5 annular ligs. of flexor sheath, C1–C3 cruciate
ligs. of flexor sheath.

93
Fig. 5-3. Hand. Dissection of the palmar plate. 1. Flexor sheath, 2. Flexor digitorum superficialis
tendon, 3. Flexor digitorum profundus tendon, 4. Flexor tendons reflected distally, 5. Palmar plate.
5.2.2 EXTENSOR ASSEMBLY (FIGS. 5-2, 5-4, 5-5)
• on dorsal surfaces of the metacarpophalangeal, proximal interphalangeal and distal
interphalangeal joints
• COMPONENTS
1) EXTENSOR EXPANSION or HOOD
○
○ a flat tendinous expansion of the extensor digitorum tendon on dorsal of the
proximal phalanx
○
○ lumbricales and interossi muscles insert
2) MEDIAN BAND or CENTRAL SLIP
○
○ from middle of extensor expansion to insert on the base of the middle phalanx
3) two LATERAL BANDS
○
○ from the sides of the extensor expansion on each side of the median band
4) TERMINAL TENDON
○
○ union of the two lateral bands to insert at the base of the distal phalanx.

94
Fig. 5-4. Hand: Dorsal view (top) and lateral views (middle, bottom) of the of the extensor
assembly. Notice the change in position of the components of the extensor assembly and the
flexor tendons when the finger is flexed (bottom). 1. terminal tendon, 2. central slip, 3. extensor
expansion, 4. tendon of ext. digitorum, 5. interosseous muscle, 6. lumbrical, 7. tendon of flex.
digitorum superficialis and 8. profundus.

95
95
Fig. 5-5. Hand. Dissection of extensor assembly. 1. Extensor digitorum tendon, 2. Lateral bands,
3. Terminal tendon, 4. Central slip, 5. Extensor expansion or hood.
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1) To replace the metacarpophalangeal joint of the index finger, using a palmar
approach, which structures would need to be cut or moved?
2) What structures attach to the palmar plate of the ring finger?
3) What muscles attach to the extensor assembly?
4) If the tunnel formed by the flexor sheath is decreased in size, what structures would
be compressed and how might it affect these structures?
5) What ligamentous structures surround the following joints?
a. Metacarpophalangeal joint?
b. Proximal interphalangeal joint?
5.3 PALM OF THE HAND
• COMPARTMENTS
1) THENAR COMPARTMENT
2) HYPOTHENAR COMPARTMENT
3) CENTRAL COMPARTMENT
4) ADDUCTOR COMPARTMENT
5) INTERMETACARPAL COMPARTMENT

97
Fig. 5-6. Hand: Drawing of the palmar region of the hand showing components of
the thenar, hypothenar and deep central spaces. 1. median N., 2. tendon of palmaris
longus, 3. ulnar A., 4. ulnar N., 5. ulnar bursa, 6. flexor retinaculum, 7. abductor digiti
minimi, 8. ulnar bursa, 9. flexor digiti minimi, 10. flexor digitorum superficialis, 11.
flexor digitorum profundus, 12. flexor sheath, 13. proper digital A., 14. synovial
sheath, 15. adductor pollicis, 16. flexor pollicis longus surrounded by radial bursa,
17. princeps pollicis A., 18. flexor pollicis brevis, 19. recurrent branch of median N.,
20. abductor pollicis brevis, and 21. radial bursa.
5.3.1 THENAR COMPARTMENT (FIGS. 5-6, 5-7, 5-8, 5-9)
• fleshy bulge on the thumb side of the palm
• CONTENTS
1) ABDUCTOR POLLICIS BREVIS muscle
2) FLEXOR POLLICIS BREVIS muscle
3) OPPONENS POLLICIS muscle
4) TENDON of the FLEXOR POLLICIS LONGUS muscle
5) MEDIAN RECURRENT NERVE from of the median nerve to the thenar muscle
6) MEDIAN PROPER DIGITAL NERVES to the skin of the thumb
7) PRINCEPS POLLICIS ARTERY
8) PROPER DIGITAL ARTERIES to the palmar surface of the thumb

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