Clinical Anatomy of the

Upper Limb
Kara Mudd, MSPAS, PA-C
Contents

• Bones and Joints

• Clinical Anatomy of Upper Limb Joints
• Clinical Anatomy of Upper Limb Muscles
• Clinical Anatomy of Nerve affect Upper Limb Muscles
• Special Diagnostic Tests
Bones and Joints of Upper Limb
Regions Bones Joints
Shoulder Girdle Clavicle Sternoclavicular Joint
Scapula Acromioclavicular Joint
Bones of Arm Humerus Upper End: Glenohumeral Joint
Lower End: See below
Bones of Forearm Radius Humeroradial Joint
Ulna Humeroulnar Joint
Proximal Radioulnar Joint
Distal Radioulnar Joint
Bones of Wrist 8 Carpal Bones Intercarpal Joint
and Hand 5 Metacarpal Carpometacarpal Joint
14 Phalanges Metacarpophalangeal Joint
Interphalangeal Joint
Upper Limb Joints
Glenohumeral Joint Dislocation

• Most commonly dislocated major joint in body.

• Ball & Socket
• Large head of humerus to shallow glenoid cavity
• Stability depends almost entirely on the strength of
surrounding muscles (Rotator Cuff).
• Commonly dislocated anteriorly and inferiorly.
• Anteriorly shoulder joint protected by subscapularis.
• Superiorly shoulder joint protected by supraspinatus.
• Posteriorly shoulder joint protected by teres minor and
infraspinatus.
• Inferior aspect of shoulder joint completely unprotected.
Glenohumeral Joint Dislocation

Labral tears are common with

traumatic shoulder dislocations
Subacromial Bursitis

• Shoulder joint in abducted position = Pain

• Subacromial bursa is located inferior to
acromion, above supraspinatus tendon.
• Pain occur when abduction because
supraspinatus tendon comes in contact with
inferior surface of acromion, inflammed bursa
slips up underneath coraco-acromial arch and
gets impinged between supraspinatus tendon
and acromion.
Injection of the Subacromial Bursa
Frozen Shoulder (adhesive capsulitis)

• Pain and uniform limitation off all

movements of shoulder joint, though
there is NO evidence of radiological
changes in the joint.
• Occurs due to shrinkage and chronic
inflammation of capsule of glenohumeral
joint
• Causes:
• When nor moving the shoulder joint
for a period of time because of:
• Pain
• Injury
• Chronic health condition
Shoulder Separation (Acromioclavicular
Subluxation)

• Tearing of coracoclavicular and coracoacromial

ligaments caused by downward blow on tip of
shoulder.
• Coracoclavicular and coracoacromial joint spaces
become 50% wider than in normal contralateral
shoulder.
• Presenting features:
1. Injured arm hangs lower than normal (contralateral
arm)
2. Noticeable bulge at tip of shoulder as a result of
upward displacement of clavicle.
Olecranon Bursitis

• Inflammation of subcutaneous olecranon bursa (lying over the

subcutaneous triangular area on dorsal surface of olecranon
process of Ulna).
• Causes a round fluctuating painful swelling of 1” or so in
circumference over olecranon.
• Occurs due to:
1. Repeated friction as occurs in students who read for long hours with head
supported by hand and elbow resting on table.
2. Trauma during falls on elbow
3. Infection from abrasions of skin covering olecranon process.
Tennis Elbow (Lateral
epicondylitis)

• Repeated or violent extension of the wrist with

forearm pronated (i.e. movements required during
backhand strokes in lawn tennis), leads to
tenderness over lateral epicondyle of humerus.
• Possibly due to:
• Sprain of radial collateral ligament.
• Tearing of fibers of extensor carpi radialis brevis
muscle.
• Inflammation of the bursa underneath extensor
carpi radialis brevis
• Strain or tear of common extensor origin.
Golfer’s Elbow (Medial
Epicondylitis)

• Repetitive use of superficial flexors of forearm,

strains their common flexor origin with subsequent
inflammation of medial epicondyle (medial
epicondylitis).
• Characterised by pain on medial side of elbow.
Radial Head Subluxation

• Also known as nursemaid’s elbow.

