ARM

ARM COMPARTMENTS
• The arm is surrounded by a layer of deep fascia that encloses its
contents like a sleeve and sends septa between the muscle groups to
facilitate their gliding on each other. The medial and lateral
intermuscular septa pass to the medial and lateral supracondylar
ridges of the humerus dividing the arm into an anterior “flexor”
compartment and a posterior “extensor” compartment.
FLEXOR COMPARTMENT

1. BICEPS BRACHII
2. BRACHIALIS
3. CORACOBRACHIALIS
Transverse humeral ligament
EXTENSOR COMPARTMENT
• TRICEPS BRACHII
• LONG HEAD
• LATERAL HEAD
• MEDIAL HEAD
• ANCONEUS
ANCONEUS
Small triangular muscle on the post-lateral aspect of
elbow, partly blended with triceps.

ORIGIN:
Lateral epicondyle of Humerus

INSERTION:
Lateral surface of olecranon and superior part of of
posterior surface of Ulna.

ACTION:
Helps the Triceps extend the forearm and tenses the
capsule of elbow joint, preventing it being pinched
during extension.
NERVE SUPPLY:
Radial Nerve
 5
.

1 6

7
2

3 11

4
10
Brachial Artery
Brachial artery is the continuation of the
axillary artery, and provides the main arterial
supply to the arm.
Begins at the INFERIOR BORDER OF TERES
MAJOR MUSCLE, and ends in the CUBITAL
FOSSA, opposite THE NECK OF RADIUS.
Divides into RADIAL and ULNAR ARTERIES.
NERVES OF
ARM
PIERCING THE INTERMUSCULAR SEPTAS
• ULNER NERVE AT THE LEVEL OF INSERTION OF CORACHOBRACHIALIS
PIERCES THE MEDIAL INTERMUSCULAR SEPTUM AND ENTERS THE
POSTERIOR COMPARTMENT OF ARM, ACCOMPANIED BY SUPERIOR
ULNAR COLLATERAL VESSELS
• RADIAL NERVE PIERCES THE LATERAL INTERMUSCULAR SEPTUM 5CM
BELOW THE DELTOID TUBEROSITY AND ENTERS THE ANTERIOR
COMPARTMENT OF ARM
 RADIAL NERVE
• Radial nerve is a terminal branch of the posterior cord and supplies the
majority of the muscles in the posterior compartment of the
arm/forearm/hand.
• Arises from posterior cord of the brachial plexus (C5-8, T1)
• Spirals poster-laterally around the Humerus with the profunda brachii artery in
the spiral groove.
• Gives off posterior cutaneous nerve of forearm, which passes posterior to lateral condyle
and supplies posterior forearm
• It pierces the lateral intermuscular septum into the anterior compartment and
runs toward the elbow between Brachiialis medially and brachioradialis
• Supplies triceps, anconeus, brachioradialis, and lateral portion of the brachialis
• Gives articular branches to the elbow joint
• Divides into deep and superficial branches at the cubital fossa.
• Deep branch in forearm
• Purely motor
• Supplies extensor carpi radialis brevis and supinator muscles
• Gives off the posterior interosseous nerve that passes between heads of the supinator and
winds around lateral aspect of radial neck and ending in the posterior compartment of
forearm
• Posterior interosseous nerve supplies extensor muscles of posterior compartment of forearm
• Superficial branch in forearm
• Purely sensory
• Located in the anterolateral aspect of the forearm with the radial artery, superficial to the
supinator and pronator teres muscles
• course toward the wrist and enters the hand dividing into dorsal digital cutaneous branches.
• Branches and supply
• muscular twigs in the arm - triceps brachii and anconeus muscles
• superficial branch of the radial nerve - supplies cutaneous sensation to the dorsal
aspect of the hand and dorsal aspect of the first to third digits and the dorsal
lateral aspect of the fourth finger
• deep branch of the radial nerve
• posterior interosseous nerve - extensor muscles in the forearm as well as brachioradialis
• articular twigs to the elbow and wrist joints
ROOF OF CUBITAL FOSSA
• SKIN
• SUBCUTANEOUS FASCIA CONTAINING MEDIAN CUBITAL VEIN. THE
LATERAL AND MEDIAL CUTAEOUS NERVES OF FOREARM.
• DEEP FASCIA (DEEP FASCIA OF FOREARM)
• BICIPITAL APONEUROSIS
FLOOR OF CUBITAL FOSSA
• BRACHIALIS
• SUPINATOR
CONTENTS OF CUBITAL FOSSA
• MEDIAN NERVE
• TERMINATION OF BRACHIAL ARTERY
• TENDON OF BICEPS BRACHII
• RADIAL NERVE “MBBR”
CLINICALS OF
ARM
Biceps Tendinitis
• The tendon of the long head of the
biceps is enclosed by a synovial
sheath, and moves back and forth in
the intertubercular sulcus (bicipital
groove) of the humerus .
• Wear and tear of this mechanism
can cause shoulder pain.
Inflammation of the tendon (biceps
tendinitis), usually the result of
repetitive microtrauma, is common
in sports involving throwing (e.g.,
baseball and cricket), and use of a
racquet (e.g., tennis).
• A tight, narrow, and/or rough
intertubercular sulcus may irritate
and inflame the tendon, producing
tenderness and crepitus (crackling
sound).
Dislocation of Tendon of Long Head of Biceps Brachii
• The tendon of the long
head of the biceps can
be partially or
completely dislocated
from the intertubercular
sulcus in the humerus.
The injury also occurs in
older persons with a
history of biceps
