UPPER LIMB (17)

Write short notes on the anatomy of the acromioclavicular and the sternoclavicular
joints

SCJ
Synovial joint between proximal end of the clavicle and the clavicular notch of the manubrium
together with a small part of the first costal cartilage
Synovial and saddle shaped
Articular cavity separated into two compartments by an articular disc
Allows movement of the clavicle in the sagittal and coronal planes; some rotation occurs

Articulations
Manubrium articular surface is a shallow concavity set at an angle of 45 degrees; covered in
hyaline cartilage

Sternal end of clavicle articular surface is flat or slightly concave and often continues over the
inferior surface of he shaft for articulation with the first costal cartilage; covered in fibrocartilage

Ligaments
Capsule - attaches to the articular margins of the joint; invests joint cavity like a sleeve; attached to
articular disc dividing joint into two cavities

Anterior and posterior sternoclavicular ligaments - capsular thickenings

Accessory ligaments
Costoclavicular ligaments
- binds clavicle and the 1st costal cartilage just lateral to the joint
- two laminae separated by bursa (anterior running superolateral; poster running superiomedial)

Interclavicular ligament
- passes across jugular notch to unite eh medial ends of the clavicle

Intracapsular structures

Articular disc
- Fibrocartilage disc dividing the joint into medial and lateral compartments
- Attached to the capsule with firm attachments to the medial end of the clavicle above and 1st
costal cartilage below

Synovial membrane - lines capsule; both medial and lateral compartments have their own synovial
membrane

Movement
Anterior and posterior movement takes place in medial compartment
Elevation (traps, SCM, levator scapulae)
Rotation
Circumduction

Blood supply - internal thoracic and supra scapular aa

Innervation - medial suprascapular n and n to subclavius

Relations
Ant - skin, SCM fibres, pec major
Post - sternohyoid, internal thoracic vessels, phrenic n
Right - brachiocephalic trunk (R), formation of R) brachiocephalic v, right lymphatic duct
Left - Brachiocephalic v, Left common carotid a, thoracic duct
ACJ

Small synovial joint between an oval facet on the medial surface of the acromion and a similar
facet on the acromial end of the clavicle.

Allows movement in the anteroposterior and vertical planes with some axial rotation

Ligaments
Capsule - sleeve like, surrounds articular surfaces

Acromnioclavicular ligament - capsular thickening superiorly

Accessory ligaments
Coracoclavicular ligaments - very strong, main joint stabilisers; two parts
- conoid ligament - inverted come between the conoid tubercle on the inferior clavicle and to the
coracoid process (posterior)
- trapezoid ligament - extends from the trapezoid line of the clavicle (lateral to the conoid
tubercle)to the coracoid process (anterior)

Intracapsular structures
Fibrocartilagenous disc - incomplete disc extends inferiorly from superior aspect of joint

Synovial membrane

Relations
Sup - deltoid m
Inf - GH joint, supraspinatus tendon, head of humerus, coracoacromial liv
Med - coracoid
Post - supraspinous fossa; suprascapular a and n

Blood supply - suprascapular a

Innrevation - lateral supraclavicular n

Write short notes on the anatomy of the glenohumeral joint

Multiaxial synovial ball and socket joint between the glenoid cavity of the scapula and the humeral
head
Permits wide range of movement of the upper limb but is relatively unstable

Articular surfaces
Both covered with hyaline cartilage
Spherical head of humerus is 3-4x the side of the of the glenoid cavity
Glenoid cavity is small and shallow, made deeper and expanded laterally by the glenoid labrum - a
fibrocartilagenous ring attached to its boundaries

Capsule
Thin and loose inferiorly to enable mobility - weakest part of capsule
Attached to the scapula beyond the supraglenoid tubercle and at the margins of the labrum
Attached to humurus around the anatomical neck
Two apertures in the capsule
- intertubercular fossa (for passage of long head)
- anterior, inferiorly to the coracoid process to allow communication btw the sub scapular bursa
and the cavity

