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Upper Limbs
Muscles, Nerves and Blood Supply
Created By Kishan Indrakumar

MUSCLES OF THE
PECTORAL REGION
Note: Long thoracic nerve- Winging of Scapula
Muscles Innervation
Pectoralis major Lateral and medial pectoral nerves
Pectoralis minor Medial pectoral nerve
Serratus anterior Long thoracic nerve.
Subclavius Nerve to subclavius

MUSCLES OF THE SHOULDER
The intrinsic muscles
Rotator Cuff
Muscles Innervation
Deltoid Axillary nerve
Teres major Lower subscapular nerve
Muscles Innervation Functions
supraspinatus Suprascapular nerve Abduction
infraspinatus Suprascapular nerve Lateral rotation
subscapularis Upper and lower
subscapular nerves.
Medial rotation
Teres minor Axillary nerve Lateral rotationCreated By Kishan Indrakumar

Tests for Rotator Cuff

MUSCLES OF THE
SHOULDER
The extrinsic muscles
Superficial Layer
Deep Layer
Notes: To test the accessory nerve
(XI)asking the patient to shrug his/her shoulders
Muscles Innervations
Trapezius Accessory nerve
Latissimus Dorsi Thoracodorsal nerve
Muscles Innervations
Levator scapulae Dorsal scapular nerve
Rhomboids Major Dorsal scapular nerve
Rhomboids Minor Dorsal scapular nerve

Movements of the shoulder
Movement Muscles responsible
Flexion
Biceps brachii (both heads)
Pectoralis major
Anterior deltoid
Coracobrachialis
Extension
Latissimus dorsi
Teres major
Posterior deltoid
Abduction
Supraspinatus (first 0-15 degrees)
Middle deltoid (next 15-90 degrees)
Trapezius (past 90 degrees)
Serratus anterior (past 90 degrees)
Adduction
Pectoralis major
Latissimus dorsi
Teres major
Lateral rotation
Infraspinatus
Teres minor
Medial rotation
Pectoralis major
Latissimus dorsi
Subscapularis
Teres major
Anterior deltoid
Hint: Teres Major,Latissmus dorsi,Pectoralis Major-Extension,adduction and medial roation

MUSCLES OF THE
UPPER ARM
Anterior compartment:
Posterior Compartment:
NOTES: The bicep tendon reflex C6, triceps reflex C7
Muscles Function Innervation
Biceps Brachii Supination of the
forearm. It also flexes
the arm at the elbow
and at the shoulder.
Musculocutaneous
nerve.
Coracobrachialis Flexion of the arm at
the shoulder
Musculocutaneous
nerve
Brachialis Flexion at the elbow Musculocutaneous
nerve
Triceps Brachii Extension of the arm at
the elbow.
Radial nerve

MUSCLES IN THE
ANTERIOR FOREARM
Superficial
Intermediate
Deep
Muscles Functions Innervation
flexor carpi ulnaris Flexion and adduction at
the wrist.
Ulnar nerve
palmaris longus Flexion at the wrist Median nerve
flexor carpi radialis Flexion and abduction at
the wrist
Median nerve
pronator teres Pronation of the forearm. Median nerve
flexor digitorum
superficialis
Flexes the
metacarpophalangeal
joints and proximal
interphalangeal joints at
the 4 fingers, and flexes at
the wrist.
Median nerve.

MUSCLES IN THE ANTERIOR
FOREARM
Deep
Notes:1.They all originate from a common tendon, which arises from the medial epicondyle
of the humerus.
2. The lateral border of the pronator teres forms the medial border of the cubital fossa
3. Flexor Pollicis Longus: This muscle lies laterally to the FDP
4. Palmaris longus: This muscle is absent in about 15% of the population.
Muscles Functions Innervation
Flexor Digitorum Profundus It is the only muscle that can
flex the distal interphalangeal
joints of the fingers. It also
flexes at metacarpophalangeal
joints and at the wrist.
The medial half (acts on the
little and ring fingers) is
innervated by the ulnar nerve.
The lateral half (acts on the
middle and index fingers) is
innervated by the anterior
interosseous branch of the
median nerve.
Flexor Pollicis Longus Flexes the interphalangeal joint
and metacarpophalangeal joint
of the thumb.
Median nerve (anterior
interosseous branch)
Pronator Quadratus Pronates the forearm Median nerve (anterior

Action of anterior muscles:

MUSCLES IN THE POSTERIOR FOREARM
Superficial Muscles
Note:1.Four of these muscles – extensor carpi radialis brevis, extensor
digitorum, extensor carpi ulnaris and extensor digiti minimi share a common
tendinous origin at the lateral epicondyle (anterior surface)
2. The extensor digiti minimi is thought to originate from the extensor
digitorum muscle
Muscles Functions Innervations
Brachioradialis Flexes at the elbow. Radial nerve.
Extensor Carpi Radialis
Longus and Brevis
Extends and abducts the
wrist.
Radial nerve
Extensor Digitorum Extends medial four fingers
at the MCP and IP joints
Radial nerve (deep branch).
Extensor Digiti Minimi Extends the little finger, and
contributes to extension at
the wrist.
Radial nerve (deep branch)
Extensor Carpi Ulnaris Extension and adduction of
wrist
Radial nerve (deep branch).
Anconeus Extends and stablises the
elbow joint. Abducts the
ulna during pronation of the
forearm.
Radial nerve