tendinitis. Usually a
sensation of popping or
catching is felt during
arm rotation.
 Rupture of Tendon of Long Head of BICEPS
• Rupture of the tendon usually results from wear and tear of an
inflamed tendon as it moves back and forth in the intertubercular
sulcus of the humerus.
• This injury usually occurs in individuals > 35 years of age. Typically, the
tendon is torn from its attachment to the supraglenoid tubercle of the
scapula. The rupture is commonly dramatic and is associated with a
SNAP AND POP. The detached muscle belly forms a ball near the
center of the distal part of the anterior aspect of the arm (Popeye
deformity).
 Popeye
deformity
• Rupture of the biceps
tendon may result from
forceful flexion of the arm
against excessive
resistance, as occurs in
weight lifters.
• However, the tendon
ruptures more often as
the result of prolonged
tendinitis that weakens it.
The rupture results from
repetitive overhead
motions, such as occurs in
swimmers and baseball
pitchers, that tear the
weakened tendon in the
intertubercular sulcus.
Deep tendon
reflex
In a normal person, when a
muscle tendon is tapped
briskly, the muscle
immediately contracts due
to a two-neuron reflex arc
involving the spinal or
brainstem segment that
innervates the muscle.
Bicipital deep tendon Reflex
• The biceps reflex is one of several deep-tendon reflexes that are
routinely tested during physical examinations.
• The relaxed limb is passively pronated and partially extended at the
elbow. The examiner’s thumb is firmly placed on the biceps tendon,
and the reflex hammer is briskly tapped at the base of the nail bed of
the examiner’s thumb.
• A normal (positive) response is an involuntary contraction of the
biceps, felt as a momentarily tensed tendon, usually with a brief jerk-
like flexion of the elbow. A positive response confirms the integrity of
the musculocutaneous nerve and the C5 and C6 spinal cord
segments. Excessive, diminished, or prolonged (hung) responses may
indicate central or peripheral nervous system disease, or metabolic
disorders (e.g., thyroid disease).
Interruption of Blood Flow in
Brachial Artery
• Stopping bleeding through manual or surgical
control of blood flow is called hemostasis.
• The best place to compress the brachial artery to
control hemorrhage is medial to the humerus
near the middle of the arm .Because the arterial
anastomoses around the elbow provide a
functionally and surgically important collateral
circulation, the brachial artery may be clamped
distal to the origin of the deep artery of the arm
without producing tissue damage.
• The anatomical basis for this procedure is that
the ulnar and radial arteries will still receive
sufficient blood through the anastomoses around
the elbow.
• Although collateral pathways confer some protection against gradual
temporary and partial occlusion, sudden complete occlusion or
laceration of the brachial artery creates a surgical emergency because
paralysis of muscles results from ischemia of the elbow and forearm
within a few hours.
• Muscles and nerves can tolerate up to 6 hours of ischemia. After this,
fibrous scar tissue replaces necrotic tissue and causes the involved
muscles to shorten permanently, producing a flexion deformity, the
ischemic compartment syndrome.
• Flexion of the fingers and sometimes the wrist results in loss of hand
power as a result of irreversible necrosis of the forearm flexor
muscles.
Volkmann ischemic contracture
FRACTURES
OF HUMERUS
• A midhumeral fracture may
injure the radial nerve in the
radial groove in the humeral
shaft. When this nerve is
damaged, the fracture is not
likely to paralyze the triceps
because of the high origin of the
nerves to two of its three
heads..
• A Fracture of the distal part
of the humerus, near the
supra-epicondylar ridges, is
called a supra-epicondylar
fracture .
• The distal bone fragment
may be displaced anteriorly
or posteriorly. The actions
of the brachialis and triceps
tend to pull the distal
fragment over the proximal
fragment, shortening the
limb.
AXILLARY NERVE
RADIAL NERVE
MEDIAN NERVE
Injury to Musculocutaneous Nerve
• Injury to the musculocutaneous nerve in the axilla is typically inflicted
by a weapon such as a knife.
• A musculocutaneous nerve injury results in paralysis of the (BBC)
coracobrachialis, biceps, and brachialis.
• MOTOR LOSS
• Flexion of the elbow joint and supination of the forearm are greatly
weakened, but not lost.
• Weak flexion and supination are still possible, produced by the
brachioradialis and supinator, respectively, both of which are supplied by the
radial nerve.
• SENSORY LOSS
• Loss of sensation may occur on the lateral surface of the forearm supplied by
the lateral antebrachial cutaneous nerve, the continuation of the
musculocutaneous nerve.
Injury to Radial Nerve in Arm