Glenoid labrum -see next question

Ligaments - see next question

Synovial Membrane
Attahed around the glenoid labrum and articular margin of humerus
Reflects back along the tendon of the long head forming a tubular sleeve (synovial sheath) and
therefore intracapsular but extrasynovial

Bursae
Subacromial/Subdeltoid - lies between deltoid and supraspinatous tendon; does not communicate
with the joint capsule

Subscapular - between the tendon of the subscapularis and the neck of the scapula;
communicates with synovial cavity via an opening in capsule

Infraspinatus - between ISp tendon and joint capsule

Subcoracoid - between subscapularis tendon and short head/coracobrachialis tendon

Arterial supply - anterior and posterior circumflex humeral aa (3rd part of axillary)
Innervation - branches of suprascapular, axillary, lateral pectoral, upper and lower sub scapular
nerves

Lymphatics - axillary

Variants

Write short notes on the glenoid labrum and ligaments of the glenohumeral joint.
Glenoid labrum and ligaments of the joint help to stabilise the mobile GH joint

Labrum
Fibrocartilagenous rim around the glenoid fossa
Deepens the glenoid fossa to prevent dislocation
Overlies hyaline cartilage
More rounded posteriorly and triangular anteriorly
Anteroinferior labrum is continuous with the inferior GHL

Bicipitolabral complex
Superior labrum configuration is determined by the insertion of the long head of biceps
Three forms:
- Long head inserts on osseous glenoid immediately above the labrum
- Insertion of the superior labrum
- Insertion into the labrum
Variants
Bufort complex - relatively deficient anterior labrum between 12-3 o'clock in 0.5% of popn
Associated with a cord like thickened MGHL

Sublabral foramen - detachment of the anterosuperior labrum; does not extend posterior to the
biceps attachment

Ligaments
Static stabilisers of the joint

Glenohumeral ligaments
Anterior thickenings of the joint capsule
Superior, middle and inferior
Pass from supraglenoid tubercle to the lesser tuberosity and inferiorly related anatomical neck of
the humerus

Coraco humeral ligament

Superiorly between the base of the coracoid process and the anterior aspect of greater tuberosity
of the humerus
Strong broad band

Transverse humeral ligament

Between the greeater and lesser tubercles of the humerus holding the tendon of long head in the
inter tubercular groove
Transverse fibres

Coracoacromial ligament
Extrinsic protective structure
Extends from medial border of acromion to the lateral border of coracoid
Triangular band in front of ACJ
Lies above head of humerus and increases surface to support it
Separated from RC by subacromial bursa

Relations
Ant - subscap bursa and tendon
Post - infraspinatus and teres minor
Sup - supraspinatus
Inf - long head, axillary n, posterior circumflex humeral aa

Arterial
Ant and post circumflex < third part of axillary
Subscap braches < axillary
Suprascap a < subclavian

Innervation - suprascap, axillary. lateral pectoral upper and lower subspace

Variants
Os acromiale
Buford complex
Sublabral recess
Sublabral foramen
Write short notes on the anatomy of the rotator cuff of the shoulder.
Four short muscles which stabilise and move the shoulder joint
Tendons blend with the articular capsule of the shoulder joint

Comprised of:

Supraspinatus
Originates at supraspinous fossa
Passes on superior aspect of shoulder joint, under trap and coracoacromial arch
Attaches on superior aspect of greater tuberosity
Separated from acromion by the subacromial bursa

A - Suprascapular a (thyrocervical trunk from subclavian)

V - suprascapular v > ECA
I - suprascapular nerve
A - abduction

Infraspinatus
Originates at the infraspinous fossa
Partly covered by the deltoid and trapezius
Inserts on posterior facet of greater tuberosity

A - suprascapular a
I - suprascapular nerve
A - external rotation

Teres minor
Originate from superior half of lateral border of scapula
Terminates on inferior facet of greater tuberosity
Difficult to separate from infraspiantus

A - Posterior cirucumflex humeral

i - Axillary nerve
A - external rotation

Subscapularis
Originates from sub scapular fossa to the lesser tuberosity (60%) or humeral neck (40%)
Thick triangular muscle lying on costal surface of scapula
Forms poster wall of axilla

