LGEM Presentation Template

Topic: High Yield Upper Limb Anatomy
Name of Presenter: Dr. Muhammad Azeem Imran
Date of Presentation: 23/07/2023
LGEM Programme:
London Global EM Programme, Director Dr Ash (Consultant Emergency Medicine, Acute Medicine & Geriatric
24/11/2024 Medicine NHS UK) 1
[email protected]
1.20-LEFT OFF TEST>>TEST OF INFRASPINATUS MUSCLE.
2.21-ABDUCTION WEAK N ESS 0-15 DEGREE>>SUPRASCAPUL AR M U SC L E
3. 22-ANOTHER FOR SUPRASCAPUL AR MUSCLE.
4. Liftoff test pic- subscapularis
5. 8. Abduction-- supraspinatus
6.9. Roots involved..finger abduction lost;; claw hand C7-T1 ( No option of C8-T1)
7.10 5. Ps oas major : T12/ L1.
8. 39. Spiral groove- radial Nerve.
9.40. Ulnar nerve injury- c7/t1 27.Supra Clavicluar fossa - c3
10.33- wound in posterolateral part of back > latissimus dorsi 11.1-Abduction of the arm > supraspinatus
12.2-axillary N injury > Teres minor
13.First layer of foot damaged structure- flexor digitorum brevis
14.Spiral fracture of humerus-- radial nerve
15.133-UNABLE TO FLEX BIG TOE AND FOOT >>FLEXOR HALLUCIS LONGUS
16.139-WINGED SCAPUL WHICH NERVE>>LTN
17.94. Adduction+ internal rotation- pectoralis major / pectoral minor/ serratous anterior.
18.141-ELBOW EXTENSION DERMATOME>>C7
19.74.medial Nerve injury spared which side- little finger.
20. Wrist drop humerus fracture- radial nerve.
21.At wrist injury inthenar emminence- oppenens pollicies.
22. Fromet sign- adductor pollicis
23.82. Anterior lateral thoracotomy - serratous anterior/ lattismusdorsi.
24.Stab woud at 5th intercostal space mid axillary line- Lattisimus dorsi, serratus anterior, P major, P minor
25.56. Knife injury to forearm – ? ECRL
26.116- Flexor tendon s heath continues with > > The little fing er 27.52. Dis tal end radius , tendon injury
28.40. Proximal phalanx flexion - Flexor digitorum superficialis 29.. Pitcure of Lift- off test- Subscapularis,......
30.2. Woman age ? 5 5 no history of injury, cannot abduct, her work
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plasterer—Supraspinatus,.......
31.3. Pt with shoulder dislocation and loss of sensation in rebridgemental area- Axillary Nerve,....
32.4. H/O injury ( not mention area) Pt can’t abduct above 9 0 degree and injury from – Roots, Divisions, Trunk, Lateral cord, Medial
cord
33.5. Wrist injury- Choose from position which can’t do- Opposition of thumb, Abd, Add,....
34.6. After injury, can’t do finger adduction, can do wrist extension, C7-T1, C5-6, C6-7,....
35.7. Feature of Fromet sign, which muscle— Adductor pollicis,.... 36.8. Antecubital fossa injury and large nerve injury, which function
impair least- Little finger,...
37.9. Radial Nerve related....
38.48. Prominent cervical spinous process- C7
39.49. GTCS with shoulder joint dislocation
40.50. Ulnar nerve – ? ? C7/T1, T1/T1 injury
41.First webspace trying to hold paper flexes the thumb (describing froment sign) muscles…….
42. involved adductor policis
43.54. Median nerve injury which function preserved- abduction of little finger
44.55. T2- Axila
45.147. Trying to make a fist---median nerve injury at the cubital fossa
46.Fall on the shoulder and not able to do the drop test- Supraspinatus, infraspinatus, teres minor , subscapularis,deltoid
47.2) Loss of sensation around deltoid area- nerve injury. Which of the muscle weakness? 48.Teres minor, infraspiantus, supraspinatus, subscapularis
49.3) Fall injury and loss of abduction and flexion of arm – C 5 C 6
50.4) Anterior dislocation of Hip Joint- What is the most stabilizer of hip joint?
51.159. Median nerve injury--opponens policis
52. Breastouterquadrentl.n=antgrouporpectoralgroup
53.81. Ifaskedmedialquadrant=parasternalnode
54. Instrinsicmusclehandsinjurylowerbrachialplexiusinjury= c8-t1
55.83. Shoulder cuff rotators–loss of medial rotation +=subscapulris 56..Thenarinjuryglasspiecesetc=opponens polices/fpl/fpbe
57. Muscle didvided during thoracotomy=latissimus Dori
59.76. Supra clavicular fossa dermatome=C3
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60. 71. Ant compartment forearm
injury=musculocutaneousnerve=c5-c7
61.72. Antcompartement of arm injury=muscula
62. medial epicondyle injury=muscle group involve wrist flexor s/elbow 63.105.dash board injury =POSTERIOR CRUCIATE LIGAMENT
injury 64.113.cutatvolarwristabdpolices/fpb/o.p
65.116-FRACTURE SHAFT HUMERUS>>RADIAL NERVE
66.117-FLEXOR TENDOR TENDON>>LITTLE FINGER
67.118-ACCESSORY NERVE INJURY>>TRAPEZIUS
68.33-THUMB DERMATOME>>C6
69.73- weakness of flexion of thumb, index and middle finger > ant interosseus nerve injury 70.47-FLEXOR CARPI RADIALIS
71.48-CASE WITH MEDIAN NERVE SUPPLY>>OPPONENS POLLICIS BREVIS
72.60-5 C M ABOVE MEDIAL EPICONDYLE STRUCTURE INJURED>>ULNAR COLLATERAL ARTERY
73.25- which one is part of thenar muscle > abductor pollicis brevis 74.113. Subscapularis- liftoff test11-ANT. SHOULDER
DISLOCATION>>GLENOHUMORAL
75.13) Stab wound at antecubital fossa and injury of brachial artery, complete transection of which artery? Profundi branchii, radial, ulnar collateral,
76.14) Same scenario- which collateral will be spared? Profundi brachii, palmar branch, dorsal arch, radial
77.36) Patient with infectious tenosynovitis pain on flexion of wrist and metacarpal phlengeal joints. Site of infections – carpel tunnel, Gryon’s canal, then
eminence, hypothenar eminence
78.37) Injury to lateral epicondyle and MRI show injury to the muscle which attached to base of 3rd metacarpal- extensor carpi radialis brevis
79.19) Shoulder joint ligament injury and cannot elevate the shoulder- acromioclavicular, coracoclavicular, glenohumural, coracohumeral
80.3.medial epicondyilitis- Ulnar nerve- wrist flexors 81.10-stab in antecubital fossa > median N
82.8. Antecubital fossa – medial nerve injury 83.9. Wrist drop – radial
84.10. Medial epicondyle injury
85.11. Lateral epicondyle injury
86.12. Froment sign – adductor pollicis
87.13. Opponens pollicis – median nerve
88.14. Superficial structure to flexor retinaculum – ulnar nerve
The supraspinatus is the most commonly injured rotator cuff muscle - it acts to initiate abduction to 15 degrees, and then assists the deltoid with contin
abduction.
24/11/2024 4
median nerve supplies skin over the lateral aspect of palm and palmar surface and fingertips of the lateral three and a half digits
Cutaneous Origin Skin Supplied
Nerve
Lateral Cervical plexus Upper half of
supraclavicular nerve (C3, C4) deltoid muscle
Superior lateral Axillary nerve Lower half of
cutaneous nerve of the arm deltoid muscle
Inferior lateral Radial nerve Lateral arm

