The Shoulder Girdle and Elbow

Anatomy 12-7-13 notes

Recap:
What innervates posterior arm and forearm?

Posterior arm and forearm innervated by the radial nerve; Deep interosseous
motor branches of radial nerve
What nerves innervate anterior forearm?
Anterior forearm innervated by ulnar and median nerves
How many muscles does ulnar nerve innervate in anterior forearm?
Ulnar nerve innervates 2 muscles ( essentially 1 ); the rest of muscles in
anterior forearm innervated by median nerve
What is deep branch of median nerve known as?
Deep branch of medial nerve anterior interosseous
What nerve gives motor innervation in the hand?
No muscle in hand innervated by radial nerve; Ulnar nerve and median nerve
innervate muscles of hand
Cutaneously what nerve gives you sensation to lateral shoulder/arm?
Axillary nerve
What nerve gives sensation to posterior arm?
Radial
What nerve gives sensation to medial arm?
Medial brachial cutaneous, which comes off medial cord
What nerve gives sensation to medial forearm?
Medial antebrachial cutaneous
What nerve gives sensation to medial aspect of hand, both palmar/volar
and dorsal?
Ulnar
What nerve gives sensation to dorsal aspect of hand on lateral side?
Radial- which gives sensation to entire lateral dorsum of hand except for
distal portions of 1, 2, 3
What gives you sensation to lateral aspect of palmar hand?
Median nerve

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4.

Slide 2:
Shoulder:
w/in shoulder girdle there are 4 different bones:
Scapula flat bone sitting on round thoracic cage
Thoracic rib cage
Clavicle anterior; thin and small
Humerus bone of upper arm

Joints classified by connective tissue between joints (amphiarthrosis

joined by cartilage; synarthroses joined by fibrous tissue; diarthroses
synovial fluid and membrane)
These bones articulate to form 3 true joints:
1. Sternoclavicular joint - between manubrium of sternum and sternal end of
clavicle
2. Acromioclavicular joint between acromion process of scapula and acromial
end of clavicle
3. Glenohumeral joint between head of humerous and glenoid fossa of
scapula)
Slide 3
3 functional joints:
1. Scapulothoracic joint between scapula as it sits on thoracic cage; joined
by muscle -therefore it is a functional joint
scapula does not sit in coronal/frontal plain; it is oblique and anterior to
coronal plane by 30 -40 degrees
scapular plane is plane in which scapula sits
shoulder elevation through scapular plane (30 degrees anterior to
coronal plane) is known as scapcion
How does shoulder elevation differ from scapular elevation?
Scapular elevation is shrugging your shoulders while shoulder
elevation is any upward movement of UE, whether it be in sagittal,
coronal, or any plane in between; shoulder elevation can mean flexion,
scapcion, abduction, or any other movement of humerus in frontal and
sagittal plane
2. Supra-humeral/sub-acromial space in between acromion process and
humeral head
Important b/c running in between 2 bony landmarks are soft tissue
structures supraspinatus tendon, infraspinatus tendon, as well as
subacromial bursa
There should not be full true bony articulation between the 2 bony
structures- must maintain space because if humeral head is allowed to
rise up and articulate w/ acromion, then structures found between the
2 bony landmarks will be impinged or crushed , leading to shoulder
impingement
3. Long head of biceps w/in bicipital groove covered by transverse humeral
ligament, which keeps long head of biceps from dislocating out of bicipital or
intertubercular groove

Long head of biceps needs to be able to slide smoothly through the

groove; if inflammed or adhesion pathology; if long head of biceps
dislocates out of groove- pathology also

Slide 4
Bony Landmarks
Scapula
on anterior surface there is concavity subscapular fossa; where
subscapularis muscle sits
coracoid process pectoralis minor attaches here
acromion process
following upward will be suprascapular notch, closed off by transverse
scapular ligament; suprascapular nerve travels through this notch and
innervates supraspinatus and infraspinatus
o suprascapular nerve comes from brachial plexus at the level of the
trunks (superior trunk), travels through suprascapular foramen and
enters concavity known as supraspinous fossa where supraspinatus
o suprascapular nerve pierce through supraspinatus and dive laterally
underneath spine of scapula and enter the infraspinous fossa (below
spine of scapula)
o where infraspinatus muscle is housed; suprascapular nerve innervates
infraspinatus
border of scapula medial border a.k.a. vertebral border; lateral
border or axillary border
inferior angle-point at bottom / superior angle - point at top
root of the spine of the scapula when spine of scapula flattens out
towards medial border
glenoid fossa concavity on lateral aspect
supraglenoid tubercle - protrusion of bone on top of glenoid fossa; long
head of biceps brachii attaches here; supraglenoid tubercle is housed
w/in the glenohumeral joint
infraglenoid tubercle - projection of bone below glenoid fossa; long head
of triceps attaches here; infraglenoid tubercle is housed outside of
glenohumeral joint

Slide 6
Clavicle:
Acromial end
Clavicular end

when looking at clavicle from above, it will resemble an S

Convex medially and concave laterally; looking w/in the deepest portion of
concavity and drop straight down - coracoid process
3

On undersurface of clavicle, 2 roughened surfaces known as trapezoid

tubercle and conoid tubercle; named for ligamentous structures attached
to them
Trapeziod ligament - attaches to trapezoid tubercle
Conoid ligament attaches to conoid tubercle
Collectively these 2 ligament are called coraco-clavicular ligaments
Slide 7
Humerus

Head-top portion
2 necks
1. Anatomical neck delineation of portion of head of humerus that is
covered w/hyaline cartilage vs. non-cartilagenous portion; articular
portion of humeral head
2. Surgical neck between head and shaft; humerus commonly fractured
at this point (surgical fixation to treat fracture here)
Large projection of bone laterally and small projection of bone medially on
anterior surface of humerus
o Lesser tubercle smaller projection; attachment for subscapularis
(one of rotator cuff muscles)
o Greater tubercle entire area from back to front; 3 facets (anterior,
lateral and posterior facets)
Supraspinatus muscle attaches to anterior facet
Infraspinatus muscle - attaches to lateral facet
Teres minor attaches to posterior (posterior and inferior)
facet
o Note: all 4 of rotator cuff muscles attach to tubercles of humerus
( S.S.I.T)
Intertubercular or bicipital groove in between the greater and lesser
tubercles long head of biceps brachii runs through this groove
Crest of greater tubercle a.k.a. lateral lip of bicipital groove
pectoralis major attaches here
Crest of lesser tubercle a.k.a. medial lip of bicipital groove latissimus
dorsi and teres major attach here
Deltoid tuberosity - Large projection of bone 1/3 of the way down on lateral
aspect of humerus; deltoid attaches here
Musculospiral or radial groove posterior aspect of humerus; on posterior
aspect, line running from medial to lateral; radial nerve, deep brachial artery
or profunda brachii run through musculospiral or radial groove
Medial and lateral epicondyles - Widest portions on humerus inferiorly
(analogous to epicondyles of femur); you can tell if medial b/c the head faces
medially and the greater/lesser tubercles, intertubercular/bicipital grove are
anterior
Lateral supracondylar ridge - ridge of bone above lateral epicondyle
4