A - subscapular a < 3rd part of axillary

I - upper and lower sub scapular nn
A - internal rotation

Write short notes on the anatomy of the scapula

Large flat triangular bone lies on posterolateral aspect of the thorax covering parts of the 2-7th ribs

Connects the humerus to the clavicle

Highly mobile
Has a head, neck and body (thin and translucent)

Articulations
Clavicle at the ACJ
Humerus at the glenoid fossa

Features:
Two surfaces
Costal surface - concave, triangular, subscapular fossa
Posterior surface - convex, spine of scapula projects ~ transversely at upper third separating it into
supraspinous and infraspinous fossae

Three angles
Lateral angle - marked by shallow somewhat comma shaped glenoid cavity which articulates with
the head of the humerus to form GH jt
- infraglenoid tubercle - site of long head of triceps attachemtn
- supraglenoid tubercle - stie long head of biceps attachment

Superior angle at level of T2

Inferior angle lies opposite spinous process of T7 near inferior border of 7th rib

Three borders
Medial border - receives serratus anterior,
Upper border - runs to coracoid provess; scapular notch for suprascapular a and n; origin of inferior
belly of omohyoid
Lateral border -

Features
Spine continues laterally into a flattened process called the acromion which projects anteriorly and
articulates with the clavicle
Superolaterally has a shallow glenoid fossa/cavity for humerus (this is the head of scapula)
Head is connected to blade-like body by a short neck
Coracoid process arises from the superior border of the head and projects superoanteriorly
Scapular notch on superior border for suprascapular n but not artery (separated by superior
transverse scapular ligament

Attachements
Medial border - serratus anterior (anterior surface), levator scapulae (superior angle), rhomoid
major and minor
Inferior angle - lattisumus dorsi
Lateral border - teres major (inf) and trees minor,
Lateral angle (glenoid) - long head of triceps (at infraglenoid tubercle) and long head of biceps
Superior border - omohyoid
Posterior surface - supraspinatus, infraspinatus
Costal surface - subscapularis
Spine - trap (sup) deltoid (inf)
Corocoid - corocoid tendon (coracobracialis and short head of biceps) pec minor

Ossification - 7 ossification centres, beigins as intramembranous ossification in utero;

endochondral ossification after birth. Complete around 20 years; epiphysis fused at 25
Blood supply - scapular anastamoses connecting 3rd part of axillary with first part of subclavian
- suprascapular a <thyrocervical trunk <1st subclavian
- transverse cervial a <thyrocervical trunk <1st subclavian
- dorsal scapular a <second part of subclavian
- subscapular <3rd part of axillary
- circumflex scapular <3rd part of axillary

Innervation - likely from n from overlying muscles - dorsal scapular n, suprascapular n

Variants - body defects

Glenoid defects
Failure to ossify

Corocoid attachements

Write short notes on the anatomy of the elbow joint.

Synovial hinge joint of the upper limb between the distal humerus and proximal radius and ulna

Articular surfaces
Humeroulnar - between trochlea of humerus and the trochlear notch of the ulna; uniaxial hing joint
allowing flexion and extension

Humeroradial - between capitellum of humerus and head of radius; hinge and pivot joint

Proximal radioulnar joint - between head of radius and radial notch of ulna

Capsule
Fibrous capsule completely encloses all three articulations
Weak anteriorly and posteiror
Attached
- superiorly - to proximal margins of coronoid and radial fossae but not quite to olecrenon fossa
- inferiorly - to margin of tracheal notch, anterior border of coronoid process and annular liv
- supported medially and laterally by ligaments
- fat pads separate fibrous joint capsule from the synovial joint

Bursae
Olecranon
Bicipitoradial
Radioulnar

Ligaments
Radial colllateral ligament complex

Ulnar collateral ligament complex

Annular ligament - surrounds the head of the radius; attached to the anterior and posterior edges
of the radial notch on the ulna; supports pronation/supination

Relations
Anti - cubital fossa and contents (brachial a, radial and ulnar a, median n
Post - triceps attaching to olecranon process; olecranon bursa
Med - common flexor origin; ulnar nerve
Lat - common extensor origin; radial nerve