cutaneous nerve of the arm below deltoid muscle
Medial Brachial plexus Medial arm

cutaneous nerve of the arm (C8, T1)
Intercostobrachi Second Axilla

al nerve intercostal nerve (T2)
Posterior Radial nerve Posterior arm
cutaneous nerve of the arm
Medial Brachial plexus Medial forearm

cutaneous nerve of the (C8, T1)
forearm
Medicine NHS UK)
24/11/2024 5
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Posterior Radial nerve Posterior
cutaneous nerve of the forearm forearm
Lateral Musculocutane Lateral forearm

cutaneous nerve of the forearm ous nerve
Superficial R adial nerve Lateral dorsum

branch of radial nerve of hand and lateral three and a half
digits
Palmar Ulnar nerve Medial half of
cutaneous branch of ulnar nerve palm
Dorsal Ulnar nerve Medial dorsum

cutaneous branch of ulnar nerve of hand and medial one and a half f
ingers
Superficial Ulnar nerve Palmar surface
branch of ulnar nerve of medial one and a half digits
Palmar Median nerve Lateral half of
cutaneous branch of median nerve palm
Palmar digital Median nerve r Palmar surface

branch ofmedian nerve and fingertips oflateral 3 & ½ digits
Medicine NHS UK)
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Dermatome Landmark
C2 Occipital Protuberance
C3 Supraclavicular Fossa
C4 Acromioclavicular Joint
C5 Lateral Antecubital Fossa
C6 Thumb
C7 Middle Finger
C8 Little Finger

T1 Medial Antecubital Fossa
T2 Apex of Axill
London Global EM Programme, Director Dr Ash (Consultant Emergency Medicine, Acute Medicine & Geriatric Medicine NHS UK)
[email protected]
11/24/2024 7
11/24/2024 [email protected] 8
Brachial plexus injury Erb’s palsy Klumpke’s palsy
Mechanism of injury Excessive increase in Sudden excessive
angle between neck and shoulder e.g. duri abduction e.g. person catching something
ng breech delivery or from fall from motor overhead as they fall or
bike or horse during a difficult delivery
Nerve roots affected C5, C6 C8, T1

Nerves affected Musculocutaneous, Ulnar and median
axillary, suprascapular and nerve to subcla nerves
vius
Muscles affected Supraspinatus, All small muscles of

infraspinatus, subclavius, biceps brachii, br hand (flexor muscles in forearm innervated
achialis, coracobrachialis, deltoid and teres by different nerve roots)
minor
Motor loss Abduction, flexion and Intrinsic hand

lateral rotation of arm, flexion and supinati movements
on of forearm
Sensory loss Lateral

