MSK Arm-Hand

Chapter 8, pages:
235-240
Chapter 9, pages: 279
Chapter 11, pages:
365-375
Chapter 13, pages:
453-455
Chapter 21, pages:
760-761

Ch 8

8.2 Upper Limb (Extremity)

OBJECTIVE

Identify the bones of the upper limb and their principal

markings.

Each upper limb (upper extremity) has 30 bones in three

locations(1) the humerus in the arm; (2) the ulna and radius
in the forearm; and (3) the 8 carpals in the carpus (wrist), the 5 metacarpals in the
metacarpus (palm), and the 14 phalanges
(bones of the digits) in the hand (see Figures 8.4 and 8.5).
The bones of the upper limb are discussed in Exhibits 8.C
through 8.E.
CHECKPOINT

4. Name the bones that form the upper limb, from proximal
to distal.

Skeleton of the ArmHumerus (Figure 8.4)

OBJECTIVE

Identify the location and surface landmarks of the

humerus.

The humerus (HU-mer-us), or arm bone, is the longest and largest

bone of the upper limb (Figure 8.4). It articulates proximally
with the scapula and distally with two bones, the ulna and the
radius, to form the elbow joint.
The proximal end of the humerus features a rounded head that
articulates with the glenoid cavity of the scapula to form the glenohumeral
(shoulder) joint. Distal to the head is the anatomical
neck, which is visible as an oblique groove. It is the former site of
the epiphyseal (growth) plate in an adult humerus. The greater
tubercle is a lateral projection distal to the anatomical neck. It is
the most laterally palpable bony landmark of the shoulder region
and is immediately inferior to the palpable acromion of the scapula

235 pic

Figure 8.4 Right humerus in relation to the scapula, ulna, and radius.
The humerus is the longest and largest bone of the upper limb.

Which parts of the humerus articulate with the radius at the elbow? With the ulna at the
elbow?

mentioned earlier. The lesser tubercle projects anteriorly. Between

the two tubercles there is a groove named the intertubercular sulcus.
The surgical neck is a constriction in the humerus just distal
to the tubercles, where the head tapers to the shaft; it is so named
because fractures often occur here.
The body (shaft) of the humerus is roughly cylindrical at its
proximal end, but it gradually becomes triangular until it is flattened
and broad at its distal end. Laterally, at the middle portion
of the shaft, there is a roughened, V-shaped area called the deltoid
tuberosity. This area serves as a point of attachment for the tendons
of the deltoid muscle. On the posterior surface of the
humerus is the radial groove, which runs along the deltoid tuberosity
and contains the radial nerve.
Several prominent features are evident at the distal end of the
humerus. The capitulum (ka-PIT-u-lum; capit- _ head) is a rounded
knob on the lateral aspect of the bone that articulates with the head
of the radius. The radial fossa is an anterior depression above the
capitulum that articulates with the head of the radius when the forearm
is flexed (bent). The trochlea (TROK-le-a _ pulley), located
medial to the capitulum, is a spool-shaped surface that articulates
with the trochlear notch of the ulna. The coronoid fossa (KOR-onoyd _ crown-shaped) is an anterior depression that receives the
coronoid process of the ulna when the forearm is flexed. The olecranon
fossa (o-LEK-ra-non _ elbow) is a large posterior depression
that receives the olecranon of the ulna when the forearm is extended
(straightened). The medial epicondyle and lateral epicondyle are
rough projections on either side of the distal end of the humerus to
which the tendons of most muscles of the forearm are attached. The
ulnar nerve may be palpated by rolling a finger over the skin surface
above the posterior surface of the medial epicondyle. This nerve is
the one that makes you feel a very severe pain when you hit your
elbow, which for some reason is commonly referred to as the funnybone,
even though this event is anything but funny.
CHECKPOINT

5. Distinguish between the anatomical neck and the surgical

neck of the humerus. Name the proximal and distal
points formed by the humerus, and indicate which parts
of the bones are involved.

Skeleton of the ForearmUlna and Radius (Figures 8.5

and 8.6)

OBJECTIVE

Identify the location and surface landmarks of the ulna

and radius.

The ulna is located on the medial aspect (the little-finger side) of

the forearm and is longer than the radius (Figure 8.5). You may
find it convenient to use an aid called a mnemonic device (neMON-ik _ memory) to learn new or unfamiliar information. One
such mnemonic to help you remember the location of the ulna in
relation to the hand is p.u. (the pinky is on the ulna side).
At the proximal end of the ulna (Figure 8.5b) is the olecranon,
which forms the prominence of the elbow. With the olecranon, an
anterior projection called the coronoid process (Figure 8.5a)
articulates with the trochlea of the humerus. The trochlear notch
is a large curved area between the olecranon and coronoid process
that forms part of the elbow joint (see Figure 8.6b). Lateral and
inferior to the trochlear notch is a depression, the radial notch,
which articulates with the head of the radius. Just inferior to the
coronoid process is the ulnar tuberosity, to which the biceps brachii
muscle attaches. The distal end of the ulna consists of a head
that is separated from the wrist by a disc of fibrocartilage. A styloid
process is located on the posterior side of the ulnas distal end.
It provides attachment for the ulnar collateral ligament to the wrist.
The radius is the smaller bone of the forearm and is located on
the lateral aspect (thumb side) of the forearm (Figure 8.5a). In
contrast to the ulna, the radius is narrow at its proximal end and
widens at its distal end.
The proximal end of the radius has a disc-shaped head that articulates
with the capitulum of the humerus and the radial notch of
the ulna. Inferior to the head is the constricted neck. A roughened
area inferior to the neck on the anteromedial side, called the radial
tuberosity, is a point of attachment for the tendons of the biceps
brachii muscle. The shaft of the radius widens distally to form a
styloid process on the lateral side, which can be felt proximal to the
thumb. The distal end of the radius contains a narrow concavity, the
ulnar notch, which articulates with the head of the ulna. The styloid
process provides attachment for the brachioradialis muscle and for
attachment of the radial collateral ligament to the wrist. Fracture of
the distal end of the radius is the most common fracture in adults
older than 50 years, typically occuring during a fall.
The ulna and radius articulate with the humerus at the elbow
joint. The articulation occurs in two places (Figure 8.6a, b): where
the head of the radius articulates with the capitulum of the humerus,
and where the trochlear notch of the ulna articulates with
the trochlea of the humerus.
The ulna and the radius connect with one another at three sites.
First, a broad, flat, fibrous connective tissue called the interosseous
membrane (in-ter-OS-e-us; inter- _ between, -osse _ bone)
joins the shafts of the two bones (see Figure 8.5). This membrane
also provides a site of attachment for some of the deep skeletal
muscles of the forearm. The ulna and radius articulate directly at
their proximal and distal ends (Figure 8.6b, c). Proximally, the
head of the radius articulates with the ulnas radial notch. This articulation
is the proximal radioulnar joint. Distally, the head of the

