The document provides an overview of the anatomy and common injuries of the upper limb. It discusses the brachial plexus and various nerve injuries it can cause. It then examines the shoulder joint and its stabilizers. Common shoulder injuries like dislocations are outlined. The arm, elbow, forearm, wrist and hand are each reviewed along with relevant surgical approaches, complications and nerve locations. Overall the document serves as a guide to the structural and functional anatomy of the upper limb.

1. Applied Anatomy of Upper Limb
Presenter Dr Kaushal Raj Kafle
Moderator Dr Nischal Ghimire

2. Brachial Plexus

3. Brachial Plexus Injuries
• Erb’s palsy
– Upper Lesion (C5,6)
– Excessive displacement of
head to opposite side and
depression of shoulder on
the same side
– Difficult delivery in infants
or fall onto shoulder in
adults
• “Waiter’s tip” deformity
• Best prognosis

4. • Klumpke Palsy
– Lower lesion C8, T1
– Avulsion injuries caused
by excessive abduction
– Poor prognosis
– Deficit of all of the small
muscles of the hand
– “Claw hand”

5. ACJ
• Acromioclavicular joint passes downward and
medially : a tendency for the lateral end of the
clavicle to ride up over the upper surface of the
acromion.
• Strong coracoclavicular ligament, binds coracoid
process to the undersurface of the lateral part of
the clavicle
• Tear in Coracoclavicular ligament : acromion
being thrust beneath the lateral end of the
clavicle

6. Shoulder Joint
• Classic ball and socket
joint
• Humeral head and
shallow glenoid cavity
• Golf ball on a tee
• 25-30% of humeral head
is in contact with glenoid
at any range of motion
• Increased ROM with risk
of potential instability

7. • Static Stabilisers
– Labrum : Fibrocartilagenous ring
• Negative suction pressure effect within GHJ
• Provides 50% 0f glenoid depth
• Anchor to glenohumeral ligaments
– Capsule
– Glenohumeral ligaments

8. – Superior Glenohumeral ligament
– Middle Glenohumeral ligament
– Inferior Glenohumeral ligament
• anterior band, axillary pouch and posterior band
• Major static stabiliser at 90 Abduction
• Acts as Hammock at the end range of motion
• Progressively taut with Increasing External and Internal
rotation

9. • Rotator interval : Capsular component of
inferior stability
– Interval between Supraspinatous and
subscapularis
– Consists Joint capsule, Coracohumeral ligament
and SGHL
– Deficiency : Inferior translation of Humerus
– Imbrication of Rotator interval : Increased stability
in inferior and anterior translation

10. • Dynamic/ Active stabilizers
– Rotator cuffs
– Tendon of long head of biceps
• Rotator Cuff muscles
compress and centre humeral
head against the glenoid
• Active compression force by
dynamic muscle counteract
the translational forces on
passive restraints
• Concavity compression
mechanism

11. Shoulder dislocation
• Least supported : Inferior
• Most common dislocation
• Anteroinferior dislocation : Abducted and Sudden
impact on humerus
• Posterior dislocation : Front Force
• Subgleniod displacement of head into
quadrangular space damage axillary nerve
• Downward displacement of humerus can also
stretch radial nerve

12. • Tear
– Anterior band of IGHL : Origin
or midsubstance
• HAGL Lesion : Humeral avulsion
of IGHL
– Anterior labrum : Bankart
lesion
– Gleniod rim fracture/Bony
Bankart : Recurrent instability
with progressive erosive bone
loss from anterior inferior
glenoid
– Hill Sachs : Impression
Fracture of posterior
superolateral humeral head

13. Arm
• Compartments

14. Compartment syndrome of Upper
arm is Rare
Can be released with single
longitudinal incision
medial, lateral, posterior