London Global EM Programme, armDr Ash (Consultant Emergency Medicine, Acute
Director Medial arm & Geriatric
Medicine
Medicine NHS UK)
Deformities
24/11/2024 Waiter’s tip [email protected] Claw hand 11
Table: Clinical Features of Ulnar Nerve Injur
y
Lesion Proximal (at elbow) Distal (at wrist)

Mechanism Fracture of medial Laceration at wrist
epicondyle
Motor Loss Wrist flexion and Finger abduction and

adduction, finger abduction and adduction adduction, flexion of ring and little finger,
, flexion of ring and little finger, abduction abduction and opposition of little finger, th
and opposition of little finger, thumb addu umb adduction, extension at IPJs
ction, extension of IPJs of all digits (less so
at index and middle finger due to sparing
of lateral two lumbricals)
Sensory Loss Medial half of palm, Palmar surface of

palmar and dorsal surface of medial one a medial one and a half fingers
nd a half fingers and medial dorsum of han
d
Signs Hand held in Claw hand

abduction (due to unopposed action of fle (unopposed extension at MCPJ and unopp
xor carpi radialis), Froment’s sign (patient i osed flexion at IPJs of ring and little finger),
s asked to hold a piece of paper between t hypothenar eminence wasting, Froment’s
humbDirector
London Global EM Programme, and Drflat
Ashpalm as paper
(Consultant is
Emergency sign Medicine & Geriatric
Medicine, Acute
Medicine NHS UK)
24/11/2024 12
[email protected]
Lesion In axilla In spiral In forearm In forearm
groove (superficial branch) (deep branch)
Mechanism Glenohumer Fracture of Stabbing/ Fracture of
al joint dislocation, fract midshaft of humerus laceration of forearm radial head or posterior
ure of proximal humeru dislocation of radius
s, ‘Saturday night syndr
ome’
Motor Loss Loss of Loss of None Weakness of

extension at elbow, wris extension at wrist and fi extension at wrist and fi
t and fingers ngers (triceps brachii s ngers (exte nsor carpi ra
pared) dialis spared)
Sensory Lower lateral Dorsum of Dorsum of None

Loss arm, posterior arm, po lateral hand and three lateral hand and three
sterior forearm, dorsu and a half fingers (cuta and a half fingers
m of lateral hand and t neous branches of arm
hree and a half fingers and forearm spared)
Signs Wrist drop
(unopposed wrist flexio
n), weakness of hand gr
ip (finger flexion is wea
k as the long flexor tend
ons are not under tensi
on
Medicine NHS UK)
24/11/2024 13
[email protected]
Axillary nerve injury results in:
•Weakness of abduction (due to paralysis of the
deltoid muscle) Weakness of lateral rotation (due to paralysis of the teres
minor muscle)
• Loss of sensation over the 'regimental badge area' on the lateral arm
Deltoid muscle atrophy giving a flattened shoulder appearance (in long-
standing cases)
Suprscapular injury
Empty Can Test: Position the patient with arms elevated to 90

degrees
in the scapular plane, with the elbow extended, and full medial
rotation and pronation of the forearm with thumbs pointing d
ownwards. Ask the patient to resist the downward force being
applied to the forearm. Test is positive is patient has pain or w
eakness.
To isolate the subscapularis muscle in examination, place the d

orsum of the patient's hand in full medial rotation on the lowe
r back and ask them to push their hand off the back (the 'lift-
off' test). Loss of power suggests a tear while pain on forced m
edial rotation suggests tendonitis.
Medicine NHS UK)
24/11/2024 14
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Muscle Subscapularis
Origin Medial two-thirds of subscapular
fossa
Insertion Lesser tubercle of humerus
Actions Medial rotation of arm at
glenohumeral joint
Innervation Upper and lower subscapular
nerve
Medicine NHS UK)
24/11/2024 15
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Muscle Supraspinatus
Function Initiation of abduction of shoulder
to 15 degrees (and then assistance of d
eltoid with continued abduction)
Innervation Suprascapular nerve

Examination Empty Can Test: Position the
patient with arms elevated to 90 degree
s in the scapular plane, with the elbow
extended, and full medial rotation and
pronation of the forearm with thumbs p
ointing downwards. Ask the patient to
resist the downward force being applie
d to the forearm. Test is positive is pati
ent has pain or weakness
Medicine NHS UK)
24/11/2024 16
[email protected]
Extensor tendon injury
Structure Terminal Extensor Central Slip of

Tendon Extensor Tendon
Attachment Distal phalanx Middle phalanx
Movements affected Loss of extension at Loss of extension at
in injury distal interphalangeal j proximal interphalange
oint al joint and flexion at di
stal interphalangeal joi
nt
Deformity in injury Mallet deformity: Boutonniere

Distal phalanx held in fi deformity: Middle phal
xed flexion anx held in fixed flexion
with hyperextension of
distal phalan
Medicine NHS UK)
24/11/2024 17
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The ulnar nerve is a continuation of the medial cord of the brachial plexus, containing fibres
from the C8 - T1 nerve roots.