ulna articulates with the ulnar notch of the radius. This articulation
is the distal radioulnar joint. Finally, the distal end of the radius
articulates with three bones of the wristthe lunate, the scaphoid,
and the triquetrumto form the radiocarpal (wrist) joint.
CHECKPOINT

6. How many joints are formed between the ulna and

radius, what are their names, and what parts of the
bones are involved?

EXHIBIT 8.D

Figure 8.5 Right ulna and radius in relation to the humerus and carpals.
In the forearm, the longer ulna is on the medial side, and the shorter radius is on the lateral side.
237 pic
What part of the ulna is called the elbow?

Pic 238

EXHIBIT 8.D

Skeleton of the ForearmUlna and Radius (Figures 8.5 and

8.6)
Figure 8.6 Articulations formed by the ulna and radius. (a) Elbow joint. (b) Joint
surfaces at proximal end of the ulna.
(c) Joint surfaces at distal ends of radius and ulna.

The elbow joint is formed by two articulations: (1) the trochlear notch of the ulna with the trochlea of
the humerus and
(2) the head of the radius with the capitulum of the humerus.
How many points of attachment are there between the radius and ulna?

Skeleton of the HandCarpals, Metacarpals, and

Phalanges (Figure 8.7)
OBJECTIVE

Identify the location and surface landmarks of the bones

of the hand.

Carpals
The carpus (wrist) is the proximal region of the hand and consists
of eight small bones, the carpals, joined to one another by ligaments
(Figure 8.7). Articulations among carpal bones are called
intercarpal joints. The carpals are arranged in two transverse
rows of four bones each. Their names reflect their shapes. The
carpals in the proximal row, from lateral to medial, are the
scaphoid (SKAF-oyd _ boatlike)
lunate (LOO-nat _ moon-shaped)
triquetrum (tr-KWE -trum _ three-cornered)
pisiform (PIS-i-form _ pea-shaped).

Figure 8.7 Right wrist and hand in relation to the ulna and radius.
The skeleton of the hand consists of the proximal carpals, the intermediate metacarpals, and the distal
phalanges.
239 pic

A boxers fracture is a fracture of the fifth metacarpal,

usually near the head of the bone. It frequently
occurs after a person punches another person or an
object, such as a wall. It is characterized by pain, swelling,
and tenderness. There may also be a bump on the side of the
hand. Treatment is either by casting or surgery, and the fracture
usually heals in about 6 weeks.

Which is the most frequently fractured wrist bone?

Mnemonic for carpal bones

Skeleton of the HandCarpals, Metacarpals, and Phalanges

The proximal row of carpals articulates with the distal ends of the
ulna and radius to form the wrist joint. The carpals in the distal
row, from lateral to medial, are the
trapezium (tra-PE -ze-um _ four-sided figure with no two
sides parallel)
trapezoid (TRAP-e-zoyd _ four-sided figure with two sides
parallel)
capitate (KAP-i-tat _ head-shaped)
hamate (HAM-at _ hooked).
The capitate is the largest carpal bone; its rounded projection,
the head, articulates with the lunate. The hamate is named for a
large hook-shaped projection on its anterior surface. In about
70% of carpal fractures, only the scaphoid is broken. This is because
the force of a fall on an outstretched hand is transmitted
from the capitate through the scaphoid to the radius.
The anterior concave space formed by the pisiform and hamate
(on the ulnar side), and the scaphoid and trapezium (on the radial
side), with the rooflike covering of the flexor retinaculum (strong
fibrous bands of connective tissue) is the carpal tunnel. The long
flexor tendons of the digits and thumb and the median nerve pass
through the carpal tunnel. Narrowing of the carpal tunnel, due to
such factors as inflammation, may give rise to a condition called
carpal tunnel syndrome (described in Clinical Connection: Carpal

Tunnel Syndrome in Exhibit 11.O).

There is a useful mnemonic for learning the names of the carpal
bones provided in Figure 8.7. The first letter of the carpal
bones from lateral to medial (proximal row, then distal row)
corresponds to the first letter of each word in the mnemonic.

Metacarpals

The metacarpus (meta- _ beyond), or palm, is the intermediate

region of the hand and consists of five bones called metacarpals.
Each metacarpal bone consists of a proximal base, an intermediate
shaft, and a distal head (Figure 8.7b). The metacarpal bones
are numbered I to V (or 15), starting with the thumb, from lateral
to medial. The bases articulate with the distal row of carpal bones
to form the carpometacarpal joints. The heads articulate with the
proximal phalanges to form the metacarpophalangeal joints. The
heads of the metacarpals, commonly called knuckles, are readily
visible in a clenched fist.

Phalanges

The phalanges (fa-LAN-jez; phalan- _ a battle line), or bones of the

digits, make up the distal part of the hand. There are 14 phalanges in
the five digits of each hand and, like the metacarpals, the digits are
numbered I to V (or 15), beginning with the thumb, from lateral to
medial. A single bone of a digit is referred to as a phalanx (FA -lanks).
Each phalanx consists of a proximal base, an intermediate
shaft, and a distal head. The thumb (pollex) has two phalanges
called proximal and distal phalanges. The other four digits have
three phalanges called proximal, middle, and distal phalanges. In
order from the thumb, these other four digits are commonly
referred to as the index finger, middle finger, ring finger, and little
finger. The proximal phalanges of all digits articulate with the
metacarpal bones. The middle phalanges of the fingers (IIV) articulate
with their distal phalanges. (The proximal phalanx of the
thumb [I] articulates with its distal phalanx.) Joints between phalanges
are called interphalangeal joints.
CHECKPOINT

7. Which is more distal, the base or the head of the

meta carpals? With which bones do the proximal
phalanges articulate?

