THE APPENDICULAR SYSTEM

Dr Saad Al Sabti

M B Ch B, Ph D (Lond)

The Musculoskeletal System

The human musculoskeletal system (also known as the
locomotor system) is an organ system that gives humans the
ability to move using their muscular and skeletal systems. The
musculoskeletal system provides form, support, stability, and
movement to the body.
It is made up of the bones of the skeleton, muscles, cartilage,
tendons, ligaments, joints, and other connective tissue that supports
and binds tissues and organs together.
Movements of different parts of the body require an interaction
between bones and muscles.
To understand how muscles produce different movements, one
should learn where the muscles attach to individual bones and the
types of joints acted on by the contracting muscles.

The Appendicular Skeleton

The appendicular skeleton consists of the bones of the upper and
lower limbs.
The upper and lower limbs are made up of bones that form the limb
girdles, and bones that form the free limbs.

The Upper Limb

The upper limb is characterized by its mobility and its ability to
grasp, strike, and conduct fine motor skills.
These characteristics are especially marked in the hand. Efficiency
of hand function results in a large part from the ability to place it in
the proper position by movements at the scapulothoracic, shoulder,
elbow, radioulnar, and wrist joints.

Bones of the upper limb consist of the bones of the shoulder girdle,
and those of the arm, the forearm, the wrist and the hand.

Bones of the Shoulder Girdle

The bones of the shoulder (pectoral) girdle consist of the clavicle
and the scapula, which articulate with one another at the
acromioclavicular joint.

The Clavicle (Collar Bone) /1

The clavicle is a long, slender bone that lies horizontally across the
root of the neck.
It articulates with the sternum and the first costal cartilage medially at
the sternoclavicular joint and with the acromion process of the
scapula laterally at the acromioclavicular joint.
The clavicle acts as a strut between the scapula and the sternum,
that holds the arm away from the trunk. It also transmits forces from
the upper limb to the axial skeleton and provides attachment for
muscles.
The clavicle is subcutaneous throughout its length;
its medial two thirds are convex forward and its lateral third is
concave forward.

Clavicle (Collar Bone) /2

The acromial end of the clavicle is flat, whereas the sternal end is
more robust and somewhat quadrangular in shape.

The inferior surface of the lateral third of the clavicle is rough

consisting of a tubercle medially, the conoid tubercle and, a lateral
roughening , the trapezoid line for the attachment of the
coracoclavicular ligament.
The superior surface of the clavicle is smoother than the inferior
surface

The Scapula /1
The scapula is a flat triangular bone that lies on the posterolateral
aspect of the thoracic cage between the second and the seventh
ribs. It connects the humerus with the clavicle.

It has two surfaces, three borders, three angles and three

processes.
On its posterior surface, the spine of the scapula projects
backward.
On the lateral end of the spine is the acromion process, which
articulates with the clavicle at the acromioclavicular joint.
The coracoid process projects upward and forward above the
glenoid cavity and provides attachment for muscles and ligaments.
The superolateral angle of the scapula forms the pear-shaped
glenoid cavity, or glenoid fossa, which articulates with the head of
the humerus at the shoulder joint.

The Scapula /2
The inferior angle of the scapula can be palpated easily in the living
subject and marks the level of the seventh rib and the spine of the
seventh thoracic vertebra.

Medial to the base of the coracoid process is the suprascapular

notch.
The anterior surface of the scapula is concave and forms the
shallow subscapular fossa.
The posterior surface of the scapula is divided by the spine into:
the smaller supraspinous fossa above and the larger
infraspinous fossa below.

Bones of the Arm:

The Humerus /1
The humerus is the bone of the arm. It articulates with the scapula
at the shoulder joint and with the radius and ulna at the elbow joint.
The upper end of the humerus has a head, which forms about one
third of a sphere and articulates with the glenoid cavity of the
scapula.
Immediately below the head is a short, narrow constriction, the
anatomical neck.
Below the neck are the greater and lesser tubercles, separated
from each other by the bicipital (intertubercular) groove or
sulcus. These tubercles serve as attachment sites for the rotator
cuff muscles of the shoulder joint

The Humerus /2
The greater tubercle is lateral in position, whereas the lesser
tubercle is anterior in position.
Where the upper end of the humerus joins the shaft, there is a
narrow surgical neck.
Because the surgical neck is weaker than the more proximal regions
of the humerus, it is one of the sites where the humerus commonly
fractures. A fracture in this area is most likely to cause damage to
the axillary nerve and posterior circumflex humeral artery. Damage
to the axillary nerve affects function of the teres minor and deltoid
muscles
About halfway down the lateral aspect of the shaft is a roughened
elevation called the deltoid tuberosity.

On the posterior surface of the humerus is the spiral (radial)

groove, which accommodates the radial nerve and the profunda
brachii artery.