 Medial supracondylar ridge above medial epicondyle

Capitulum - Round structure on lateral side; capitulum articulates w/ radius
Trochlea spool-like structure medially; articulates w/ ulna; medial lateral
portions medial portion descends down more inferiorly
Radial fossa concavity above capitulum; head of radius fits into here when
elbow fully flexed
Coranoid fossa concavity superior to trochlea; in full elbow flexion,
coranoid process of ulna fits into coranoid fossa on humerus
Olecranon fossa - posteriorly, large concavity or fossa; accepts olecranon
process of ulna

Slide 8
Ulna
Olecranon process - Proximal posterior aspect of ulna; fits into olecranon
fossa of humerus
Trochlear notch of ulna - Bi-concave nature on either side; articulates w/
trochlear of humerus
Coranoid process lip at botton of trochlea; at full elbow flexion it will fit
into coranoid fossa of humerus
Radial notch concavity where ulna accepts radius; when radial notch
articulates w/ radial head, it forms a proximal radial ulnar joint
Ulnar tuberosity - Roughened area of bone just inferior to coranoid
process; brachialis attaches here
Ulnar styloid process - Projection of bone on most inferior aspect of ulna
Ulnar head - Bulbous portion superior to ulnar styloid process; fits into ulnar
notch of radius to form distal radial ulnar joint
Ulnar head bump on distal medial aspect of forearm
Note: Ulna is medial and radius is lateral; radius on same side as 1 st digit and
lateral
Slide 9
Radius
Most proximal part of radius is radial head
Fovea- indentation on top radius; possibly comes into contact w/ lateral
portion of the humerus (capitulum)
Neck
Radial tuberosity - Large projection of bone inferior to neck of humerus
radius; biceps brachii attaches here

Pronation palms face down and supination is palms face upward or

anterior the radius rotates around the ulna in pronation/supination;
small amount of movement in ulna but majority of movement is in radius.

 In order to produce pronation/supination, the muscle must attach to

radius
Biceps attaches to radial tuberosity, brachialis attaches to ulnar tuberosity;
therefore brachialis cannot cause any type of supination/pronation; biceps
can cause supination
Ulnar notch distally on radius; where head of ulna articulates w/ radius
distally
Radial styloid process distal aspect of radius
Dorsal tubercle of radius (Listers tubercle)- Projection of bone on
posterior aspect of radius; extensor pollicus longus loops around this and
changes direction
articular surface for 2 carpal bones (bones of wrist)- scaphoid and lunate;
very most distal aspect on under surface of radius

Note:

Slide 10
Carpals 8 carpal bones
Proximal row and distal row 4x2 (drawing)
Proximal row:
Scaphoid - Most proximal and lateral carpal bone; convex surface proximally
and concave distally; kidney bean appearance
Lunate medial to scaphoid; crescent
Triquetrum further medially; 3 sides
Pisoform last carpal bone in proximal row; it is not medial to triquetrum; it
is not connected to triquetrum; it sits superficial to triquetrum sesamoid
bone; embedded w/in tendon of flexor carpi ulnaris
Distal row:
Trapezium most lateral; articulates w/ 1st metacarpal of thumb
Trapezoid medial to trapezium; articulates w/ 2nd trapezoid metacarpal
Capitate keystone-like appearance; in the center of wrist; large and
articulates w/ 3rd metacarpal
Hamate most distal and medial; articulates w/ 4th and 5th (analogous to
cuboid -tarsal bone)
o On anterior surface of hamate large projection of bone anterior to it
hook of hamate
o Between hook of hamate and pisiform there is space Guyons canal
or piso-hamate
Mnemonic- Some Lovers Try Positions That They Cant Handle.

Slide 11
Hand
Metacarpals 5
Heads are convex and bases are concave
6

2 sesamoid bones sitting at head of metacarpals 9medial and lateral);

embedded w/in tendon of flexor pollicus brevis
Phalanges distal to metacarpals; 14 total
In the thumb 2 proximal and distal phalanges; interphalangela joint in
between
In digits 2 through 5 3 phalanges (proximal, middle, and distal); proximal
interphalangeal (PIP) joint in between proximal and middle phalanges; distal
inetrphalangeal (DIP) joint in between middle and distal phalanges
Saying that a muscle attaches to the DIP is incorrect b/c DIP is a joint and
muscle attaches to bone

Slide 12
Sternoclavicular Joint
Union between sternal end of clavicle and the manubrium of sternum
Significance of this joint in regard to stability in the UE: sternoclavicular joint
is the only attachment of UE to axial skeleton; no other true joint that
attaches UE to axial skeleton
Joint must be strong to witstand forces that must travel through it
Synovial saddle joint - both concave and convex qualities on the sternal end
of clavicle and on facet of manubrium
3 D.O.F. where clavicle moves on sternum: elevation & Depression,
Protraction & retraction, and posterior rotation (posterior rotation Is the actual
movement; anterior rotation is the return to resting position)
Posterior rotatation of clavicle only occurs at end range shoulder elevation
Incongruency in this joint; therefore there is well developed fibrocartilagenous
disc found w/in joint that takes up spaces in between 2 articular surfaces and
increase congruency and enhance movement
Supporting this joint is anterior and posterior sternoclavicular ligament
Connecting from clavicle to clavicle is interclavicular ligament only 1
spanning from end to end; superior to clavicle
Costoclavicular ligament in between clavicle and 1 st rib, inferior to clavicle
Elevation of clavicle elevate scapula and clavicle elevates ; depression is
opposite
Protraction of clavicle protract scapula clavicle will also move anteriorly;
retraction is posterior movement of clavicle
Slide 13
Acromioclavicular joint union between acromial end of clavicle and
acromion process of scapula
Plane synovial joint - flat surface sitting on another flat surface
3 DOF anterior/posterior tipping, internal/external rotation,
upward/downward rotation

Fibrocartilagenous support structure disc is smaller and less developed than

in the sternoclavicular joint
As you protract scapula it moves forward, but the motion at
acromioclavicular joint is actually rotation.