• Vulnerable for preschool children (1-3 years old).
• Annular ligament is funnel-shaped in adults, but its sides are
vertical in young children. (When child is suddenly lifted/pulled
up when forearm is in pronated position, head or radius may slips
out partially from annular ligament).
• Pain and limitation of supination.
Aspiration of Elbow Joint

• Locate the head of radius and capitulum of

humerus. (flex elbow to 90 degrees, pronate and
supinate forearm and feel with the thumb its
rotation).
• Insert needle in the palpable depression between
proximal part of radial head and capitulum in a
direction directly forwards, the joint being flexed to
right angle and forearm semi pronated.
• Safest and most direct approach. When elbow is
distended with pus, the capsule bulges to either
side of triceps and hence the pus can easily and
effiviently be drained.
Upper limb Muscles
Preferred site for
Intramuscular Injection

Deltoid Muscles
• Well-developed in most adults
and easily accessible.
• Injection given in the lower half
to avoid injury to axillary nerve.
• Exact site of injection: Needle
should be inserted in center of
triangle.
• Place 4 fingers across deltoid
muscle with top finger kept along
acromial process, injection site is
3 fingers breadth below acromial
process.
Ruptured Supraspinatus

• Active initiation of abduction is not

possible.
• Patient gradually develop a trick of
tilting his body towards injured
side so that the arm swings away
from the body due to gravity
leading to 15 degrees initial
abduction. Later deltoid and
scapular rotators come into play to
do the required job.
• Sometimes may also lift arm on the
side of injury with opposite hand
to cause initial abduction
Upper Limb Nerves
Injury to the Long Thoracic Nerve

• Causes:
-Surgical injury
-axillary node dissection
-trauma

• Results in paralysis of the serratus anterior and

winged scapula/inability to abduct the arm
Paralysis of Serratus Anterior

• Functions of Serratus Anterior

• Keeps medial border of scapula in contact with
chest wall.
• Important role in abduction of arm and elevation
of arm above horizontal.
• Pulls scapula forward as in throwing, pushing and
punching.
• Effects of paralysis of serratus anterior
• Medial border of scapula stands out from the chest
wall, particularly when patient is asked to press
against a wall in front of him (winged scapula).
• Inability to raise arm above head.
• Inability to carry arm forward in breast stroke
swimming (Swimmer’s Palsy).
Suprascapular Nerve Entrapment

• Entrapment may occur as it passes through

suprascapular notch or in spinoglenoid
notch.
• Effects:
• Typical dull posterior and lateral shoulder pain.
• Tenderness, 2.5cm lateral to midpoint of spine of
scapular
• Weakness of shoulder abduction and external
rotation due to involvement of supraspinatus and
infraspinatus muscles.
Erb-Duchenne Paralysis (Erb’s Palsy)

• Brachial plexus injury at Erb’s point (C5, C6).

• Maybe injured during childbirth, due to
forcible downward traction of shoulder with
lateral displacement of head to other side
(Usually during forceps delivery).
• Upper limb assumes typical “waiter’s tip
position”:
• Shoulder adducted and medially rotated.
• Elbow extended
• Forearm pronated
Axillary Nerve damage

• Axillary nerve usually damaged by fractures of surgical neck of

humerus or due to an inferior dislocation of shoulder joint.
• Effects:
• Loss or weakness of abduction of shoulder (between 15 degrees to 90
degrees) due to paralysis of Deltoid.
• Rounded contour/profile of shoulder is lost due to paralysis of deltoid
• Sensory loss over lower half of the outer aspect of shoulder ‘regimental
badge area’.
Paralysis of teres minor is not easily demonstrated clinically.
Effects of Radial Nerve Injury

• Severity and symptoms

depend on site of lesion
• Most common clinical
finding is wrist drop
 Radial Nerve Injury (Axilla)
• Causes:
• Prolonged use of crutches (Crutch Paralysis)
• Effects:
• Loss of extension of elbow due to paralysis of
triceps.
• Loss of extension of wrist due to paralysis of
extensor muscles of forearm (Wrist Drop).
• Supination of forearm in elbow extension not
possible (paralysis of supinator)
• Loss of sensation over:
• Posterior surface of lower part of arm and
narrow strip over back of forearm
• Over lateral side of dorsum of hand and lateral
3½ fingers
• Loss of triceps and supinator reflexes.
Radial Nerve Injury (Radial Groove)

• Causes:
• Fracture of shaft of humerus
• Improper intramuscular injection
• Prolonged pressure
• Effects:
• Triceps brachii is spared (extension of elbow is possible)
• Other effects are similar as those of a lesion of radial nerve in axilla
Ulnar Nerve

Usually injured at
following sites:
Elbow
Cubital tunnel
Wrist
Hand
Effects depending on site
of lesion
Ulnar Nerve Injury at Elbow

• Easily damaged (lies in ulnar groove behind medial epicondyle of humerus)