Innervation
Musculocutanous and radial nn
Ulnar, median and AIN may supply articular branches

Movements

Write short notes on the anatomy of the collateral ligaments of the elbow

Radial collateral ligament complex

Lateral thickening of the joint capsule
Strong triangular band - resists varus force
Extends proximally from lateral epicondyle of humerus and blends distally with the annual lgamtne
of the radius
4 components
- radial collateral - lateral epicondl to the annular igametn
- lateral ulnar collateral- lateral epicondyle to the supinator crest of the ulna
- annular - from the posterior to the anterior margins of the radial notch encircling the radial head
- accessory lateral collateral lig - from inferior margin of annular ligament to supinator crest of
ulna

Ulnar collateral ligament

Medial thickening of joint capsule
Triangular in shape -resists valgus force
Runs from medial epicondyle of the humerus to the tubercle on coronoid process and olecranon of
elbow
Three tendon bundles
- anterior bundle - from undersurface of med epicondyle to medial aspect of coronoid process
- posterior bundle - from medial epicodyle to medial part of olecranon
- transverse oblique band - bridges notch from olecranon to coronoid to deepen socket for
trochlea

Relations - ulnar nerve travels between anterior and posterior bands

FCU superificial
Triceps posterior
FDS origin from part of UCL

Write short notes on the anatomy of the lunate bone

Moon shaped carpal bone in the proximal carpal row

Surfaces
Palmar surface broader than dorsal
Deep concavity for distal articulation with capitate; small facet for hamate
Cylindrical proximal facet for articulation with radius
Lateral narrow semilunar facet for scaphoid
Medial quadrilateral facet for triquetrum
Dorsal and volar surfaces are rough for ligament attachment
Artiulations
Radius, capitate, scaphoid, triquetrum, hamate

Ligaments
Ulnolunate, radiolunate
Radioscapholunate - volar
Scapholunate - volar and dorsal
Lunotriquetral - volar and dorsal

Blood supply - dorsal and palmar branches

Innervation - interosseous branches of radial and median nerves
Ossification - 4 years

Variation
Bipartate, tripartate
Absence of medial facet for articulation with hamate
Carpal fusion
Absence (rare)
Space of Despot/medial intercarpal space - interval between L, Tq, C, H

Write short notes on the anatomy of the scaphoid bone (in the wrist). Draw a clear diagram
and anatomical relations of the scaphoid bone
Largest carpus in proximal row; important for stability and movement at the wrist
Boat shaped
Long axis is directed obliquely with long axis aligned from the medial portion of the distal radiius to
the articulation with the 1st and 2nd MCs
Divided into proximal and distal poles with waist in between
Dorsal surface is rough and pierced by nutrient foramen
Round tubercle on the volar radial aspect of the distal pole which can be palpated

Forms radial border of carpal tunnel

Articulations
Radius proximally - smooth convex surface
Lunate medially - concave semilunar facet
Capitate, trapezium and trapezoid distally - two separate convex articular surfaces split by a bony
ridge; radially it artistes with Td and Tz and medially with capitate

Attachements
Dorsal radiocarpal, radial collateral, scapholunate, radioscapholunate, scaphocapitate
Flexor retinaculum
APB

Relations
Radial a crosses dorsal surface of scaphoid in anatomical snuff box
Contents of carpal tunnel

Blood supply 75% from branches of radial artery thru nutrient foramina; retrograde vascular supply
to proximal pole puts proximal pole at risk for AVN with waist #s
Innervation - articular n from radial and median

Variants
Bipartate
Coalistion (rare)
Hypoplaisa
Dorsal blood supply variations
Os centrale (additional bone located on dorsal aspect btw scaphoid, capitate and trapezoid

Ossification - single centre, begins at 4yo

Write short notes on the anatomy of the wrist joint.

