Pectoral Girdle & Upper Limb Anatomy

Anatomy Musculoskeletal: Pectoral Girdle and Upper Limb
ANATOMY MUSCULOSKELETAL
PECTORAL GIRDLE
&
UPPER LIMB
Name : ________________________
Matrix No: ________________________
Created by Hermizan Halihanafiah 2012
1

Pectoral Girdle : Bones, Articulation and Movements
2

Bone Specificatio
n
Explanation
Clavicle
Type long bone
Position lies horizontally in the superior and anterior to the thoracic cage, superior to the
1st
rib
Structure
• Shaft – S shape, medial 2/3 convex anteriorly, lateral 1/3 concave anteriorly
• Sternal end / medial end – slightly expanded, quadrangular (rounded),
medial aspect of the clavicle
• Acromial end / lateral end – slightly expanded, flattened / broad, lateral
aspect of the clavicle.
• Conoid tubercle – postero-inferior aspect of the acromial end, attachment
for coracoclavicular ligament.(conoid ligament)
• Trapezoid line – ridge extending laterally from the conoid tubercle,
attachment for coracoclavicular ligament.(trapezoid ligament)
• Costal tuberosity – inferior aspect of the sternal end, attachment for
costoclavicular ligament.
Articulation
Sternoclavicular joint
- Articulation between sternal end of the clavicle and clavicular notch of
manubrium sternum.
- Synovial saddle joint
- Supporting ligament – sternoclavicular ligament (ant/post), interclavicular
ligament (superiorly), costoclavicular ligament (inferiorly).
- Movement – elevation, depression, anterior movement in a horizontal
direction.
- Clinical importance – rare
Acromioclavicular joint
- Articulation between acromial end of the clavicle and acromion process of
the scapula.
- “ Point of the Shoulder”
- Synovial planar joint
- Supporting ligaments – AC joint is a weak joint, strengthen via
 Acromioclavicular ligament – from superior aspect of the acromion
process to the superior aspect of the clavicle (acromial end)
 Coracoclavicular ligament - anchor clavicle to the coracoid process of the
scapula , consist 2 part (conoid lig – from conoid tubercle, trapezoid lig –
trapezoid line)
 Coracoacromial ligament – attach between coracoid process and
acromion process & form the ligamentous arch – protection for the head
of humerus (stability for the GH joint).
- Subluxation and dislocation due to fall on the shoulder.
3

Bone Specificatio
n
Explanation
Type flat, irregular and triangular
Position Posterior bone of the pectoral girdle, lying on the posterolateral aspect of the
thoracic cage and extending from 2nd
– 7th
ribs.
Posterior Aspect
• Body – triangular in shape
4