The Humerus /3
The body (shaft) of the humerus has an anterior, medial and lateral
borders.
The lower end of the humerus possesses the medial and lateral
epicondyles for the attachment of muscles and ligaments, the
rounded capitulum for articulation with the head of the radius, and
the pulley-shaped trochlea for articulation with the trochlear notch of
the ulna.
Above the capitulum is the radial fossa, which receives the head of
the radius when the forearm is flexed.
Above the trochlea anteriorly is the coronoid fossa, which during
the same movement (flexion) receives the coronoid process of the
ulna.
Above the trochlea posteriorly is the olecranon fossa, which
receives the olecranon process of the ulna when the forearm is
extended

Bones of the Forearm

The bones of the forearm are the radius and the ulna.

The Radius /1
The radius is the lateral bone of the forearm.
Its proximal end articulates with the humerus at the elbow joint
and with the ulna at the proximal radioulnar joint.
Its distal end articulates with the scaphoid and lunate bones of the
wrist at the wrist joint and with the ulna at the distal radioulnar
joint.
At the proximal end of the radius is the small circular head.

The Radius /2
The upper surface of the head is concave and articulates with the
convex capitulum of the humerus.
The circumference of the head articulates with the radial notch of the
ulna at the proximal radioulnar joint.
Below the head, the bone is constricted to form the neck.

Below the neck is the radial (bicipital) tuberosity for the insertion
of the biceps brachii muscle.
The shaft of the radius, in contradistinction to that of the ulna, is
wider below than above.

The Radius /3
The shaft of the radius has three borders (anterior, posterior and
interosseous), and three surfaces (anterior, posterior and
lateral).
It has a sharp interosseous border medially for the attachment of the
interosseous membrane that binds the radius and ulna together.
The pronator tubercle, for the insertion of the pronator teres
muscle, lies halfway down on its lateral side.
At the distal end of the radius is the styloid process; this projects
distally from its lateral margin.
On the medial surface of the distal end is the ulnar notch, which
articulates with the head of the ulna at the distal radioulnar joint.

The Radius /4
The inferior articular surface of the radius bone articulates with the
scaphoid and lunate carpal bones.
On the posterior aspect of the distal end is a small tubercle, the
dorsal tubercle, which acts as a pulley for the tendon of the
extensor pollicis longus muscle.

The Ulna /1
The ulna is the medial bone of the forearm.
Its proximal end articulates with the humerus at the elbow joint and
with the head of the radius at the proximal radioulnar joint.

Its distal end articulates with the radius at the distal radioulnar joint,
but it is excluded from the wrist joint by the articular disc.
The proximal end of the ulna is large and is known as the olecranon
process; this forms the prominence of the elbow.

The Ulna /2
The olecranon process has a notch on its anterior surface, the
trochlear notch, which articulates with the trochlea of the humerus.
Below the trochlear notch is the triangular coronoid process, which
has on its lateral surface the radial notch for articulation with the
head of the radius.
At the junction of the anterior surface of the coronoid process with
the front of the body is a rough eminence, the tuberosity of the
ulna or (ulnar tuberosity), which gives insertion to the brachialis
muscle.
The shaft of the ulna tapers from above downard.
The ulna has three borders (anterior, posterior and interosseous),
and three surfaces (anterior , posterior and medial).

It has a sharp interosseous border laterally for the attachment of

the interosseous membrane.

The Ulna /3
The posterior border is sharp and subcutaneous and can be easily
palpated throughout its length.
Below the radial notch is a depression, the supinator fossa, which
gives clearance for the movement of the radial tuberosity of the
radius.
The posterior border of the fossa is sharp and is known as the
supinator crest; it gives origin to the supinator muscle.

At the distal end of the ulna is the small rounded head, which has a
projection from its medial aspect, the styloid process.

Bones of the Wrist & Hand /1

There are eight carpal bones, made up of two rows of four bones
each.

The proximal row consists of (from lateral to medial) the

scaphoid, lunate, triquetrum, and pisiform bones.
The distal row consists of (from lateral to medial) the trapezium,
trapezoid, capitate, and hamate bones.
Together, the bones of the carpus present on their anterior surface
a concavity (carpal arch), to the lateral and medial edges of which
is attached a strong membranous band called the flexor
retinaculum.

Bones of the Wrist & Hand /2

In this manner, an osteofascial tunnel, the carpal tunnel, is formed
for the passage of the median nerve and the flexor tendons of the
digits.

The canal is narrow, and when any of the nine long flexor tendons
passing through it swell or degenerate, the narrowing of the canal
often results in the median nerve becoming entrapped or
compressed, a common medical condition known as carpal tunnel
syndrome.
There are five metacarpal bones, each of which has a base, a
shaft, and a head.

The first metacarpal bone of the thumb is the shortest and most
mobile. It does not lie in the same plane as the others but occupies
a more anterior position.
It is also rotated medially through a right angle so that its extensor
surface is directed laterally and not backward (posteriorly) as the
other metacarpal bones do.

Bones of the Hand /3

The bases of the metacarpal bones articulate with the distal row of
the carpal bones at the carpo-metacarpal joints, whereas the
heads, which form the knuckles, articulate with the proximal
phalanges at the metacarpo-phalangeal joints.
The shaft of each metacarpal bone is slightly concave forward and
is triangular in transverse section. Its surfaces are posterior, lateral,
and medial.
There are three phalanges for each of the fingers but only two for
the thumb.

