Station 1: Scapula, clavicle, sternum, humerus, radius and ulna.

UPPER LIMB GIRDLE

General information: A limb consists of two parts: a girdle and the limb proper. The girdle
attaches the limb to the axial skeleton. In the upper limb the, girdle (also known as the
pectoral girdle) consists of the scapula and clavicle. At its lateral end , the clavicle
attaches to the acromion of the scapula (acromioclavicular joint) and to the coracoid
process of the scapula (via the coracoclavicular ligament. At its medial end, the clavicle is
attached to the manubrium and the costal cartilage of 1st rib (forming the
sternoclavicular joint). The latter provides the only bony attachment of the upper limb to
the axial skeleton. The acromioclavicular and sternoclavicular joints allow the scapula to move
in a variety of planes. This movement is achieved by several muscles which also help to keep
the scapula in contact with the thorax.
a) Examine the bones, articulated skeleton and the diagrams; identify and learn the
important parts of the clavicle and scapula, and their arrangement to form the pectoral girdle.
i) Palpate the jugular notch. Move your finger laterally and palpate the joint between the
manubrium and the clavicle (sternoclavicular joint). Move your shoulder in various directions
and note how this joint also moves.
ii) What part of the clavicle is most commonly fractured?
iii) Explain why a fall on the outstretched hand can result in a fractured clavicle
iv) Describe the movements of the scapula
iv) Palpate acromion (point of shoulder) then palpate the clavicle and the
acromioclavicular joint. Find the lateral part of the clavicle and move your finger just
inferior to the clavicle into a soft depression and at this site palpate the coracoid process of
the scapula. Note how the coracoid process is more easily palpated if you protract your
shoulder (ie push your shoulder anteriorly).
Clavicle 3 MBBS 1 Case 2, semester 2| The University of Adelaide

LIMB PROPER
General information: The upper limb can be divided into 3 segments. The proximal
segment has 1 bone, the humerus; the middle segment has 2 bones, the radius (lateral
bone) and the ulna (medial bone). The distal segment consists of carpals (8 bones in two
rows), metacarpals (5 bones) and phalanges. The thumb is digit 1 and is most laterally
placed when the upper limb is in the anatomical position. It has only 2 phalanges, while the
other 4 digits have 3 phalanges each.
The upper limb can be divided into the shoulder, arm, elbow, forearm, wrist and hand. At
this stage, we will not learn the detailed anatomical features of these regions, but instead
focus on the range of movements at the joints present in these regions.

b) Examine the bones, articulated skeleton (including the articulated hand) and the
diagrams and learn the basic anatomical features and their arrangement in the limb:

1) Humerus (proximal end, shaft and distal end)

i) In the articulated skeleton, you will notice that the head of the humerus is large and does
not fit snugly into the glenoid cavity (i.e. like in the hip joint) to increase the stability of the
joint. Why did natural selection favour the current arrangement?
ii) Demonstrate abduction, adduction, flexion, extension, medial rotation and lateral
rotation movements of the arm at the shoulder joint.

iii) Palpate the acromioclavicular and sternoclavicular joints separately. When palpating
each joint, abduct, adduct, flex and extend arm and feel the movements at each joint.
iv) Palpate the greater tubercle. 4 MBBS 1 Case 2, semester 2| The University of Adelaide

2) Radius and ulna (proximal ends, shafts and distal end)

In the articulated skeleton, examine and learn how the ulna and radius articulate with the
humerus, and how the radius articulates with the ulna (i.e. proximal and distal). Demonstrate
the specific movements (particularly, pronation and supination) at these articulations.
i) Palpate the medial and lateral epicondyles of the humerus and olecranon process of
the ulna. Now, palpate all 3 structures with one hand and become familiar with the triangular
relationship. In posterior dislocation of the elbow joint and supracondylar fracture of
the humerus, describe the relationship of the 3 structures (medial epicondyle, lateral
epicondyle and olecranon process).
ii) Extend the elbow joint, palpate the lateral epicondyle with the index finger and move the
finger inferiorly to the dipression at the back of the elbow joint. Now, pronate and supinate
the hand. Describe what you could palpate and identify the structure. Note, this is the
same point where you could insert a needle to aspirate fluid from the elbow joint in
conditions where there is fluid accumulation in the joint.
iii) Palpate the styloid process of the radius and ulna. Are they at the same level? Explain.
Examine the distal ends of the radius and ulna. The radius has articular surfaces for the carpal
bones (scaphoid and lunate). The ulna does not articulate directly with the carpal bones, but
via a cartilaginous articular disc. 5 MBBS 1 Case 2, semester 2| The University of Adelaide

List 2 muscles that supinate the forearm: In the anatomical position, with the arms
extended to the sides of the trunk and palms facing forward, the arms are already in the
supinated position. The motion of supination turns the palms anteriorly or superiorly to the supine
(face-up) position. Another way of thinking about supination is how someone would move their
hands to look at their palms or to hold a bowl of soup. The supinator muscle of the forearm and
the biceps brachii of the upper arm supinate the forearm by pulling on the radius. These
muscles rotate the radius in the opposite direction of the pronator muscles, moving the distal end
of the radius back to its position on the lateral side of the wrist. Full supination moves the hand,
wrist, and forearm almost 180 degrees so that the palm faces anteriorly or superiorly, depending
on the position of the arm.
List 2 muscles that pronate the forearm: Two muscles in the forearm, the pronator teres
and pronator quadratus, work together to achieve pronation by pulling on the radius bone of
the forearm. The radius is specially designed to rotate at the elbow and wrist joints around the

other forearm bone, the ulna. During pronation, the distal end of the radius rotates around the
ulna from its position on the lateral side of the wrist to the medial side of the wrist. This action
turns the hand, wrist, and forearm almost 180 degrees so that the palm faces posteriorly or
inferiorly, depending on the position of the arm.

Why is it better to test supination and pronation with the elbow flexed?
Contrary to popular belief, the biceps brachii is not the most powerful flexor of the forearm, a role which actually
belongs to the deeper brachialis muscle. The biceps brachii functions primarily as a powerful supinator of the
forearm (turns the palm upwards). This action, which is aided by the supinator muscle, requires the elbow to
be at least partially flexed. If the elbow, or humeroulnar joint, is fully extended, supination is then primarily
carried out by the supinator muscle. In contrast to the biceps brachii, Supinator is able to

do this in all positions of elbow flexion and extension.

Station 2: Bones of the wrist and hand.
The eight bones of the wrist are called carpals. The five metacarpals and phalanges are the
bones of the hand. The thumb only has two phalanges, while the other fingers have three.
i) Describe the arrangement of the carpal bones at the wrist and identify them (The X-ray of
the hand will help). Now examine the prosected hand and learn how the carpal bones are
arranged to form an arch (the carpal arch) that is bridged anteriorly by the flexor
retinaculum to form a tunnel (the carpal tunnel). Ten tendons and a nerve pass through the
carpal tunnel.
ii) Describe the arrangement of the metacarpal bones and phalanges and the movements
possible.
iii) Identify the carpals on the X-ray
Summary of hand movements
Hand at the wrist joint: Flexion, extension, abduction and adduction (aka radial and ulnar
deviation).
Digits at the metacarpophalangeal joints: Flexion, extension, abduction, adduction, opposition
and reposition.
Phalanges at proximal and distal interphalangeal joints: flexion and extension.
At this stage, this knowledge will be useful in learning and understanding nerve injuries,
particularly those of ulnar and median nerves.