Scapula
Structure
Structure
• Spine - posterior surface of the scapula, diving posterior surface into
supraspinous fossa (upper 1/3) and infraspinous fossa (lower 2/3),
attachment for trapezius and deltoid muscles.
• Supraspinous fossa – shallow depression above the spine, attachment for
the supraspinatus muscle.
• Infraspinous fossa – shallow depression below the spine, attachment for the
infraspinatus muscle.
• Acromion process – broadened, lateral aspect of the spine, at the medial
border have facet for articulation with clavicle.
• Superior angle – the junction between superior and middle borders
• Inferior angle – the junction between lateral and medial borders
• Lateral angle / acromial angle – the junction between superior and lateral
borders.
• Medial / vertebral border – facing vertebra column, palpable for most of its
length, attachment site for several muscles (teres minor, teres major,
rhomboid major, rhomboid minor, levator scapulae, serratus anterior)
• Lateral border / axillary border – facing axilla, attachment for several
muscles (teres major and teres minor)
Lateral Aspect
• Head of scapula – referred to lateral angle, the junction between superior
border and lateral borders.
• Glenoid cavity – pear shaped depression, articulation with head of humerus
• Supraglenoid tubercle – blunt projection, superior to the glenoid cavity,
attachment for long head of biceps brachii.
• Infraglenoid tubercle – blunt projection, inferior to the glenoid cavity,
attachment for the long head of triceps.
Anterior Aspect
• Subscapular fossa – large anteriorly depression, attachment site for the
subscapularis muscle.
• Scapular notch – depression at lateral end of the superior border, pathway
for the suprascapular nerve.
• Coracoid process – anterior projection from the superior border, attachment
site for ligament (coracoclavicular ligament) and several muscles
(pectoralis minor, coracobrachialis & short head of biceps brachii)
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Articulation
Acromioclavicular joint – Articulation between acromial end of clavicle and
acromion process of scapula.
Glenohumeral joint / shoulder joint
- Articulation between head of humerus and glenoid cavity of scapula
- Type – synovial ball and socket
- Most mobile, least stable and vulnerable to injury.
- Strengthening structure:
 Extracapsular structure
o Ligaments – coracohumeral ligaments (from coracoid process of
scapula to the greater tubercle of humerus), glenohumeral ligament
(superior, inferior and middle – attach from glenoid cavity of scapula
to the lesser tubercle and anatomical neck of humerus), transverse
humeral ligament (attach between lesser and greater tubercle, turn the
bicipital groove into tunnel, holding tendon of long head of biceps)
o Rotator cuff muscles – supraspinatus, infraspinatus, teres minor and
subscapularis (contraction these muscles pulled head of humerus into
glenoid cavity).
o Bursae – subscapular bursa, subacromial bursa, subdeltoid bursa,
subcoracoid bursa (avoid friction)
 Intracapsular structure
o Glenoid labrum/rim – fibrocartilaginous rim surround the edge of the
glenoid cavity, deepened the socket
- Movement – flexion / extension, abduction/adduction, medial
rotation/lateral rotation, horizontal adduction/horizontal abduction,
circumduction.
- Clinical importance – anterior and posterior dislocation, recurrent
dislocation, frozen shoulder
- Superior portion – impingement area, this area contain structures that can
be damage due to repeated overuse (suprapinatus, long head of biceps,
glenoid labrum, coracohumeral ligament, subacromial bursa. The actual
impingement occurs in the abducted position with the arm rotated.
Scapulothoracic joint / scapulocostal joint
- Physiologic joint - Not a true joint (holding by musculotendinous structure)
- Don’t have any synovial capsule and ligamentous attachment.
- Articulation between anterior surface of the scapula and posterior surface
of the 2nd
– 7th
ribs
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- Highly mobile joint
- Stabilization via several muscle – trapezius, rhomboid major, rhomboid
minor, serratus anterior
- Movement gliding – abduction / adduction (protraction / retraction),
elevation / depression, upward rotation / downward rotation.
- Movement of the scapulothoracic joint – increase the ROM of the GH
joint.
Arm : Bones, Articulations and Movements
Bone Specification Explanation
Type Long bone
Position Largest bone of upper limb, bony part of the arm (brachium)
Proximal part
• Head – rounded in shape, articulate with glenoid cavity of scapula
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Humerus
Structure
• Anatomical neck – constriction area adjoining the head
• Greater tubercle (tuberosity) – blunt projection, posterolaterally, attachment
site for several muscles (supraspinatus, infraspinatus, teres minor)
• Lesser tubercle (tuberosity) – blunt projection, anteriorly, attachment site for
subscapularis muscle.
• Intertubercular sulcus / bicipital groove – between greater and lesser tubercle,
cover by transverse humeral ligament, contain tendon for long head of biceps.
• Surgical neck – constricted area, adjoining site between shaft and proximal
part, mostly fracture occur here.
Shaft/body
• Long, proximally cylindrical in shape, and gradually become flat and
triangular in shape distally.
• Deltoid tuberosity – roughen area located anterolaterally, attachment site for
the deltoid muscles.
• Radial/spiral groove – posterior surface, extend obliquely from medial to
lateral site of the shaft, location for the radial nerve
Distal part
• Distal end of the lateral border – lateral supracondylar ridge, lateral
epicondyle and capitulum.
• Lateral supracondylar and lateral epicondyle – attachment for the extensor
hand muscles.
• Capitulum – rounded in shape, articulate with head of radius
• Radial fossa – superior to the capitulum, receive head of radius during elbow
flexion
• Distal end of the medial border – medial supracondylar ridge, medial
epicondyle, trochlear
• Medial epicondyle –attachment site for the several ligaments and flexor hand
muscles, at the posterior surface – pathway for the ulnar nerve
• Trochlea – pulley/spool in shape, articulate with trochlear notch of ulna.
• Coronoid fossa – anteriorly, superior to the trochlea, rceive coronoid process
of ulna during elbow flexion.
• Olecranon fossa – posteriorly, superior to the trochlea, receive olecranon of
ulna during elbow extension.
Proximally – glenohumeral / shoulder joint
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Articulation
Distally – Elbow joint (include humeroulnar, humeroradial and proximal
radioulnar joint) – these joints enclose by single fibrous capsule
Humeroulnar joint (true elbow joint)
- Articulation between trochlea of humerus and trochlear notch of ulna.
- Synovial hinge joint.
- Strengthening structure
 Ulnar collateral ligament – on the medial side of the joint, attach from medial
epicondyle of humerus to the coronoid process and olecranon process of ulna.
 Provide Valgus stability of the elbow
- Movement - flexion / extension
Humeroradial joint
- Articulation between capitulum and head of radius.
- Synovial hinge joint
 Radial collateral ligament – on the lateral side of the elbow, attach form the
lateral epicondyle of the humerus to the annular ligament.
 Provide Varus stability for the elbow.
- Movement - flexion / extension
Proximal radioulnar joint
- Articulation between head of radius and radial notch of ulna.
- Synovial pivot joint.
 Annular ligament – surrounds head of radius and attach to the edge of the
radial notch of ulna.
 Support head of radius.
- Movement – pronation / supination
Forearm : Bones, Articulations and Movements
Bone Specificatio
n
Explanation
Type Long Bone
Position Lateral bone of forearm
9

