This document provides an overview of the anatomy of the upper limb, including bones, joints, muscles, vasculature and common injuries. It describes the key bones of the upper limb - clavicle, scapula, humerus, radius, ulna and bones of the hand. Important joints like the shoulder, elbow and wrist are discussed. Common fractures at various bone locations and their clinical implications are summarized. The document also touches on development of the upper limb buds and various congenital limb abnormalities.

1. Dr. Akalanka Jayasinghe
MBBS(SL),MS(SL),MRCS(England),MRCS(Edinburgh)
Consultant Orthopaedic Surgeon
CLINICAL ANATOMY OF
UPPER LIMB

2. Intended Learning Outcomes
BONES OF UPPER LIMB
• Clavicle
• Scapula
• Humerus
• Bones of Forearm
• Bones of Hand
• Surface Anatomy of Upper Limb Bones
FASCIA, EFFERENT VESSELS, CUTANEOUS INNERVATION,
AND MYOTOMES OF UPPER LIMB
• Fascia of Upper Limb
• Venous Drainage of Upper Limb
• Cutaneous Innervations of Upper Limb

4. Clavicle
• It is the most commonly fractured bone in
the body.
• The fracture occurs due to falling on the
shoulder or the outstretched hand.
• It is most commonly fractured at the
junction of the middle and outer thirds
(weakest point).
• The lateral fragment :
 Depressed by the weight of the arm
 Pulled medially and forwards by the
adductors of arm (especially pectoralis
major).
• The medial fragment :
 Pulled upward by the sternomastoid.
 Involvement of supraclavicular nerves
can be the cause of persistent pain
over the side of the neck.

6. Sternoclavicular Joint
• Occasionally dislocated because
of strong ligaments around
 Anterior dislocation: medial
end of clavicle pulled forward
and upward
 Posterior dislocation: medial
end of clavicle pulled
backward, which may press
trachea, esophagus & great
vessels in the root of the neck
Anterior
dislocation

7. Acromioclavicular Joint
• The stability of the
acromioclavicular joint depends on
the strong coracoclavicular ligament
• The joint may get injured by a
severe blow such as a hard fall on
the shoulder.
• The acromian thrusts beneath the
lateral end of the clavicle tearing
the coracoclavicular ligament. This
condition is called shoulder
separation, as the shoulder
separates (falls away) from the
clavicle because of the weight of
the upper limb.
• The displaced lateral end of clavicle
is easily palpable

9. Bony Anatomy
Joints and Articulations
•
STATIC STABILIZERS

10. Clinical Correlations: Humerus fractures
• Fracture of the greater tubercle:
occurs by direct trauma or by
violent contractions of the
supraspinatus muscle. The bone
fragment has the attachments of
the supraspinatus, infraspinatus,
and teres minor muscles, whose
tendons form parts of the
rotator cuff.
• Fracture of the surgical neck may
injure the axillary nerve and the
posterior humeral circumflex
artery as they pass through the
quadrangular space.

11. Humerus
• Fractures of the proximal end:
 Humeral head fracture:
 may occur in anterior or posterior
dislocations of shoulder
 Lesser tuberosity fracture
 Surgical neck fractures: may result in injury
to axillary nerve

12. Shoulder Joint
• It is the most commonly dislocated
large joint.
• Dislocations happen when a force
overcomes the strength of the
rotator cuff muscles and the
ligaments of the shoulder.
• Nearly all dislocations are anterior
inferior dislocations, meaning that
the humerus slips out of the front
of the glenoid.
• Only three percent of dislocations
are posterior dislocations, or out
the back.

13. • Anterior inferior dislocation
 Sudden violence applied to the
humerus when the joint is fully
abducted. The humeral head moves
downward onto the inferior weak
part of the capsule which tears.
 The humeral head comes to lie
inferior to the glenoid fossa
 The acromion acts as a fulcrum and
the head of the humerus is pulled
upward and forwards by the strong
flexors and adductors.
• Posterior displacement
 It is due to direct violence to the
front of the joint.
 The shoulder loses its rounded
appearance as the greater
tuberosity is no more bulging
laterally.
 The axillary nerve can be damaged.