Synovial articulartion between the distal radius and the proximal carpal row (scaphoid, lunate and
triquetrum)
Other articulations contributing to wrist motion include DRUJ, mid carpal joint, intercarpal joints and
CMCJs

Articular surfaces
Concave surface of the distal radius contains a triangular lateral portion for articulation with
scaphoid and a medial square facet for articulation with the lunate.
Triquetrum articulates only in extreme adduction

Capsule/menisci/cartilage

Fibrous capsule encloses the joint and is attached around the articular surfaces from distal radius
and ulna and proximal row of carpals (sans pisiform)
Extends proximally over the proximal radius as the palmar radial recess
Strengthened by dorsal and palmar radiocarpal ligaments and radial and ulnar collateral ligaments

TFCC
Composed of triangular cartilage with apex pointing at the radius.
Located on the ulnar aspect of the wrist joint between the ulna and lunate and triquetrum of
proximal carpal tow
Also composed of:
- volar and dorsal radioulnar lig
- ulnotriquetral lit
- ulnolunate lig
- ulnar collateral ligament
- meniscal homologue - fold in the ulnar capsule interposed between the ulnar styloid and Tq
- ECU tendon sheath

Transmits portion of axial load to the ulna

Stabilises DRUJ
Stabilises ulnar carpals

LIgaments
Palmar radiocarpal and dorsal radiocarpal
Palmar ulnocarpal
UCL
RCL
Arterial supply - from dorsal and palmar carpal arches

Innervation from AIN, PIN and dorsal deep branches of ulnar n

Lymphatics - supratrochlear nodes

Variations
Supernumarary bones - os central, os radiale externum
Ulnar variance

Snuff box
Margins
Prox - distal radius
Distal - 1st CMCJ
Dorsal EPL
Volar - APL and EPB
Base - distal radius scaphoid, Tz, 1st CMCJ
Contents - Radial a, superficial radial n, cephalic v

Guyons canal - fibro-osseous triangular canal

Margins
Ulnar border - pisiform, pisohamate lig, FCU
Radial border - hook of hamate
Roof - superificial/volar carpal ligament
Floor - flexor retinaculum
Contents - ulnar artery and ulnar nerve

Write short notes on the anatomy of the transverse carpal ligament (flexor retinaculum)

Transverse ligament running from scaphoid tubercle and ridge of Tz to the pisiform and hook of
hamate which forms the carpal tunnel

Carpal tunnel
Fibro-osseous tunnel that acts as a passageway from the forearm to the anterior hand

Boundaries
Floor - arch formed by concave anterior surface of the carpal bones
Roof - flexor retinaculum - sheath of tough CT with transverse fibres
Lateral - scaphoid tuberle and ridge of Tz
Medial - pisiform and hook of hamate

Contents (superficial to deep)

FDS
FDP (both in common ulnar sheath
FPL
Median nerve

FCR travels in flexor retinaculum, technically not in tunnel

Inserting on to flexor retinaculum:

Palmaris longus and palmaris brevis
Palmar aponeurosis

Originate from flexor retinaculum:

Thenar and hypothenar mm

Passing over it:

Ulnar a, ulnar n, palmar cutaeous branch of median n, palmar branch of radial a

Variants
Bifid median neve
Palmar cutanous branch through tunnel
Motor branch prior to tunnel

Write short notes on the course and distribution of the deep branch of the ulnar nerve in the
hand.

Ulnar nerve is formed from C8 and T1 nerve roots; one of the terminal branches of the medial cord
of the brachial plexus

Course
Axilla
Runs down axilla between axillary artery and vein

Arm
Runs in anterior compartment along medial inter muscular septum
Pierces medial intermuscular septum at midhumerus to enter posterior compartmetn
Descents anterior to medial head of triceps
Passes posterior to elbow in cubital tunnel between the medial epicondyle and olecranon process

Forearm
Enters anterior compartment between two heads of FCU
Joins ulnar a and runs medial to it, lying on FDP belly and lateral to FCU tendon
Becomes superficial in the distal forearm
Passes through Guyons canal with artery, superficial to the flexor retinaculum to enter the head