Muscles of the Shoulder

Muscles of the Shoulder

The shoulder muscles can be described according to their location
and the areas of the skeleton to which they are attached into, the:

A. Anterior axioappendicular muscles (pectoralis major, pectoralis

minor, subclavius and serratus anterior.
B. Posterior axioappendicular muscles, of which there are three
subgroups:
1.superficial posterior axioappendicular muscles
( trapezius and latissimus dorsi)
2 .deep posterior axioappendicular muscles (levator scapulae and
rhomboids)
3. Scapulohumeral muscles (deltoid, teres major, and the four
rotator cuff muscles : the supraspinatus, infraspinatus, teres minor, and
subscapularis.

A. Anterior Axioappendicular Muscles /1

Four anterior axioappendicular or pectoral muscles move the
pectoral girdle: these are the pectoralis major, pectoralis minor,
subclavius, and serratus anterior.
The fan-shaped pectoralis major covers the superior part of the
anterior aspect of the thorax. It has two heads of origin, a clavicular
head and a sternocostal head,

The pectoralis major muscle is responsible for the muscular mass

that forms most of the anterior wall of the axilla, with its inferior
border forming the anterior axillary fold.
The pectoralis major and the adjacent deltoid muscle form the
narrow deltopectoral groove, in which the cephalic vein runs.
However, the muscles diverge slightly from each other superiorly
and, along with the clavicle, form the clavipectoral triangle.

A. Anterior Axioappendicular Muscles /2

The pectoralis major adducts, flexes, and medially rotates the arm.
The smaller triangular pectoralis minor muscle lies in the anterior
wall of the axilla, where it is almost completely covered by the
pectoralis major. The pectoralis minor muscle stabilizes the scapula
and is used when stretching the upper limb forward to touch an
object that is just out of reach.
With the coracoid process, the pectoralis minor forms a "bridge"
under which vessels and nerves pass to the arm.
Thus the pectoralis minor is a useful anatomical and surgical
landmark for structures in the axilla (e.g., the axillary artery).

A. Anterior Axioappendicular Muscles /3

The subclavius muscle lies almost horizontally when the arm is in
the anatomical position. This small, round muscle is located inferior
to the clavicle and affords some protection to the subclavian vessels
and the superior trunk of the brachial plexus if the clavicle fractures.
The serratus anterior muscle overlies the lateral part of the thorax
and forms the medial wall of the axilla.
This broad sheet of thick muscle fibers was given its name because
of the saw tooth appearance of its fleshy slips or digitations (L.
serratus, a saw). By keeping the scapula closely applied to the
thoracic wall, the serratus anterior anchors this bone, enabling other
muscles to use it as a fixed bone for movements of the humerus.
The muscle is supplied by the long thoracic nerve. Paralysis of
serratus anterior muscle leads to a condition referred to as winging
of the scaula, in which the scapula protrudes from the back of the
person in an abnormal position.

B. Posterior Axioappendicular &

Scapulohumeral Muscles
The posterior axioappendicular muscles attach the upper limb to
the axial skeleton. The posterior shoulder muscles are divided into
three groups:
1. Superficial posterior axioappendicular muscles: trapezius and
latissimus dorsi.

2. Deep posterior axioappendicular muscles: levator scapulae and

rhomboids
3. Scapulohumeral muscles: deltoid, teres major, and the four
rotator cuff muscles (supraspinatus, infraspinatus, teres minor, and
subscapularis).

1. Superficial Posterior Axioappendicular Muscles /1

The trapezius muscle provides a direct attachment of the pectoral
girdle to the trunk.
This large trapezoid muscle covers the posterior aspect of the neck and
the superior half of the back.

The trapezius attaches the pectoral girdle to the cranium and vertebral
column and assists in suspending the upper limb.
The fibers of the trapezius muscle are divided into three parts that have
different actions at the scapulothoracic joint between the scapula and
the thoracic wall:
Descending (superior) part elevates the scapula (e.g., when squaring
shoulders).
Middle part retracts the scapula (i.e., pulls it posteriorly).
Ascending (inferior) fibers depress the scapula and lower the shoulder.

1. Superficial Posterior Axioappendicular Muscles /2

The latissimus dorsi is a large, fan-shaped muscle that covers the
inferior part of the back from the T6 vertebra to the iliac crest.
It passes from the trunk to the humerus and acts directly on the
shoulder joint and indirectly on the pectoral girdle (scapulothoracic
joint).
The latissimus dorsi muscle extends, adducts, and medially rotates
the arm.

2. Deep Posterior Axioappendicular Muscles

True to its name, the levator scapulae muscle acts with the
superior part of trapezius to elevate the scapula.
The superior third of the levator scapulae lies deep to the
sternocleidomastoid muscle; the inferior third is deep to the
trapezius muscle..
Acting bilaterally, the levator scapulae muscles extend the neck;
acting unilaterally, the muscle contributes to lateral flexion of the
neck.
The two rhomboids (rhomboid major and minor) lie deep to the
trapezius and form parallel bands that pass inferolaterally from the
vertebrae to the medial border of the scapula.
The thin flat rhomboid major is approximately two times wider than
the thicker rhomboid minor lying superior to it.
The rhomboids retract and rotate the scapula, depressing the
glenoid cavity. They also assist the serratus anterior in holding the
scapula against the thoracic wall and fixing the scapula during
movements of the upper limb.