14. • In Adhesive Capsulitis (frozen shoulder) there is
limited movement. The cause of limited movement
may to some extent be anatomical/pathological.
Anatomically the capsule may become adherent to
itself, reducing the range of motion.

15. Subacromial Impingement
• Neer proposed that 95% of rotator cuff tears are due to chronic impingement
between the humeral head and the coracoacrominal arch.

16. Rotator Cuff Tendinitis
• Results due to excessive overhead
activity of the upper limb.
• It is a common cause of pain in the
shoulder region
• Normally during abduction of the
shoulder joint, friction between the
supraspinatus tendon and the
acromion is minimized by the
subacromial bursa.
• Degenerative changes in the bursa
are followed by degenerative
changes in the tendon of
supraspinatus that may extend to the
tendons of the other rotator cuff
• There is a spastic pain in the middle
range of abduction.

17. Rupture of the Supraspinatus Tendon
• In advanced cases of
tendinitis, the necrotic
supraspinatus tendon may
become calcified and
rupture
• The patient is unable to
initiate abduction of the
arm

18. Biceps Brachii & Osteoarthritis of the Shoulder Joint
• Advanced osteoarthritic
changes in the shoulder
joint can cause erosion
of the tendon of the long
head of biceps by
osteophytic changes.
• The tendon may be
reptured.

19. Humerus
• Fractures of the shaft:
 Are common
 The displacement of the fragments
depends on the relation of the site of
fracture to the insertion of the deltoid.
muscle
• If the fracture line is proximal to the deltoid
insertion:
 The proximal fragment is adducted by the
pectoralis major, latissimus dorsi and teres
major.
 The distal fragment is pulled proximally by
deltoid, biceps & triceps.
• If the fracture line is distal to the deltoid
insertion:
 The proximal fragment is abducted by
deltoid.
 The distal fragment is pulled proximally by
the biceps & triceps.
 The radial nerve can be injured.

20. • Fracture of the shaft may injure
the radial nerve and deep
brachial artery in the spiral
groove.
• Supracondylar fracture (common
in children) is a fracture of the
distal end of the humerus:
occurs when the child falls on
the outstretched hand with the
elbow partially flexed and may
injure the median nerve.
• Fracture of the medial
epicondyle may damage the
ulnar nerve. This nerve may be
compressed in a groove behind
the medial epicondyle “funny
bone,” causing numbness.
Clinical Correlations: Humerus fractures

21. Elbow Anatomy
Medial Elbow

22. Elbow Anatomy
Lateral Elbow

23. Humerus
• Fractures of the lower end:
 Supracondylar fracture:
 Common in children
 May injure median nerve
and brachial artery
 Medial epicondyle fracture:
 May injure the ulnar nerve
 If need Opposite side Xray
for comparison

24. Radial head fracture

25. Ulna
• Medial and longer of the two forearm
bones
• Structures you need to identify:
1. Olecranon ( curved projection on the
back of the elbow that provides an
attachment site for the triceps tendon)
2. Coronoid Process (below the trochlear
notch, attachment site for the
m.brachialis)
3. Trochlear Notch (receives the trochlea
of the humerus)
4. Ulnar Tuberosity (prominence distal to
the coronoid process that provides an
attachment site for the m. brachialis)
5. Radial Notch (accommodates the head
of the radius at the proximal radioulnar
joint)
6. Head (articulates with the articular disk
of the distal radioulnar joint and has a
styloid process)

26. Olecranon Fracture

27. Elbow Joint
• Dislocations are common and
most are posterior.
• Pulled Elbow: occurs in children,
when the child is lifted by the
upper limb. The radial head is
pulled out of the annular ligament

29. Tennis Elbow(Lateral Epicondylities)
• Caused by partial tear or
degeneration of the origin of
superficial extensor muscles
attached to the lateral
epicondyle
• It results due to excessive use of
these muscles as in tennis,
violinists and housewives.
• Results in pain and tenderness
over the lateral epicondyle that
radiates to the lateral side of
the forearm