• Injury to the radial nerve superior to the origin of

its branches to the triceps brachii results in paralysis of the
triceps, brachioradialis, supinator, and extensor muscles of
the wrist and fingers.

• Loss of sensation in areas of skin supplied by

this nerve also occurs.
• When the nerve is injured in the radial groove, the
triceps is usually not completely paralyzed but only
weakened because only the medial head is affected;
however, the muscles in the posterior compartment of the
forearm that are supplied by more distal branches of the
nerve are paralyzed. The characteristic clinical sign of

radial nerve injury isWRIST DROP —

inability to extend the wrist and the fingers at the
metacarpophalangeal joints. Instead, the relaxed wrist
assumes a partly flexed position owing to unopposed
tonus of flexor muscles and gravity.
WRIST DROP—
inability to extend the
wrist and the fingers
at the
metacarpophalangeal
joints. Instead, the
relaxed wrist assumes
a partly flexed
position owing to
unopposed tonus of
flexor muscles and
gravity.
Venipuncture in Cubital Fossa
• The cubital fossa is the common site for sampling and
transfusion of blood and intravenous injections because of
the prominence and accessibility of veins. When the most
common pattern of superficial veins is present, the median
cubital vein is selected.
• This vein lies directly on the deep fascia, running
diagonally from the cephalic vein of the forearm to the
basilic vein of the arm. It crosses the bicipital aponeurosis,
which separates it from the underlying brachial artery and
median nerve and provides some protection to the latter.
VENIPUNCTURE OF MEDIAN CUBITAL VEIN
• A tourniquet is placed around the midarm to distend the veins in the
cubital fossa. Once the vein is punctured, the tourniquet is removed
so that when the needle is removed the vein will not bleed
extensively.
• The median cubital vein is also a site for the introduction of cardiac
catheters to secure blood samples from the great vessels and
chambers of the heart. These veins may also be used for coronary
angiography.
MEDIAL CUBITAL
VEIN WAS USED
FOR BLOOD
LETTING IN THE
PAST.
 Forearm
Distal unit of the upper limb, extends from the
elbow to the wrist and contains 2 bones joined
by interosseous membrane:
• Radius
• Ulna
Flexor pronator muscles of FOREARM
• 17 muscles cross the elbow joint.
• The flexor-pronator muscular compartment
• The extensor muscular compartment.
• FLEXOR MUSCLES ORIGINATE FROM COMMON FLEXOR ORIGIN AT
MEDIAL EPICONDYLE
• ARRANGED IN THREE LAYERS
• Superficial layer
• Intermediate layer
• Deep layer
Superficial Layer
4 muscles

•PRONATOR TERES
•FLEXOR CARPI RADIALIS
•PALMARIS LONGUS
•FLEXOR CARPI ULNARIS
INTERMEDIATE LAYER
•FLEXOR DIGITORUM SUPERFICIALIS
(FDS)
DEEP LAYER
•FLEXOR DIGITORUM PROFUNDUS (FDP)
•FLEXOR POLICIS LONGUS (FPL)
•PRONATOR QUADRATUS
 NERVE SUPPLY OF MUSCLES