Radius
Structure
- Head – rounded, with concave superior surface, articulate with capitulum of
humerus and radial notch of ulna.
- Neck – narrow/constricted portion, distal to head
- Radial tuberosity – distal to the neck, on the medial aspect, attachment site
for the biceps brachii muscles.
- Interosseous border – on the medial surface of the shaft, attachment for the
intersosseous membrane that connects with the shaft of ulna to form middle
radioulnar joint.
- Ulnar notch – distal end, located on the medial side, articulates with the
head of ulna to form distal radioulnar joint.
- Radial styloid process – distal end, prominent process on the lateral aspect
which can be palpated.
- Distal surface articulates with scaphoid, lunate and triquetrum to form
radiocarpal joint / wrist joint.
Articulation
Humeroradial joint
- Articulation between head of radius and capitulum of humerus
- Articulation between head of radius and radial notch of ulna
Middle radioulnar joint
- Articulation between shaft of radius and shaft of ulna connect via
interosseous membrane.
- Synarthroses / immovable joint
Distal radioulnar joint
- Articulation between head of ulna and ulnar notch of radius
- Synovial pivot joint
- Movement – pronation / supination
- Strengthen via palmar and distal radioulnar ligaments.
Radiocarpal Joint/wrist joint
- Articulation between distal end of radius and radial styloid process with
scaphoid, lunate and triquetrum
- Synovial condyloid / ellipsoidal joint
- Strengthen by
 Ulnar collateral ligament – medial aspect of the wrist, attached to the ulnar
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styloid process and the triquetrum and pisiform
 Radial collateral ligament – lateral aspect of the wrist – attached to the
radial styloid process and the scaphoid
 Palmar radiocarpal ligament – anterior aspect of the wrist, attached from the
radius to the scaphoid, lunate and the triquetrum.
 Dorsal radiocarpal ligament – posterior aspect of the wrist, attached form
the radius to the scaphoid, lunate and triquetrum.
 Palmar ulnocarpal ligament. – anterior aspect of the wrist, attached from the
ulnar styloid process to the lunate and triquetrum.
- Movement – flexion / extension, radial deviation (abduction) /ulnar
deviation (adduction).
Bone Specificatio
n
Explanation
Ulnar
Type Long Bone
Position Medial aspect of forearm
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Structure
- Olecranon – proximal end, postero-superior projection, articulates with
olecranon fossa of humerus when elbow extension, can be palpated,
attachment site for the triceps brachii.
- Coronoid process – proximal end, antero-inferior projection, articulates
with coronoid fossa of humerus when elbow flexion.
- Ulnar tuberosity – anterior surface, distal to the coronoid process,
attachment site for the brachialis muscle.
- Trochlear notch – depression between coronoid process and olecranon
process, articulates with the trochlea of humerus.
- Radial notch – depression located lateral aspect of the coronoid process,
articulate with head of radius.
- Interosseous border – located lateral aspect of the shaft, attachment site for
- Head of ulna – distal end, small and rounded, surrounds by articular disc
- Ulnar styloid process – project medial and posteriorly which can be
palpated.
Articulation
Humeroulnar joint
- Artculation between trochlea of humerus and trochlear notch of ulna.
- Articulation between head of radius and radial notch of ulna
Middle radioulnar joint
- Articulation between shaft of radius and shaft of ulna connect via
Distal radioulnar joint
- Articulation between head of ulna and ulnar notch of radius
Hand : Bones, Articulations and Movements
Bone Specificatio
n
Explanation
12

Carpal
Type Short bone (except pisiform – sesamoid)
Position - 2 rows of carpal bones form the wrist region.
- Proximal row, form lateral to medial – scaphoid, lunate, triquetrum and
pisiform
- Distal row, from lateral to medial – trapezium, trapezoid, capitate and
hamate.
Structure
Scaphoid
- Boatlike in shape
- the largest of the proximal row of carpal bone
- Consist tubercle on its palmar surface – attachment for the palmar
aponeuresis & muscle.
- Articulate with radius, lunate, trapezium and trapezium.
- The most frequently fractured of the carpal bones – fall onto outstretched
hand.
Lunate
- Moonlike in shape
- Articulate with radius, scaphoid, triquetrum and capitate.
Triquetrum
- Three cornered in shape
- Attachment site for the ulnar collateral ligament.
- Articulate with radius, pisiform, lunate and hamate.
Pisiform
- Pea-like in shape.
- Sesamoid bone – embedded within tendon flexor carpi ulnaris
- Protect the tendon and increase the mechanical effect.
- Articulate with triquetrum.
Trapezium
- Four sided figure
- At its palmar surface, contain tubercle and groove
- Groove – contain tendon of flexor carpi radialis and flexor retinaculum.
- Tubercle – attachmen for the thenar muscles
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Carpal
Structure
- Articulation with trapezoid, scaphoid, 1st
and 2nd
metacarpals.
Trapezoid
- Small and irregular
- Articulation with 2nd
metacarpal, capitate, trapezium and scaphoid.
Capitate
- Head shaped
- The largest of the carpal bone
- Articulation with 2nd
– 4th
metacarpals, hamate, lunate, scaphoid and
trapezoid.
Hamate
- Hooked like structure
- Consist hamulus (hook) which projects on the palmar surface.
- Hamulus is contributed to the medial wall of the carpal tunnel and also
attachment for the flexor retinaculum.
- Articulation with the triquetrum, capitate, 4th
and 5th
metacarpals.
Articulation
Radiocarpal joint
- Articulation between distal end of the radius and the scaphoid, lunate and
triquetrum of the carpal bones.
Intercarpal joint
- Proximal row - Articulation between scaphoid, lunate, triquetrum and
pisiform
- Distal row - Articulation between trapezium, trapezoid, capitate and
hamate
- Synovial planar joint
- Movement – gliding motion
Midcarpal joint
- Articulation between proximal row and distal row of carpal bone.
(Articulation between the scaphoid, lunate and triquetrum (proximally)
and trapezium, trapezoid, capitate and hamate (distally).
- Synovial planar joint.
- Movement – gliding motion
Carpometacarpal joint
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Carpal
Articulation
- Articulation between distal row of carpal bones and metacarpal.
- 5 carpometacarpal joint
- 1st
carpometacarpal joint
• Modified saddle joint
• Articulation between 1st
metacarpal (base) and the distal surface of the
trapezium.
• Supporting ligaments
 Lateral ligament - lateral surface of the trapezium to the lateral side of
the base of metacarpal.
 Palmar ligament - oblique band, from palmar surface of the trapezium
to the medial side of the base metacarpal.
 Dorsal ligament - oblique band, from dorsal surface of the trapezium
to the medial side of the base metacarpal.
• Movement – flexion / extension, abduction / adduction, rotation,
opposition / reposition
• Permitting the ability to hold and manipulate objects (pinch grip, tripod
pinch and chuck grip)
- 2nd
– 5th
carpometacarpal joint
 Articulation between distal row of carpal bones and 2nd
– 5th
base of
metacarpal
 Synovial ellipsoidal joint
 Supporting ligaments
- Dorsal ligament – the strongest ligament, attached from the dorsal
surface of the carpal and metacarpal.
- Palmar ligament - attached from the palmar surface of the carpal
and metacarpal.
- Interosseous ligament – attached from capitate and hamate to the 3rd
and 4th
metatarsal.
 Movement – gliding motion
15