30. Golfer’s Elbow (Medial Epicondylitis)
• Caused by partial tear or
degeneration of the origin of
superficial flexor muscles
attached to the medial
epicondyle
• It results due to excessive use
of these muscles as in playing
golf
• Results in pain and tenderness
over the medial epicondyle
that radiates to the medial side
of the forearm

31. Monteggia / Galeazzi fracture

32. Radius
• Fracture of the distal end (Colle’s
fracture):
• It is due to a fall on the outstretched
hand in patients over (50) years.
• The distal fragment of the radius is
pulled posteriorly and superiorly
• The distal articular surface is directed
posteriorly.
• The posterior displacement produces a
posterior bump.
• The deformity is referred to as, ‘dinner-
fork deformity’ because the forearm
and wrist resemble the shape of a
dinner fork.
• Smith’s fracture is a reversed Colle’s as
the distal segment is displaced
anteriorly

33. Fracture of the Scaphoid Bone
• Common in young adults
• Fracture line passes through the narrowest part of
the bone
• The blood supply to scaphoid may come from its
distal end and the only way the proximal pole can
receive any blood supply and nutrients is through
the rest of the bone. Thus a fracture of the scaphoid
in the proximal pole or waist, deprives the proximal
fragment of its arterial supply, and this fragment
undergoes avascular necrosis.
• If the fragments will not unite properly, there will
be permanent pain and weakness at the wrist
• Deep tenderness in the anatomical snuff box after
a fall on an outstretched hand in a young adult is an
indication of fracture of scaphoid bone

34. Scaphoid fracture Mx

35. Compartment syndromes of the forearm
• The deep facial sheath, the
interosseous membrane & the
fibrous intermuscular septae
divide the forearm into
compartments, that contain
muscles, vessels and nerves
• There is very little room within
each compartment, and any
edema will cause secondary
vascular compression.
• The veins are affected first and
later the arteries

36. Volkmann’s Ischaemic Contracture
• It is the contractures of the muscles of the forearm
that follows fractures of the distal end of the
humerus or fractures of the radius and ulna.
• Spasm of a localized segment of the brachial artery
reduces the blood flow to the flexors and extensor
muscles so that they under go ischemic necrosis.
• The flexor muscles are mostly affected
• The muscles are replaced by fibrous tissue, which
contract and result in the deformity

37. • 3 types of deformity exists:
 The long flexors of the carpals and
fingers are more contracted than
extensors. The wrist joint is flexed
and the fingers are extended.
 The long extensors of the fingers
are greatly contracting The wrist
and metacarpo-phalngeal joints
are extended. The interphalngeal
joints are flexed.
 Both the flexor and extensor are
contracted:
 The wrist joint and the
interphalangeal joints are flexed.
The metacarpo-phalangeal joints
are extended.

38. Dupuytren’s Contracture
• It is a localized thickening and
contracture of the palmar aponeurosis.
• It commonly starts near the root of the
ring finger pulling it to the palm and
flexing it at the metacarpo-phalngeal
joint. Later the little finger is involved.
• In long standing cases prolonged pulling
of the fibrous sheaths of these two
fingers would flex their proximal
interphalangeal joints
• Their distal interphalangeal joints are
not involved and they actually become
extended
• Dupuytren's disease is familial, and may
be associated with cigarette smoking,
vascular disease, epilepsy, and diabetes.

39. Bony
Anatomy
• Phalanges: 14
• Sesamoids: 2
• Metacarpals: 5
• Carpals
• Proximal row: 4
• Distal row: 4
• Radius and Ulna
Lister’s tubercle

40. • Bennett’s fracture is a
fracture of the base of the
metacarpal of the thumb.
• Boxer’s fracture is a fracture
of the necks of the second
and third metacarpals, seen
in professional boxers, and
typically of the fifth
metacarpal in unskilled
boxers
CLINICAL
CORRELATES: Fractures of carpal bones

41. Muscles

42. Tenosynovitis & Infection of the Fascial Spaces of Palm
• May get infected and
distended with pus, after
penetrating wounds of
the palm

43. Pulp-Space Infection (Felon)
• This is the commonest hand infection.
Pus more often gathers in the finger tips
than anywhere else in the hand.
• It is more common in the thumb and
index fingers.
• Bacteria enter the space through
needles or nails.
• Accumulation of inflammatory exudate
within the small compartments of the
pulp would rapidly increase its pressure.
There is little room for swelling, so that
infection causes a throbbing pain early.
• If infection is not decompressed, it can
extend into the terminal phalanx.