Ch 9
Elbow joint
OBJECTIVE

Describe the anatomical components of the elbow joint

and the movements that can occur at this joint.

Defi nition
The elbow joint is a hinge joint formed by the trochlea and capitulum
of the humerus, the trochlear notch of the ulna, and the
head of the radius.

Anatomical Components
1. Articular capsule. The anterior part of the articular capsule covers
the anterior part of the elbow joint, from the radial and coronoid
fossae of the humerus to the coronoid process of the ulna and
the anular ligament of the radius. The posterior part extends from

the capitulum, olecranon fossa, and lateral epicondyle of the humerus

to the anular ligament of the radius, the olecranon of the
ulna, and the ulna posterior to the radial notch (Figure 9.13a, b).
2. Ulnar collateral ligament. Thick, triangular ligament that extends
from the medial epicondyle of the humerus to the coronoid
process and olecranon of the ulna (Figure 9.13a). Part of this
ligament deepens the socket for the trochlea of the humerus.
3. Radial collateral ligament. Strong, triangular ligament that
extends from the lateral epicondyle of the humerus to the anular
ligament of the radius and the radial notch of the ulna
(Figure 9.13b).
4. Anular ligament of the radius. Strong band that encircles the
head of the radius. It holds the head of the radius in the radial
notch of the ulna (Figure 9.13a, b).
Figure 9.13 Right elbow joint.
The elbow joint is formed by parts of three bones:
humerus, ulna, and radius.

Movements
The elbow joint allows flexion and extension of the forearm (see
Figure 9.5c).

Pic 279
Tennis elbow most commonly refers to pain at or near the lateral
epicondyle of the humerus, usually caused by an improperly executed
backhand. The extensor muscles strain or sprain, resulting in pain.
Little-league elbow, inflammation of the medial epicondyle, typically
develops as a result of a heavy pitching schedule and/or a schedule
that involves throwing curve balls, especially among youngsters.
In this disorder, the elbow joint may enlarge, fragment, or separate.
A dislocation of the radial head is the most common upper
limb dislocation in children. In this injury, the head of the radius
slides past or ruptures the radial anular ligament, a ligament that
forms a collar around the head of the radius at the proximal radioulnar
joint. Dislocation is most apt to occur when a strong pull is
applied to the forearm while it is extended and supinated, for instance,
while swinging a child around with outstretched arms.

CLINICAL CONNECTION |

Tennis Elbow, Little-League

Elbow, and Dislocation of
the Radial Head
CHECKPOINT

15. At the elbow joint, which ligaments connect (a) the

humerus and the ulna, and (b) the humerus and the
radius?
Which movements are possible at a hinge joint?

Ch 11

MUSCLE ORIGIN INSERTION ACTION INNERVATION

FOREARM FLEXORS
Biceps brachii
(BI-seps BRA -ke-;
biceps _ two heads of
origin; brachii _ arm)

Long head originates from tubercle

above glenoid cavity of scapula
(supraglenoid tubercle).
Short head originates from coracoid
process of scapula.
Radial tuberosity of
radius and bicipital
aponeurosis.*
Flexes forearm at elbow joint,
supinates forearm at radioulnar
joints, and fl exes arm at shoulder
joint.
Musculocutaneous
nerve.
Brachialis
(bra-ke-A -lis)

Distal, anterior surface of humerus. Ulnar tuberosity and

coronoid process of ulna.
Flexes forearm at elbow joint. Musculocutaneous
and radial nerves.
Brachioradialis
(bra _-ke-o -ra-de-A -lis;
radi _ radius)

Lateral border of distal end of

humerus.
Superior to styloid
process of radius.
Flexes forearm at elbow joint;
supinates and pronates forearm at
radioulnar joints to neutral position.
Radial nerve.
FOREARM EXTENSORS
Triceps brachii
(TRI-seps _ three heads
of origin)

Long head originates from

infraglenoid tubercle, a projection
inferior to glenoid cavity of scapula.
Lateral head originates from lateral
and posterior surface of humerus.
Medial head originates from entire
posterior surface of humerus inferior
to a groove for the radial nerve.
Olecranon of ulna. Extends forearm at elbow joint and
extends arm at shoulder joint.
Radial nerve.
Anconeus
(an-KO -ne -us;
ancon _ elbow)

Lateral epicondyle of humerus. Olecranon and superior

portion of shaft of ulna.
Extends forearm at elbow joint. Radial nerve.
FOREARM PRONATORS
Pronator teres
(PRO -na -tor TE-rez;
pronator _ turns palm
posteriorly; tero _ round
and long) (see also
Figure 11.17a)

Medial epicondyle of humerus and

coronoid process of ulna.

Midlateral surface of
radius.
Pronates forearm at radioulnar
joints and weakly fl exes forearm at
elbow joint.
Median nerve.
Pronator quadratus
(PRO -na-tor kwod-RA -tus;
quadratus _ square,
four-sided) (see also
Figure 11.17ac)

Distal portion of shaft of ulna. Distal portion of shaft

of radius.
Pronates forearm at radioulnar
joints.
Median nerve.
FOREARM SUPINATOR
Supinator
(SOO-pi-na -tor
_ turns palm anteriorly)
(see also Figure 11.17b,c)

Lateral epicondyle of humerus

and ridge near radial notch of ulna
(supinator crest).
Lateral surface of
proximal one-third of
radius.
Supinates forearm at radioulnar
joints.
Deep radial nerve.

*The bicipital aponeurosis is a broad aponeurosis from the tendon of insertion of the biceps brachii muscle that descends
medially across the brachial artery and fuses with
deep fascia over the forearm fl exor muscles (see Figure 11.17a). It also helps to protect the median nerve and brachial artery.