THE POSTERIOR FOREARM
Deep Muscles
Note: The supinator lies in the floor of the cubital fossa. It has two heads, which the deep
branch of the radial nerve passes between.
The abductor pollicis longus,The extensor pollicis brevis ,extensor pollicis longus borders of the
anatomical snuffbox in the hand.
Long extensor attach to the proximal phalanx while flexor not. On the flexor side it is interossi
and lumbricals that’s account for claw hand when these small muscles fail
Supinator Supinates the forearm Radial nerve (deep branch)
Abductor Pollicis Longus Abducts the thumb Radial nerve (posterior
interosseous branch).
Extensor Pollicis Brevis Extends at the
metacarpophalangeal and
carpometacarpal joints of the
thumb
Radial nerve (posterior
Extensor Pollicis Longus Extends all joints of the thumb:
carpometacarpal,
metacarpophalangeal and
interphalangeal.
Radial nerve (posterior
interosseous branch).
Extensor Indicis Proprius Extends the index finger Radial nerve (posterior

MUSCLES OF THE HAND
Thenar Muscles
Hypothenar Muscle
The median nerve innervates all the thenar muscles.
The ulnar nerve innervates the muscles of the hypothenar eminence
Muscles Movement Innervation
Opponens Pollicis Opposes the thumb, by
medially rotating and flexing
the metacarpal on the
trapezium.
Median nerve.
Abductor Pollicis Brevis Abducts the thumb. Median nerve.
Flexor Pollicis Brevis Flexes the
metacarpophalangeal (MCP)
joint of the thumb.
Median nerve.
Opponens Digiti Minimi It rotates the metacarpal of the
little finger towards the palm,
producing opposition
Ulnar nerve.
Abductor Digiti Minimi Abducts the little finger Ulnar nerve
Flexor Digiti Minimi Brevis Flexes the MCP joint of the little
finger.
Ulnar Nerve.

Other Muscles in the Palm
Note : Adductor Pollicis- Attachments: One head originates from metacarpal
III. The other head originates from the capitate and adjacent areas of
metacarpals II and III. Both attach into the base of the proximal phalanx of the
thumb- Froment's sign
Palmaris Brevis Wrinkles the skin of
the hypothenar
eminence and
deepens the
curvature of the
hand, improving
grip.
Ulnar nerve
Adductor Pollicis Adductor of the
thumb
Ulnar nerve.

Lumbricals
Origin and Insertion Actions Innervations
Each lumbrical originates
from a tendon of the
flexor digitorum
profundus. They pass
dorsally and laterally
around each finger, and
inserts into the extensor
hood
The flex at the MCP joint,
and extend at the
interphalangeal (IP)
joints of each finger.
The medial two
lumbricals (of the little
and ring fingers) are
innervated by the ulnar
nerve. The lateral two
lumbricals (of the index
and middle fingers) are
innervated by the
median nerve

Interossei
Dorsal Interossei
• There are four dorsal interossei muscles.
• Attachments: Each interossei originates from the lateral and medial surfaces of the
metacarpals. They attach into the extensor hood and proximal phalanx of each finger.
• Actions: Abduct the fingers at the MCP joint.
• Innervation: Ulnar nerve.
Palmar Interossei
• These are located anteriorly on the hand. There are three palmar interossei
muscles.
• Attachments: Each interossei originates from a medial or lateral surface of a
metacarpal, and attaches into the extensor hood and proximal phalanx of same finger.
• Actions: Adducts the fingers at the MCP joint.
• Innervation: Ulnar nerve.

Upper Limbs Nerves and
Nerve Injury

Brachial plexus
The plexus is formed by the anterior
rami (divisions) of the cervical spinal nerves C5,
C6, C7 and C8, and the first thoracic spinal
nerve, T1.
The brachial plexus is divided into five parts;
roots, trunks, divisions, cords and branches (a
good mnemonic for this
is Read That Damn Cadaver Book)

Brachial plexus injuries
Types of Injury Motor involvement sensation
Upper lesions ( C5,C6)
Erb-Duchenne Palsy
In infants during a difficult
delivery In infants during a
difficult delivery
In adults following a fall on or a
blow to the shoulder
Muscles affected are:
Abductors (supraspinatus &
deltoid)
lateral rotators (Infraspinatus
&teres minor) of the shoulder
Subclavius, biceps, brachialis &
coracobrachialis.
Nerves Affected:
Nerve to sublavius
Suprascapular nerve
Axillary nerve
Musculocutaneous nerve
Loss of abduction(C5),external
rotation(C5) ,flexion of
elbow(C5) and
supination(?Biceps brachai) (C6)
Thus The limb hangs limply by
the side, and is medially rotated
The forearm is pronated and
extended (porters tip)
There is loss of sensation down
the lateral side of the arm & the
forearm