Ligaments:
Superior and inferior acromioclavicular ligaments found above and
below the joint; Weak ligaments when injury at this joint, these ligaments
would be injured first; injury to acromioclavicular joint (sublux or dislocatethis
joint0 shoulder separation
Coracoclavicular ligaments primary support structures of this jointstrong; 2 components (trapeaoid and conoid ligments which attach from
coracoid process to lateral inferior aspect of clavicle
o Resists separation between clavicle and acromion
o Trapezoid ligament has trapezoid appearance
o Conoid ligament cone-type appearance; conoid ligament at rest is
wound; cone-shaped appearance b/c it is twisted and wound; as you bring
arm upward there will be greater degree of separation between coracoid
process and clavicle, placing stretch on these ligaments; as conoid
unwinds it pulls clavicle into posterior rotation; as arm comes upward in
order to reach full range of motion, clavicle must posteriorly rotate
Motion of sternoclavicular joint is dictated by ligament that supports the
acromioclavicular joint
Slide 14
Glenohumeral Joint articulation between glenoid fossa of the scapula
and humeral head.
Mobile joint; sacrifice stability
humeral head is 3x the size of glenoid greater mobility and lesser stability
Synovial ball and socket most mobile
3 DOF: flexion/extension, abduction/adduction, internal/external rotation
Fibrocartilagenous support structure analogous to LE (acetabular labrum); in
shoulder glenoid labrum
Projecting out from glenoid fossa is fibrocartilagenous labrum
Since supraglenoid tubercle sits on glenoid fossa, long head of biceps has
direct attachment to glenoid labrum
Glenoid labrum is continuous w/ joint capsule; any tear to glenoid labrum will
decrease pressure and stability w/in joint
Tear to superior portion of labrum SLAP tear Superior Labrum Anterior to
Posterior; long head of biceps can also be involved
Bankhart tear on posterior inferior aspect of labrum
Joint capsule delineations:
o Superior on top
o Middle most anterior aspect of joint
8

Inferior redundancies or folds of tissue allow movement (shoulder

elevation); redundancies in inferior capsule must be allowed to expand;
in some individuals fibrous connections begin to form(unknown origin)
and become adhesed and inflammed, decreasing full range of motion
called frozen shoulder (clinically known as adhesive capsulitis); natural
progression of frozen shoulder whether you touch patient or not they
will get better in a year o 2 years
o Posterior posterior aspect of joint capsule
Ligaments: intracapsular they blend in w/ joint capsule
Superio GH ligament sitting on top of superior joint capsule
Middle GH on middle joint capsule
Inferior GH complex along inferior
Foramen of Weichtbreaht - Space or gap in between middle and inferior
joint capsule; most common site of anterior subluxation and dislocation of
GH joint; it is also reason why anterior dislocations are more common than
posterior dislocations of GH joint
Posterior dislocations are less common b/c scapula sits at an angle
if scapula sat in frontal plane and articulated w/ humerus, there is nothing
blocking posterior dislocation
Since scapula is oriented at 30 to 45 degrees anterior to the frontal plane and
the humeral head is articulated, as you move posteriorly, you hit posterior
aspect of glenoid fossa producing a bony block
This increases posterior stability

GH joint is unstable.
In order to fully function dynamic stability (vs. static stability)
Static stability is all these soft tissue structures that stabilize the joint at rest
(joint capsule ligamentous structures, fibrocartilagenous labrum- static
structures that stabilize joint); they alone are not enough to stabilize GH joint
even at rest
o In someone w/ cerebrovascular (CV) accident (stroke) wh loses muscle
tone on that side of body, gravity acting on arm hanging on side can
cause inferior dislocation
o Humeral head pulled inferiorly b/c no tone in muscles to hold humeral
head in place even if all of these static structures are still in place
Dynamic stability needed for full function of GH joint dynamic stability from
muscles that attach to scapula rotator cuff muscles

Slide15
Scapulothoracic joint - Functional joint between flat scapula and round
thoracic cage
Movements at acromioclavicular joint maintains articulation of scapula w/
round thoracis cage
To maintain articulation, adequate muscular activity needed
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Scapular winging pathological movement in which scapula lifts away from

ribcage (and decrease congruency if found)
Scapula can lift away at inferior angle or medial border
Muscles that attach to medial border on anterior surface serratus anterior
(p.282 in atlas)
If serratus anterior is weak, as individual moves UE, inferior angle of scapula
will lift away
Rhomboid minor and major also attach to medial border; weaknesses in these
muscles can also cause scapular winging
Motions : (3 DOF)
Elevation/depression: elevation (shoulder shrugging)
Protraction/retraction: a.k.a. scapular abd/adduction
Upward/downward rotation: rotation named for orientation of glenoid fossa
all of this proximal movements position the distal portion of UE; when you
want to reach w/ hand, scapula or glenoid fossa points in same direction
As an individual goes into scapular elevation, congruency decreased between
scapula and thoracic cage
Elevation at scapulothoracic joint anterior tipping at acromioclavicular joint
to maintain congruency and sternoclavicular joint also elevates (whatever the
scapula does the clavicle does also)
Depressionof scapula posterior tipping at acromioclavicular joint and
depress the clavicle
Protraction at scapulothoracic joint - internal rotation at AC joint and at
sternoclavicular joint protraction as well
Retraction of scapula external rotation at AC joint and clavicle also retracts
Note: To move scapula, sternoclavicular joint must move also.
Upward rotation at scapulothoracic joint upward rotation at AC joint also,
and elevation at sternoclavicular joint (elevation continues at sternoclavicular
joint until conoid ligament becomes taut; then posterior rotation occurs
conoid ligament is taut at its wound state and as it unwinds, then posterior
rotation at sternoclavicular joint
Upward rotation of scapula = upper trapezius