Muscles of the Arm That Move the Radius and Ulna

(Figure 11.16)
OBJECTIVE

Describe the origin, insertion, action, and innervation of

the muscles of the arm that move the radius and ulna.

Most of the muscles that move the radius and ulna (forearm
bones) cause flexion and extension at the elbow, which is a hinge
joint. The biceps brachii, brachialis, and brachioradialis muscles
are the flexor muscles. The extensor muscles are the triceps brachii
and the anconeus (Figure 11.16).
The biceps brachii is the large muscle located on the anterior
surface of the arm. As indicated by its name, it has two heads of origin
(long and short), both from the scapula. The muscle spans both
the shoulder and elbow joints. In addition to its role in flexing the
forearm at the elbow joint, it also supinates the forearm at the radioulnar
joints and flexes the arm at the shoulder joint. The brachialis
is deep to the biceps brachii muscle. It is the most powerful flexor of

the forearm at the elbow joint. For this reason, it is the workhorse EXHIBIT 11.M

Muscles of the Arm That Move the Radius and Ulna (Figure 11.16)

CONTIN

UED

of the elbow flexors. The brachioradialis flexes the forearm at the

elbow joint, especially when a quick movement is required or when
a weight is lifted slowly during flexion of the forearm.
The triceps brachii is the large muscle located on the posterior
surface of the arm. It is the more powerful of the extensors of the
forearm at the elbow joint. As its name implies, it has three heads of
origin, one from the scapula (long head) and two from the humerus
(lateral and medial heads). The long head crosses the shoulder joint;
the other heads do not. The anconeus is a small muscle located on
the lateral part of the posterior aspect of the elbow that assists the
triceps brachii in extending the forearm at the elbow joint.
Some muscles that move the radius and ulna are involved in
pronation and supination at the radioulnar joints. The pronators,
as suggested by their names, are the pronator teres and pronator
quadratus muscles. The supinator of the forearm is aptly named
the supinator muscle. You use the powerful action of the supinator
when you twist a corkscrew or turn a screw with a screwdriver.
In the limbs, functionally related skeletal muscles and their associated
blood vessels and nerves are grouped together by fascia
into regions called compartments. In the arm, the biceps brachii,
brachialis, and coracobrachialis muscles compose the anterior
(flexor) compartment. The triceps brachii muscle forms the posterior
(extensor) compartment.

RELATING MUSCLES TO MOVEMENTS

Arrange the muscles in this exhibit according to the following
actions on the elbow joint: (1) flexion and (2) extension; the following
actions on the forearm at the radioulnar joints: (1) supination
and (2) pronation; and the following actions on the humerus
at the shoulder joint: (1) flexion and (2) extension. The same muscle
may be mentioned more than once.
CHECKPOINT

19. Flex your arm. Which group of muscles is contracting?

Which group of muscles must relax so that you can flex
your arm?
366 pic

Figure 11.16 Muscles of the arm that move the radius and ulna (forearm
bones).

The anterior arm muscles flex the forearm, and the posterior arm muscles extend it.
367 pic
Which muscles are the most powerful flexor and the most powerful extensor of the
forearm?

MUSCLE ORIGIN INSERTION ACTION INNERVATION

SUPERFICIAL ANTERIOR (FLEXOR) COMPARTMENT OF THE FOREARM
Flexor carpi radialis
(FLEK-sor KAR-pe -ra _-de-A -lis;

fl exor _ decreases angle

at joint; carpi _ wrist;
radi _ radius)

Medial epicondyle of humerus. Metacarpals II

and III.
Flexes and abducts hand (radial
deviation) at wrist joint.
Median nerve.
Palmaris longus
(pal-MA-ris LON-gus;
palma _ palm; longus _ long)

Medial epicondyle of humerus. Flexor retinaculum

and palmar
aponeurosis (fascia
in center of palm).
Weakly fl exes hand at wrist joint. Median nerve.
Flexor carpi ulnaris
(u l-NAR-is _ ulna)

Medial epicondyle of humerus

and superior posterior border
of ulna.
Pisiform, hamate,
and base of
metacarpal V.
Flexes and adducts hand (ulnar
deviation) at wrist joint.
Ulnar nerve.
Flexor digitorum superfi cialis
(di-ji-TOR-um
soo_-per-fi sh_-e-A -lis;
digit _ fi nger or toe;
superfi cialis _ closer to surface)

Medial epicondyle of humerus,

coronoid process of ulna, and
ridge along lateral margin or
anterior surface (anterior oblique
line) of radius.
Middle phalanx of
each fi nger.*
Flexes middle phalanx of each fi nger
at proximal interphalangeal joint,
proximal phalanx of each fi nger at
metacarpophalangeal joint, and hand
at wrist joint.
Median nerve.

DEEP ANTERIOR (FLEXOR) COMPARTMENT OF THE FOREARM

Flexor pollicis longus
(POL-li-sis _ thumb)

Anterior surface of radius and

interosseous membrane (sheet of
fi brous tissue that holds shafts of
ulna and radius together).
Base of distal
phalanx of thumb.
Flexes distal phalanx of thumb at
interphalangeal joint.
Median nerve.
Flexor digitorum profundus
(pro -FUN-dus _ deep)

Anterior medial surface of

body of ulna.
Base of distal
phalanx of each
fi nger.
Flexes distal and middle phalanges of
each fi nger at interphalangeal joints,

proximal phalanx of each fi nger at

metacarpophalangeal joint, and hand
at wrist joint.
Median and ulnar
Nerves

Muscles of the Forearm That Move the Wrist,

Hand, Thumb, and Digits (Figure 11.17)
OBJECTIVE

Describe the origin, insertion, action, and innervation of

the muscles of the forearm that move the wrist, hand,
and digits.