44. • Pus from the pulp can track:
 through to the skin outside
 through the periosteum, causing
osteomyelitis of the distal
phalanx.
• Since the blood supply of the
diaphysis of the phalanx passes
through the pulp space (in children),
the infection would result in necrosis
of the diaphysis. Its epiphysis is
supplied by a separate artery, so this
usually survives the infection.
• The synovial sheaths of the affected
fingers can be involved because of
their close relationships to the
proximal part of the pulp space.

45. Venipuncture
• The superficial veins of the upper limb are
used for venipuncture, transfusion and
cardiac cathetrization.
• When a patient is in shock, the superficial
veins are not always visible. It is very
important to know their course and the
relations to important landmarks.
• The cephalic vein:
 At the wrist, it passes posterior to the
styloid process of the radius.
 In the cubital fossa it is separated from
the brachial artery by the bicipital
aponeurosis which protects the artery
from irritating drugs.
 In the deltopectoral groove, it
communicates with the external jugular
vein by a small vein that passes in front of
the clavicle. Fracture of the clavicle can
tear this communicating vein and causes
a large hematoma.

46. Thank U & Good Luck

47. LIMB BUDS
• 4th week: limb buds become
visible from the ventrolateral
body wall
• Mesenchymal core covered by a
layer of cuboidal ectoderm.
• Primary ossification centers are
present in all long bones of the
limbs by the 12th week of
development.
5 weeks

48. Amelia
complete absence of one or
more of the extremities

49. Meromelia
partial absence of one or more of the extremities
Phocomelia
Sometimes the long bones are absent, and rudimentary
hands and feet are attached to the trunk by small,
irregularly shaped bones

50. Teratogen-induced limb defects
• Many children with limb malformations were born between
1957 and 1962.
• Many mothers of these infants had taken thalidomide,a
sleeping pill and antinauseant.
• It was established that thalidomide causes absence or gross
deformities of the long bones, intestinal atresia, and cardiac
anomalies.
• Since the drug is now being used to treat AIDS and cancer
patients, there is concern that its return will result in a new
wave of limb defects.
• Most sensitive period for teratogen-induced limb
malformations is the fourth and fifth weeks of development.

51. Micromelia
all segments of the extremities are present but abnormally short
•

52. Brachydactyly
The digits are shortened

53. Syndactyly
two or more fingers or toes are fused
• Mesenchyme between prospective digits in hand-
and footplates is removed by cell death (apoptosis).
• In 1 per 2,000 births this process fails, and the
result is fusion between two or more digits.

54. Polydactyly
• The presence of extra fingers or toes
• The extra digits frequently lack proper muscle
connections.
• Abnormalities involving polydactyly are usually
bilateral

55. Ectrodactyly
• Absence of a digit
• Usually occurs unilaterally

56. Cleft hand and foot
(lobster claw deformity)
• Consists of an abnormal cleft between the second
and fourth metacarpal bones and soft tissues.
• The third metacarpal and phalangeal bones are
absent, and the thumb and index finger and the
fourth and fifth fingers may be fused.

57. Hand-foot-genital syndrome
• Mutations in HOXA13
• Fusion of the carpal bones and small
short digits.
• Partially (bicornuate) or completely
(didelphic) divided uterus
• Abnormal positioning of the urethral
orifice
• Hypospadias
• A combination of syndactyly and
polydactyly (synpolydactyly).

58. Craniosynostosis–radial aplasia
syndrome
• Congenital absence or deficiency of the radius
• Absent thumbs
• Short curved ulna

59. Amniotic bands
• Ring constrictions and amputations of the limbs or
digits .