Dr Saad Al Sabti
M B Ch B, Ph D (Lond)
Bones of the upper limb consist of the bones of the shoulder girdle,
and those of the arm, the forearm, the wrist and the hand.
The Scapula /1
The scapula is a flat triangular bone that lies on the posterolateral
aspect of the thoracic cage between the second and the seventh
ribs. It connects the humerus with the clavicle.
The Scapula /2
The inferior angle of the scapula can be palpated easily in the living
subject and marks the level of the seventh rib and the spine of the
seventh thoracic vertebra.
The Humerus /2
The greater tubercle is lateral in position, whereas the lesser
tubercle is anterior in position.
Where the upper end of the humerus joins the shaft, there is a
narrow surgical neck.
Because the surgical neck is weaker than the more proximal regions
of the humerus, it is one of the sites where the humerus commonly
fractures. A fracture in this area is most likely to cause damage to
the axillary nerve and posterior circumflex humeral artery. Damage
to the axillary nerve affects function of the teres minor and deltoid
muscles
About halfway down the lateral aspect of the shaft is a roughened
elevation called the deltoid tuberosity.
The Humerus /3
The body (shaft) of the humerus has an anterior, medial and lateral
borders.
The lower end of the humerus possesses the medial and lateral
epicondyles for the attachment of muscles and ligaments, the
rounded capitulum for articulation with the head of the radius, and
the pulley-shaped trochlea for articulation with the trochlear notch of
the ulna.
Above the capitulum is the radial fossa, which receives the head of
the radius when the forearm is flexed.
Above the trochlea anteriorly is the coronoid fossa, which during
the same movement (flexion) receives the coronoid process of the
ulna.
Above the trochlea posteriorly is the olecranon fossa, which
receives the olecranon process of the ulna when the forearm is
extended
The Radius /1
The radius is the lateral bone of the forearm.
Its proximal end articulates with the humerus at the elbow joint
and with the ulna at the proximal radioulnar joint.
Its distal end articulates with the scaphoid and lunate bones of the
wrist at the wrist joint and with the ulna at the distal radioulnar
joint.
At the proximal end of the radius is the small circular head.
The Radius /2
The upper surface of the head is concave and articulates with the
convex capitulum of the humerus.
The circumference of the head articulates with the radial notch of the
ulna at the proximal radioulnar joint.
Below the head, the bone is constricted to form the neck.
Below the neck is the radial (bicipital) tuberosity for the insertion
of the biceps brachii muscle.
The shaft of the radius, in contradistinction to that of the ulna, is
wider below than above.
The Radius /3
The shaft of the radius has three borders (anterior, posterior and
interosseous), and three surfaces (anterior, posterior and
lateral).
It has a sharp interosseous border medially for the attachment of the
interosseous membrane that binds the radius and ulna together.
The pronator tubercle, for the insertion of the pronator teres
muscle, lies halfway down on its lateral side.
At the distal end of the radius is the styloid process; this projects
distally from its lateral margin.
On the medial surface of the distal end is the ulnar notch, which
articulates with the head of the ulna at the distal radioulnar joint.
The Radius /4
The inferior articular surface of the radius bone articulates with the
scaphoid and lunate carpal bones.
On the posterior aspect of the distal end is a small tubercle, the
dorsal tubercle, which acts as a pulley for the tendon of the
extensor pollicis longus muscle.
The Ulna /1
The ulna is the medial bone of the forearm.
Its proximal end articulates with the humerus at the elbow joint and
with the head of the radius at the proximal radioulnar joint.
Its distal end articulates with the radius at the distal radioulnar joint,
but it is excluded from the wrist joint by the articular disc.
The proximal end of the ulna is large and is known as the olecranon
process; this forms the prominence of the elbow.
The Ulna /2
The olecranon process has a notch on its anterior surface, the
trochlear notch, which articulates with the trochlea of the humerus.
Below the trochlear notch is the triangular coronoid process, which
has on its lateral surface the radial notch for articulation with the
head of the radius.
At the junction of the anterior surface of the coronoid process with
the front of the body is a rough eminence, the tuberosity of the
ulna or (ulnar tuberosity), which gives insertion to the brachialis
muscle.
The shaft of the ulna tapers from above downard.
The ulna has three borders (anterior, posterior and interosseous),
and three surfaces (anterior , posterior and medial).
The Ulna /3
The posterior border is sharp and subcutaneous and can be easily
palpated throughout its length.
Below the radial notch is a depression, the supinator fossa, which
gives clearance for the movement of the radial tuberosity of the
radius.
The posterior border of the fossa is sharp and is known as the
supinator crest; it gives origin to the supinator muscle.
At the distal end of the ulna is the small rounded head, which has a
projection from its medial aspect, the styloid process.
The canal is narrow, and when any of the nine long flexor tendons
passing through it swell or degenerate, the narrowing of the canal
often results in the median nerve becoming entrapped or
compressed, a common medical condition known as carpal tunnel
syndrome.
There are five metacarpal bones, each of which has a base, a
shaft, and a head.
The first metacarpal bone of the thumb is the shortest and most
mobile. It does not lie in the same plane as the others but occupies
a more anterior position.
It is also rotated medially through a right angle so that its extensor
surface is directed laterally and not backward (posteriorly) as the
other metacarpal bones do.
The trapezius attaches the pectoral girdle to the cranium and vertebral
column and assists in suspending the upper limb.