Muscles of the forearm that move the wrist, hand, and digits are
many and varied (Figure 11.17). Those in this group that act on the
digits are known as extrinsic muscles of the hand (ex-_ outside)
because they originate outside the hand and insert within it. As you
will see, the names for the muscles that move the wrist, hand, and
digits give some indication of their origin, insertion, or action.
Based on location and function, the muscles of the forearm are
divided into two groups: (1) anterior compartment muscles and (2)
posterior compartment muscles. The anterior (flexor) compartment
muscles of the forearm originate on the humerus; typically
insert on the carpals, metacarpals, and phalanges; and function primarily
as flexors. The bellies of these muscles form the bulk of the
forearm. One of the muscles in the superficial anterior compartment,
the palmaris longus muscle, is missing in about 10% of individuals
(usually in the left forearm) and is commonly used for
tendon repair. The posterior (extensor) compartment muscles of
the forearm originate on the humerus, insert on the metacarpals

and phalanges, and function as extensors. Within each compartment,

the muscles are grouped as superficial or deep.
The superficial anterior compartment muscles are arranged
in the following order from lateral to medial: flexor carpi radialis,
palmaris longus, and flexor carpi ulnaris (the ulnar nerve
and artery are just lateral to the tendon of this muscle at the wrist).
The flexor digitorum superficialis muscle is deep to the other
three muscles and is the largest superficial muscle in the forearm.
The deep anterior compartment muscles are arranged in the
following order from lateral to medial: flexor pollicis longus (the
only flexor of the distal phalanx of the thumb) and flexor digitorum
profundus (ends in four tendons that insert into the distal
phalanges of the fingers).
The superficial posterior compartment muscles are arranged
in the following order from lateral to medial: extensor
carpi radialis longus, extensor carpi radialis brevis, extensor
digitorum (occupies most of the posterior surface of the forearm
and divides into four tendons that insert into the middle and distal
phalanges of the fingers), extensor digiti minimi (a slender muscle usually connected
to the extensor digitorum), and extensor
carpi ulnaris.
The deep posterior compartment muscles are arranged in the
following order from lateral to medial: abductor pollicis longus,
extensor pollicis brevis, extensor pollicis longus, and extensor
indicis.
The tendons of the muscles of the forearm that attach to the wrist
or continue into the hand, along with blood vessels and nerves, are
held close to bones by strong fasciae. The tendons are also surrounded
by tendon sheaths. At the wrist, the deep fascia is thickened
into fibrous bands called retinacula (retinacul _ holdfast).
The flexor retinaculum is located over the palmar surface of the
carpal bones. The long flexor tendons of the digits and wrist and the
median nerve pass deep to the flexor retinaculum. The extensor
retinaculum is located over the dorsal surface of the carpal bones.
The extensor tendons of the wrist and digits pass deep to it.
Golfers elbow is a condition that can be caused by strain of
the flexor muscles, especially the flexor carpi radialis, as a result
of repetitive movements such as swinging a golf club.
Strain can, however, be caused by many actions. Pianists, violinists,
movers, weight lifters, bikers, and those who use computers are
among those who may develop pain near the medial epicondyle
(medial epicondylitis).

EXHIBIT 11.M

MUSCLE ORIGIN INSERTION ACTION INNERVATION

SUPERFICIAL POSTERIOR (EXTENSOR) COMPARTMENT OF THE FOREARM
Extensor carpi radialis longus
(eks-TEN-sor _ increases
angle at joint)

Lateral supracondylar
ridge of humerus.
Metacarpal II. Extends and abducts hand at wrist joint
(ulnar deviation).
Radial nerve.
Extensor carpi radialis brevis
(brevis _ short)

Lateral epicondyle of
humerus.
Metacarpal III. Extends and abducts hand at wrist joint. Radial nerve.
Extensor digitorum Lateral epicondyle of
humerus.
Distal and middle
phalanges of each fi nger.
Extends distal and middle phalanges
of each fi nger at interphalangeal joints,
proximal phalanx of each fi nger at
metacarpophalangeal joint, and hand at
wrist joint.
Radial nerve.
Extensor digiti minimi
(DIJ-i-te MIN-i-me ;
minimi _ smallest)

Lateral epicondyle of
humerus.
Tendon of extensor
digitorum on phalanx V.
Extends proximal phalanx of little fi nger
at metacarpophalangeal joint and hand at
wrist joint.
Deep radial nerve.
Extensor carpi ulnaris Lateral epicondyle of
humerus and posterior
border of ulna.
Metacarpal V. Extends and adducts hand at wrist joint
(ulnar deviation).
Deep radial nerve.

DEEP POSTERIOR (EXTENSOR) COMPARTMENT OF THE FOREARM

Abductor pollicis longus
(ab-DUK-tor _ moves
part away from midline)

Posterior surface of
middle of radius and
ulna and interosseous
membrane.
Metacarpal I. Abducts and extends thumb at
carpometacarpal joint and abducts hand at
wrist joint.
Deep radial nerve.
Extensor pollicis brevis Posterior surface of
middle of radius and
interosseous membrane.
Base of proximal phalanx
of thumb.
Extends proximal phalanx of thumb
at metacarpophalangeal joint, fi rst
metacarpal of thumb at carpometacarpal
joint, and hand at wrist joint.
Deep radial nerve.
Extensor pollicis longus Posterior surface of
middle of ulna and
interosseous membrane.
Base of distal phalanx of
thumb.
Extends distal phalanx of thumb at

interphalangeal joint, extends fi rst

metacarpal of thumb at carpometacarpal
joint, and abducts hand at wrist joint.
Deep radial nerve.
Extensor indicis
(IN-di-kis _ index)

Posterior surface of
ulna and interosseous
membrane.
Tendon of extensor
digitorum of index fi nger.
Extends distal and middle phalanges of
index fi nger at interphalangeal joints,
proximal phalanx of index fi nger at
metacarpophalangeal joint, and hand at
wrist joint.
Deep radial nerve.

Muscles of the Forearm That Move the Wrist, Hand, Thumb, and
Digits (Figure 11.17) C O N T I N U E D
EXHIBIT 11.N

RELATING MUSCLES TO MOVEMENTS

Arrange the muscles in this exhibit according to the following actions
on the wrist joint: (1) flexion, (2) extension, (3) abduction
(radial deviation), and (4) adduction (ulnar deviation); the following
actions on the fingers at the metacarpophalangeal joints: (1) flexion
and (2) extension; the following actions on the fingers at the interphalangeal

joints: (1) flexion and (2) extension; the following

actions on the thumb at the carpometacarpal, metacarpophalangeal,
and interphalangeal joints: (1) extension and (2) abduction; and the
following action on the thumb at the interphalangeal joint: flexion.
The same muscle may be mentioned more than once.
CHECKPOINT

20. Which muscles and actions of the wrist, hand, thumb,

and fingers are used when writing?