Table: Anatomical Overview of the Ulnar Nerve
Nerve Ulnar
Nerve roots C8 – T1
Plexus cords Medial cord
Motor Supply All the intrinsic muscles of the
hand (except for the thenar muscles
and the lateral two
lumbricals), the flexor carpi ulnaris

and the medial half of the flexor dig
itorum profundus
Sensory supply Medial half of palm, palmar and

dorsal surface of medial one and a h
alf fingers and medial dorsum of han
Medicine NHS UK)
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Branches of Ulnar Origin Supply
Nerve
Muscular branch Forearm Flexor carpi ulnaris,
medial half of flexor digit
orum profundus
Palmar cutaneous Forearm Skin of medial half of

branch palm
Dorsal cutaneous Forearm Skin of dorsum of
branch medial one and a half fin
gers and associated dorsa
l hand area
Deep branch Hand Hypothenar muscles

(abductor digiti minimi, fl
exor digiti minimi, oppon
ens digiti minimi), medial
two lumbricals, adducto
r pollicis and interossei
Superficial branch Hand
Medicine NHS UK)
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[email protected]
Muscle Function Innervation
Coracobrachialis Flexion of arm Musculocutaneous

nerve
Biceps brachii Flexion and supination Musculocutaneous
of forearm (primary), fl nerve
exion of arm (accessory
)
Brachialis Flexion of forearm Musculocutaneous

nerve; small contributi
on by radial nerve to la
teral part of muscle
Medicine NHS UK)
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[email protected]
Coracobrachialis
The coracobrachialis flexes the arm at the glenohumeral joint. It is inner
vated by the musculocutaneous nerve.
Biceps brachii
The biceps brachii is primarily a powerful flexor of the forearm at the elbow joint and
supinator of the forearm. It is
also an accessory flexor of the arm at the glenohumeral joint (with the coracobrachi
alis muscle). It is innervated by the musculocutaneous nerve.
Brachialis
The brachialis flexes the forearm at the elbow joint. It is innervated pri
marily by the musculocutaneous nerve with a small contribution from t
he radial nerve.
Coracobrachialis Flexion of arm Musculocutaneous
nerve
Biceps brachii Flexion and supination Musculocutaneous
of forearm (primary), flexion of arm nerve
(accessory)
Brachialis Flexion of forearm Musculocutaneous

nerve; small contribution by radial
nerve to lateral part ofmuscle
Medicine NHS UK)
24/11/2024 21
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Nerve Axillary
Mechanism of injury Dislocation of the glenohumeral
joint, fracture of the surgical neck of th
e humerus, trauma or surgery to the sh
oulder, incorrect use of axillary crutche
s
Motor loss Loss of abduction of the arm at

the glenohumeral joint and weakness o
f lateral rotation
Sensory loss Lateral arm (regimental badge

area)
Signs Atrophy of deltoid – flattened
shoulder appearan
Medicine NHS UK)
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The flexor muscles of the anterior forearm all originate from the medial humeral
epicondyle.
Table: Digital Attachments of the Long Flexor Tendons
Flexor Tendon Distal Attachment

Flexor pollicis longus Base of distal phalanx of thumb
Flexor digitorum profundus Distal phalanges of all four digits
Flexor digitorum superficialis Middle phalanges of all four digits
Flexor carpi ulnaris Pisiform, hook of hamate and 5th
metacarpal
Flexor carpi radialis Base of 2nd and 3rd metacarpal
Palmaris longus Palmar aponeurosi
Medicine NHS UK)
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Thenar Muscles
Opponens pollicis Medially ro Median nerve

tates
thumb
Abductor pollicis Abducts th Median nerve

brevis umb at
MCPJ
Flexor pollicis brevis Flexes thu Median nerv

mb at MCPJ
Adductor policies Adduction of thumb at

MCPJ ..supplied by ulnar nerve

Medicine NHS UK)
24/11/2024 25
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Finger Movements Primary Muscle (Assisting
Muscles)
Flexion of MCPJ of digits 2 – 5 Lumbricals (flexor digitorum
superficialis, flexor digitorum profun
dus, flexor digiti minimi, interossei)
Flexion of PIPJ of digits 2 – 5 Flexor digitorum superficialis

(flexor digitorum profundus)
Flexion of DIPJ of digits 2 – 5 Flexor digitorum profundus
Extension of MCPJ of digits 2 – 5 Extensor digitorum, extensor
indicis, extensor digiti minimi
Extension of PIPJ and DIPJ of Lumbricals and interossei
digits 2 – 5 (extensor digitorum)
Adduction of digits 2 – 5 Palmar interossei
Abduction of digits 2 – 4 Dorsal interossei
Abduction of little finger Abductor digiti minimi
Opposition of little finger Opponens digiti minimi
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Table: Movement of the Thumb
Joints
Flexion of thumb at MCPJ Flexor pollicis longus and brevis