Type Of Injury Motor Involvement Sensation
Lower lesions (C8,T1)
(Klumpke Palsy)
When falling from a height
Difficult delivery in which baby’s
upper limb is pulled excessively
Result of malignant metastases from
the lungs in the lower deep cervical
lymph nodes
A cervical rib A cervical rib
Usually the lowest root (T1) of the
brachial plexus is involved
The fibers from this segment of the
spinal cord supply the small muscles
of the hand (Interossei and
lumbricals).
Paralysis and wasting of small muscles
of hand occurs
Clawed appearance due to:
Hyperextension of the
metacarpophalangeal joints (the
extensor digitorum is unopposed by
the lumbricals and interossei and
extends the metacarpophalangeal
joints).
Flexion of the interphalangeal joints
(the flexor digitorum superficialis and
profundus are unopposed by the
lumbricals and interossei, the middle
and terminal phalanges are flexed).
There is also sensory loss along the
medial side of the forearm, hand and
medial 2 fingers Often associated
with Horner’s syndrome (drooping of
upper eyelid & constricted pupil) due
to traction of sympathetic fibers

Long Thoracic Nerve Lesion (Nerve
to Serratus Anterior): (C5,C6,C7)
This nerve may be injured by:
• Blows or pressure in the posterior triangle of the neck
• During a radical mastectomy surgical procedure.
The serratus anterior muscle:
• Pulls the medial border of the scapula to the posterior thoracic wall
and stabilizes it there.
• Rotates scapula during the abduction of arm above a right angle
• The patient shows difficulty in raising the arm above the head If
patient is asked to push against a wall, the medial border of the
scapula will be pushed away from the thoracic wall and protrude like a
wing, on the side of the lesion. 'winged scapula'.
• Decrease flexion and abduction of the arm
• No sensory loss

Axillary Nerve
• Spinal roots: C5 and C6.
• Motor functions: Innervates the teres minor and
deltoid muscles
• Sensory functions: Gives rise to superior lateral
cutaneous nerve of arm, which innervates the
skin over the lower deltoid ‘(‘regimental badge
area’).

Axillary Nerve Lesion
Axillary nerve may get injured:
• Due to downward dislocation of humeral head In shoulder
dislocation
• Fracture of the surgical neck of humerus
Muscles involved:
• Deltoid and teres minor muscles become paralyzed
• Abduction of the shoulder is impaired. The paralyzed
deltoid wastes rapidly (loss of rounded contour of the
shoulder) .Diminished flexion and extension
• Loss of sensation over the lower half of deltoid muscle

The Musculocutaneous
Nerve
• Nerve roots: C5-C7.
• Motor functions: Innervates the
muscles in the anterior
compartment of the arm – the
coracobrachialis, biceps brachii
and the brachialis
• Sensory functions: Gives rise to
the lateral cutaneous nerve of
forearm, which innervates skin on
the lateral surface of the forearm.

Radial Nerve
• Nerve roots: C5-T1.
• Sensory: Innervates most of the skin of the posterior side of forearm,
and the dorsal surface of the lateral side of the palm, and lateral three
and a half digits.
• Motor: Innervates the triceps brachii (extends at the elbow), and the
majority of the extensor muscles in the forearm (extends the wrist and
fingers and supinates the forearm).

The muscles supplied by the radial nerve and its two
main motor branches
Branch Muscles supplied
The radial nerve
Medial head of triceps brachii
Lateral head of triceps brachii
Anconeous
Brachioradialis
Extensor carpi radialis longus
The deep branch of the radial nerve
Extensor carpi radialis brevis
Supinator
The posterior interosseous nerve
Extensor digitorum
Extensor digiti minimi
Extensor carpi ulnaris
Abductor pollicis longus
Extensor pollicis brevis
Extensor pollicis longus
Extensor indicisCreated By Kishan Indrakumar

Sensory Functions
There are four branches of the radial nerve that provide cutaneous innervation to the
skin of the upper limb. Three of these branches arise in the upper arm:
Lower lateral cutaneous nerve of arm – Innervates the lateral aspect of the upper
arm, below the deltoid muscle.
Posterior cutaneous nerve of arm – Innervates the posterior surface of the upper arm.
Posterior cutaneous nerve of forearm – Innervates a strip of skin down the middle of
the posterior forearm.
The fourth branch – the superficial branch – is a terminal division of the radial nerve.
It innervates the dorsal surface of the lateral three and half digits, and their
associated palm area.

