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UNIT 1: UPPER EXTREMITY ANATOMY

BPT 110 - Human Anatomy 2 | Rita A. Patel Institute of Physiotherapy

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1.1 OSTEOLOGY OF THE UPPER EXTREMITY

Clavicle

• S-shaped bone; only bone connecting upper limb to axial skeleton
• Medial 2/3 - convex anteriorly; Lateral 1/3 - concave anteriorly
• Articulates medially with manubrium sterni (sternoclavicular joint) and laterally with acromion of scapula (acromioclavicular joint)
• Most commonly fractured bone in the body - fracture typically at junction of medial 2/3 and lateral 1/3
• Clinical: Medial fragment pulled up by sternocleidomastoid; lateral fragment pulled down by gravity + deltoid

Scapula

• Flat triangular bone on posterior thoracic wall (ribs 2-7)
• Key features: Glenoid cavity (articulates with humeral head), Acromion, Coracoid process (attachment for muscles and ligaments), Spine of scapula, Supraspinous and infraspinous fossae, Subscapular fossa
• Rotator cuff muscles attach to the scapula: SITS - Supraspinatus, Infraspinatus, Teres minor (supraspinous/infraspinous fossa), Subscapularis (subscapular fossa)

Humerus

• Longest bone of upper limb
• Proximal end: Head (articulates with glenoid), anatomical neck, greater tuberosity (SITS attachments), lesser tuberosity, intertubercular (bicipital) groove, surgical neck
• Shaft: Deltoid tuberosity (deltoid attachment), spiral groove (radial nerve runs here)
• Distal end: Capitulum (articulates with radial head), Trochlea (articulates with ulna), medial and lateral epicondyles, coronoid fossa (anteriorly), olecranon fossa (posteriorly), radial fossa
• Clinical: Surgical neck fracture = axillary nerve injury; Mid-shaft fracture = radial nerve injury (wrist drop); Medial epicondyle fracture = ulnar nerve injury ("claw hand")

Radius

• Lateral bone of forearm
• Proximal: Head (disc-shaped - articulates with capitulum and radial notch of ulna), neck, radial tuberosity (biceps attachment)
• Distal: Wider end - articulates with scaphoid and lunate; radial styloid process

Ulna

• Medial bone of forearm
• Proximal: Olecranon (triceps attachment), coronoid process, trochlear notch (articulates with trochlea of humerus), radial notch (articulates with radial head)
• Distal: Head of ulna, ulnar styloid process

Carpal Bones (8 bones - 2 rows)

• Scaphoid - most commonly fractured carpal bone; avascular necrosis risk
• Lunate - most commonly dislocated carpal bone
• Hamate - has a hook; hook of hamate fracture causes ulnar nerve injury

Metacarpals (5) and Phalanges

• 5 metacarpals (I-V); each has base, shaft, head
• Phalanges: Digits 2-5 have 3 phalanges (proximal, middle, distal); Thumb has 2 (proximal, distal)

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1.2 SOFT PARTS OF THE UPPER EXTREMITY

Breast & Pectoral Region

• Pectoralis Major: Origin - medial clavicle, sternum, costal cartilages 1-6; Insertion - intertubercular groove; Action - flexion, adduction, medial rotation of arm; Nerve - medial and lateral pectoral nerves (C5-T1)
• Pectoralis Minor: Origin - ribs 3-5; Insertion - coracoid process; Action - depresses scapula; Nerve - medial pectoral nerve
• Serratus Anterior: Origin - lateral surfaces ribs 1-8; Insertion - medial border of scapula; Action - protracts and rotates scapula upward; Nerve - Long thoracic nerve (C5,6,7)
  • Clinical: Long thoracic nerve injury causes "winged scapula"

Axilla

• Pyramid-shaped space between arm and chest wall
• 4 walls: Anterior (pectorals), Posterior (subscapularis, teres major, latissimus dorsi), Medial (serratus anterior + ribs), Lateral (bicipital groove of humerus)
• Contents: Axillary artery (continuation of subclavian), axillary vein, brachial plexus cords and branches, lymph nodes (5 groups: anterior/pectoral, posterior/subscapular, lateral, central, apical)
• Axillary lymph nodes drain the breast - important in breast cancer staging

Brachial Plexus

• Musculocutaneous nerve (C5, C6) - from lateral cord - flexors of arm
• Axillary nerve (C5, C6) - from posterior cord - deltoid + teres minor
• Radial nerve (C5-T1) - from posterior cord - extensors of arm & forearm
• Median nerve (C5-T1) - from lateral + medial cords - flexors of forearm, LOAF muscles of hand
• Ulnar nerve (C8, T1) - from medial cord - most intrinsic hand muscles