Flexion of thumb at IPJ Flexor pollicis longus
Extension of thumb at CMCJ and Extensor pollicis longus and brevis
MCPJ
Extension of thumb at IPJ Extensor pollicis longus
Abduction of thumb Abductor pollicis longus and
brevis
Adduction of thumb Adductor pollicis
Opposition of thumb Opponens pollicis
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Lymphatic Drainage of Breast
The lymphatic drainage of the breast is of great clinical importance

due to its role in the metastasis of breast cancer cells.
There are three main groups of lymph nodes that receive lymph from
breast tissue: Approximately 7 5 % of lymphatic drainage is via
lymphatic vessels that drain laterally and superiorly into axillary
lymph nodes.
Most of the remainder ( 2 0 % ) is into medial parasternal lymph nodes,
which lie deep to the anterior thoracic wall associated with the internal
thoracic artery.
Some drainage ( 5 % ) may follow the lateral branches of posterior intercostal
arteries and connect with posterior intercostal lymph nodes situated near
the heads and necks of ribs.
From here:
Axillary nodes drain into the subclavian trunks
Parasternal nodes drain into the bronchomediastinal trunks
Intercostal nodes drain either into the thoracic duct or into the
bronchomediastinal trunks
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Shoulder joint
Joint Shoulder (Glenohumeral)

Type Synovial ball and socket joint
Articulations Head of humerus and glenoid
cavity of scapula
Stabilising Factors Rotator cuff muscle tendons, long
head of biceps brachii muscle
tendon, coracoacromial arch, extrac
apsular ligaments (glenohumeral lig
aments, coracohumeral ligament, t
ransverse humeral ligament)
Movements Flexion, extension, abduction,

adduction, medial rotation and later
al rotatio
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Muscles involved in movements of
Movement
shoulder joint Main Muscles Involved Main Nerves Involved
Flexion Pectoralis major, Pectoral nerves,
deltoid, coracobrachialis, axillary nerve, musculocut
biceps brachii aneous nerve
Extension Deltoid and latissimus Axillary nerve,

dorsi, teres major, triceps thoracodorsal nerve, lower
brachii subscapular nerve, radial
nerve
Abduction Deltoid and Axillary nerve,

supraspinatus suprascapular nerve
Adduction Pectoralis major, Pectoral nerves,
latissimus dorsi, triceps br thoracodorsal nerve, radial
achii nerve
Medial Rotation Subscapularis, Subscapular nerves,

pectoralis major, latissimus pectoral nerves, thoracodo
dorsi, teres major rsal nerve
Lateral Rotation Infraspinatus and Suprascapular nerve,

teres minor axillary nerve
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Movements of elbow joint:
Movement Main Muscles Involved Main Nerves Involved

Flexion Biceps brachii, Musculocutaneous
brachialis, brachioradia nerve, radial nerve
lis
Extension Triceps brachii, Radial nerve

anconeus
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Joint Ligaments
The collateral ligaments of the elbow are medial and lateral thickenings of the joint
capsule. The radial collateral ligament arises from the lateral epicondyle of the
humerus and blends distally with the annular ligament of the radius.
The ulnar collateral ligament arises from the medial epicondyle and distally
attaches to the olecranon and coronoid process of the ulna.
The annular ligament is a strong band of fibres that encircles the head of the radius,
and retains it in contact with the radial notch of the ulna. The annular ligament is
attached by both its ends to the anterior and posterior margins of the radial notch of
the ulna.
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Flexor Retinaculum
It prevents them from bowstringing.

It is attached laterally to the scaphoid and trapezium and medially to the pisiform and
the hook of the hamate.
The thenar and hypothenar muscles arise from the flexor retinaculum.
Relations
The ulnar artery, ulnar nerve, and tendon of the palmaris longus pass into the hand
anterior to the flexor retinaculum, and therefore do not pass through the carpal
tunnel.
The flexor carpi radialis tendon passes through the lateral aspect of the flexor
retinaculum into the hand.
The four tendons of the flexor digitorum profundus, the four tendons of the flexor
digitorum superficialis, the tendon of the flexor pollicis longs and the median
nerve pass into the hand posterior to the flexor retinaculum, within the carpal tunnel.
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Branches of Radial Origin Supply
Nerve
Radial nerve Axilla Triceps brachii,
extensor carpi radialis
longus, brachioradialis
Posterior cutaneous Axilla Skin of posterior arm
nerve of the arm
Inferior lateral Arm Skin over lateral
cutaneous nerve of the arm aspect of lower arm
Posterior cutaneous Arm Strip of skin down
nerve of the forearm middle of posterior forearm
Deep branch which Forearm Posterior
continues as the posterior interosseous ne compartment of forearm: superficial musc
rve les (extensor carpi radialis brevis, extensor
digitorum, extensor digiti minimi, extenso
r carpi ulnaris) and deep muscles (supinat
or, abductor pollicis longus, extensor pollic
is longus and brevis, extensor indicis)
Superficial branch Forearm

London Global EM Programme, Dr Ash (Consultant Emergency Medicine, Acute
Director Skin of dorsum
Medicine & of the
Geriatric
24/11/2024 Medicine NHS UK) hand and lateral three and a half34finger
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Anatomical snuff box
Anatomical Boundaries Structure(s)