Radial Nerve-In the Axialla
Type of Injury:
• Pressure of the upper end of badly fitting crutch pressing up in to the armpit (crutch palsy)
• The drunkard falling asleep with his arm over the back of a chair (saturday night palsy).
• Fractures or dislocations of the upper end of the humerus.
Motor loss:
• Triceps, anconaeus and long extensor of the wrist are paralysed.
• The patient is unable to extend the elbow joint, wrist joint and fingers (Extensor weakness of the metacarpophalangeal joint. Interphalangeal joints
are intact because of the interossei and lumbricals)
• “Wrist drop” or flexion of the wrist occurs as a result of the unopposed flexor muscles of the wrist.
• This is a very disabling injury, since a person can't flex the fingers strongly for gripping an object with the wrist fully flexed.
• The brachioradialis and supinator muscles are paralyzed, but supination can still be performed due to intact biceps brachii
Sensation loss :
Due to the overlap of sensory innervation by adjacent median & ulnar nerves, the area of total anaesthesia is relatively small, overlying the first dorsal
interosseous muscle (between the 1 st and 2 nd metacarpal bones) . +/- lower lateral cutaneous nerve
Test:
Sensation as described.
Extensor wrist and elbow against resistance.

Injury in the Radial Groove
Type of Injury
Fracture of the shaft of humerus
Callus formation
Pressure on the back of the arm on the edge of the operating table in an unconscious patient
Prolonged application of tourniquet.
Motor loss :
The injury to radial nerve occurs most commonly in the distal part of the groove beyond the origin of the nerve to the triceps & anconeus (so that extension of
the elbow is possible), and beyond the origin of the cutaneous nerves
The long extensors of the forearm are paralyzed and this will result in a "wrist drop".
Extensor weakness in the wrist and finger-metacarpophalangeal joint
Extension of elbow preserved
Sensation loss:
Loss of sensation from small area overlying the first dorsal interosseous muscle.
Lower lateral cutaneous nerve is intact
Tests:
Extensor of the wrist against resistant- paralyzed
Intact elbow extension

Injury to the Deep Branch of the Radial Nerve
Type of Injury:
It may be damaged in fractures of the proximal end of the radius or during dislocation of the radial head.
Motor loss:
Intact forearm extension and flexion with intact hand extension.Only weakness of finger extensors.
Extensor weakness of the metacarpophalangeal joint. Interphalangeal joints are intact because of the
interossei and lumbricals
Nerve supply to the supinator and extensor carpi radialis longus will be undamaged and because the later
muscle is powerful it will keep the wrist joint extended and wrist drop will not occur.
Extension of the elbow is intact
Sensation loss:
There will be no sensory loss since this is a motor nerve.
Tests:
• Power of extension of metacarpophalangeal joint
• No sensory loss

Injury to the Superficial Branch of the Radial
Nerve
Type of Injury:
It may be damaged as a result of stab injury, or pressure from
handcuffs & tight bangles
Motor loss: There will be no motor loss since this is a sensory nerve
Sensation loss:
There is a small loss of sensation over the dorsal surface of the hand
and the dorsal surfaces of the roots of the lateral three fingers

Summary – Radial Nerve
Motor sensation
Axilla Loss of extension of elbow and wrist.
Wrist drop
Loss of sensation between first dorsal interosseous
muscle (between the 1 st and 2 nd metacarpal
bones)
+/- lower lateral cutaneous nerve
Radial Groove loss of wrist extension and finger
Wrist drop
elbow extension intact(distal part of the groove
beyond the origin of the nerve to the triceps &
anconeus (so that extension of the elbow is
possible)
and beyond the origin of the cutaneous nerves
Loss of sensation between first dorsal interosseous
muscle (between the 1 st and 2 nd metacarpal
bones)
Lower lateral cutaneous nerve is intact.
Radial head- Deep Branch of the Radial Nerve Finger extension – only metacarpophalangeal joint
No wrist drop because of extensor carpi radials
longus intact
No sensory loss
Superficial Branch of Radial nerve No Motor loss There is a small loss of sensation over the dorsal
surface of the hand and the dorsal surfaces of the
roots of the lateral three fingers

Median Nerve
• Nerve roots: C6 – T1. (Also contains fibres from C5 in some individuals).
• Motor functions: Innervates the flexor muscles in the anterior compartment
of the forearm (except the flexor carpi ulnaris and part of the flexor
digitorum profundus, innervated by the ulnar nerve). Also supplies
innervation to the thenar muscles and lateral two lumbricals in the hand.
• Sensory functions: Gives rise to the palmar cutaneous branch, which
innervates the lateral part of the palm, and the digital cutaneous branch,
which innervates the lateral three and a half fingers on the anterior (palmar)
surface of the hand.

Median Nerve branches
The median nerve
Pronator teres
Flexor carpi radialis
Palmaris longus
Flexor digitorum superficialis
The anterior interosseous nerve
Flexor digitorum profundus (lateral ½)
Flexor pollicis longus
Pronator quadratus
(Note: all are deep muscle layer)
The recurrent branch
Thenar muscles
 Opponens pollicis
 Abductor pollicis brevis
 Flexor pollicis brevis

Sensory Functions
Palmar cutaneous branch – Arises in the forearm and
travels into the hand. It innervates the lateral aspect of
the palm. This nerve does not pass through the carpal
tunnel, and is spared in carpal tunnel syndrome.
Palmar digital cutaneous branch – Arises in the
hand. Innervates the palmar surface and fingertips of
the lateral three and half digits.