Figure 11.17 Muscles of the forearm that move the wrist, hand, thumb, and
digits.

The anterior compartment muscles function as flexors, and the posterior compartment muscles
function as extensors.
370 pic
371 pic What structures pass deep to the flexor retinaculum?

*Reminder: The thumb or pollex is the fi rst digit and has two
phalanges: proximal and distal. The remaining digits, the fi ngers,
are numbered IIV (25), and each has three
phalanges: proximal, middle, and distal.

MUSCLE ORIGIN INSERTION ACTION INNERVATION

THENAR (LATERAL ASPECT OF PALM)
Abductor pollicis brevis
(ab-DUK-tor POL-li-sis
BREV-is; abductor _ moves part
away from middle; pollicis _
thumb; brevis _ short)

Flexor retinaculum, scaphoid,

and trapezium.
Lateral side of proximal
phalanx of thumb.
Abducts thumb at
carpometacarpal joint.
Median nerve.
Opponens pollicis (op-PO nenz _ opposes)

Flexor retinaculum and

trapezium.
Lateral side of metacarpal I
(thumb).
Moves thumb across palm to
meet any fi nger (opposition) at
carpometacarpal joint.
Median nerve.
Flexor pollicis brevis (FLEK-sor
_ decreases angle at joint)

Flexor retinaculum, trapezium,

capitate, and trapezoid.

Lateral side of proximal
phalanx of thumb.
Flexes thumb at
carpometacarpal and
metacarpophalangeal joints.
Median and
ulnar nerves.
Adductor pollicis (ad-DUK-tor
_ moves part toward midline)

Oblique head originates from

capitate and metacarpal II and
III. Transverse head originates
from metacarpal III.
Medial side of proximal
phalanx of thumb by tendon
containing sesamoid bone.
Adducts thumb at
carpometacarpal and
metacarpophalangeal joints.
Ulnar nerve.

HYPOTHENAR (MEDIAL ASPECT OF PALM)

Abductor digiti minimi (DIJ-ite
MIN-i-me; digit _ fi nger or
toe; minimi _ smallest)

Pisiform and tendon of fl exor

carpi ulnaris.
Medial side of proximal
phalanx of little fi nger.
Abducts and fl exes little fi nger
at metacarpophalangeal joint.
Ulnar nerve.
Flexor digiti minimi brevis Flexor retinaculum and
hamate.
Medial side of proximal
phalanx of little fi nger.
Flexes little fi nger at
carpometacarpal and
metacarpophalangeal joints.
Ulnar nerve.
Opponens digiti minimi Flexor retinaculum and
hamate.
Medial side of metacarpal V
(little fi nger).
Moves little fi nger across palm
to meet thumb (opposition) at
carpometacarpal joint.
Ulnar nerve.
INTERMEDIATE (MIDPALMAR)
Lumbricals (LUM-bri-kals;
lumbric _ earthworm)
(four muscles)

Lateral sides of tendons and

fl exor digitorum profundus of
each fi nger.
Lateral sides of tendons
of extensor digitorum on
proximal phalanges of each
fi nger.
Flex each fi nger at
metacarpophalangeal joints
and extend each fi nger at
interphalangeal joints.
Median and
ulnar nerves.

Palmar interossei (PAL-mar

in_-ter-OS-e -i; palma _ palm;
inter- _ between; -ossei _
bones) (three distinct muscles
but some describe four)

Sides of shafts of metacarpals

of all digits (except III).
Sides of bases of proximal
phalanges of all fi ngers
(except III).
Adduct and fl ex each
fi ngers (except III) at
metacarpophalangeal joints
and extend these digits at
interphalangeal joints.
Ulnar nerve.
Dorsal interossei (DOR-sal _
back surface) (four muscles)

Adjacent sides of metacarpals. Proximal phalanx of

fi ngers IIIV.
Abduct fi ngers IIIV at
metacarpophalangeal
joints, fl ex fi ngers IIIV at
metacarpophalangeal joints,
and extend fi ngers IIIV at
interphalangeal joints.
Ulnar nerve.

Muscles of the Palm That Move the DigitsIntrinsic

Muscles of the Hand (Figure 11.18)
OBJECTIVE

Describe the origin, insertion, action, and innervation of

the muscles of the palm that move the digits (the intrinsic
muscles of the hand).

Several of the muscles discussed in Exhibit 11.N move the digits

in various ways and are known as extrinsic muscles of the
hand. They produce the powerful but crude movements of the
digits. The intrinsic muscles of the hand in the palm produce
the weak but intricate and precise movements of the digits that
characterize the human hand (Figure 11.18). The muscles in this
group are so named because their origins and insertions are
within the hand.
The intrinsic muscles of the hand are divided into three groups:
(1) thenar, (2) hypothenar, and (3) intermediate. The thenar
muscles include the abductor pollicis brevis, opponens pollicis,
flexor pollicis brevis, and adductor pollicis (acts on the thumb but

EXHIBIT 11.O

Muscles of the Palm That Move the DigitsIntrinsic

Muscles of the Hand (Figure 11.18)
OBJECTIVE

Describe the origin, insertion, action, and innervation of

the muscles of the palm that move the digits (the intrinsic
muscles of the hand).