+ lower trapezius + serratus anterior

In order to properly rotate scapula you need all 3 muscles; weakness to any
of these will drastically alter ability to upwardly rotate scapula
Upper trapezius elevates scapula (shrugging); lower trapezius depresses
scapula
Upper trapezius primarily acts upon acromion; lower trapezius acts on spine
of scapula
If one portion of muscle pulling upward and the other pulling downward,
glenoid fossa upwardly rotates; however, if upper and lower trapezius is all
you have (upwardly rotating), you lose congruency;upward rotation along
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with serratus anterior(pulls scapula down against rib cage) maintain

congruency during upward rotation
Deficiency to serratus anterior scapular winging ; for example, . long
thoracic nerve palsy (LTN innervates anterior serratus) would cause scapulr
winging
Weakness of lower trapezius no upward rotation b/c no downward pull on
medial side of scapula; instead scapular elevation ; when scapula elevated,
glenoid fossa points laterally (if shoulder is shrugged while elevating arm
over your head range of motion decreased b/c glenoid is not oriented in
direction that UE needs to move into)
Another factor that affects full ROM of shoulder not at GH joint but it plays a
role functionally if you lack thoracic extension, you cant fully reach
overhead (when someone highly kyphotic reaches overhead, GH joint is being
torqued beyond what it can do)
Slide 16
Other Ligaments of the Shoulder
Coracoacromial ligament (arch) attaches from coracoid process to acromion
process does not cross any joints and does not support any joints; forms a
buttress to provide stability and prevent humeral head from translating too
far superiorly and anteriorly (in lab, can be seen as after you reflect deltoid
from its proximal attachments)
Transverse humeral ligament covers tendon of long head of biceps ensuring
that it stays in the bicipital groove

Slide 17
Rotator Cuff 4 muscles
1. Supraspinatus sits in supraspinous process fossa above spine of scapula
(innervated by suprascapular nerve- which comes off superior trunk of
brachial plexus and travels through suprascapular notch)
Projects laterally with its tendon travelling underneath acromion
process through subacromial or suprahumeral space and inserts into
most anterior facet on greater tubercle
Function: does not participate in GH stability; main function is
Abduction or shoulder elevation; important b/c initiates shoulder
elevation (from 0 to 30 degrees); deltoid works though entire
range of motion except for initial portion
If acute supraspinatus tear or injury to suprascapular nerve, could not
move arm from their side or elevate UE; however if their arm was lifted
to 30 degrees, deltoid can take over
2. Infraspinatus infraspinous fossa inferior to spine of scapula; innervated by

suprascapular nerve

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projects out laterally, partially underneath acromion process in

subacromial space and inserts into most lateral facet on greater
tubercle
Function: strong external rotator of humerus; most active when arm at
the side, when humerus is lying in same plane as scapula (scapular
plane)
3. Teres minor attach approx. half way up to lateral border of scapula;
innervated by axillary nerve
Projects out laterally and insert into most posterior and inferior facet
on greater tubercle
Teres major is not part of rotator cuff; attaches to lateral border of
scapula, more at the inferior angle; projects laterally and inserts into
humerus at same location of latissimus dorsi medial lip of bicipital
groove (crest of lesser tubercle)
Quadrangular space (QS) (teres minor & major, long head of triceps
and lateral head of triceps, neck of humerus) axillary nerve and
posterior circumflex humeral artey travel through here
Triangular interval - Inferior to QS inferior to teres major radial nerve
and deep brachial artery/profunda brachii found here
Function: external rotator; most active into external rotation when arm
abducted into 90 degrees
4. Subscapularis innervated by 2 nerves (upper and lower subscapular nerves)
can be accessed through axilla; if you reach around scapula from the
back, middle trapezius first, then rhomboid maj/minor, then serratus
anterior, then subscapularis
Attaches from subscapular fossa to lesser tubercle; other three rotator
cuff muscles attach to greater tubercle
Function: internal rotator (only one); most active when arm is at the
side in plane of scapula (scapular plane)

Relationship between:
deltoid and supraspinatus synergists
subscapularis and infraspinatus antagoists
infraspinatus and teres minor synergists

Deltoid pulls upward and outward and 3 muscles (infraspinatus, teres

minor, subscapularis) will stabilize( refer to drawing)
orientation of fibers of deltoid causes it to pull upward and outward; if upward
force is not counteracted humeral head will approach on acromion process and
impinge upon supraspinatus tendon, infraspinatues tendon, subacromial bursa.
The fibers of Rotator cuff muscles (infraspinatus, teres minor subscapularis) are
orientated inferio-medially; they wil pull medially and downward, counteracting
upward pull of deltoid, maintaining humeral head w/in the glenoid fossa; as
deltoid contracts, you will go into shoulder elevation rather than impinging
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Slide 19
Persiscapular muscles attach and surround scapula 17 muscles attach to scapula
(including latissimus dorsi
Trapezius spinal accessory nerve CN XI
upper portion affects cervical spine; also performs scapular elevation; lower
traps provide scapular depression; middle trapezius scapular retraction or
adduction
when upper and lower traps fire at same time, upward rotation in conjuction w/
serratus anterior
Rhomboid minor/major and levator scapula innervated by dorsal scapular
nerve (emerges from C5, C3, and C4 like the phrenic nerve).
Rhomboid minor attaches to root of spine of scapula.
Rhomboid major attaches just inferior on the medial border.
Motion of rhomboids retraction; fibers run obliquely; They will also pull upward
on the medial border, causing downward rotation of glenoid fossa (reaching
behind your back)
Levator scapula attaches to transverse process and near superior angle
going upward
Elevates medial aspect scapula, causing downward rotation c1-c4 transverse
processes.
Serratus anterior innervated by LTN attached to medial border of scapula
on anterior surface and the 1st 8 ribs
Function: protraction or abduction of scapula (part of upward rotation force
coupling)

Pectoralis minor
Pec. major does not attach to scapula; deep to this is pectoralis minor which
attaches to coracoid process and ribs 3 to 5 (innervated by medial and lateral
pectoral nerve coming from medial and lateral cords)
Pulls scapula into protraction; also pulls inferiorly; as it pulls inferiorly on lateral
aspect of scapula it will downwardly rotate or depress scapula
Biceps brachii- muscle in anterior arm; 2 heads
Long head travels through intertubercular groove covered by transverse
humeral ligament, courses over humeral head and attaches to glenoid fossa at
supraglenoid tubercle
Short head attaches to coracoid process
2 distal attachments: tendinous attachment found laterally and attaches to
radial tuberosity; medial attachment is bicipital aponeurosis (flat tendon) that
blends in w/ fascia of forearm
Crosses 3 joints:
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1. both heads GH joint