3. Scapulohumeral Muscles /1
The six scapulohumeral muscles (the deltoid, teres major,
supraspinatus, infraspinatus, subscapularis, and teres minor) are
relatively short muscles that pass from the scapula to the humerus
and act on the shoulder joint.

The deltoid is a thick powerful muscle forming the rounded contour

of the shoulder. The muscle is divided into clavicular (anterior),
acromial (middle), and spinal (posterior) parts that can act
separately or as a whole.
When all three parts contract simultaneously, the arm is abducted.
The anterior (clavicular) fibers of deltoid muscle flex and medially
rotate the arm; the posterior (spinal) fibers of the muscle extend and
laterally rotates the arm.

3. Scapulohumeral Muscles /2
From the fully adducted position, abduction of the arm must be
initiated by the supraspinatus muscle. The deltoid becomes fully
effective as an abductor after the initial 15 of abduction.
The teres major is a thick rounded muscle that lies on the
inferolateral third of the scapula. It adducts and medially rotates the
arm, but along with the deltoid and rotator cuff muscles it is an
important stabilizer of the humeral head in the glenoid cavity during
movement.

Rotator cuff muscles

Four of the scapulohumeral muscles supraspinatus,
infraspinatus, teres minor, and subscapularis are called rotator
cuff muscles because they form a musculotendinous rotator cuff
around the glenohumeral joint.
The supraspinatus, besides being part of the rotator cuff muscles,
initiates the first 15 or so of abduction movement of the arm.
The tendons of the rotator cuff muscles blend with the capsule of the
shoulder joint, reinforcing it as the musculotendinous rotator cuff,
which protects the joint and gives it stability.
Contraction of these muscles holds the relatively large head of the
humerus firmly against the small and shallow glenoid cavity during
arm movements.

The Axilla (Arm pit) /1

The axilla or arm pit is the pyramidal shaped hollow space which is
located inferior to the shoulder and superior to the skin and axillary
fascia where your arm and body meet.
The shape and size of the axilla varies, depending on the position of
the arm; it almost disappears when the arm is fully adducted.
The axilla provides a passageway for vessels and nerves going into
and out from the upper limb.
The axilla has an apex, base, and four walls, three of which are
muscular:

The Axilla /2

The apex of the axilla is the cervicoaxillary canal, the passageway

between the neck and the axilla. It is bounded by the 1st rib,
clavicle, and superior edge of the scapula. Arteries, veins,
lymphatics, and nerves traverse this superior opening to pass into or
out from the arm.
The base of the axilla is formed by the concave skin, subcutaneous
tissue, and axillary (deep) fascia extending from the arm to the
thoracic wall forming the axillary fossa.

The Axilla /3

The anterior wall of the

axilla is formed by the
pectoralis major and
minor muscles and the
pectoral and
clavipectoral fascia
associated with them.

The clavipectoral
fascia is a sheet of
membrane filling in the
space between clavicle
and pectoralis minor,
limited laterally by the
coracoid process.

The anterior axillary

fold is the inferiormost
part of the anterior wall
of the axilla. It is formed
by the inferior border of
pectolaris major muscle.

The Axilla /4
The posterior wall of the axilla is formed superiorly by the scapula
and the subscapularis muscle on its anterior surface and inferiorly
by the teres major and latissimus dorsi.
The posterior axillary fold is the inferiormost part of the posterior
wall that may be grasped. It is formed by the teres major and
latissimus dorsi muscles.
The medial wall of the axilla is formed by the thoracic wall (1st-4th
ribs and intercostal muscles) and the overlying serratus anterior
muscle.

The Axilla /5
The lateral wall of the axilla is the narrow bony wall formed by the
intertubercular groove of the humerus.

The axilla contains the axillary artery and its branches, the axillary
vein and its tributaries, nerves of the cords and branches of the
brachial plexus, lymphatic vessels, and several groups of axillary
lymph nodes, all embedded in axillary fat.
Proximally, the neurovascular structures in the axilla are ensheathed
in a sleeve-like extension of the cervical fascia, the axillary sheath

The Arm (Upper Arm, Brachium)

The arm proper (brachium), sometimes called the upper arm, the
region between the shoulder and the elbow, is composed of the
humerus with the elbow joint at its distal end.
The arm extends from the shoulder to the elbow.
Two types of arm movement occur at the elbow joint: flexionextension and pronation - supination.
The muscles performing these movements are clearly divided into
anterior (flexor) and posterior (extensor) groups.
The chief action of both groups of muscles is at the elbow joint, but
some muscles also act at the shoulder joint.

Fascial Compartments of the Arm

The arm is enclosed in a sheath of deep fascia.
Two intermuscular fascial septa (the medial intermuscular and
the lateral intermuscular) extend from this sheath and are attached
to the medial and lateral borders of the humerus, respectively.
By this means, the arm is divided into an anterior and a posterior
fascial compartment, with each compartment having its own
muscles, nerves and blood vessels.