The fibers of the trapezius muscle are divided into three parts that have
different actions at the scapulothoracic joint between the scapula and
the thoracic wall:
Descending (superior) part elevates the scapula (e.g., when squaring
shoulders).
Middle part retracts the scapula (i.e., pulls it posteriorly).
Ascending (inferior) fibers depress the scapula and lower the shoulder.
3. Scapulohumeral Muscles /1
The six scapulohumeral muscles (the deltoid, teres major,
supraspinatus, infraspinatus, subscapularis, and teres minor) are
relatively short muscles that pass from the scapula to the humerus
and act on the shoulder joint.
3. Scapulohumeral Muscles /2
From the fully adducted position, abduction of the arm must be
initiated by the supraspinatus muscle. The deltoid becomes fully
effective as an abductor after the initial 15 of abduction.
The teres major is a thick rounded muscle that lies on the
inferolateral third of the scapula. It adducts and medially rotates the
arm, but along with the deltoid and rotator cuff muscles it is an
important stabilizer of the humeral head in the glenoid cavity during
movement.
The Axilla /2
The Axilla /3
The clavipectoral
fascia is a sheet of
membrane filling in the
space between clavicle
and pectoralis minor,
limited laterally by the
coracoid process.
The Axilla /4
The posterior wall of the axilla is formed superiorly by the scapula
and the subscapularis muscle on its anterior surface and inferiorly
by the teres major and latissimus dorsi.
The posterior axillary fold is the inferiormost part of the posterior
wall that may be grasped. It is formed by the teres major and
latissimus dorsi muscles.
The medial wall of the axilla is formed by the thoracic wall (1st-4th
ribs and intercostal muscles) and the overlying serratus anterior
muscle.
The Axilla /5
The lateral wall of the axilla is the narrow bony wall formed by the
intertubercular groove of the humerus.
The axilla contains the axillary artery and its branches, the axillary
vein and its tributaries, nerves of the cords and branches of the
brachial plexus, lymphatic vessels, and several groups of axillary
lymph nodes, all embedded in axillary fat.
Proximally, the neurovascular structures in the axilla are ensheathed
in a sleeve-like extension of the cervical fascia, the axillary sheath
The musculocutaneous nerve pierces it, and the distal part of its
attachment indicates the location of the nutrient foramen of the
humerus.
The coracobrachialis muscle helps flex and adduct the arm and
stabilizes the shoulder joint.
From medial to lateral, the cubital fossa contains the median nerve,
the bifurcation of the brachial artery into the ulnar and radial
arteries, the tendon of biceps brachii muscle, and the radial nerve.
Lying in the superficial fascia covering the fossa are the cephalic
and the basilic veins and their tributaries.
The Forearm
The forearm lies between the elbow and the wrist and contains two
bones, the radius and ulna, which are joined by an interosseous
membrane.
The role of forearm movement, occurring at the elbow and
radioulnar joints, is to assist the shoulder in the application of force
and in controlling the placement of the hand in space.
Muscles of Forearm
The tendons of the forearm muscles pass through the distal part of
the forearm and continue into the wrist, hand, and fingers.
The flexors and pronator muscles of the forearm are in the anterior
compartment of the forearm and are served mainly by the median
nerve; the one and a half muscle exceptions are innervated by the
ulnar nerve.
The FDP flexes the fingers in slow action; this action is reinforced by
the FDS when speed and flexion against resistance are required.
When the wrist is flexed at the same time the metacarpophalangeal
and interphalangeal joints are flexed, the long flexor muscles of the
fingers are operating over a shortened distance between
attachments, and the action resulting from their contraction is
consequently weaker.
The superficialis tendon, having united again, then divides into two
further slips, which are attached to the borders of the base of the
middle phalanx.
Each tendon of the flexor digitorum profundus, having passed
through the superficialis tendon, is inserted into the base of the distal
phalanx.
The tendon of this muscle to the index finger is joined on its medial
side by the tendon the extensor indicis muscle. The tendon of the
little finger is joined on its medial side by the tendon of the extensor
digiti minimi.
The Hand
The palmar aspect of the hand features a central concavity that
separates two eminences: a lateral more prominent thenar
eminence proximal to the base of the thumb, and a medial, smaller
hypothenar eminence proximal to the base of the little finger.
The anterior surface of each finger from the metacarpal head to the
base of the distal phalanx is provided with a strong, fibrous sheath
called the fibrous flexor sheaths, that is attached to the sides of
the phalanges.
The sheath and the bones form a blind tunnel in which the long
flexor tendons of the finger lie.
Palmar apponeurosis
In the palm, the deep fascia is greatly thickened to protect the
underlying tendons, nerves, and blood vessels and is called the
palmar apponeurosis.
The palmar apponeurosis is continuous proximally with the palmaris
longus tendon, and it is attached to the flexor retinaculum.
Muscles of Hand
The intrinsic muscles of the hand are located in five
compartments:
Thenar muscles in the thenar compartment: abductor pollicis
brevis, flexor pollicis brevis, and opponenes pollicis.
This ligament (the anular ligament) encircles and holds the head of
the radius in the radial notch of the ulna, forming the proximal
radioulnar joint and permitting pronation and supination of the
forearm.
This angle is called the carrying angle and is named for the way
the forearm angles away from the body when something is carried,
such as a pail of water.
The obliquity of the angle is more pronounced in women than in
men.
The elbow joint is supplied by articular branches arising from the
musculocutaneous, median, radial, and ulnar nerves.