Several of the muscles discussed in Exhibit 11.N move the digits

in various ways and are known as extrinsic muscles of the
hand. They produce the powerful but crude movements of the
digits. The intrinsic muscles of the hand in the palm produce
the weak but intricate and precise movements of the digits that
characterize the human hand (Figure 11.18). The muscles in this
group are so named because their origins and insertions are
within the hand.
The intrinsic muscles of the hand are divided into three groups:
(1) thenar, (2) hypothenar, and (3) intermediate. The thenar
muscles include the abductor pollicis brevis, opponens pollicis,
flexor pollicis brevis, and adductor pollicis (acts on the thumb but is not in the thenar
eminence). The abductor pollicis brevis is a
thin, short, relatively broad superficial muscle on the lateral side of
the thenar eminence. The flexor pollicis brevis is a short, wide
muscle that is medial to the abductor pollicis brevis muscle. The
opponens pollicis is a small, triangular muscle that is deep to the
flexor pollicis brevis and abductor pollicis brevis muscles. The adductor
pollicis is fan-shaped and has two heads (oblique and
transverse) separated by a gap through which the radial artery
passes. The thenar muscles plus the adductor pollicis form the thenar
eminence, the lateral rounded contour on the palm that is also
called the ball of the thumb.
The three hypothenar muscles act on the little finger and form
the hypothenar eminence, the medial rounded contour on the
palm that is also called the ball of the little finger. The hypothenar
muscles are the abductor digiti minimi, flexor digiti minimi brevis,
and opponens digiti minimi. The abductor digiti minimi is a
short, wide muscle and is the most superficial of the hypothenar
muscles. It is a powerful muscle that plays an important role in
grasping an object with outspread fingers. The flexor digiti minimi
brevis muscle is also short and wide and is lateral to the abductor
digiti minimi muscle. The opponens digiti minimi muscle
is triangular and deep to the other two hypothenar muscles.
The 11 or 12 intermediate (midpalmar) muscles include the
lumbricals, palmar interossei, and dorsal interossei. The lumbricals,
as their name indicates, are worm-shaped. They originate
from and insert into the tendons of other muscles (flexor digitorum
profundus and extensor digitorum). The palmar interossei
are the smallest and more anterior of the interossei muscles. The
dorsal interossei are the most posterior of this series of muscles.
Both sets of interossei muscles are located between the metacarpals
and are important in abduction, adduction, flexion, and extension
of the fingers, and in movements in skilled activities such

as writing, typing, and playing a piano.

The functional importance of the hand is readily apparent
when you consider that certain hand injuries can result in permanent
disability. Most of the dexterity of the hand depends on
movements of the thumb. The general activities of the hand are
free motion, power grip (forcible movement of the fingers and
thumb against the palm, as in squeezing), precision handling (a
change in position of a handled object that requires exact control
of finger and thumb positions, as in winding a watch or threading
a needle), and pinch (compression between the thumb and index
finger or between the thumb and first two fingers).
Movements of the thumb are very important in the precise activities
of the hand, and they are defined in different planes from comparable
movements of other digits because the thumb is positioned
at a right angle to the other digits. The five principal movements of
the thumb are illustrated in Figure 11.18g and include flexion (movement
of the thumb medially across the palm), extension (movement
of the thumb laterally away from the palm), abduction (movement
of the thumb in an anteroposterior plane away from the palm), adduction
(movement of the thumb in an anteroposterior plane toward
the palm), and opposition (movement of the thumb across the palm
so that the tip of the thumb meets the tip of a finger). Opposition is
the single most distinctive digital movement that gives humans and
other primates the ability to grasp and manipulate objects precisely.
EXHIBIT 11.O Muscles of the Palm That Move the DigitsIntrinsic Muscles of

the Hand
(Figure 11.18)
FIGURE 11.18

CONTINUED

CONTINUED

DORSAL INTEROSSEI
Metacarpal V
Proximal phalanx
of little finger
(e)

Pic 374

373 pic

Figure 11.18 Muscles of the palm that move the digitsintrinsic muscles of the
hand.

The intrinsic muscles of the hand produce the intricate and precise movements of the digits that
characterize the human hand.

375 carpal tunnel

The carpal tunnel is a narrow passageway formed anteriorly by
the flexor retinaculum and posteriorly by the carpal bones.
Through this tunnel pass the median nerve, the most superficial
structure, and the long flexor tendons for the digits (see Figure 11.18f).
Structures within the carpal tunnel, especially the median nerve, are
vulnerable to compression, and the resulting condition is called carpal
tunnel syndrome. Compression of the median nerve leads to sensory

changes over the lateral side of the hand and muscle weakness in the
thenar eminence. This results in pain, numbness, and tingling of the
fingers. The condition may be caused by inflammation of the digital
tendon sheaths, fluid retention, excessive exercise, infection, trauma,
and/or repetitive activities that involve flexion of the wrist, such as keyboarding,
cutting hair, or playing the piano. Treatment may involve the
use of nonsteroidal anti-inflammatory drugs (such as ibuprofen or aspirin),
wearing a wrist splint, corticosteroid injections, or surgery to cut
the flexor retinaculum and release pressure on the median nerve.

RELATING MUSCLES TO MOVEMENTS

Arrange the muscles in this exhibit according to the following
actions on the thumb at the carpometacarpal and metacarpophalangeal
joints: (1) abduction, (2) adduction, (3) flexion,
and (4) opposition; and the following actions on the fingers at the
metacarpophalangeal and interphalangeal joints: (1) abduction,
(2) adduction, (3) flexion, and (4) extension. The same muscle
may be mentioned more than once.
CHECKPOINT

21. How do the actions of the extrinsic and intrinsic muscles

of the hand differ?
375 pic
Muscles of the thenar eminence act on which digit?

Ch 13

Brachial Plexus (Figure 13.8)

OBJECTIVE

Describe the origin, distribution, and effects of damage to

the brachial plexus.