Median At the Elbow
Type of Injury:
supracondylar fracture of humerus
Motor:
• Muscles affected: Pronator muscles of the forearm, All long flexors of the wrist and fingers except flexor carpi ulnaris and medial half of flexor
digitorum profundus.
• Thenar muscles (except adductor pollicis (ulnar) ) and radial lumbricals
• Loss of pronation. Hand is kept in supine position.
• Wrist shows weak flexion, and ulnar deviation (? Due to intact flexor carpi ulnaris )
• No flexion possible on the interphalangeal joints of the index and middle fingers
• Weak flexion of ring and little finger
• Thumb is adducted and laterally rotated, with loss of flexion of terminal phalanx and loss of opposition
• Wasting of thenar eminence
• Hand looks flattened and “apelike”, and presents an inability to flex the three most radial digits when asked to make a fist
• Ulnar deviation,Thenar wasting,Papal benediction On fingers( when asked to make fist)
Sensory:
• The radial side of the palm .Palmer aspect of the lateral 3½ fingers
• Distal part of the dorsal surface of the lateral 3½ fingers
Tests:Sensory loss-pulp of index finger
• Motor: pronation. abductor pollicis brevis +/- opposition
• Both interphalangeal joint of index and thumb (flexor pollics longus)pulp-pulp-lossCreated By Kishan Indrakumar

Median Nerve At Wrist
Type of Injury:
• Wrist Often injured by penetrating wounds.
Motor loss:
• Muscles affected: thenar muscles (expect adductor pollicis ). radial 2 lumbricals
• Flexion is alright because of flexor pollicis longus
• Thenar muscles are paralyzed and atrophy in time so that the thenar eminence becomes flattened.-
Apelike hand
• Opposition and abduction of thumb are lost
Sensation loss:
Sensory & trophic changes are the same as in the elbow region injuries.
Tests:
• Sensory loss- pulp of the index finger.
• Motor- abduction (+/- opposition )Interphalangeal joint and pronation are intactCreated By Kishan Indrakumar

Carpel Tunnel
Type of Injury:
Compression of median nerve in the carpal tunnel
Motor loss:
Weak motor function of thumb, index & middle finger
Sensory loss:
• Burning pain or ‘pins and needles’ along the distribution of median nerve to lateral 3½ fingers
• No sensory changes over the palm as the palmer cutaneous branch is given before the median
nerve enters the carpal tunnel
Test:
Tapping over carpel tunnel- tingling sensation over the medial nerve .sensation should be maintained
at radial side of the palm. Created By Kishan Indrakumar

Summary- Median Nerve
Median nerve at elbow Median nerve at wrist
Motor loss
Weak wrist flexion and abduction
Loss of thumb abduction and opposition
Loss of flexion of index and middle fingers
Loss of thumb abduction and opposition
Wrist and finger flexion intact (due to intact AIN)
Sensory loss
Lateral 3 and ½ fingers and nail beds
Lateral side of palm
Lateral 3 and ½ fingers and nail beds
Lateral side of palm (but can be preserved depending upon
palmar cutaneous branch)
Hand deformity
Ulnar deviation of wrist
Thenar wasting
Papal bendiction on flexing fingers
Thenar wasting
No ulnar deviation of wrist or papal benediction (due to intact
AIN)

Ulnar Nerve
• Spinal roots: C8-T1.
• Motor functions: Innervates the muscles of the hand (apart from the
thenar muscles and two lateral lumbricals), flexor carpi ulnaris and
medial half of flexor digitorum profundus.
• Sensory functions: Innervates the anterior and posterior surfaces of
the medial one and half fingers, and the associated palm area.

The muscles supplied by the ulnar nerve and
its two main motor branches
Muscular branches of the ulnar nerve (in the forearm)
Flexor carpi ulnaris
Flexor digitorum profundus (medial ½)
The deep branch of the ulnar nerve
(in the hand)
Hypothenar muscles
Opponens digiti minimi
Abductor digiti minimi
Flexor digiti minimi brevis
3rd and 4th lumbricals
Dorsal interossei
Palmar interossei
Adductor pollicis
Flexor pollicis brevis (deep head)
The superficial branch of the ulnar nerve (in the hand) Palmaris brevis

Sensory Functions
There are three branches of the ulnar nerve that are
responsible for its cutaneous innervation.
Two of these branches arise in the forearm, and travel
into the hand:
Palmar cutaneous branch: Innervates the skin of the
medial half of the palm.
Dorsal cutaneous branch: Innervates the skin of the
medial one and a half fingers, and the associated
dorsal hand area.
The last branch arises in the hand itself:
Superficial branch – Innervates the palmar surface of
the medial one and a half fingers