• Erb's palsy (C5, C6) - "waiter's tip" - arm adducted, internally rotated, forearm pronated
• Klumpke's palsy (C8, T1) - "claw hand" - intrinsic muscles of hand paralysed
• Axillary nerve - deltoid paralysis, loss of sensation over regimental badge area
• Radial nerve - wrist drop (loss of wrist and finger extension)
• Median nerve - "ape hand" (thenar wasting), loss of thumb opposition; carpal tunnel syndrome
• Ulnar nerve - "claw hand" (ring and little fingers), loss of intrinsic hand muscles

Front of Arm (Anterior Compartment)

Back of Arm (Posterior Compartment)

Cubital Fossa

• Triangular depression anterior to elbow joint
• Boundaries: Base = line between medial and lateral epicondyles; Medial border = pronator teres; Lateral border = brachioradialis; Floor = brachialis
• Contents (lateral to medial): Tendon of Biceps brachii, Brachial artery (bifurcates into radial and ulnar), Median nerve
  • Mnemonic: "B, B, M" or "Really Needs Beer, Tender Mercies"
• Radial nerve lies just deep to brachioradialis (lateral margin) - divides into superficial and deep (posterior interosseous) branches here
• Ulnar nerve does NOT pass through the cubital fossa - it passes behind medial epicondyle
• Bicipital aponeurosis covers and protects the brachial artery and median nerve anteriorly
• Median cubital vein crosses the roof - commonly used for venepuncture / IV cannula

Forearm - Front (Flexor Compartment)

1. Pronator teres
2. Flexor carpi radialis
3. Palmaris longus
4. Flexor carpi ulnaris
5. Flexor digitorum superficialis (intermediate layer)

• Flexor digitorum profundus
• Flexor pollicis longus
• Pronator quadratus

Forearm - Back (Extensor Compartment)

Palm

• Thenar eminence (thumb mound): Abductor pollicis brevis, Flexor pollicis brevis, Opponens pollicis - all supplied by Median nerve (recurrent branch)
• Hypothenar eminence (little finger mound): Abductor digiti minimi, Flexor digiti minimi, Opponens digiti minimi - supplied by Ulnar nerve
• Lumbricals (4): Arise from FDP tendons; flex MCP, extend IP joints; Lateral 2 = Median nerve; Medial 2 = Ulnar nerve
• Interossei (7): 4 dorsal (abduct fingers - DAB), 3 palmar (adduct fingers - PAD) - all Ulnar nerve
• Adductor pollicis: Ulnar nerve

• Lumbricals 1 & 2
• Opponens pollicis
• Abductor pollicis brevis
• Flexor pollicis brevis (superficial head)

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1.3 JOINTS OF THE UPPER EXTREMITY

Shoulder Girdle Joints

• Only bony connection between upper limb and axial skeleton
• Synovial saddle joint; has an articular disc
• Movements: elevation, depression, protraction, retraction, rotation
• Strong joint; rarely dislocates

• Between acromion and lateral end of clavicle
• Synovial plane joint; reinforced by coracoclavicular ligaments (conoid + trapezoid)
• Commonly injured in shoulder separation

Shoulder Joint (Glenohumeral Joint)

• Type: Synovial ball-and-socket joint (most mobile joint in the body)
• Articulation: Head of humerus (large ball) with glenoid cavity of scapula (shallow socket)
• Glenoid labrum deepens the socket (fibrocartilaginous rim)
• Joint capsule: Attached to margins of glenoid and anatomical neck of humerus; reinforced by 3 glenohumeral ligaments and tendons of rotator cuff
• Rotator Cuff (SITS): Stabilizes humeral head in glenoid
  • Supraspinatus - abduction initiation (0-15°)
  • Infraspinatus - lateral rotation
  • Teres minor - lateral rotation
  • Subscapularis - medial rotation
• Movements: Flexion, extension, abduction, adduction, medial/lateral rotation, circumduction
• Abduction: 0-15° Supraspinatus; 15-90° Deltoid; 90-180° Trapezius + Serratus anterior (scapular rotation)
• Most common dislocation: Anteroinferior (humeral head exits below glenoid) - axillary nerve at risk
• Coracoacromial arch - protects the superior aspect of the joint

Elbow Joint

• Type: Complex synovial joint with 3 articulations sharing one synovial cavity
  1. Humeroulnar (trochlea-trochlear notch) - hinge, flexion/extension
  2. Humeroradial (capitulum-radial head) - hinge + rotation
  3. Proximal radioulnar (radial head-radial notch of ulna) - pivot, pronation/supination
• Capsule: Reinforced by medial (ulnar) and lateral (radial) collateral ligaments; Annular ligament holds radial head in radial notch
• Fat pads: Overlie coronoid, olecranon, radial fossae - displaced on imaging in effusion ("sail sign")
• Carrying angle: 10-15° valgus normally (more in females)
• Clinical: "Pulled elbow" (Nursemaid's elbow) in children - radial head subluxation from annular ligament; Golfer's elbow - medial epicondylitis; Tennis elbow - lateral epicondylitis (ECRB origin)