2. humero ulnar joint causing elbow flexion
3. proximal radial ulnar joint pronation/supination
biceps can cause shoulder flexion b/c anterior to shoulder; b/c it is anterior to
elbow it causes elbow flexion; and also supination since it attaches to radius
innervated by musculocutaneous nerve since it is in anterior arm
Triceps brachii 3 heads innervated by radial nerve
long head - sits on top of medial head and attaches to infraglenoid tubercle
lateral head attaches on superior lateral aspect of humerus
medial head inferio medial aspect of humerus
all 3 muscles come together in triceps tendon and insert into olecranon process
at tendon of triceps is olecranon bursa
there is no attachment of long head to humerus; to fing medial head, find long
head and separate it away; medial head attached to posterior humerus
triceps crosses shoulder joint posteriorly (long head attaches to infraglenoid
tubercle) to produces shoulder extension
all 3 heads attach to to olecranon process, crossing posterior to humeral ulnar
joint produce elbow extension
cannot produce pronation or supination b/c olecranon process is on ulnar, nor
are they affected by pronated/supinated position
lateral head has a lot of type 2 fibers (explosive /powerful movement/heavy
weight) and medial head has large quantity of type 1 fibers (endurance/light
weight/reps until failure); long head is affected by shoulder position since it
crosses shoulder joint
corachobrachialis anterior arm; therefore innervated by
musculocutaneous nerve; most of the time it pierces though muscle
attaches to coracoid process (along w/ pec minor and short head of biceps);
projects inferiorly and found deep to short head of biceps and inserts into
proximal 3rd of humerus on medial aspect
functions: flex shoulder, adduct, and horizontal adduction (adduction in a flexed
position)
Omohyoid (neck)
attaches to scapula; not a lot of function in UE
Deltoid 3 heads: all innervated by axillary nerve

1.
2.
3.

anterior
middle
posterior
attaches to lateral 3rd of clavicle, acromion process, lateral 3rd of spine of
scapula, and all 3 heads insert into deltoid tuberority

14

predominantly there will not be agonist and antagonistic function from 1 muscle
unless it has several heads and is categorized as a convergent muscle, such as
the deltoid
anterior deltoid produces shoulder flexion, internal rotation and horizontal
adduction
posterior deltoid produces shoulder extension, external rotation, and horizontal
abduction
all 3 heads contract at same time, producing shoulder abduction in coronal plane
paralysis or injury to posterior head abduction will come slightly forward;
pathology to anterior head will cause movement to be slightly posterior

Slide 20
Other Muscles that affect UE but do not have attachment to scapula:
Pectoralis major innervated by medial and lateral pectoral nerve (emerge from
medial and lateral cords
2 heads (clavicular and sternocostal)
Clavicular head attaches to medial 3rd of clavicle; sternocostal head attaches to
costal cartilages and sternum along ribs 2 through 6; converge together and
both insert into lateral lip of bicipital groove a.k.a. crest of greater tubercle
Function (both heads together): adduct humerus, internally rotate humerus, and
horizontally adduct humerus
Individually: sternocostal head can extend an already flexed arm (from flexion to
extension); clavicular head can flex an extended arm (from extension to flexion)

Latissimus dorsi innervate by thoracodorsal nerve a.k.a. middle

subscapular nerve which emerges from posterior cord
Originates from thoracolumbar fascia that has attachments to ileum/iliac crest;
attaches to spinous processes of T7 to T12, projects down laterally, inserts into
medial lip of bicipital groove
Often assisted by teres major (originates near inferior angle of scapula and
inserts into medial lip of bicipital groove); both have same function
Functions: shoulder or humeral extension, humeral adduction, humeral internal
rotation
Lat pull down adduction of humerus
Pec major or latissimus dorsi do not have attachments to scapula, but when they
contract at same time they can depress scapula (when you put hands down on
flat surface and push body upwards, lats and pec major contract)
In rehab, this is important (pec major minor and lats both depress scapula) for
assistive devices (krutch or walker); when person presses on assistive device
they should depress scapule; if weakness in pec major or lats, person will go
down when they use assistive device
Subclavius2:24
15

Between 1st rib and inferior to clavicle; innervated by nerve to subclavius, which
emerges from superior trunk
Can either elevate 1st rib (respiratory function) or depress clavicle
In order for SCM to function, subclavius has to depress clavicle (w/ regarg to
movement of head)
SCM innervated by spinal accessory nerve CN XI, same at trapezius
Attaches to manubrium of sternum, mastoid process and medial 3 rd of clavicle
Since cranium weighs more than clavicle, when SCM contracts the clavicle
moves upward
To produce cervical flexion, rotation, side bending (in order for SCM to affect
cervical spine) subclavius has to stabilize clavicle by pulling inferiorly
Scalenes

st

Anterior attaches to 1 rib

Middle attaches to 1st rib
Posterior attaches to 2nd rib
Brachial plexus and subclavian artery travel between anterior and middle
scalenes
If hypertrophy in ant, middle, or posterior scalenes, brachial plexus
can become compressed symptoms include paraesthesia
(numbness & tingling) or weakness
Slide 23
Elbow Joint 4 joints
1. Humero-ulnar joint between humerus and ulna; trochlea of humerus w/ troclear
notch of ulna
synovial hinge joint 1 DOF (flexion/extension)
medial portion of trochlea is larger and extends down more inferiorly; it
will cause ulna to carry a normal lateral angulation (between radius and
ulna) carrying angle
carrying angle is more of a valgus angulation assists in clearing hips as
we ambulate
females have a larger carrying angle than males
Ligament: both are complexes formed by several different bands of
ligaments
o Medial (ulnar ) collateral ligament originate on medial epicondyle
of humerus, project downward and attach to proximal aspectof
ulna near ulnar tuberosity; MCL resists valgus force
o Lateral (radial) collateral ligament originates on lateral epicondyle
and project downward and blend into the annular ligament
(ligament that surrounds head of radius) and blends in w/ proximal
aspect of radius distal to the head; LCL resist varus force