Bone Specificatio
n
Explanation
Metacarpal
Type Miniature long bones
Position - 5 metacarpal bones, numbered I – V (lateral to medial) form the palmar
of the hand,
- Distal to distal row of carpal bones and proximal to the phalanges.
Structure
- Head – rounded, located distally, and articulates with corresponding
phalanx.
- Shaft / body – middle portion, anterior border concave longitudinal.
- Base – expanded, articulate with appropriate carpal bones. The base of
2nd
– 5th
metacarpal articulates each other.
Articulation
Carpometacarpal joint
Metacarpophalangeal joint
- Articulation between proximal head of metacarpal and base of proximal
phalanges.
- Synovial ellipsoidal joint
- Strengthen by – collateral ligament (strong and flank the joints), palmar
ligaments and deep transverse metacarpal ligaments.
- Movement –flexion / extension, abduction / adduction
Intermetacarpal joint
- Articulation between based of the 2nd
– 5th
metacarpal.
- Strengthen by palmar ligament, dorsal ligament and interosseous
ligament.
- Movement – slightly gliding.
16

Bone Specificatio
n
Explanation
Phalanges
Type Miniature long bones
Position Distal to the metacarpal, forming the 14 fingers (14 digits)
Structure
There are 14 phalanges. Every digits consist 3 phalanges (proximal,
intermediate and distal), except thumb only have 2 phalanges (proximal and
distal)
- Head – distally, expanded, distal phalanges support the tissue of the
finger tips
- Shaft / body – intermediate portion, anterior border are concave
longitudinally.
- Base – proximally, expanded, articulates with either the phalanges or the
metacarpal to it.
Articulation
Metacarpophalangeal joint
Interphalangeal Joint
- Articulation between phalanges bone itself
- Synovial hinge joint
- All digits compose by 2 interphalangeal joints; proximal IP and distal IP,
except thumb only have one.
- Strengthen ligaments – palmar ligament / volar plate (floor of the IP) and
2 collateral ligaments (on the lateral and medial side of the IP).
- Movement – flexion / extension
Muscles of the Pectoral Girdle
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Attachment Site Joint Muscle Origin Insertion Action
Clavicle – humerus GH Anterior fibre of Deltoid Lateral 1/3 (anterior
surface)
Deltoid tuberosity Flexion
Clavicle origin of
pectoralis major
Medial half (anterior
surface)
Bicipital groove (lateral
lip) of humerus
Flexion, medial
rotation, horizontal
adduction
Sternum – humerus GH Sternocostal fibre of
pectoralis major
Anterior surface of
sternum, costal
cartilages of upper 6th
or 7th
ribs.
Bicipital groove (lateral
lip) of humerus
Extension , medial
rotation, horizontal
adduction
Scapula – humerus GH Coracobrachialis Coracoid process Middle shaft (opposite to
deltoid tubesoity)
Flexion and
adduction
Middle fiber of deltoid Acromion process Deltoid tuberosity Abduction
Posterior fiber of deltoid Spine Deltoid tuberosity Extension
Supraspinatus Supraspinous fossa Greater tubercle (upper
aspect)
Initially abduction
(15 degrees)
Infraspinatus Infraspinous fossa Greater tubercle (middle
aspect)
Lateral rotation
Subscapularis Subscapular fossa Lesser tubercle Medial rotation
Teres minor Upper 2/3, lateral
border
Greater tubercle (postero-
inferior aspect)
Lateral rotation
Teres major Inferior angle and
lateral border
Bicipital groove (medial
lip)
Adduction,
extension
Vertebrae – ribs -
humerus
GH Latissimus dorsi Spinous processes T7-
T12, L1-L5, last 3 / 4
ribs, posterior iliac
crest, inferior angle of
scapula.
Bicipital groove Extension,
adduction medial
rotation.
Ribs – clavicle SC Subclavius 1st
costal cartilage Inferior surface of
acromial end
Pulls clavicle
forward and
downward.
Ribs – scapula SCo,
AC
Pectoralis minor 3rd
– 5th
ribs (near costal
cartilage)
Coracoid process Protraction,
downward rotation,
assist in force
inhalation
Serratus anterior Upper 8 or 9 ribs Medial border Protraction, upward
rotation
Scapula – radius EL, GH Long head of biceps Supraglenoid tubercle Radial tuberosity &
bicipital aponeuresis
Elbow flexion,
assist shoulder
18