Muscles of The Arm

Of the four arm muscles, three flexors (biceps brachii, brachialis,
and coracobrachialis) are in the anterior (flexor) compartment of
the arm and are supplied by the musculocutaneous nerve, and one
extensor (triceps brachii) is in the posterior compartment of the
arm, supplied by the radial nerve.

In addition to the triceps muscle in the posterior compartment of the

arm, there is a small triangular muscle the anconeus, covering the
posterior aspect of the elbow.

Anterior compartment of the arm

Biceps brachii muscle
The biceps brachii muscle, as its name implies, has two heads : a
long head and a short head.

A broad fascial band, the transverse humeral ligament, passes

from the lesser to the greater tubercle of the humerus and converts
the intertubercular groove into a canal for the tendon of the long
head of the biceps.
When the elbow is extended, the biceps is a simple flexor of the
forearm; however, as the elbow flexion approaches 90 and more
power is needed, the biceps with the forearm in supination produces
flexion, but with the forearm in pronation the biceps is the prime
mover (most powerful) supinator of the forearm.
A triangular membranous band, the bicipital aponeurosis, runs
from the biceps tendon across the cubital fossa and merges with the
antebrachial (deep) fascia covering the flexor muscles in the medial
side of the forearm.

Brachialis & coracobrachialis muscles

The brachialis is a flattened fusiform muscle that lies posterior
(deep) to the biceps brachii muscle.
It is the prime flexor muscle of the forearm, producing the greatest
amount of flexion force. It flexes the forearm in all positions and
during slow and quick movements.
The coracobrachialis, an elongated muscle in the superomedial
part of the arm, is a useful landmark for locating other structures in
the arm.

The musculocutaneous nerve pierces it, and the distal part of its
attachment indicates the location of the nutrient foramen of the
humerus.
The coracobrachialis muscle helps flex and adduct the arm and
stabilizes the shoulder joint.

Posterior compartment of the arm

Triceps brachii muscle
The triceps brachii is a large fusiform muscle in the posterior
compartment of the arm that arises by means of three heads, a
long, lateral, and medial.
The triceps is the main extensor muscle of the forearm at the elbow.
The anconeus is a small muscle located in the inferior aspect of the
arm. It assists triceps in extending the forearm as well as stabilizing
the elbow joint.

The Cubital fossa

The cubital fossa is the shallow triangular depression on the
anterior surface of the elbow.
The boundaries of the cubital fossa are:
- The base of the triangle is an imaginary line connecting the
medial and lateral epicondyles of the humerus.
- Medially, the pronator teres muscle
- Laterally, the brachioradialis muscle

From medial to lateral, the cubital fossa contains the median nerve,
the bifurcation of the brachial artery into the ulnar and radial
arteries, the tendon of biceps brachii muscle, and the radial nerve.
Lying in the superficial fascia covering the fossa are the cephalic
and the basilic veins and their tributaries.

The Forearm
The forearm lies between the elbow and the wrist and contains two
bones, the radius and ulna, which are joined by an interosseous
membrane.
The role of forearm movement, occurring at the elbow and
radioulnar joints, is to assist the shoulder in the application of force
and in controlling the placement of the hand in space.

Fascial compartments of the forearm

The forearm is enclosed in a sheath of deep fascia, which is
attached to the periosteum of the posterior subcutaneous border of
the ulna.
Together with the interosseous membrane and fibrous intermuscular
septa, this fascial sheath divides the forearm into several
compartments, with each compartment having its own muscles,
nerves and blood supply.

Flexor & Extensor Retinacula

Retinacula are bands of deep fascia that hold the long flexor and
extensor tendons in position at the wrist.
The flexor retinaculum is attached medially to the pisiform bone
and the hook of hamate and laterally to the tubercle of the scaphoid
and the trapezium bones.
The extensor retinaculum is attached medially to the pisiform bone
and the hook of the hamate and laterally to the distal end of the
radius.
The bones of the hand in the wrist region (carpal bones) and the
flexor retinaculum form the carpal tunnel.

Muscles of Forearm
The tendons of the forearm muscles pass through the distal part of
the forearm and continue into the wrist, hand, and fingers.
The flexors and pronator muscles of the forearm are in the anterior
compartment of the forearm and are served mainly by the median
nerve; the one and a half muscle exceptions are innervated by the

ulnar nerve.

The extensors and supinator muscles of the forearm are in the

posterior compartment and are all innervated by the radial nerve.

Flexor- Pronator Muscles of the Forearm /1

The flexor-pronator muscles are in the anterior compartment of the
forearm.
The tendons of most flexor muscles pass across the anterior surface
of the wrist and are held in place by the flexor retinaculum, a
thickening of the deep fascia of the forearm.
The flexor muscles are arranged in three layers:
1. A superficial layer of four muscles which are the pronator
teres, flexor carpi radialis, palmaris longus, and flexor carpi
ulnaris.

These muscles are all attached proximally to the medial epicondyle

of the humerus, the common flexor origin.