Ulnar Nerve Injury at elbow
Type of Injury:
• Fractures of the medial epicondyle
Motor:
• Flexor carpi ulnaris, Medial half of flexor digitorum profundus, small muscles of the hands, except the muscles of thenar eminence and first two
lumbricals.
• Loss of Adductor pollicis
• Flexion of the wrist will result in abduction-Radial deviation – loss of flexor carpi ulnaris
• The thumb is abducted and extended with the distal phalanx flexed (difficulty in holding a piece of paper between thumb and index finger).
• The adduction and abduction of fingers is lost (difficulty in holding a piece of paper between fingers).
• The lateral two fingers are fully extended with a slight flexion of the distal phalanges(because lateral lumbricals are intact which is innervated by
medial nerve)- less claw
• The medial two fingers are hyperextended at the metacarpophalangeal joints but flexed at the distal phalangeal joints. (because of loss of medial
lumbricals)- less claw then wrist injury because of loss FDP
• Wasting of the hypothenar eminence
• The dorsum of the hand shows hollowing between the metacarpal bones
• The hand resembles a "claw" and is called a claw hand. The clawing becomes most obvious when the person is asked to straighten their fingers.
Sensation:
• Sensory loss over the anterior & posterior surfaces of the palm & medial one and half finger
Tests:
• Place paper between straight fingers,try to abducting fingers
• Fromens test

Ulnar Nerve at Wrist
Type Of Injury:
Due to cuts and stab
Motor:
• The small muscles of the hands are paralyzed, except the muscles of thenar eminence , first two lumbricals,FDP and flexor
carpi ulnaris
• Claw hand (because no interossi there for there no flexions of metacarpophalangeal joint , so they are extended by long
extensors)
• Note : less clawing in the index and middle finger as lateral lumbricals are intact
• More claw in the ring and index finger as FDP is intact.
• No Radial deviation because flexor carpi ulnar is intact
Sensation:
Unlar 1 ½ fingers.Dorsal and palmer cutaneous brach may be spared
Tests:
• Same as for ulnar elbow.Wasting of 1st interosseous

Ulnar Nerve Injury Summary
Motor sensation
At elbow The lateral two fingers are fully extended with a
slight flexion of the distal phalanges- Less claw
The medial two fingers are hyperextended at the
metacarpophalangeal joints but flexed at the distal
phalangeal joints- less claw than wrist because loss
of FDP
The adduction and abduction of fingers is lost
The thumb is abducted and extended with the distal
phalanx flexed
Radial deviation-loss of flexor carpi ulnaris
Wasting of the hypothenar eminence
Sensory loss over the anterior & posterior surfaces
of the palm & medial one and half finger
At wrist Same as wrist except
More claw in ring and little finger as FDP intact and
No radial deviation -intact flexor carpi unlaris
Unlar 1 ½ fingers.Dorsal and palmer cutaneous
branch may be spared

Nerve Blocks

Median Nerve Block
Anatomy:
At the wrist the median nerve lies under the flexor retinaculum on the anterior aspect of the
wrist, under or immediately radial to the tendon of palmaris longus and 5–10mm medial to
the tendon of flexor carpi radialis. Just proximal to the flexor retinaculum, the median nerve
gives off the palmar cutaneous branch, which travels superficially to supply the skin of the
thenar eminence and the central palm.
Carpal tunnel syndrome is a contraindication to median nerve block.
Technique:
Ask the patient to flex the wrist slightly and bend the thumb to touch the little finger, in
order to identify palmaris longus.
Use a 0. 6mm (23G) needle and ≈5–10mL of 1% lidocaine.
Insert the needle vertically at the proximal wrist skin crease, between palmaris longus and
flexor carpi radialis, angled slightly towards palmaris longus, to a depth of 1 cm. If
paraesthesiae occur withdraw the needle by 2–3 mm.
Block the palmar cutaneous branch by injecting another 1–2mL SC while withdrawing the
needle.
Inject ≈5mL of LA slowly.
Some people do not have a palmaris longus tendon—in this case, identify flexor carpi
radialis and insert the needle on its ulnar side.
Ultrasound allows blockade of the median nerve in the forearm.

Ulnar Nerve Block
Anatomy:
In the distal forearm the ulnar nerve divides into a palmar branch (which travels
with the ulnar artery to supply the hypothenar eminence and palm) and a dorsal
branch (which passes under flexor carpi ulnaris to supply the ulnar side of the
dorsum of the hand).
Technique:
Use a 0.6mm (23G) needle and 5–10mL of 1% lidocaine. Avoid adrenaline in
peripheral vascular disease.
Check the radial pulse before blocking the ulnar nerve.
Feel the ulnar artery and flexor carpi ulnaris tendon and insert the needle between
them at the level of the ulnar styloid process.
Aspirate and look for blood in the syringe. Withdraw the needle 2–3mm if
paraesthesiae occur.
Block the dorsal branch of the ulnar nerve by SC infiltration of 3–5mL of LA from
flexor carpi ulnaris around the ulnar border of the wrist.
Inject 5mL of LA.

Radial Nerve Block
In the distal part of the forearm the radial nerve passes under the tendon
of brachioradialis and lies subcutaneously on the dorsum of the radial side
of the wrist, where it separates into several branches and supplies the
radial side of the dorsum of the hand.
Technique
Infiltrate LA subcutaneously around the radial side and dorsum of the wrist
from the tendon of flexor carpi radialis to the radio-ulnar joint. Beware of
inadvertent IV injection.
Use a 0.6mm (23G) needle and 5mL of 1% lidocaine, with or without
adrenaline.
Radial nerve block involves an infiltration technique and often has a more
rapid onset and shorter duration of action than median nerve and ulnar
nerve blocks. In combined blocks, experts may use lidocaine with
adrenaline in order to prolong the anaesthetic and ↓ the risk of lidocaine
toxicity.