flexion
Short head of biceps Coracoid process Radial tuberosity &
bicipital aponeuresis.
Elbow flexion,
assist shoulder
flexion
Scapula – ulna EL, GH Long head of triceps Infraglenoid tubercle Olecranon process Elbow extension,
assist in shoulder
extension.
Vertebra – clavicle SC Upper fiber of trapezius Superior nuchal line,
external occipital
protuberance,
ligamentum nuchae,
spinous C7
Lateral 1/3 Elevation of scapula
Vertebra - scaoula SCo,
AC
Middle fiber of trapezius Spinous process T1-T5 Acromion process Retraction and
assist in upward
rotation
Lower fiber of trapezius Spinous Process T6-
T12
Spine Depression,
retraction and
upward rotation.
Levator scapulae Transverse process C1-
C4
Medial border (between
superior angle and root of
spine)
Elevation and assist
in downward
rotation.
Rhomboid minor Spinous process C7 &
T1
Medial border (root of
spine)
Retraction, and
assist in elevation
and downward
rotation.
Rhomboid major Spinous process T2-T5 Medial border (between
root of spine and inferior
angle)
Retraction, and
assist in elevation
and downward
rotation.
Adaptation from Florence P. Kendall (2005)
*GH – Glenohumeral Jt, SC – Sternocostal Jt, AC – Acromioclavicular Joint, SCo – Scapulocostal Jt, EL – Elbow Joint,
Muscles of the Elbow
19

24 muscles cross the elbow joint. Some of them act on the elbow joint exclusively, and others act on the
wrist and hand joints. Most of these muscles are capable of producing as many as three movements at the
elbow, wrist and fingers joint and usually one movement is dominant. There are four main muscles group;
anterior flexors, posterior extensor, lateral extensor – supinators, and medial flexor-pronators.
Elbow Flexors
Muscle Joint Origin Insertion Action
Long head of
biceps
GH, EL & RU Supraglenoid tubercle of
scapula
Radial tuberosity & bicipital
aponeuresis
Elbow flexion, assist in
shoulder flexion and elbow
supination.
Short head of
biceps
GH, EL & RU Coracoid process of scapula Radial tuberosity & bicipital
aponeuresis
supination.
Brachialis EL Anterior surface, distal half
shaft of humerus
Ulnar tuberosity & coronoid
process of ulna.
Elbow flexion
Brachioradialis EL Lateral supracondylar ridge of
humerus
Styloid process of radius Elbow flexion
* The brachialis plays a bigger role when forearm in the pronated position
* The biceps brachii plays a bigger role when forearm in the supinated position
* The brachioradialis plays a bigger role when forearm in the neutral position (midpronation)
Elbow Extensors
Long head of
triceps
GH, EL Infraglenoid tubercle of
humerus
Olecranon process of ulna Elbow extension, assist in
shoulder extension
Lateral head of
triceps
EL Lateral and posterior of
humerus (superior to radial
groove)
Olecranon process of ulna Elbow extension,
Medial head of
triceps
EL Posterior surface of humerus
(inferior to radial groove)
Olecranon process of ulna Elbow extension,
Anconeus EL Lateral epicondyle of humerus Olecranon process of ulna Elbow extension,
* GH – Glenohumeral joint, EL – Elbow joint, RU – Radioulnar joint
Elbow Supinators
20

Long head of
biceps
GH, EL & RU Supraglenoid tubercle of
scapula
Radial tuberosity & bicipital
aponeuresis
supination.
Short head of
biceps
GH, EL & RU Coracoid process of scapula Radial tuberosity & bicipital
aponeuresis
supination.
Supinator EL, RU Lateral epicondyle of humerus Lateral surface proximal 1/3
shaft of radius
Elbow supination
Elbow Pronators
Pronator teres RU, EL Medial epicondyle of humerus
and coracoid process of ulna
Mid-lateral surface of radius Elbow pronation, assist in
elbow flexion
Pronator
quadratus
RU Medial surface, distal ¼ of the
ulna
Lateral surface, distal ¼ of the
radius
Elow pronation
* GH – Glenohumeral joint, EL – Elbow joint, RU – Radioulnar joint
Muscles of the Wrist and Hand
21

Most of the muscles that act at the wrist and finger joints originate outside the hand in the region of the
elbow joint. These groups of muscles known as an extrinsic hand muscles. These muscles enter the hand as
tendons that can be quiet long and either terminate at the carpal bones, or reach the tips of the phalanges.
The tendon that crossing wrist are held by flexor retinaculum anteriorly and extensor retinaculum
posteriorly.
39 muscles work on the wrist and hand, and no muscles work alone; agonist and antagonist work in pairs.
The extrinsic hand muscles provide considerable strength and dexterity to the fingers without adding muscle
bulk to the hand.
There are muscles that act on the hand joint and have an origin and insertion within the hand. These muscles
termed as an intrinsic hand muscles. Intrinsic hand muscles will create the movement at the MCP and IP and
form the fleshy musculature of the hand.
Extrinsic Hand Muscles
Most of the extrinsic hand muscles originate from elbow region. These muscles can be divided into; anterior
compartment muscles of forearm (flexor) and posterior compartment muscles of forearm (extensor).
Anterior compartment Muscles (Flexors)
Superficial Muscles Group
Flexor Carpi
Radialis
EL, RC Medial epicondyle of humerus Base of 2nd
and 3rd
metacarpal Radial deviation (abduction)
and assist in wrist flexion
Palmaris longus EL, RC Medial epicondyle of humerus Flexor retinaculum and palmar
aponeuoresis.
Assist wrist flexion
Flexor carpi
ulnaris
EL, RC Medial epicondyle of humerus Pisiform, hamate and base of
5th
metacarpal.
Ulnar deviation (adduction)
and assist in wrist flexion.
Flexor digitorum
superficialis
EL, RC, MCP,
PIP
Medial epicondyle of humerus,
coronoid process of ulna and
oblique line of the radius
Middle phalanges of the 2nd
–
5th
digits.
PIP flexion, assist MCP
flexion and Wrist flexion.
Deep Muscles Group
Flexor pollicis
longus
EL, RC, TMC,
MCP, IP
Medial epicondyle of humerus,
coronoid process of ulna,
anterior surface shaft of radius
and interosseous membrane.
Base of the distal phalanx of
thumb.
IP flexion, assist MCP
flexion, Assist TMC flexion
and RC flexion.
Flexor digitorum
profundus
EL,RC, MCP,
PIP, DIP
Anteromedial surface proximal
¾ of the ulna and interosseous
membrane.
Base of the distal phalanges
(except thumb)
DIP flexion, assist in PIP
flexion, MCP flexion, RC
flexion
*EL – Elbow joint, RC – Radiocarpal joint, MCP – Metacarpophalangeal joint, PIP – Proximal Interphalangeal joint,
DIP – Distal Interphalangeal joint, TMC – Trapeziometacarpal joint.
Posterior Compartment Muscles of Forearm (mostly Extensor)
22