Flexor- Pronator Muscles of the Forearm /2

2. An Intermediate layer, consisting of one muscle, the flexor
digitorum superficialis [FDS].
3. A deep layer of three muscles: the flexor digitorum profundus
[FDP], the flexor pollicis longus, and the pronator quadratus.
The five superficial muscles and the intermediate muscle cross the
elbow joint; the three deep muscles do not.
Functionally, the brachioradialis muscle is a flexor of the forearm,
but it is located in the posterior (posterolateral) or extensor
compartment and is thus supplied by the radial nerve. Therefore, the
brachioradialis is a major exception to the generalization that the
radial nerve supplies only extensor muscles and that all flexors lie in
the anterior compartment.

Flexor- Pronator Muscles of the Forearm /2

The long flexors of the digits (FDS and FDP) also flex the
metacarpophalangeal and wrist joints.

The FDP flexes the fingers in slow action; this action is reinforced by
the FDS when speed and flexion against resistance are required.
When the wrist is flexed at the same time the metacarpophalangeal
and interphalangeal joints are flexed, the long flexor muscles of the
fingers are operating over a shortened distance between
attachments, and the action resulting from their contraction is
consequently weaker.

Flexor- Pronator Muscles of the Forearm /3

Extending the wrist increases their operating distance, and thus their
contraction is more efficient in producing a strong grip.
Tendons of the long flexors of fingers pass through the distal part of
the forearm, wrist, and palm and continue to the medial four digits.
The FDS flexes the middle phalanges; the FDP flexes the distal
phalanges.
The pronator quadratus muscle is the prime mover for pronation.
The pronator quadratus initiates pronation and is assisted by the
pronator teres when more speed and power are needed.

Insertion of the long flexor tendons

Each tendon of the flexor digitorum superficialis is divided into two
halves that pass around the profundus tendon and meet on its
posterior surface.

The superficialis tendon, having united again, then divides into two
further slips, which are attached to the borders of the base of the
middle phalanx.
Each tendon of the flexor digitorum profundus, having passed
through the superficialis tendon, is inserted into the base of the distal
phalanx.

Extensor Muscles of the Forearm /1

The extensor muscles are in the posterior compartment of the
forearm, and all are innervated by branches of the radial nerve.
These muscles are organized into three functional groups:
- Muscles that extend and abduct or adduct the hand at the wrist
joint (extensor carpi radialis longus, extensor carpi radialis
brevis, and extensor carpi ulnaris).

- Muscles that extend the medial four digits (extensor digitorum,

extensor indicis, and extensor digiti minimi).
- Muscles that extend or abduct the thumb (abductor pollicis
longus [APL], extensor pollicis brevis [EPB], and extensor
pollicis longus [EPL]).
Besides, there is the supinator muscle lying between the lateral
epicondyle of the humerus and the neck and shaft of radius, the
action of which is supination of the forearm.

Extensor Muscles of the Forearm /2

The extensor tendons are held in place in the wrist region by the
extensor retinaculum, which prevents bowstringing of the tendons
when the hand is extended at the wrist joint.
As the tendons pass over the dorsum of the wrist, they are covered
with synovial tendon sheaths, which reduce friction for the
extensor tendons as they traverse the osseofibrous tunnels formed
by the attachment of the extensor retinaculum to the distal radius
and ulna.
The extensor muscles are organized anatomically into superficial
and deep layers.

Extensor Muscles of the Forearm /3

Four superficial extensors (extensor carpi radialis brevis,
extensor digitorum, extensor digiti minimi, and extensor carpi
ulnaris) are attached proximally by a common extensor tendon to
the lateral epicondyle of the humeus.
The proximal attachment of the other two superficial extensors
(brachioradialis and extensor carpi radialis longus) is to the
lateral supracondylar ridge of the humerus.
The four flat tendons of the extensor digitorum pass deep to the
extensor retinaculum to the medial four fingers.

Extensor Muscles of the Forearm /4

On the dorsum of the hand, the tendons of extensor digitorum
spread out as they run toward the fingers. Adjacent tendons are
linked proximal to the metacarpophalangeal joints by three oblique
intertendinous connections that restrict independent extension of
the fingers.
Consequently, normally no finger can remain fully flexed as the
other ones are fully extended.
On the distal ends of the metacarpals and along the phalanges, the
four tendons of extensor digitorum flatten to form extensor
expansions.

Extensor Muscles of the Forearm /5

The tendons of the interosseous and lumbrical muscles of the hand
join the lateral bands of the extensor expansion.
The deep extensor muscles of forearm, abductor pollicis longus
(APL), extensor pollicis brevis (EPB), and extensor pollicis
longus (EPL) act on the thumb.
The extensor indicis muscle confers independence to the index
finger in that it may act alone or together with the extensor
digitorum.
The tendons of the APL and EPB bound the triangular anatomical
snuffbox laterally, and the tendon of the EPL bounds it medially.
The snuffbox is visible as a hollow on the lateral aspect of the wrist
when the thumb is extended fully.

Insertion of the long extensor tendons /1

The four tendons of the extensor digitorum muscle fan out over
the dorsum of the hand.