16

Note: In elbow extension, less movement into valgus and varus

b/c olecranon fits into olecranon fossa, forming a bony block.
2. Radio-humeral joint between fovea of radius and capitulum of humerus
Does not articulate when arm hangs on side in non-weight bearing; head
of radius and radial fossa of humerus (superior to capitulum) articulates
when in full flexion
Only other time you will have contact between fovea of radius and
capitulum is in full weight bearing; load of entire body running through the
humerus will compress joint and cause contact between radius and
humerus
Note: The next two joints are mechanically linked; as you move distal radioulnar
joint, you must move proximal radioulnar joint.
3. Proximal Radio-ulnar 4. Distal Radio-ulnar radius rotates around ulnar head; at proximal radioulnar
joint spinning occurs while this is happening
In situ, (at proximal joint) ligament runs from the ulna at one aspect of
radial notch, around radial head, back to ulna to the other side of radial
notch annular ligament (blends into lateral collateral ligament
o Annular ligament closes off proximal radioulnar joint
o Lining inner surface of annular ligament is hyaline cartilage, which
reduces friction
Both proximal and distal radioulnar joints are pivot joints 1DOF
spinning/rotation
The motion at both radioulnar joints is pronation/supination; motion of
radius rotating over ulna occurs at distal radioulnar joint
If you have full mobility at distal radioulnar joint and hypomobility or
restriction or internal fixation of proximal radioulnar joint you will not
produce pronation/supination (radial head cannot spin w/in annular
ligament)

At distal radioulnar joint, 2 ligaments attaching from ulnar notch of radius

one on volar and one on dorsal surface: palmar or volar radioulnar
ligament and dorsal radioulnar ligament
o Palmar radioulnar ligament more anterior?; function to resist
excessive supination
o Dorsal radioulnar ligament more posterior resists excessive
pronation

Between radius and ulna interosseous membrane (syndesmosis joint)

functions in stabilizing and holding 2 bones together and transmit forces.
Fibers of interosseous membrane run medially and inferiorly from radius to ulna.
Any force transmitted through hand first goes through scaphoid (commonly
fractured carpal bone), then to radius pushing upward on radius towards
17

capitulum putting tension on interosseous membrane, wich transmit force to

ulna, then to humerus, to scapula to sternum to axial skeleton
If great quantity or velocity of force cannot be translated adequately in time,
head of radius can fracture being driven into capitulum; only other time when
there is contact between head of radius and capitulum in weight bearing

Slide 24
Muscle of the Arm
Musculocutaneous nerve motor in anterior arm and sensory in lateral
forearm
3 muscles in anterior arm innervated by musculocutaneous:
1. Biceps brachii 2 proximal and 2 distal attachments; short head attaches to
coracoid process and long head attaches to supraglenoid tubercle proximally; 2
distal attachments are radial tuberosity and bicipital aponeurosis blending in w/
the fascia of forearm
Crosses 3 joints (shoulder flexion/elbow flexion/forearm supination)
More active when in supinated position and recruited more when lifting
heavy load or trying to produce large quantity of force rapidly
2. Coracobrachialis attaches to coracoid process and inserts into proximal 3 rd of
medial humerus; nerve often pierces muscle; shoulder adduction, flexion, and
horizontal adduction
3. Brachialis attaches to distal 2/3 of anterior humerus; project downward
crossing humeral joint and inserts into ulnar tuberosity; elbow flexion ( no
supination b/c not attached to ulna radius); may not produce large amounts of
force but it will always be active during elbow flexion; flexing elbow while in
supination, neutral or while pronated brachialis is always active
Between biceps brachii and brachialis: brachial artery, median nerve, and
ulnar nerve
Posterior arm innervated by radial nerve:
1. Triceps brachii 3 heads long, lateral, and medial
1. Long head crosses shoulder joint attaching to infraglenoid tubercle
2. Lateral head attaches to proximal lateral aspect of humerus
3. Medial head attaches to distal medial portion of humerus
Medial and lateral heads are separated by musculospiral groove on
humerus (radial nerve travels through musculospiral groove).
All 3 heads insert into olecranon process; triceps crosses 2 joints
(GH joint and humeroulnar joint); produce GH extension &
humeroulnar extension).
2. Anconeus desihnated as posterior arm muscle, but found in proximal forearm
on lateral aspect
1. Small triangle; attaches to lateral epicondyle to olecranon process and
then proximal aspect of shaft of ulna
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2. Should be elbow extensor, but since it is small it is more likely an elbow

stabilizer; allows biceps brachii to act solely as a supinator; if forearm
pronated w/ ulnar humeral joint extended, and biceps contract, forearm
would end up flexed and supinated
3. With elbow flexed (for instance, to grab a door knob) and to supinate,
biceps is working; anconeus acts as stabilizer and keeps elbow from
flexing; biceps on its own would flex elbow in order to supinate w/o going
into further flexion while using biceps, anconeus stabilizes
Slide 25
Muscles of the Forearm
Flexors or extensors: flexor group on anterior forearm and extensors on posterior
forearm.
Flexor group originates on medial aspect of humerus and extensor group
originates on lateral aspect of humerus
Any muscles in extensor compartment innervated by some branch of radial
nerve
Muscles of flexor compartment - ulnar nerve innervates 1 and median
nerve innervates everything else
All muscles attaching to medial or lateral humerus and project downward
throughout forearm, with some crossing the wrist; some cross elbow;
muscles that have distal attachment to ulna and cross elbow joint will also be
weak elbow flexors; therefore to stretch muscles, extend elbows

Flexor compartment 3 layers: superficial, intermediate, deep

Superficial contains 4 muscles: medial to lateral
1. Flexor carpi ulnaris originates on medial epicondyle of humerus,
projecting downward as most medial muscle in flexor compartment;
pisoform embedded w/in its tendon at the wrist; inserts into hook of
hamate and final insertion in base of 5th metacarpal
Ulnar nerve and ulnar artery- Deep to flexor carpi ulnaris
Ulnar nerve innervates FCU; it is sandwiched between FCU and
medial half of flexor digitorum profundis (can see in dissection)
All of flexor carpi ulnaris and medial half of flexor digitorum
profundis innervated by ulnar nerve (1 muscles)
Function: both flexion of wrist and ulnar deviation a.k.a. palmar
adduction (palm moves medially through coronal plane; when it
contracts by itself, pulls wrist into flexion w/ ulnar deviation
2. Palmaris longus small thin muscle w/ short belly originating on
medial epicondyle; thin long tendon travels superficial to flexor
retinaculum which covers carpal tunnel, enters hand and blend in w/
palmar aponeurosis w/in palmar surface of hand (analogous to
plantaris in LE)