Medial border Tendon of extensor pollicis longus
Lateral border Tendons of the abductor pollicis
longus and extensor pollicis brevis
Proximal border Radial styloid process
Distal border 1st metacarpal
Floor Scaphoid and trapezium bones
Roof Skin
Contents Radial artery, terminal portion of
the superficial branch of the radial n
erve, cephalic vein
Contents
The radial artery crosses the fl oor of the anatomical snuff box. Subcutaneously terminal parts of the
superfi cial branch of the radial nerve and the origin of the cephalic vein pass over the anatomical sn
uff box.
The anatomical snuff box is important clinically as the scaphoid is palpable within the snuff box; loc
alised pain and tenderness of the anatomical snuff box is most likely due to a scaphoid fracture.
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Digital attachment of long flexor tendons
: Long tendons attachments
Muscle Tendon Distal Attachment
Extensor carpi radialis longus Dorsal surface of base of 2nd
metacarpal
Extensor carpi radialis brevis Dorsal surface of base of 2nd and
3rd metacarpal
Extensor digitorum Dorsal aspects of bases of middle
and distal phalanges of index, middle, ring
and little fingers via extensor hoods
Extensor carpi ulnaris Tubercle on base of 5th

metacarpal
Abductor pollicis longus Lateral side of base of 1st

metacarpal
Extensor pollicis longus Dorsal surface of base of distal
phalanx of thumb
Extensor pollicis brevis Dorsal surface of base of proximal
phalanx of thumb
Extensor indicis Extensor hood of index finger
Extensor digiti minimi Extensor hood of little finger
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M C Q S PEARLS
>Compression of the median nerve in the carpal tunnel will result in weakness and
atrophy of the thenar muscles resulting in weakness of opposition, abduction and
flexion of the thumb at the metacarpophalangeal joint and LOW anaesthesia or
paraesthesia over the distribution of the palmar digital branch of the median nerve
(skin over the palmar surface and fingertips of the lateral three and a half digits). The
adductor pollicis muscle is innervated by the ulnar nerve, and abduction of the fingers
is produced by the interossei, also innervated by the ulnar nerve.
Flexion of the interphalangeal joint of the thumb is produced by the flexor pollicis
longus, and flexion of the distal interphalangeal joint of the index finger is produced by
the flexor digitorum profundus. Median nerve injury at the wrist will not affect the long
flexors of the forearm as these are innervated by the anterior interosseous nerve
which arises in the proximal forearm.
>Positive Tine's test (tapping lightly over the nerve at the wrist elicits symptoms in
the median nerve
distribution
o Positive Phalen's test (holding the wrist in flexion for 6 0 s elicits symptoms in the
median nerve distribution)
Positive carpal tunnel compression test (pressure over the proximal end of the carpal
ligament (proximal wrist crease) with the thumbs elicits symptoms in the median
nerve distribution)
> The radial nerve innervates the triceps brachii and the posterior compartment of
the forearm.
The radial nerve in
the arm is most susceptible to midshaft fractures of the humerus due to its course in
the spiral groove. Extension
of the forearm is not affected as the triceps brachii is spared. There is loss of
LondonofGlobal EM Programme, Director Dr Ash (Consultant Emergency Medicine, Acute Medicine & Geriatric
extension of the wrist and MCPJs
[email protected]
the fingers and weakness of supination of the forearm. The cutaneous branches of the arm and forearm have
already arisen and sensation loss occurs only on the dorsum of the lateral hand and three and a half digits.
>The supraspinatus, infraspinatus and teres minor muscles of the rotator cuff all insert into the greater tubercle of the humerus, as does
the coracohumeral ligament. The subscapularis inserts into the lesser tubercle of the humerus and thus is least likely to be affected.
>Loss of flexion at the distal interphalangeal joint of the ring and little finger is likely due to paralysis of the medial half of the flexor digitorum
profundus, innervated by the ulnar nerve. Flexion at the proximal interphalangeal joint is preserved as this is a function of the flexor digitorum
superficialis, innervated by the median nerve. Ulnar nerve injury at the wrist would not affect the long flexors, so the injury must have been
more proximal.
>The ulnar nerve innervates the interossei and the medial two lumbricals, which are important muscles in extension of the fingers at the
interphalangeal joints. Flexion at the proximal interphalangeal joints is produced primarily by the flexor digitorum superficialis, innervated by
the median nerve. Sensation to the dorsum of the
medial hand is innervated by the dorsal cutaneous branch of the ulnar nerve which arises in the forearm, proximal to the site of laceration.
Extension of the the thumb is primarily a function of the radial nerve, and opposition of the thumb, the median nerve.