15. Surgical Approach to Humerus
Proximal Humerus Deltopectoral 10-15 cm straight
incision along the
deltopectoral
groove just above
coracoid process
Deltoid Axillary
Nerve
Pectoralis major
Medial and lateral
pectoral nerve
Lateral Approach Tip of acromian to
lateral aspect of
Forearm
No intramuscular
plain
split Deltoid
Shaft Of humerus Anterior approach Tip of coracoid,
deltopectoral
groove to lateral
arm along lateral
border of biceps
Proximal as above
distal
Medial Brachialis :
Musculocutaneous
lateral Brachialis :
Radial nerve

16. Elbow
• 3–9 degrees of external rotation
• 4–8 degree of valgus relative to
the humeral shaft.
• Spool shaped trochlea : 300
degree arc of articular cartilage
• The lateral column
– 20° of valgus
– flexed 10° to 20° relative to the
humeral shaft.
• The medial column
– 40 to 45 degrees of varus
– 10 to 20 degrees of flexion

17. • Anatomic restoration of these bony structures
is necessary to protect elbow stability
• The greatest density of trabecular and cortical
bone is located anterolateral and posterior-
medial respectively

18. • Prevent iatrogenic injury during surgical
exposure.
– Radial nerve : spiral groove 7 to 14 cm proximal to the
lateral epicondyle
– between the brachialis and brachioradialis
– crosses the radial shaft approximately 4cm distal to
joint.
– Ulnar nerve : posterior compartment approximately 8
cm proximal to the medial epicondyle at the arcade of
Struthers
– posterior to the medial epicondyle
– Under Osbornes fascia / Cubital tunnel

19. Elbow stabilizers
• Primary stabilizers
Humero-ulnar joint
Medial collateral ligament
Lateral collateral ligament
• Secondary stabilizers
Radiocapitellar joint
Joint capsule – in particular the anterior aspect
Origins of the common flexor and extensor tendons

20. Elbow
3 point bony relation

21. “TERRIBLE TRIAD” INJURIES OF THE
ELBOW
• elbow dislocation in
conjunction with
fractures of the radial
head and coronoid
• disruption of the
lateral collateral
ligament with
progression to the
medial structures

22. Epicondyliltis
• Medial (Golfers elbow)
– Common Flexors
– Screw drivers, hammer, painting
• Lateral (Tennis elbow):
– Common extensor
– ECRB

23. • Ulna Straight, longer and
slight proximal bow
• Subcutaneous through its
length
• Radius Bowed from distal
metaphysis to just distal to
biciptal tuberosity
• Just at Biceps insertion 13o
in opposite direction radial
bow to articulate with
capitellum
• PRUJ most congruent in
supinated forearm

24. • Restoration of radial bow
– Directly proportional to Functional
outcome and Grip Strength
– 80% function restored if bow is
maintained with in 1.5mm
– Average max Radial Bow is 15mm
across the interosseus menbrane

25. • metaphysis of the radius
– cancellous bone
– 2–3 cm proximal to the radiocarpal joint.
– prone to fracture at the junction of the
corticocancellous bone
• volar cortex is concave, thicker, and easier
to align during fracture reduction
• dorsal cortex is convex, thin, and often
multifragmented
• Radiocarpal articular
– 10–14° of volar tilt,
– approx 22° of ulnar inclination

26. • Neutral forearm
– Radiocarpal joint 80-85%
– Ulno carpal joint 15-20%
• Change in Ulnar variance/Radial Tilt
– Positive ulnar Variance of 2.5mm: 42% of load on distal
ulna
– Negative ulnar variance of 2.5mm: 4.3% load on distal ulna
• Dorsal Malunion: Decreased grip strength, Adaptive
Dorsal Carpal Instability, accelerates joint arthrosis
• DRC Ligaments: sites for small avulsion fracture off
Distal radius

27. • Distal radius : 2 concave surfaces
• Scaphoid fossa : elliptical :
• Lunate fossa : spherical : allows more flexion
extension of lunate
• DRUJ : Rotation and Translation
• Triangular Fibrocartlagenous Complex : TFCC
form dorsal and Volar radioulnar ligaments
– Any radial deformity , esp radial shortening , alter the
kinematics of Radio carpal Joint and DRUJ