19

 Crosses anterior to wrist wrist flexion and tenses superficial

palm
Not everyone has this; some may have only on one side
Can be used for tendon transfers; also used for reconstructed
ulnar collateral ligament procedure called Tommy John surgery
(pitchers)
Nerve in this area repeated with repeated valgus force- ulnar
nerve (which can cause numbness and tingling in 4 th and 5th
digits)
Very often during ligament reconstruction, ulnar nerve removed
from cubital tunnel and relocated into cubital fossa (anterior);
(median nerve also travels through cubital fossa
3. Flexor carpi radialis attached to medial condyle, course down and
insert into bases of 2nd and 3rd metacarpals; radial artery is lateral to
tendon of flexor carpi radialis
Wrist flexion and radial deviation
Median nerve
Note: Anterior muscles innervated by either ulnar or median;
besides flexor carpi ulnaris and medial half of flexor digitorum
profundus, median nerve innervates everything else.
4. Pronator teres will not project down to wrist like all other muscles in
superficial compartment
Originates on medial epicondyle as well as send fibers to medial
supercondylar ridge; it will cross over to lateral forearm and
insert into radius at mid shaft (half way down forearm
Note: You do not have to move any structures to see superficial or
intermediate layers.

Intermediate layer only 1 muscle flexor digitorum superficialis do not

need to move any structures to see it and found deep to superficial muscles;
more visible on medial side
4 tendons go to digits 2, 3, 4, 5
Originate on medial epicondyleand project downward
2. Innervated by Median nerve -Found on undersurface
3. Travels through carpal tunnel in 2 X 2 orientation 2 tendons on top of 2
tendons through carpal tunnel
4. Deep to flexor retinaculum in palm; cross over metacarpalphalangeal
joint and proximal interphalangeal joint and insert into middle
phalange
5. Flexes PIP joint, MCP, wrist, but not distal interphalangeal joint b/c it
doesnt cross joint
6. To get deeper flexor digitorum superficialis must be moved to the side
7. Common flexor wad common origin muscle belly
20

Deep
1. Flexor digitorum profundis originates on medial aspect of ulna and
has attachment to coranoid process; projects downward deep to flexor
digitorum superficialis; tendons are pearly white and larger in width
Travels through carpal tunnel in 4 x 1 (all 4 tendons in one flat plane)
Travel parallel to FDS; both muscles housed together in common
tenosynovium
Crosser wrist, metacarpophalangeal joints, and DIP joints of digits 2, 3,
4, 5, then it inserts into distal phalanges on 2, 3, 4, and 5 can affect
every joint from wrist to distal phalanges
Lateral part innervated by anterior interosseous nerve (branch of
median nerve) and medial half by ulnar nerve
Most distal motor portion of radial nerve posterior interosseous;
everything posterior is radial nerve.
2. Flexor pollicus longus 1 tendon laterally; attachments to distal aspect
of radius
Different appearance and fiber orientation than FDP (fusiform or
parallel or strap muscle fibers in same direction as tendon)- FPL is
pennate (fibers insert obliquely into tendon)
Travels through carpal tunnel, course along volar surface of 1 st digit
and insert into distal phalange of 1st digit
Innervation: anterior interosseous nerve
Note: Nine tendons and 1 nerve 10 structures travel though carpal
tunnel.
3. Pronator quadratus along distal aspect of forearm (need to split flexor
digitorum profundis away from flexor pollicus longus to see it)
Attaches to both radius and ulna distally
Square muscle pronation
Sites on top of interosseous membrane
nerve and artery that provide innervation and perfusion will course
along intersosseous membrane and terminate at pronator quadratus
anterior interosseous nerve and artery

Extensors (wrist) - designated as superficial and deep (no intermediate layer);

Originate on lateral aspect of humerus
Superficial Layer
1. Brachioradialis - very 1st muscle to identify in forearm is
brachioradialis (landmark) closest muscle to flexor compartment that
still originates in lateral humerus

21

 Originates on lateral supracondylar ridge (above epicondyle) and

project downward along lateral radius and insert just proximal to
radial styloid prcess
Anything anterior to brachioradialis is in flexor compartment;
anything posterior is extensor.
Innervated by radial nerve. Nerve between barchialis and
brachioradialis on lateral arm (after radial tunnel radial nerve
splits into superficial and deep radial nerves
Nerve travelling underneath brachioradialis that runs parallel to
it and enters the dorsum of hand to provide sensation to lateral
portion superficial radial nerve
Brachioradialis does not cross wrist joint, it attaches to radial
styloid; therefore it can only affect elbow (humeral ulnar joint)
Motion: elbow flexor, even though it is in the extensor
compartment; elbow flexor primarily when in neutral forearm
position; weakly give you supination when already pronated &
weakly give you pronation when already supinated brings you
back to neutral position
Note:
When you flex elbow and forearm is supinated, biceps brachii and brachialis
are working.
When you flex elbow and forearm is neutral, brachialis and brachioradialis
are working.
When you flex elbow and forearm is pronated, brachialis is working (elimated
every0 other muscles therefore only brachialis is functioning when you are
pronated, unless a super heavy load is being lifted biceps is also recruited.
g
2. Extensor carpi radialis longus next muscle coursing from
brachioradialis medially?
Also originates onlateral supracondylar ridge, project down
inferiorly; has a long tendon that inserts into base of 2 nd
metacarpal
Innervated by deep radial nerve
Wrist extensor and radial deviation
3. Extensor carpi radialis brevis medial to ECRL
Has large thick muscle belly (shorter tendon)
Originates on lateral epicondyle and inserts into base of 3 rd
metacarpal
Wrist extension and radial deviation , but ability to produce
radial deviation is much less than ECRL
Innervated by deep radial nerve; nerve comes off after deep
and superficial radial nerves have split apart
Note: These differ from flexor carpi radialis b/c the FCR attaches distally
to base of 2nd and 3rd, where as in extensor side there are 2 different
22