>The axillary nerve and associated blood vessels (the posterior circumflex humeral artery and vein) enter the deltoid by passing posteriorly
around the surgical neck of the humerus. Injury to the axillary nerve may be caused by: dislocation of the glenohumeral joint, fracture of the
surgical neck of the humerus, trauma or surgery to the shoulder, or incorrect use of axillary crutches.
>sterniclavicular joint is saddle shaped
>The supratrochlear lymph nodes lie subcutaneously above the medial epicondyle, medial to the basilic vein. They drain the ulnar side of the
forearm and the medial hand. Differential diagnosis for enlarged lymph nodes includes skin infections, skin malignancies and lymphoma.
>The supratrochlear lymph nodes lie subcutaneously above the medial epicondyle, medial to the basilic vein. They drain the ulnar side of the
forearm and the medial hand. Differential diagnosis for enlarged lymph nodes includes skin infections, skin malignancies and lymphoma.
>The thenar muscles (opponens pollicis, abductor pollicis brevis and flexor pollicis brevis) are all innervated by the median nerve. The flexor
pollicis longus in the anterior forearm is also innervated by the median nerve. The adductor pollicis, an intrinsic hand muscle, is innervated by
the ulnar nerve. The muscles of the hand supplied by the median nerve can be remembered using the mnemonic, "LOAF" for Lumbricals 1 &
2, Opponens pollicis Abductor pollicis brevis and Flexor pollicis brevis.
>The pectoralis minor muscle protracts the scapula (by pulling the scapula anteriorly on the thoracic wall) and depresses the lateral angle
of the scapula.
London
>A supracondylar fracture most Global EM Programme,
commonly results in Director
injury toDr the
Ash (Consultant Emergency
median nerve. Medicine,
The axillary nerveAcute
may Medicine & Geriatric
be damaged in a surgical neck38of
24/11/2024 Medicine NHS UK)
humerus fracture. The radial nerve may be damaged [email protected]
in a midshaft humerus fracture. The ulnar nerve may be damaged in a medial epicondylar fracture.
>The radial nerve innervates the posterior muscles in the arm and forearm, which primarily act to produce extension of the forearm, wrist
and fingers. In injury to the radial nerve in the axilla, you would expect the triceps brachii muscle to also be affected, and thus extension
at the elbow to be lost in association with loss of sensation over the inferior lateral arm and posterior arm and forearm. In injury at the
mid-humerus the triceps brachii muscle and the cutaneous branches of the arm and forearm are usually spared. The superficial branch
of the radial nerve has no motor supply and thus cannot solely be affected in this case.
>The supraspinatus is the most commonly injured rotator cuff muscle. The supraspinatus muscle acts to initiate abduction from O degrees,
and then assists the deltoid with continued abduction.
> In a median nerve injury at the elbow:
Flexion of the index and middle fingers at the IPJs is lost due to paralysis of the flexor digitorum superficialis and the lateral half of the flexor
digitorum profundus.
Flexion of the MCPJs of the index and middle fingers are lost due to paralysis of the lateral two lumbrical muscles.
Flexion of the ring and little fingers are preserved as these are supported by the medial half of the flexor digitorum profundus and the medial
two lumbrical muscles, innervated by the ulnar nerve.
>proximal median nerve lesion at the elbow may occur due to supracondylar fracture of the humerus or from deep penetrating wounds to the
arm. Flexion, abduction and opposition of the thumb at the MCPJ and IPJ are lost due to paralysis of the thenar muscles and the flexor pollicis
longus.
>A supracondylar fracture is most commonly associated with damage to the median nerve. Paralysis of the lateralhalf of the flexor digitorum
profundus would cause loss of flexion at the distal interphalangeal joint of the index finger but not the ring finger, as the medial half is
innervated by the ulnar nerve. Median nerve injury results in
paralysis of the thenar muscles with loss of opposition of the thumb.
> 'waiter's tip' deformity seen in Erb's palsy, usually resulting from an injury to the
superior trunk of the brachial plexus and involving the C 5 and C 6 nerve roots. There is loss/ weakness ofabduction, flexion and lateral
rotation of the arm, flexion and supination of the forearm and extension of the wrist.
>The strong coracoclavicular ligament (made up of two ligaments, the conoid and trapezoid ligament) is the main stabilising force at the
acromioclavicular joint.
>The acromioclavicular joint is reinforced by two main ligaments; a small acromioclavicular ligament and a much larger coracoclavicular
ligament. London Global EM Programme, Director Dr Ash (Consultant Emergency Medicine, Acute Medicine & Geriatric
[email protected]
Thank you
•Presenter name
•Email address
London Global EM Programme, Director Dr Ash