Medial nerve supplies all muscles except 1.5

muscles.
Ulnar nerve supplies 1.5 muscles namely
•Flexor carpi Ulnaris
•Medial half of Flexor Digitorum Profundus
ARTERIES OF
FOREARM
ARTERIES OF THE FOREARM
Brachial artery divides in ulnar and radial artery at the level of neck of radius.
The ulnar artery
is a terminal branch of the brachial artery, arising at the proximal aspect of the
forearm. Along with the radial artery, it is one of the main arteries of the forearm.
Origin
• The ulnar artery arises as a large terminal branch of the brachial artery at the
inferior aspect of the cubital fossa .
Course
• The ulnar artery courses along the ulnar aspect of the forearm deep to the flexor
muscles. It then enters the hand after passing through the Guyon canal (ulnar
canal) located between the pisiform and the hook of hamate. It then divides into
its terminal branches at the carpal region of the hand .
 Branches
• The main branches of the ulnar artery include the anterior and
posterior ulnar recurrent arteries, the common interosseous, the
palmar carpal arch, the superficial palmar arch, and the dorsal carpal
branch.
Termination
• The ulnar artery terminates at the hand via its branches; the palmar
carpal arch, the superficial palmar arch, and the dorsal carpal branch.
Supply
• The ulnar artery supplies the periarticular anastomoses of the elbow
via the anterior and posterior ulnar recurrent arteries. It also supplies
the medial and central forearm muscles,
the median and ulnar nerves, and the common flexor sheath.
 RADIAL ARTERY
The radial artery is a terminal branch of the brachial
artery and arises at the level of neck of radius. It is one of the
two main arteries of the forearm, along with the ulnar artery.
Course
• The radial artery runs along the radial aspect of the anterior
compartment of the forearm under the brachioradialis,
lateral to the flexor carpi radialis tendon. For the distal
section of its course, the radial artery lies on the surface of
the radius. The radial artery proceeds along the floor of
the anatomical snuff box, passing dorsally around
the scaphoid and trapezium. At the carpal region of the
hand, the radial artery forms the deep palmar arch of the
hand and anastomoses with the ulnar artery.
Branches
• The branches of the radial artery in the forearm include the :
radial recurrent artery, palmar carpal branch, dorsal carpal
branch, muscular branches, superficial palmar branch
Termination
• The radial artery terminates in the hand, anastomosing with
the ulnar artery by forming the deep palmar arch .
Supply
• The radial artery provides blood supply to the elbow joint,
lateral forearm muscles, radial nerve, carpal bones and
joints, thumb, and lateral side of the index finger.
Brachial Artery
ANASTAMOSIS AROUND ELBOW JOINT
 Ulnar nerve
The ulnar nerve is one of the terminal branches of the brachial plexus and has motor
and sensory supply to the forearm and hand.
Origin
• The ulnar nerve originates as a terminal branch of the medial cord of the brachial
plexus with nerve root fibers from C8-T1.
Course
Forearm
• The ulnar nerve enters the forearm from the arm via the two heads of flexor carpi
ulnaris (FCU) muscle. It subsequently lies superficial to flexor digitorum
profundus and deep to FCU and medial to the ulnar artery. At the wrist, the ulnar
nerve runs lateral to the tendon of FCU.
Hand
• The ulnar nerve enters the hand superficial to the flexor retinaculum and
inside Guyon's canal. Then it divides into its terminal branches at the level of the
pisiform bone.
• Prior to passing the flexor retinaculum at the wrist, the ulnar nerve gives off the
dorsal cutaneous branch.
Terminal branches
• palmar cutaneous branch
• branch to palmaris brevis
• superficial terminal branch
• deep terminal branch
Supply
• The ulnar nerve has both sensory and motor supply:
• motor
• flexor carpi ulnaris, flexor digitorum profundus (medial half)
• hypothenar muscles
• 3rd and 4th lumbricals, interossei muscles,
• flexor pollicis brevis (deep head), adductor pollicis
• palmaris brevis
• sensory
• articular innervation to elbow, wrist, carpal and phalangeal joints
• cutaneous innervation to ulnar aspect of the hand, 5th finger, medial 4th finger
 Median nerve
The median nerve is one of the five main nerves originating from the brachial
plexus and provides motor and sensory innervation to parts of the forearm and
hand.
Origin
• The median nerve is formed from a lateral root from the lateral cord and a medial
root from the medial cord of the brachial plexus. It forms from nerve roots
originating at C5-T1.
Course
• In the cubital fossa, the median nerve lies medial to the brachial artery and
the biceps brachii tendon.
• The median nerve enters the forearm between the two heads of pronator teres
muscle and gives off the anterior interosseous nerve. It courses towards the wrist
deep to flexor digitorum superficialis and superficial to flexor digitorum
profondus muscle and enters the hand through the carpal tunnel (the only nerve
to traverse the carpal tunnel), passes deep to the flexor retinaculum at the wrist.
On entering the palm, it gives off motor and cutaneous branches.
• Branches
• muscular branch just above elbow supplies pronator teres muscle
• muscular branch at elbow: supplies superficial layer of flexor compartment,
including: flexor digitrum superficialis, palmaris longus, flexore carpi
radialis
• anterior interosseous nerve: supplies deep layer of flexor muscles of the
forearm apart from the ulnar half of flexor digitorum profundus
• palmar cutaneous branch: arising from vololateral aspect before median
nerve entering wrist, superficial to the carpal tunnel and lies between
palmaris longus and flexor carpi radialis and supplies the cutaneous
innervation to the palm and skin over thenar eminence
• recurrent branch: motor branch in the hand: supplies thenar
muscles including abductor pollicis brevis, superficial head of flexor pollicis
brevis, and opponens pollicis and the radial two lumbricals
• digital cutaneous branch: palmar aspect of the thumb, index and middle
fingers and the radial half of the ring finger
• articular branches to the elbow, wrist, carpal and phalangeal joints