muscles (EXRL inserts into base of 2nd metacarpal and ECRB inserts into
the base of 3rd.)
Deep radial nerve pierces through supinator after it gives off a branch
that innervates ECRL; deep radial nerve innervates supinator and
emerges from supinator as posterior interosseous nerve. Every
other muscle is innervated by post. Int. nerve.
Innervates
4. Extensor digitorum - Medial to ECRB; 4 tendons
Originates on lateral epicondyle; it will course downwards and
inserts at base of middle phalange; it barely crosses over
proximal interphalangeal (PIP) joint
Innervated by posterior interosseous nerve
Does not extend interphalangeal joints; no effect on PIP joint;
primarily affects metacarpophalangeal joint and wrist joint
(extension in both)
5. Extensor digiti minimi (medially)
Extra tendon that goes to 5th digit (2 tendons go to 5th digit 1
from extensor digitorum and 1 from extensor digiti minimi)
Only inserts at same level as ext. digitorum distal to PIP
Extension of metacarpophalangeal joint and wrist, particularly at
5th digit
6. Extensor carpi ulnaris most medial muscle in extensor
compartment
Originates in lateral epicondyle; projects down along ulna
alongside flexor carpi ulnaris, inserts into base of 5 th metacarpal
Innervated by posterior interosseous nerve; (since it is
extensor compartment it has to be innervated by radial nerve,
specifically post. Int. nerve [every other muscle beyond
supinator is innervated by post. Inter. nerve])
Wrist extension w/ ulnar deviation
Tennis elbow lateral epicondylitis muscle affected Ext Carpi Radialis Brevis,
which originates on lateral epicondyle. Muscles attaching here begin to pull
away, inflammation on bony landmark. More force (or tighter grip) produced
when wrist extended. Person will go into wrist extension to get tighter grip to hit
the ball. If grip is too large they need to produce more force to squeeze and
they will torque more into wrist extension. Muscle is irritated and inflammation
on lateral elbow as a result.

Deep Layer
1. Supinator proximal aspect of posterior forearm
Originates on lateral epicondyle, has projections across to
proximal radius and radial tuberosity
23

 Provides you w/Supination; not powerful supinator b/c biceps is

powerful supinator; its like brachialis during any type of
supination, it is always going to function
Innervated by deep radial nerve
Note: the last 4 muscles affect either the index finger or thumb. In order
for us to see ext. indices and ext. pollicus longus, we need to move ext.
digitorum to the side; muscle belly closer to ulna (more medial) is ext.
indices.
2. Extensor indices proprius
Projects downward and inserts just distal to proximal
interphalangeal joint of 2nd digit (it is 2nd tendon that inserts here
tendon of ext. indices travels deep to ext. digitorum). If
deviated away from tendon of ext. digitorum at all it will be
found more medial
3. Extensor pollicus longus lateral (closer to radius)

Middle third of ulna and interosseous membrane Project down

and lop around Listers or Dorsal tubercle (bony landmark on
dorsal surface of radius); changes direction to insert into distal
phalanxge of the 1st digit
Function: Interphalangeal joint extension of 1 st digit and MCP
joint; some radial deviation
4. Extensor pollicus brevis wraps aound radius
Diverge away and travel along dorsum of 1st digit, inserting into
base of proximal phalanxge
Function: extension of MCP joint and some radial deviation
5. Abductor pollicis longus - Both wrap around radius
Distal ulna, interosseous membrane, radius - Courses around
and is visible on anterior surface of hand, inserting into base of
1st metacarpal
Function: abduct thumb at carpometacarpal joint and some
radial deviation

Splenius capitis apspinous processes of c7-t3, mastoid process of temporal bone lateral superior
nuchal line, nuchal ligament
ipsilateral lateral flexion and rotation and bilateral = capital and
upper cervical extension.
Middle scalene flexio transverse processes to 1st rib
Anterior scalene c3-c6 transverse processes to 1st rib
Posterior scalene c5 c7 transverse processes to 2nd rib
Abductor pollicis longus ongus longus s longusinterosseous membrane. TO base of 1st
metacarpal.

24

Extensor pollicis longus middle third of ulna, interosseous membrane, base of proximal
phalanx

Note: Ext. pollicus longus, ext. pollius brevis, abd. Pollicus longus
form the boundaries of anatomical snuff box; all 3 innervated by
post. Interosseous nerve (from radial).
Cross section of wrist refer to drawing in lecture.

References:

rectus abdominus costal cartilages of ribs 5-7, xiphoid process,

pubic symphysis, pubic crest = flexes trunk and compresses
abdominal viscera.
Inferior oblique spinous process c2- transverse process of c 1
Superior oblique - trasverse process of c2 inferior nyhal line
Rectus capitus posterior major spinous process of c2 to inferior
nuchal line
Rectus capitus posteior minor posterior tubercle of c1 to inferior
nuchal line

25

Flexor carpi ulnaris pisiform embedded in its tendon. Hook of

hamate. Base of 5th metacarpal originates on the medial epicondyle.
Pisiform increases the lever arm by increasing the distance it has to
travel because it goes over the pisiform. Pisiform also acts as an
anatomical pulley to change the direction of the flexor carpi ulnaris
Internal oblique - thoracolumbar fascia, iliac crest, inguinal
ligament, ribs 10 12, linea alba
External oblique - ribs 5-12, linea alba, pubic tubercle, iliac crest.
Rectus abdominus - pubic symphysis, pubic crest, xiphoid process,
costal cartilages of ribs 5-7
Transverse abdominus - costal cartilages of ribs 7 12 thoracolumbar
fascia, iliac crest inguinal ligament linea alba

Internal oblique - 10 12
External oblique 5- 12
Transversus abdominus 7 - 12
Diaphragm - costal cartilages of rib
Xiphoid process, costal cartilages of lower 6 ribs that have costal
cartilages central tendon of the diaphraggm .

Pisiform on triquetrum.

Flexor retinaculum, specifically the transverse carpal ligament

attaches to the scaphoid and trapezium and hamate and pisiform.

26

27

28

29

30

Ulnar nerve comes off of medial cord, runs down medial arm, under
flexor carpi ulnaris, through guyons canal into the hand.
Median nerve comes off of the contributions from the lateral and medial
cords. Runs through the cubital fossa, between the two heads of pronator
teres, through the carpal tunnel and into the hand to supply th elater 3.5
fingers on the palmar side and the tips on the dorsal side.

31

32

abductor pollicis brevis retinaculum, base of proximal phalanx.

scaphoid trapezium, flexor

33