• Causes:
• Fracture of medial epicondyle
• Effects:
• Loss of flexion of terminal phalanges of ring and little finger due to
paralysis of flexor digitorum profundus (medial half)
• Weakness of flexion and adduction of wrist due to paralysis of flexor
carpi ulnaris
• Ulnar Claw Hand
• Loss of adduction and abduction of fingers due to paralysis of Palmar
(adductors) and dorsal (abductors) interossei
• Loss of adduction of thumb due to paralysis of adductor pollicis.
• Flattening of hypothenar eminence and depression of interosseous
space due to atrophy of hypothenar and interosseous muscles
Ulnar Nerve Injury at Cubital Tunnel (Cubital
Tunnel Syndrome)

• Cubital Tunnel – Formed by tendinous arch

connecting 2 heads of flexor carpi ulnaris
(arise from humerus and ulna)
• Causes:
• Entrapment of ulnar nerve in this cubital tunnel
(osseofibrous tunnel).
• Effects same as ulnar nerve lesion in elbow
Median Nerve

• Injury usually injured at following

sites:
Axilla
Wrist
Carpal Tunnel
• Effects depending on site of
lesion
Median Nerve Injury at Axilla

• Motor Effects:
• Weakness of pronation of forearm due to paralysis of pronators.
• Deviation of wrist to Ulnar side on wrist flexion due to unopposed action of
flexor carpi ulnaris.
• Weakness of flexion of distal phalanx of thumb and index finger.
• Wasting of thenar muscles due to paralysis.
• Loss of opposition of thumb due to paralysis of opponens pollicis.
• Loss of flexion and weakness of abduction of thumb.
• Ape-hand deformity
• Sensory Effects:
• Loss of cutaneous sensations over palmar surface of lateral 3½ digits and
radial two-thirds of palm
 Medial Nerve Injury at Carpal Tunnel
(Carpal Tunnel Syndrome)
• Compression of medial nerve in carpal tunnel.
• More common in women than man.
• Causes
• Tendosynovitis
• Bony encroachment (osteoarthritis/injury)
• Myxoedema, pregnancy, hypothyroidism etc conditions
resulting in fluid accumulation.
• Weight gain.
• Symptoms
• Painful paraesthesia and numbness affecting radial 3½
digits of hand.
• Wasting and weakness of thenar muscles.
• Loss of sensation or hypoaesthesia to light touch and
pin prick over palmar aspect of radial 3½ digits and
corresponding part of hand except skin over thenar
eminence
Special Tests
Yergason Test

• To determine if biceps tendon is stable in bicipital groove.

• Steps:
• Instruct patient to fully flex elbow.
• Clinician grasp the flexed elbow in one hand while holding
his wrist with other hand.
• External rotate patient’s arm as he resists, at the same time
pull downward his elbow.
• If biceps tendon is unstable in bicipital groove, it will pop out
the groove and patient will experience pain; If stable, it remains
secure and patient have no experience of discomfort.
Drop Arm Test

• To detects any tears in the rotator cuff.

• Steps:
• Instruct patient to fully abduct his arm.
• Asked patient slowly lower it to his side.
• Of there are tears in rotator cuff (especially supraspinatus), arm will
drop to side from a position of about 90° abduction.
• Patient still will not be able to lower his arm smoothly and slowly no
matter how many times he tries.
• If he is able to hold his arm in abduction, gentle tap on forearm will
cause arm to fall to his side.
Apprehension Test

• To test for chronic shoulder dislocation or labral tear.

• Steps:
• Clinician abduct and externally rotate patient's arm to a position where it
might easily dislocate
• If patient's shoulder is ready to dislocate, the patient will have a
noticeable look of apprehension and alarm on his face and will
resist further motion.
Elbow Stability Test

• To assess stability of medial and lateral collateral ligaments of elbow.

• Steps:
• Clinician cup posterior aspect of patient's elbow in one hand and hold patient's
wrist with the other.
• The hand on the elbow will act as fulcrum, other hand will force the forearm
during the test.
• Instruct patient to flex his elbow few degrees while forcing his forearm
laterally, producing valgus stress on joint’s medial side.
• Then do it in reverse direction.
• Notice if any gapping collateral ligament with the clinician hand that act
as fulcrum.
Questions?
References

• Singh, V. (2007) Clinical & Surgical Anatomy, 2nd edn. Elsevier; New
Delhi.
• Snell, R.S. (2007) Clinical Anatomy: An Illustrated Review with
Questions and Explanations, 3rd Edn. Lippincott Williams &
Wilkins; Philadelphia.
• Slide share presentation by Gan Quan Fu, PT,
• Thieme
• http://orthoinfo.aaos.org