The tendon of this muscle to the index finger is joined on its medial
side by the tendon the extensor indicis muscle. The tendon of the
little finger is joined on its medial side by the tendon of the extensor
digiti minimi.

Insertion of the long extensor tendons /2

Each extensor expansion is a triangular tendinous aponeurosis that
wraps around the dorsum and sides of a head of the metacarpal and
the base of the proximal phalanx.
Near the proximal interphalangeal joint, the extensor expansion then
splits into three bands: a central band, which is inserted into the
base of the middle phalanx, and two lateral bands, which pass to
the base of the distal phalanx.
The tendons of the interosseous and lumbrical muscles of the hand
join the lateral bands of the extensor expansion.

The Hand
The palmar aspect of the hand features a central concavity that
separates two eminences: a lateral more prominent thenar
eminence proximal to the base of the thumb, and a medial, smaller
hypothenar eminence proximal to the base of the little finger.
The anterior surface of each finger from the metacarpal head to the
base of the distal phalanx is provided with a strong, fibrous sheath
called the fibrous flexor sheaths, that is attached to the sides of
the phalanges.

The sheath and the bones form a blind tunnel in which the long
flexor tendons of the finger lie.

Synovial flexor sheaths

In the hand, the tendons of the flexor digitorum superficialis and
profundus muscles invaginate a common synovial sheath.
The medial part of this common synovial sheath extends distally
without interruption on the tendon of the little finger.
The lateral part of the sheath stops abruptly on the middle of the
palm, and the distal ends of the long flexor tendons of the index, the
middle, and the ring fingers acquire digital synovial sheaths as
they enter the finger.
The flexor pollicis longus tendon has its own synovial sheath that
passes into the thumb.
These sheaths allow the long tendons to move smoothly, with a
minimum of friction, beneath the flexor retinaculum and the fibrous
flexor sheaths.

Palmar apponeurosis
In the palm, the deep fascia is greatly thickened to protect the
underlying tendons, nerves, and blood vessels and is called the
palmar apponeurosis.
The palmar apponeurosis is continuous proximally with the palmaris
longus tendon, and it is attached to the flexor retinaculum.

The distal end of the apponeurosis divides at the bases of the

fingers into four slips that pass into the fingers forming the fibrous
digital sheaths.
The palmar apponeurosis is continuous also with the deep fascia
covering the thenar and hypothenar eminences.

Muscles of Hand
The intrinsic muscles of the hand are located in five
compartments:
Thenar muscles in the thenar compartment: abductor pollicis
brevis, flexor pollicis brevis, and opponenes pollicis.

Hypothenar muscles in the hypothenar compartment: abductor

digiti minimi, flexor digiti minimi brevis, and opponens digiti minimi.
Adductor pollicis muscle in the Adductor compartment
The short muscles of the hand, the lumbricals, in the central
compartment together with the long flexor muscles.
The interossei muscles in separate interosseous compartments
between the metacarpals.

The Shoulder Joint /1

The glenohumeral (shoulder) joint is a ball and socket synovial
joint that permits a wide range of movements; however, its mobility
makes the joint relatively unstable.

Articulation and Joint capsule

The large humeral head articulates with the relatively shallow
glenoid cavity of the scapula, which is deepened slightly by the ringlike, fibrocartilaginous structure the glenoid labrum.
Both articular surfaces are covered with hyaline cartilage.
The glenoid cavity accepts little more than a third of the humeral
head, which is held in the cavity by the tonus of the
musculotendinous rotator cuff muscles (supraspinatus,
infraspinatus, teres minor, and subscapularis).

The Shoulder Joint /2

The loose fibrous layer of the joint capsule surrounds the
glenohumeral joint and is attached medially to the margin of the
glenoid cavity and laterally to the anatomical neck of the humerus.

Superiorly, the fibrous layer encloses the proximal attachment of the

long head of biceps brachii to the supraglenoid tubercle of the
scapula within the joint.
The inferior part of the joint capsule, the only part not reinforced by
the rotator cuff, muscles, is its weakest area. It is in this area that the
capsule is particularly lax and lies in folds when the arm is adducted;
however, it becomes taut when the arm is abducted

The Shoulder Joint /3

The synovial membrane lines the internal surface of the joint
capsule and reflects from it onto the glenoid labrum and the
humerus as far as the articular margin of the head.
The synovial membrane also forms a tubular sheath for the tendon
of the long head of the biceps brachii.
Anteriorly, there is a communication between the subscapular bursa
and the synovial cavity of the joint.

Nerve supply: The shoulder joint is supplied by the axillary and

suprascapular nerves.

Ligaments of the shoulder joint /1

The glenohumeral ligaments, evident only on the internal aspect of
the capsule, strengthen the anterior aspect of the capsule.
The glenohumeral ligaments are intrinsic ligaments that are part of
the fibrous layer of the joint capsule.
The coracohumeral ligament, a strong band that passes from the
base of the coracoid process to the anterior aspect of the greater
tubercle of the humerus, strengthens the capsule superiorly.
The transverse humeral ligament is a broad fibrous band that runs
from the greater to the lesser tubercles of the humerus, bridging
over the intertubercular groove and converting the groove into a
canal for the tendon of the long head of biceps brachii and its
synovial sheath.