Superficial Muscles Group
Extensor carpi
radialis longus
EL, RC Lateral supracondylar ridge of
humerus
Dorsal surface, base of 2nd
metacarpal.
Wrist Radial deviation
(abduction), assist wrist
extension
Extensor carpi
radialis brevis
EL, RC Lateral epicondyle of humerus, Dorsal surface, base of 3rd
metacarpal.
Wrist extension, assist wrist
radial deviation (abduction)
Extensor
digitrum
EL, RC, MCP,
DIP, PIP
Lateral epicondyle of humerus Dorsal surface, base of distal
and middle phalanges of 2nd
–
5th
digits.
PIP and DIP extension,
assist in MCP extension, RC
extension
Extensor digiti
minimi
EL, RC. MCP,
PIP, DIP
Lateral epicondyle of humerus Blend together with tendon
extensor digitorum of 5th
digit.
Extension PIP and DIP,
assist in MCP and RC
extension.
Extensor carpi
ulnaris
EL, RC Lateral epicondyle of humerus
and posterior border of ulna.
Base of 5th
metacarpal Wrist ulnar deviation, assist
in wrist extension.
Deep Muscles Group
Abductor pollicis
longus
TMC, RC Posterior surface mid-shaft of
radius and ulna, interosseous
membrane
Base of 1st
metacarpal (thumb) TMC abduction and
extension, wrist radial
deviation and wrist flexion.
Extensor pollicis
brevis
MCP, TMC, RC Posterior surface body of
radius, interosseous membrane
Dorsal surface, base of
proximal phalanx of the thumb.
MCP extension, TMC
extension & abduction,
assist in RC radial deviation.
Extensor pollicis
longus
IP, MCP, TMC,
RC
Posterior surface middle 1/3 of
the radius, interosseous
membrane.
Dorsal surface, base of the
distal phalanx of the thumb
IP extension, assist in MCP
and TMC extension, assist
in RC extension and radial
deviation
Extensor indicis PIP, DIP, MCP Posterior surface body of ulna Blend together with tendon
extensor digitorum of the index
finger
MCP extension, IP
extension
*EL – Elbow joint, RC – Radiocarpal joint, MCP – Metacarpophalangeal joint, PIP – Proximal Interphalangeal joint,
DIP – Distal Interphalangeal joint, TMC – Trapeziometacarpal joint.
Intrinsic Hand Muscles
23

Intrinsic hand muscles are the muscles that have origin and insertion within the hand and it give bulky
appearance to the hand. Intrinsic hand muscles produce weak but very intricate and precise movements of
the digits (fine motor movements). These muscles can be divided into thenar muscles, hypothenar muscles
and intermediate muscles.
Thenar Muscles Group (move the thumb)
Abductor pollicis
brevis
MCP, TMC Flexor retinaculum, scaphoid
and trapezium
Base of the proximal phalanx
of the thumb
MCP and TMC abduction
Opponens
pollicis
TMC Flexor retinaculum, trapezium Entire length of the 1st
metacarpal
TMC opposition (flexes,
abducts and slightly medial
rotates)
Flexor pollicis
brevis
TMC, MCP Flexor retinaculum, trapezium,
trapezoid, capitate
of the thumb
MCP and TMC flexion
Adductor pollicis MCP, TMC Oblique head: capitate and base
of 2nd
and 3rd
metacarpal
Transverse head:palmar surface
of 3rd
metacarpal.
of the thumb.
MCP and TMC adduction
Hypotenar Muscles Group (move the little finger)
Abductor digiti
minimi
MCP Tendon flexor carpi ulnaris and
pisifom.
of the little finger
MCP abduction
Flexor digiti
minimi brevis
MCP Flexor retinaculum, hamate Base of the proximal phalanx
of the little finger
MCP flexion
Opponens digiti
minimi
5th
CMC Flexor retinaculum, hamate Entire length of the 5th
metacarpal
CMC opposition
Intermediate Muscles Group
lumbricalis DIP, PIP, MCP 1st
& 2nd
: lateral surface of the
Flexor digi Profundus of the
index and middle finger
3rd
: adjacent side of the FDP of
the middle and ring finger
4th
:adjacent side of the FDP of
the ring and little fingers
Lateral border of the tendon
extensor digitorum of the
respective fingers.
IP extension, simultaneously
MCP flexion (2nd
– 5th
digits)
Palmar interossei MCP, DIP, PIP 1st
: base of 1st
metacarpal,
medial side
2nd
: length of 2nd
metacarpal,
medial side
3rd
: length of 4th
metacarpal,
1st
: base of proximal phalanx
(thumb), medial side
2nd
(index finger), medial side.
3rd
MCP adduction of 1st
, 2nd
,
3rd
and 4th
digits.
Assist in IP extension of 2nd
,
3rd
and 4th
digits.
24