Digital Nerve Block
Digital nerve block is used frequently for simple operations on the fingers and toes.
A dorsal and a palmar digital nerve run along each side of the finger and thumb. Similarly,
there are dorsal and plantar nerves in the toes.
1% plain lidocaine is often used, but bupivacaine (0.5% plain) is preferable because it is less
painful on injection, and gives prolonged anaesthesia and analgesia. The traditional advice is
never to use adrenaline or any other vasoconstrictor. In an adult use 1–2mL of LA on each
side of the finger, thumb, or big toe. Use smaller volumes in the other toes or in children.
Insert the needle from the dorsum on the lateral side of the base of the digit, angled slightly
inwards towards the midline of the digit, until the needle can be felt under the skin on the
flexor aspect.
Use a 0.6 × 25 mm (23G) needle (0.5 × 16 mm, 25G, in small children).
Aspirate to check the needle is not in a blood vessel.
Slowly inject 0.5–1mL. Continue injecting as the needle is withdrawn.
If anaesthesia is needed for the nail bed of the great toe give an additional injection of LA
subcutaneously across the dorsum of the base of the proximal phalanx, to block the dorsal
digital nerves and their branches. This is also required for anaesthesia of the dorsum of the
digit proximal to the middle phalanx.
Repeat on the medial side of the digit.
Anaesthesia develops after ≈5min. The maximum volume that can be used in a finger, thumb,
or big toe is 5mL. Use less in the other toes or in children

Digital Nerve Block
Single Injection Digital Nerve Block:
Anaesthesia of the distal phalanx and DIP joint can be
achieved by a single subcutaneous injection in the
volar aspect of the base of the finger. Pinch the soft
tissues just distal to the proximal skin crease. Insert a
25G needle just beneath the skin at the midpoint of
the skin crease and inject 2–3mL of 0.5% bupivacaine.
Massage the LA into the soft tissues.
Digital Block at metacarpal Level:
Digital nerves can be blocked where they run in the
interspaces between the metacarpals. Insert a thin
needle in the palm through the distal palmar crease,
between the flexor tendons of adjacent fingers.
Injection of 3–4mL of 1% plain lidocaine will block the
adjacent sides of these two fingers. Anaesthesia
develops after 5–10min. Alternatively, a dorsal
approach can be used: this is often preferred because
it is less painful, but there is an ↑ risk of inadvertent
venepuncture and the digital nerves are further from
the dorsal surface, so a deep injection is needed.

Haematoma Block
A Colles fracture can be manipulated after infiltration of LA into the fracture haematoma and
around the ulnar styloid. This often provides less effective anaesthesia than Bier's block and a
poorer reduction. It converts a closed fracture into an open one and so there is a theoretical risk
of infection, but in practice this is rare.
Contraindications and warnings
Fractures >24 hours old (since organization of the haematoma would prevent spread of the LA).
Methaemoglobinaemia (avoid prilocaine).
Infection of the skin over the fracture.
Drug and dosage
15mL of 1% plain prilocaine. Lidocaine can be used, but there is a lower margin of safety. Never
use solutions containing adrenaline.
Technique
Use a 20mL syringe and 0.6 × 25mm needle. Full asepsis is essential. Insert the needle into the
fracture haematoma and aspirate blood to confirm this. Inject slowly to minimize pain and
reduce the risk of high blood levels and toxicity. Anaesthesia develops in ≈5min and lasts for 30–
60min. Sometimes anaesthesia is inadequate for proper manipulation and so an alternative
anaesthetic is needed.

Flexor Retinaculum
The following structures pass beneath the flexor retinaculum from
medial to lateral:
Flexor digitorum superficialis,Flexor digitorum profundus,Median
nerve,Flexor pollicis longus
Flexor carpi radialis
The following structures pass superficial to the flexor retinaculum
from medial to lateral:
Flexor carpi ulnaris tendon,Ulnar nerve,Ulnar artery,Palmar
cutaneous branch of the ulnar nerve,Palmaris longus
tendon,Palmar cutaneous branch of the median nerve
The tendons of palmaris longus and flexor carpi ulnaris are partly
attached to the surface of the flexor retinaculum.
The thenar and hypothenar muscles originate from the flexor
retinaculum:
Abductor pollicis brevis,Flexor pollicis brevis,Opponens
pollicis,Flexor digiti minimi,Opponens digiti minimi,Abductor digiti
minimi