Ligaments of the shoulder joint /2

The coracoacromial arch is an extrinsic, protective structure
formed by the smooth inferior aspect of the acromion and coracoid
process of the scapula, with the coracoacromial ligament
spanning between them.
The coracoacromial arch overlies the head of the humerus,
preventing its superior displacement from the glenoid cavity.
The arch is so strong that a forceful superior thrust of the humerus
will not fracture it; the shaft of the humerus or clavicle fractures first.

Movements at the shoulder joint /1

The shoulder joint has more freedom of movement than any other joint
in the body. This freedom results from the laxity of its joint capsule and
the large size of the humeral head compared with the small size of the
glenoid cavity.
The shoulder joint allows movements around the three axes and
permits flexion-extension, abduction-adduction and rotation (medial
and lateral) of the humerus, and circumduction.
Flexion: Normal flexion is about 90

Extension: Normal extension is about 45

Abduction: Abduction of the upper limb occurs both at the shoulder
joint and between the scapula and the thoracic wall. The middle fibers
of deltoid, assisted by the supraspinatus are involved.

Movements at the shoulder joint /2

Adduction: Normally, the upper limb can be swinged 45 across the
front of the chest.
Lateral rotation: Normal lateral rotation is 40 to 45.
Medial rotation: Normal medial rotation is about 55.
Circumduction: This is not an independent movement but rather a
combination of the above movements.

The Elbow Joint /1

The elbow joint, a hinge type of synovial joint, is located 2-3 cm
inferior to the humeral epicondyles.

Articulation and joint capsule

The spool-shaped trochlea and spheroidal capitulum of the humerus
articulate with the trochlear notch of the ulna and the slightly
concave superior aspect of the head of radius, respectively;
therefore, there are humero-ulnar and humero-radial articulations.

The fibrous layer of the joint capsule surrounding the joint is

attached to the humerus at the margins of the lateral and medial
ends of the articular surfaces of the capitulum and trochlea.
Anteriorly and posteriorly, it is carried superiorly, proximal to the
coronoid and olecranon fossae.

The Elbow Joint /2

The synovial membrane lines the internal surface of the fibrous
layer of the joint capsule.
It is continuous inferiorly with the synovial membrane of the proximal
radioulnar joint.
The joint capsule is weak anteriorly and posteriorly but is
strengthened on each side by ligaments.

Ligaments of elbow joint /1

The collateral ligaments of the elbow joint are strong triangular

bands that are medial and lateral thickenings of the fibrous layer of
the joint capsule.
The lateral, fanlike radial collateral ligament extends from the
lateral epicondyle of the humerus and blends distally with the anular
ligament of the radius.

This ligament (the anular ligament) encircles and holds the head of
the radius in the radial notch of the ulna, forming the proximal
radioulnar joint and permitting pronation and supination of the
forearm.

Ligaments of elbow joint /2

The medial, triangular ulnar collateral ligament extends from the
medial epicondyle of the humerus to the coronoid process and
olecranon process of the ulna.
It consists of three bands:
(1) the anterior cord-like band is the strongest,
(2) the posterior fan-like. band is the weakest, and,
(3) the slender oblique band deepens the socket for the trochlea of
the humerus.

Movements at the elbow joint

Flexion and extension movements occur at the elbow joint
The long axis of the fully extended ulna makes an angle of
approximately 170 with the long axis of the humerus.

This angle is called the carrying angle and is named for the way
the forearm angles away from the body when something is carried,
such as a pail of water.
The obliquity of the angle is more pronounced in women than in
men.
The elbow joint is supplied by articular branches arising from the
musculocutaneous, median, radial, and ulnar nerves.

The Wrist Joint /1

The wrist joint is an ellipsoidal synovial joint between the distal
end of radius and the articular disc overlying the distal end of ulna
proximally, and the scaphoid, lunate and triquetral bones distally.
The proximal articular surface forms an ellipsoid concave surface,
which is adapted to the distal ellipsoid convex carpal surface.
Because the radial styloid process extends further distally than does
the ulnar styloid process, the hand can be adducted to a greater
degree than it can be abducted.

The Wrist Joint /2

The joint capsule encloses the joint and is attached above to the
distal ends of radius and ulna and below to the proximal row of
carpal bones.

The synovial membrane lines the capsule and is attached to the

margins of the articular surfaces.
The joint cavity does not communicate with that of the distal
radioulnar joint or with the joint cavities of the intercarpal joints.
There are anterior and posterior ligaments strengthening the
capsule, as well as a medial ligament attached to the styloid
process of the ulna and to the triquetral bone, and a lateral
ligament between the styloid process of the radius and the
scaphoid bone.

The Wrist Joint /3

The following movements are possible at the wrist joint: flexion,

extension, abduction, adduction and circumduction.

Rotation is not possible because the articular surfaces are ellipsoid

shaped.
The wrist joint is innervated by the anterior interosseous nerve and
the deep branch of ulnar nerve.