(Consultant Emergency Medicine, Acute Medicine &
Geriatric Medicine NHS UK)
[email protected]
40 11/24/2024

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Topic: High Yield Upper Limb Anatomy

Name of Presenter: Dr. Muhammad Azeem Imran

Date of Presentation: 23/07/2023

Inferior lateral​ Radial nerve​ Lateral arm​

Medial​ Brachial plexus​ Medial arm​

Intercostobrachi​ Second​ Axilla​

Medial​ Brachial plexus​ Medial forearm​

Lateral​ Musculocutane​ Lateral forearm​

Superficial​ R adial nerve​ Lateral dorsum​

Dorsal​ Ulnar nerve​ Medial dorsum​

Palmar digital​ Median nerve r​ Palmar surface​

C2​​ Occipital Protuberance​​

C3​​ Supraclavicular Fossa​​

C4​​ Acromioclavicular Joint​​

C5​​ Lateral Antecubital Fossa​​

C7​​ Middle Finger​​

C8​ Little Finger​

Nerve roots affected​ C5, C6​ C8, T1​

Muscles affected​ Supraspinatus,​ All small muscles of​

Motor loss​ Abduction, flexion and​ Intrinsic hand​

Sensory loss​ Lateral

Lesion​ Proximal (at elbow)​ Distal (at wrist)​

Motor Loss​ Wrist flexion and​ Finger abduction and​

Sensory Loss​ Medial half of palm,​ Palmar surface of​

Signs​ Hand held in​ Claw hand​

Motor Loss​ Loss of​ Loss of​ None​ Weakness of​

Sensory​ Lower lateral​ Dorsum of​ Dorsum of​ None​

Empty Can Test: Position the patient with arms elevated to 90

To isolate the subscapularis muscle in examination, place the d

Innervation​ Suprascapular nerve​

Structure​ Terminal Extensor​ Central Slip of​

Deformity in injury​ Mallet deformity:​ Boutonniere​

​ lumbricals), the flexor carpi ulnaris​

Sensory supply​ Medial half of palm, palmar and​

Palmar cutaneous​ Forearm​ Skin of medial half of​

Deep branch​ Hand​ Hypothenar muscles​

Superficial branch​ Hand​ ​

Coracobrachialis​ Flexion of arm​ Musculocutaneous​

Brachialis​ Flexion of forearm​ Musculocutaneous​

Brachialis​​ Flexion of forearm​​ Musculocutaneous​​

Motor loss​ Loss of abduction of the arm at​

Sensory loss​ Lateral arm (regimental badge​

Table: Digital Attachments of the Long Flexor Tendons

Flexor Tendon​ Distal Attachment​

Opponens pollicis​ Medially ro Median nerve​

Abductor pollicis​ Abducts th Median nerve​

Flexor pollicis brevis​ Flexes thu Median nerv​

Adductor policies​ Adduction of thumb at​

Flexion of PIPJ of digits 2 – 5​ Flexor digitorum superficialis​

Flexion of thumb at MCPJ​ Flexor pollicis longus and brevis​

The lymphatic drainage of the breast is of great clinical importance

Joint​ Shoulder (Glenohumeral)​

Movements​ Flexion, extension, abduction,​

Extension​ Deltoid and latissimus​ Axillary nerve,​

Abduction​ Deltoid and​ Axillary nerve,​

Medial Rotation​ Subscapularis,​ Subscapular nerves,​

Lateral Rotation​ Infraspinatus and​ Suprascapular nerve,​

Movement​ Main Muscles Involved​ Main Nerves Involved​

Extension​ Triceps brachii,​ Radial nerve​

It prevents them from bowstringing.

Inferior lateral Radial nerve Lateral arm

Medial Brachial plexus Medial arm

Intercostobrachi Second Axilla

Medial Brachial plexus Medial forearm

Lateral Musculocutane Lateral forearm

Superficial R adial nerve Lateral dorsum

Dorsal Ulnar nerve Medial dorsum

Palmar digital Median nerve r Palmar surface

C2 Occipital Protuberance

C3 Supraclavicular Fossa

C4 Acromioclavicular Joint

C5 Lateral Antecubital Fossa

C7 Middle Finger

C8 Little Finger

Nerve roots affected C5, C6 C8, T1

Muscles affected Supraspinatus, All small muscles of

Motor loss Abduction, flexion and Intrinsic hand

Sensory loss Lateral

Lesion Proximal (at elbow) Distal (at wrist)

Motor Loss Wrist flexion and Finger abduction and

Sensory Loss Medial half of palm, Palmar surface of

Signs Hand held in Claw hand

Motor Loss Loss of Loss of None Weakness of

Sensory Lower lateral Dorsum of Dorsum of None

Innervation Suprascapular nerve

Structure Terminal Extensor Central Slip of

Deformity in injury Mallet deformity: Boutonniere

lumbricals), the flexor carpi ulnaris

Sensory supply Medial half of palm, palmar and

Palmar cutaneous Forearm Skin of medial half of

Deep branch Hand Hypothenar muscles

Superficial branch Hand

Coracobrachialis Flexion of arm Musculocutaneous

Brachialis Flexion of forearm Musculocutaneous

Brachialis Flexion of forearm Musculocutaneous

Motor loss Loss of abduction of the arm at

Sensory loss Lateral arm (regimental badge

Flexor Tendon Distal Attachment

Opponens pollicis Medially ro Median nerve

Abductor pollicis Abducts th Median nerve

Flexor pollicis brevis Flexes thu Median nerv

Adductor policies Adduction of thumb at

Flexion of PIPJ of digits 2 – 5 Flexor digitorum superficialis

Flexion of thumb at MCPJ Flexor pollicis longus and brevis

Joint Shoulder (Glenohumeral)

Movements Flexion, extension, abduction,

Extension Deltoid and latissimus Axillary nerve,

Abduction Deltoid and Axillary nerve,

Medial Rotation Subscapularis, Subscapular nerves,

Lateral Rotation Infraspinatus and Suprascapular nerve,

Movement Main Muscles Involved Main Nerves Involved

Extension Triceps brachii, Radial nerve

Superficial branch Forearm

Anatomical Boundaries Structure(s)

Extensor carpi ulnaris Tubercle on base of 5th

Abductor pollicis longus Lateral side of base of 1st