28. Forearm Compartments

29. Compartment Syndrome Release
• curvilinear and extends
from the proximal ulnar to
gently curve radially and
finally return to the ulnar
• extends into the mid-palm
just ulnar to thenar crease
• Mobile wad compartment
separately decompressed

30. Surgical approach to Forearm
Radius Dorsal Approach :
Thompson
anterior and distal to
the lateral
epicondyle
distally
just distal and ulnar
to Lister's tubercle
Proximally
ECRB (radial nerve)
EDC (pin nerve)
Distally
ECRB (radial nerve)
EPL (pin nerve)
Volar Approach :
Henrys
lateral to biceps
tendon on flexor
crease of elbow
end at radial styloid
process
Proximally
brachioradialis (radial
nerve)
pronator teres (median
nerve)
Distally
brachioradialis (radial
nerve) FCR (median
nerve)
Ulna Boyds Approach linear longitudinal
incision over
subcutaneous border
of ulna
ECU (PIN nerve)
FCU (ulnar nerve)

31. • THomsp
Thompson’s Approach Henry’s Approach
Direct Ulnar Approach

32. Wrist and Hand
• Carpal Bones and Ligaments

33. Perilunate dislocation
• Intrinsic Ligament connects carpal to carpal
bone
• Extrinsic Ligament Connects radius to carpus
and carpus to metacarpus
• Space of Poirier : Ligament free area between
the radioschapolunate, long radiolunate
ligament at midcarpus level
• Area of potential weakness

34. Scaphoid Non Union
• The fracture line : narrowest part of the bone
• Bathed in Synovial fluid
• Blood vessels Retrograde
• Occasionally confined to the distal end

35. Keinboch’s Disease
• Single vessel to lunate 7%
• I pattern more at risk of AVN

36. Radial Nerve

37. Median Nerve

38. Ulnar Nerve

39. Compressive Neuropathies
• Radial Tunnel Syndrome
• Carpal Tunnel Syndrome
• Pronator Tunnel Syndrome
• Ulnar Tunnel Syndrome
• Cubital Tunnel Syndrome

40. Radial Tunnel Syndrome
– compressive neuropathy
of the (PIN) at the level of
proximal forearm
– Radial Tunnel
– pain only (maximal
tenderness 3-5 cm distal
to lateral
epicondyle) without
any motor or sensory
dysfunction

41. Carpal Tunnel Syndrome
• Narrowest at the level of the
hook of the hamate
• Compressive Neuropathy at the
level of wrist
– Predisposing factor
– Pathologic (inflamed) synovium –
• Paresthesia in thumb, index,
middle finger and radial half of
ring finger
• Thenar atrophy, Positive Phanel
test, Tinel test and Dunkan Test

42. Pronator Syndrome
• Compressive Neuropathy at the level of
Elbow
• Symptoms similar to CTS
– Worsen with Supination Pronation
– Pain over Proximal Volar Forearm
– Sensory defecit over the distribution
of palmar cutaneous branch which
arise 4-5 cm proximal to CT
– No Night Symptoms
• Negative Provocative test at Distal
Carpal Tunnel

43. Ulnar Tunnel Syndrome
• Compressive Neuropathy
– Guyon's canal
– ganglion cyst.
– paresthesias of the small and ring
finger with intrinsic weakness
• Zone 3 pure sensory
• Zone 2 pure motor
• Zone 1 mixed motor and sensory
• Weakened grasp, pinch and
intrinsic muscles

44. Cubital Tunnel Syndrome
• fibers to FCU and FDP are central and hand
intrinsic fibers are peripheral
• Hand Symptoms more predominant

45. Summary
• Upper limb is the non weight bearing limb
• Stability is sacrificed to mobility in upper limb
• Derived from Lateral plate mesoderm
• Brachial plexus forms the basis of Nervous
supply
• Knowledge of structure without the
understanding of function is almost useless
clinically because the aim of the treatment is
to preserve or restore the function

46. • Thank You