The roots (anterior rami) of spinal nerves C5C8 and T1 form the
brachial plexus (BRA -ke-al), which extends inferiorly and laterally
on either side of the last four cervical and first thoracic vertebrae
(Figure 13.8a). It passes above the first rib posterior to the
clavicle and then enters the axilla.
Since the brachial plexus is so complex, an explanation of its
various parts is helpful. As with the cervical and other plexuses,
the roots are the anterior rami of the spinal nerves. The roots of
several spinal nerves unite to form trunks in the inferior part of
the neck. These are the superior, middle, and inferior trunks. Posterior
to the clavicles, the trunks diverge into divisions, called the
anterior and posterior divisions. In the axillae, the divisions unite
to form cords called the lateral, medial, and posterior cords. The
cords are named for their relationship to the axillary artery, a large
artery that supplies blood to the upper limb. The branches of the
brachial plexus form the principal nerves of the brachial plexus.
The brachial plexus provides almost the entire nerve supply of
the shoulders and upper limbs (Figure 13.8b). Five large terminal
branches arise from the brachial plexus: (1) The axillary nerve
supplies the deltoid and teres minor muscles. (2) The musculocutaneous
nerve supplies the anterior muscles of the arm. (3) The
radial nerve supplies the muscles on the posterior aspect of the arm and forearm. (4)
The median nerve supplies most of the muscles

of the anterior forearm and some of the muscles of the hand.

(5) The ulnar nerve supplies the anteromedial muscles of the
forearm and most of the muscles of the hand.

Injuries to Nerves
Emerging from the
Brachial Plexus
Injury to the superior roots of the brachial plexus (C5C6) may result
from forceful pulling away of the head from the shoulder, as might
occur from a heavy fall on the shoulder or excessive stretching of an
infants neck during childbirth. The presentation of this injury is characterized
by an upper limb in which the shoulder is adducted, the
arm is medially rotated, the elbow is extended, the forearm is pronated,
and the wrist is flexed (Figure 13.8c). This condition is called
Erb-Duchenne palsy or waiters tip position. There is loss of sensation
along the lateral side of the arm.
Injury to the radial (and axillary) nerve can be caused by improperly
administered intramuscular injections into the deltoid
muscle. The radial nerve may also be injured when a cast is applied
too tightly around the mid-humerus. Radial nerve injury is indicated
by wrist drop, the inability to extend the wrist and fingers (Figure
13.8c). Sensory loss is minimal due to the overlap of sensory innervation
by adjacent nerves.
Injury to the median nerve may result in median nerve palsy,
which is indicated by numbness, tingling, and pain in the palm and
fingers. There is also inability to pronate the forearm and flex the
proximal interphalangeal joints of all digits and the distal interphalangeal
joints of the second and third digits (Figure 13.8c). In addition,
wrist flexion is weak and is accompanied by adduction, and thumb
movements are weak.
Injury to the ulnar nerve may result in ulnar nerve palsy,
which is indicated by an inability to abduct or adduct the fingers,
atrophy of the interosseous muscles of the hand, hyperextension of
the metacarpophalangeal joints, and flexion of the interphalangeal
joints, a condition called clawhand (Figure 13.8c). There is also loss
of sensation over the little finger.
Injury to the long thoracic nerve results in paralysis of the serratus
anterior muscle. The medial border of the scapula protrudes,
giving it the appearance of a wing. When the arm is raised, the vertebral
border and inferior angle of the scapula pull away from the
thoracic wall and protrude outward, causing the medial border of
the scapula to protrude; because the scapula looks like a wing, this
condition is called winged scapula (Figure 13.8c). The arm cannot
be abducted beyond the horizontal position.
Compression of the brachial plexus on one or more of its nerves
is sometimes known as thoracic outlet syndrome. The subclavian
artery and subclavian vein may also be compressed. The compression
may result from spasm of the scalene or pectoralis minor
muscles, the presence of a cervical rib (an embryological anomaly),
or misaligned ribs. The patient may experience pain, numbness,
weakness, or tingling in the upper limb, across the upper thoracic
area, and over the scapula on the affected side. The symptoms of
thoracic outlet syndrome are exaggerated during physical or emotional
stress because the added stress increases the contraction of
the involved muscles.

NERVE ORIGIN DISTRIBUTION

Dorsal scapular (SKAP-u -lar) C5 Levator scapulae, rhomboid major, and rhomboid minor muscles.
Long thoracic (tho -RAS-ik) C5C7 Serratus anterior muscle.
Nerve to subclavius (sub-KLA -ve-us) C5C6 Subclavius muscle.
Suprascapular C5C6 Supraspinatus and infraspinatus muscles.
Musculocutaneous (mus_-ku -lo -ku -TAN-e-us) C5C7 Coracobrachialis, biceps brachii, and brachialis

muscles.
Lateral pectoral (PEK-to -ral) C5C7 Pectoralis major muscle.
Upper subscapular C5C6 Subscapularis muscle.
Thoracodorsal (tho-RA -ko -dor-sal) C6C8 Latissimus dorsi muscle.
Lower subscapular C5C6 Subscapularis and teres major muscles.
Axillary (AK-si-lar-e) C5C6 Deltoid and teres minor muscles; skin over deltoid and superior posterior aspect

of arm.
Median C5T1 Flexors of forearm, except fl exor carpi ulnaris; ulnar half of fl exor digitorum profundus, and

some muscles of hand (lateral palm); skin of lateral two-thirds of palm of hand and fi ngers.
Radial C5T1 Triceps brachii, anconeus, and extensor muscles of forearm; skin of posterior arm and forearm,
lateral two-thirds of dorsum of hand, and fi ngers over proximal and middle phalanges.
Medial pectoral C8T1 Pectoralis major and pectoralis minor muscles.
Medial cutaneous nerve of arm (ku -TA -ne-us) C8T1 Skin of medial and posterior aspects of distal third
of arm.
Medial cutaneous nerve of forearm C8T1 Skin of medial and posterior aspects of forearm.
Ulnar C8T1 Flexor carpi ulnaris, ulnar half of fl exor digitorum profundus, and most muscles of hand;
skin of medial side of hand, little fi nger, and medial half of ring fi nger.

CHECKPOINT

6. Injury of which nerve could cause paralysis of the serratus

anterior muscle?
Brachial plexus projected to surface

Figure 13.8 Brachial plexus in anterior view.

The brachial plexus supplies the shoulders and upper limbs.
454 pic

455 is in word doc 17

Ch 21

Figure 21.19 Arch of the aorta and its branches. Note in (c) the arteries that
constitute the cerebral arterial circle (circle of Willis).

The arch of the aorta ends at the level of the intervertebral disc between the fourth and fifth thoracic
vertebrae.