The extensor retinaculum
The extensor retinaculum (dorsal carpal ligament) of the hand is the thickened
part of the antebrachial fascia that holds the tendons of the extensor muscles in
place. It is located on the back of the forearm, just proximal to the hand.
It is continuous with the palmar carpal ligament, which is located on the
anterior side of the forearm. The palmar carpal ligament is a different structure
to the flexor retinaculum of the hand, but the two are frequently confused.
It is a strong, fibrous band that extends obliquely downwards and medially
across the back of the wrist. It is attached laterally to the lateral margin of the
radius and medially to the triquetral bone and the pisiform bone. It is not
attached to the ulna.
The following structures pass beneath the extensor retinaculum from medial to
lateral:
• Extensor carpi ulnaris
• Extensor digiti minimi
• Extensor digitorum and extensor indicis
• Extensor pollicis longus and extensor carpi radialis brevis
• Abductor pollicis longus and extensor pollicis brevis
• Radial artery (in the anatomical snuffbox)
•
The following structures pass superficial to the extensor retinaculum from
medial to lateral:
• Dorsal cutaneous branch of the ulnar nerve
• Basilic vein

THE ANATOMICAL SNUFFBOX
• Ulnar (medial) border: Tendon
of the extensor pollicis longus.
• Radial (lateral) border: Tendons
of the abductor pollicis longus and
extensor pollicis brevis.
• Proximal border: Styloid process
of the radius.
• Floor: Carpal bones; scaphoid
and trapezium.
• Roof: Skin.
• The main contents of the
anatomical snuffbox are the radial
artery, a branch of the radial
nerve, and the cephalic vein.

THE CARPAL TUNNEL
The carpal tunnel is formed by two layers: a deep carpal arch and a superficial flexor
retinaculum. The deep carpal arch forms a concave surface, which is converted into a tunnel by
the overlying flexor retinaculum.
Carpal Arch
Concave on the palmar side
Formed laterally by the scaphoid and trapezium tubercles
Formed medially by the hook of the hamate and the pisiform
Flexor Retinaculum
Thick connective tissue
Turns the carpal arch into the carpal tunnel by bridging the space between the medial and lateral
parts of the arch.
Originates on the lateral side and inserts on the medial side of the carpal arch.
The tendon of flexor pollicis longus
Four tendons of flexor digitorum profundus
Four tendons of flexor digitorum superficialis
median nerve.
Once it passes through the carpal tunnel, the median nerve divides into 2 branches: the
recurrent branch and palmar digital nerves.
The palmar digital nerves give sensory innervation to the palmar skin and dorsal nail beds of
the lateral three and a half digits. They also provide motor innervation to the lateral two
lumbricals. The recurrent branch supplies the thenar muscle group.

THE CUBITAL FOSSA
Lateral border – The medial border of the brachioradialis muscle.
Medial border– The lateral border of the pronator teres muscle.
Superior border – An imaginary line between the epicondyles of the humerus.
The floor of the cubital fossa is formed proximally by the brachialis, and distally by the
supinator muscle. The roof consists of skin and fascia, and is reinforced by the bicipital
aponeurosis. Within the roof runs the median cubital vein, which can be accessed for
venepuncture
Radial nerve – This is not always strictly considered part of the cubital fossa, but is in the
vicinity, passing underneath the brachioradialis muscle. As is does so, the radial nerve
divides into its deep and superficial branches.
Biceps tendon – It runs through the cubital fossa, attaching to the radial tuberosity, just
distal to the neck of the radius.
Brachial artery – The brachial artery supplies oxygenated blood the forearm. It bifurcates
into the radial and ulnar arteries at the apex of the cubital fossa.
Median nerve – Leaves the cubital between the two heads of the pronator teres. It
supplies the majority of the flexor muscles in the forearm.
Mnemonic for contents of the cubital fossa – Really Need Beer To Be At My Nicest.

THE AXILLA REGION
Apex – Also known as the axillary inlet, this is formed by lateral border of the
first rib, superior border of scapula, and the posterior border of the clavicle.
Lateral wall – Formed by intertubercular groove of the humerus.
Medial wall – Consists of the serratus anterior and the thoracic wall (ribs and
intercostal muscles).
Anterior wall – Contains the pectoralis major and the underlying pectoralis minor
and the subclavius muscles.
Posterior wall – Formed by the subscapularis, teres major and latissimus dorsi.
Content:
Axillary artery, Axillary vein, Brachial plexus, Biceps brachii and
coracobrachialis, Axillary Lymph nodes
Clinical Relevance
Thoracic Outlet Syndrome, Lymph Node Biopsy

Blood Supply

Bone

Summaries

Cutaneous Nerves Of Upper Limbs

Segmental Nerve Supply in Upper Limbs

Dermatomes
The key dermatomes are:
• C5 – The area over the deltoid
• C6 – The thumb
• C7 – The middle finger
• C8 – The little finger
• T4 – The nipple line
• T8 – The xiphisternum
• T10 – The umbilicus
• T12 – The symphysis pubis
• L4 – The medial aspect of the calf
• L5 - The web space between the 1st and 2nd toe
• S1 – The lateral border of the foot
• S3 – The ischial tuberosity area
• S4, S5 – The perianal region

Reflex
Biceps reflex: C5 and C6
Supinator reflex: C5 and C6
Triceps reflex: C7 and C8
Knee-jerk reflex: L3 and L4
Ankle-jerk reflex: S1

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