lateral side
4th
: length of 5th
metacarpal,
lateral side
(ring finger), lateral side.
4th
(little finger), lateral side
Dorsal Interossei MCP, PIP, DIP Adjacent sides of the
metacarpals in each interspace
(for example: 1st
dorsal
interossei – adjacent sides
between 1st
and 2nd
metacarpals)
1st
: base of proximal phalanx of
index finger (lateral side)
2nd
of middle finger (lateral side)
3rd
base of proximal phalanx of
middle finger (medial side)
4th
:base of proximal phalanx of
ring finger (medial side)
MCP abduction (2nd
, 3rd
and
4th
digits)
Assist in MCP flexion and
PIP and DIP extension.
* MCP – Metacarpophalangeal joint, PIP – Proximal Interphalangeal joint, DIP – Distal Interphalangeal joint,
TMC – Trapeziometacarpal joint, CMC – Carpometacarpal joint
25

Nerves Supply of the Shoulder and Upper Limb
The sources of the nerves supply to the shoulder girdle and the entire of upper limb mostly from the
networks of the ventral rami of spinal nerves termed as a brachial plexus and also some contribution from
the cervical plexus.). Brachial plexus have a root from ventral rami of cervical spinal nerves C5 until C8
and thoracic spinal nerve T1 and give motor and cutaneous distribution to the shoulder and upper limb
region. (Please refer to the text books and ppt for further explanation
Source Level Spinal Segment (root) Nerves
Motor /
sensory
Muscles
Cervical
plexus
Cervical nerve
and cranial
nerve (XI)
C(1), C2, C3 & Cranial
nerve (XI)
Spinal accessory
nerve
Motor and
Sensory
Sternocleidomastoid
C2, C3, C4 & Cranial
nerve (XI)
Spinal accessory
nerve
Fiber of trapezius
Brachial
Plexus
Roots
C3, C4, C5 Dorsal scapular nerve
Motor
Levator scapulae
C4, C5 Dorsal scapular nerve
Rhomboid major and rhomboid
minor
C5, C6, C7, C(8) Long thoracic nerve Serratus anterior
Superior Trunk
(middle &
inferior - no
nerves arise)
C5, C6 Subclavian nerve
Motor
subclavius
C4, C5, C6 Suprascapular nerve Supraspinatus and infraspinatus
Posterior cord
C5, C6, C7
Upper and lower
subscapular nerves
Motor Subcapularis and teres major
C6, C7, C8 Thoracodorsal nerve Motor Latissimus dorsi
C5, C6 Axillary nerve
Motor and
sensory
Deltoid and teres minor
C5, C6, C7, C8, T1 Radial Nerve
Motor and
sensory
Triceps, anconeus, supinator,
brachioradialis, extrinsic hand
muscles (extensor group)
Lateral cord C5, C6, C7 Lateral pectoral nerve Motor Pectoralis major (upper)
C5, C7
Musculocutaneous
nerve
Motor and
sensory
coracobrachialis
C5, C6
Musculocutaneous
nerve
Motor and
sensory
Biceps brachii, brachialis
C5, C6, C7 Lateral root of median
nerve
Motor and
sensory
Pronator teres and quadratus, All
flexor group of extrinsic hand
muscles (except FCU, medial
half FDP), 1st
& 2nd
Lumbricalis,
OP, APB, FPB
26

Medial cord
C8, T1 Medial pectoral nerve Motor
Pectoralis major (lower),
pectoralis minor
C8, T1
Medial root of median
nerve
Motor and
sensory
Pronator teres and quadratus, All
flexor group of extrinsic hand
muscles (except FCU, medial
half FDP), 1st
& 2nd
Lumbricalis,
OP, APB, FPB
C8, T1 Ulnar nerve
Motor and
sensory
FCU, medial half FDP, most of
the intrinsic hand muscles
(except LOAF innervates by
median nerve)
27

Peripheral Nerves of Upper Limb
Five terminal branches arise from the brachial plexus and innervate most of the skin and muscles of the
pectoral girdle and upper limb. These five nerves are axillary, musculocutaneous, radial, median and ulnar
nerves.
Nerve Root Pathway Motor
innervation
Sensory innervation Nerve lesion
Axillary C5,
C6
- Posterior cord
- Lies anterior to
subscapularis m and
posterior to axillary artery.
- Winds posteriorly around
the neck of humerus
- Terminates as a anterior and
posterior branches
Anterior branch
– anterior and
lateral fiber of
deltoid
Posterior branch
– posterior fiber
of deltoid and
teres minor
Posterior branch will
terminates as a upper
lateral brachial cutaneous
nerve – skin lower part of
the deltoid
Dislocation of the GH
joint, fracture of the
humeral neck –
weakness of the deltoid
(muscle wasting).
Musculocutameous C5 –
C7
- Lateral cord
- Opposite lower border of the
pectoralis minor
- Pierce coracobrachialis
m and descends laterally
between biceps and brachialis
to the lateral side of the arm.
- Pierce the deep fascia on
the elbow and continue to the
forearm as a lateral
anterbrachial cutaneous
nerve.
Along the
pathway, supply
coracobrachialis,
biceps brachii
and brachialis
Antebrachial cutaneous
nerve – divide into
anterior and posterior
branches
Anterior branch – skin of
anterolateral surface of
forearm as far as ball of
the thumb
Posterior branch – skin of
posterolateral surface of
forearm
Fracture of the
humerus, patient with
neuralgic amyothrophy
Weakness of elbow
flexion
Radial C5 –
T1
-Posterior cord
-Descend posterior to the
axillary artery
-Enter the radial groove at the
back of the humerus and
enter anterior compartment of
the arm.
-Continue the jurney between
brachialis and brachioradialis
-At the distal part of humerus,
passes anterior to the lateral
epicondyle and enter the
forearm
-And terminate as superficial
and deep terminal branches.
Arm: triceps
brachii,
anconeus,
supinator,
brachioradialis
Forearm:
extrinsic hand
muscles
(extensor group)
Arm
Posterior Brachial
Cutaneous nerve – skin
back on the arm
Inferior lateral brachial
cutaneous nerve – skin at
the lower lateral aspect of
the arm
Forearm
Posterior antebrachial
cutaneous nerve – skin at
the back of the forearm
Hand
Superficial branch – back
of the hand
Fracture of the
midshaft of humerus
(radial groove) – ‘wrist
drop’- the hand can’t
be lifted against gravity
and the power grip is
weak.
28