Radio-Ulnar Joints

• Proximal radio-ulnar joint - at elbow (pivot joint, within elbow capsule)
• Distal radio-ulnar joint - at wrist (pivot joint)
• Together allow pronation and supination of the forearm (~180°)
• Interosseous membrane connects radius and ulna throughout the shaft

Wrist Joint (Radiocarpal Joint)

• Type: Synovial ellipsoid/condylar joint
• Articulation: Distal radius + articular disc (over ulna) articulates with scaphoid, lunate, triquetrum
• Movements: Flexion, extension, abduction (radial deviation), adduction (ulnar deviation)
• Ulnar deviation > radial deviation (because radial styloid extends more distally)
• Ligaments: Palmar radiocarpal, dorsal radiocarpal, radial and ulnar collateral ligaments

Joints of the Hand

• Intercarpal joints - plane synovial; limited gliding
• Carpometacarpal (CMC) joints:
  • Thumb (1st CMC) = saddle joint - widest range: flexion, extension, abduction, adduction, opposition, circumduction
  • 2nd-5th CMC = plane joints, limited movement
• Metacarpophalangeal (MCP) joints - condylar joints; flexion, extension, abduction, adduction
• Interphalangeal (IP) joints - hinge joints; flexion and extension only
  • Each finger has proximal IP (PIP) and distal IP (DIP)
  • Thumb has one IP joint only

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1.4 ARCHES OF THE HAND & SKIN OF THE PALM AND DORSUM

Arches of the Hand

• At the level of the distal carpal row (capitate is the keystone)
• Rigid, fixed arch

• At the level of the metacarpal heads (2nd metacarpal is the keystone)
• Flexible, mobile; allows cupping of the palm

• Runs from wrist through each ray (digit) to the fingertips
• Maintained by the intrinsic and extrinsic muscles of the hand

Skin of the Palm

• Thick, hairless, non-mobile skin (tightly bound to palmar aponeurosis by fibrous bands)
• Rich in sweat glands and sensory nerve endings
• Palmar aponeurosis is a triangular sheet of deep fascia; its thickening can cause Dupuytren's contracture (fibrosis causing flexion deformity of ring/little fingers)
• Digital flexor creases indicate positions of joints (the skin crease does not overlie the joint directly)

Skin of the Dorsum of Hand

• Thin, loose, and mobile (allows swelling/oedema to accumulate here easily)
• Hairy skin; no palmar aponeurosis equivalent
• Dorsal venous network drains into cephalic vein (lateral) and basilic vein (medial)

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BLOOD SUPPLY OF UPPER EXTREMITY

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VENOUS AND LYMPHATIC DRAINAGE

Superficial Veins

• Cephalic vein: Begins on dorsum of hand, runs along lateral forearm and arm, drains into axillary vein
• Basilic vein: Begins on dorsum, runs along medial aspect, drains into brachial vein / axillary vein
• Median cubital vein: Connects cephalic and basilic in front of elbow - used for venepuncture

Lymphatic Drainage

• Superficial lymphatics follow superficial veins
• Deep lymphatics follow arteries
• All lymphatics of upper limb drain to axillary lymph nodes (5 groups) and then to subclavian trunk

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QUICK REVISION TABLE - NERVE INJURIES

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• 1.1 Osteology - All 7 bone groups (clavicle, scapula, humerus, radius, ulna, carpals, metacarpals/phalanges) with clinical fracture patterns
• 1.2 Soft Parts - Pectoral region, axilla, brachial plexus (full table), all muscle compartments (arm front/back, forearm front/back, palm), cubital fossa in detail, nerves and blood vessels
• 1.3 Joints - Shoulder girdle, glenohumeral joint, elbow, radio-ulnar, wrist, hand joints
• 1.4 Arches of hand - All 3 arches + skin of palm and dorsum

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BD Chaurasia for BPT - The Honest Answer

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What Chaurasia Does Well

• Written specifically for Indian medical/paramedical students - language is simple and clear
• Covers all topics in your syllabus - nothing is missing
• Has good clinical notes and muscle tables (origin, insertion, nerve supply, action)
• The line diagrams are excellent for exam drawing
• Widely used across all BPT/MBBS programs in India

Where You Can Supplement (Optional, Not Mandatory)

• Joints and clinical anatomy - Snell's Clinical Anatomy has better clinical correlations if you ever feel Chaurasia's joint descriptions are brief
• Brachial plexus diagram - Some students find Chaurasia's plexus diagram slightly complex; a quick YouTube visual helps
• For practical/viva - Cunningham's Manual of Practical Anatomy (also on your list) is useful alongside Chaurasia

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