Ulnar C7
– T1
-Medial cord
Passes down the medial side
of the arm between biceps
and triceps
-At the elbow, the nerve lies
behind, and contact with the
medial epicondyle of
humerus
At the forearm give motor
branches to FCU and medial
half of FDP.
-Just above the wrist, the
nerve branch off to the
superficial and deep branch.
Forearm – FCU
and medial half
FDP
Hand – via deep
branch supply
hypothenar
muscles, palmar
& dorsal
interossei,
medial half of
lumbricalis and
adductor pollicis
Superficial branch
supply
Skin anterior and
posterior of the
hand( medial aspect of
the hand, ring and little
fingers)
Injury to the elbow
whether traumatic or
entrapment near to the
medial epicondyle.
Ulnar nerve lesion will
give appearance known
as a claw hand.
Claw hand – little and
ring finger curl in
flexion deformity and
MCP hyperextension –
due to paralysis of
lumbricalis.
Median C5-
T1
-Lateral and medial cords
-Passes down the arm with the
brachial artery and medial to
the MC nerve. At the elbow
lies on the brachialis and
medial to the tendon of
biceps.
-Passes anterior to the elbow
joint (within cubital fossa)
and then down and supply
flexor muscles of forearm.
-In the hand, passes through
the carpal tunnel and then
divide into motor and
cutaneous branch.
Elbow –
pronator teres,
FCR, Palmaris
Longus, FDS
Forearm – lateral
half FDP, FPL,
and pronator
quadratus
Hand – thenar
muscles (except
adductor
pollicis) and
lateral half
lumbricalis.
Cutaneous branches -
skin of the palmar aspect
of the thumb and the
lateral 2 ½ fingers and the
distal ends of the same
fingers and skin of distal
phalanx on same finger
Carpal tunnel
syndrome –
compression of median
nerve (pain, numbness
and tingling) within
carpal tunnel.
29

Important Area of the Upper Limb
Area Borders Contents Clinical Importance
Axilla
Pyramidal
space inferior
to GH joint.
Provide
passageway for
vessels and
nerves going to
and from the
upper limb.
Apex: Cervico-axillary canal (space
between neck and axilla, posterior to
the clavicle)
Base: skin, subcutaneous tissue
(axillary fossa)
Anterior wall: Pectoralis major and
minor and form anterior axillary fold
Posterior wall: subscapularis, scapula,
teres major and latissimus dorsi. Teres
major and latissimus dorsi form
posterior axillary fold.
Medial wall: thoracic wall and
underlying serratus anterior
Lateral wall: Intertubecular sulcus of
humerus
- Axillary artery
and its branches
- Axillary veins and
its tributaries
- Nerves of the
cords and
branches of the
brachial plexus
- Lymphatic vessels
- Several groups of
axillary lymph
nodes.
Enlargement of axillary
lymph nodes – due to
infection on upper limb
Injury to axillary vein –
profuse bleeding and
risk of the air emboli.
Superior view of the axilla region and its related contents
30

Cubital Fossa
Shallow
triangular
depression on
the anterior
surface of
elbow.
Superior: imaginary line connection
between medial and lateral epicondyle
of humerus
Medial : pronator teres
Lateral: brachioradialis
Floor: brachialis and supinator
Roof: Bicipital aponeurosis,
subcutaneous tissue and skin
- Terminal part of
brachial artery
and veins
- Biceps brachii
tendon
- Median nerve
- Radial nerve
In the subcutaneous
tissue – medial
cubital vein, basilic
vein and cephalic
vein.
Venous blood drainage
from median cubital
vein, cephalic vein and
basilica vein.
Blood pressure
measurement – brachial
artery
Anterior View of cubital fossa and its related structures
Carpal Lateral border: scaphoid and Tendon Flexor Carpal Tunnel
31

Tunnel
Concave
surface located
at the palmar
surface of the
wrist
trapezium
Medial border: pisiform and hamate
Roof: Flexor retinaculum (transverse
carpal ligament) attach between bones
of the medial and lateral borders.
digitorum profundus
Tendon flexor
digitorum
superficialis
Tendon flexor
pollicis longus
Median nerve
Syndrome
Compression of the
median nerve,
microvascular
insufficiency of the
median nerve and
prolong vibration of the
median nerve.
Numbness, pain and
tingling of the hand.
32

Pectoral Girdle & Upper Limb Anatomy

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