Hand
Enters medial to the artery
Divides into superficial and deep branches

Branches
No branches in arm but gives articular branches to elbow
Forearm
- Muscular supply to FCU and medial 1/2 of FDP
- Dorsal cutaneous branch - arises distal forearm > dorsal 5th and ulnar half of 4th fingers and
posteromedial hand
- palmar cutanous branch - arise mid forearm > medial palm

Hand
- superficial branch - supply anterior palmar surface of medial 1.5 fingers
- deep branch - hypothenar muscles, medial two lumbricals, articular branches to wrist,
intercarpa, CMC and inter metacarpal joints

Variations
C7 nerve root contribution from lateral cord
Derived from C8 only
May pass in front of medial epicondyle or sublux out of tunnel
Dorsal branch absent

Deep branch of ulnar nerve in the hand

Ulnar nerve enters hand through Guyons canal between pisiform and the hook of hamate
alongside the ulnar artery
Bifurcates into superficial and deep branches which run alongside each other for a short distance
Deep branch is primarily motor
Accompanied by the deep palmar branch of the ulnar artery

Deep branch passes between the abductor digiti minimi and flexor digiti minimi
Perforates opponens digiti minimi and follows the course of the deep palmar arch beneath the
flexor tendons

Branches to:
Articular branches to wrist
Hypothenar m (abductor, flexor, opponens and addcutor
Crosses the deep part of the hand and innervates all the interosseus muscles and the 3rd and 4th
lumbricals
Ends by innervating adductor pollicis and medial head of FPB

Write short notes on the anatomy of the median nerve.

Principal nerve of the anterior forearm fascial compartment
Passes through but no branches to axilla or arm
Formed by:
- lateral root of median nerve (from lateral cord) - C 5, 6, 7
- medial root of median nerve (from medial cord) - C8 T1

Course
Shoulder/Axilla
Confluence of lateral and medial roots of respective cords
Unite in front of axillary a and exits lower axilla

Arm
Enters arm lateral to brachial artery, crossing it in mid arm
Descends medially between biceps and triceps muscles

Elbow
Lies medial to the brachial artery, deep to the bicipital aponeurosis and anterior to BR
Courses deep to median cubital vein
Gives off articular branches and muscular branches:
Forearm
Exits cubital fossa between the two heads of pronator teres
Travels between FDS and FDP
Gives off AIN

Wrist - travels through carpal tunnel deep to the flexor retinaculum btw FDS and FCR

Hand - gives off palmar cutaneous and muscular branches

Branches
Arm - none
Articular to elbow

Forearm
Unbranched median nerve
- innervates all superficial and middle compartment flexors except FCU and ulnar half of FDP

AIN
- follows anterior interosseous a
- supplies deep flexor m (FDP, FPL) and pronator quadrates

Palmar cutanous branch

- arises prximal to flexor retinaculum and supplies skin to lateral part of palm

Hand
Recurrent branch - Thenar muscles (APB, FPB, opponents brevis)
Digital cutaneous branches - sensory to lateral 3.5 digits on palmar side and 2-4th on dorsal side
Lumbrical nerve - 1 and 2 innervation

Variants
May receive two bundles from medial or lateral cord
Union between medial and lateral branches may as distal as elbow
May pass behind axillary artery or brachial a
May pass superficial or deep to pronator trees

Radial nerve
Largest branch of the brachial plexus
Continuation of the posterior cord (C5-T1)
Mixed motor and sensory
Primary nerve of the posterior arm and forearm (extensors)

Course
Shoulder/Axilla
Arises from posterior cord (C5-T1)
Descends posterior to the third part of the axillary artery
Passes out out of axilla though triangular space

Arm
Passes between long and medial heads of triceps
Lies in spiral groove of humerus
Accompanies profunda brachii a and v
Half way down it pierces lateral inter muscular septum to enter anterior compatermnt
Travels between brachialis and brachioradialis muscles
Crosses anterior to lateral epicondyle in elbow

Gives muscular branches to triceps, brachialis, brachioradialis, ECRL

Sensory branch - Posterior cutanous nerve of foream
Articular branches to elbow

Forearm
Divides into two branches distal to the elbow

Superificial branch
Entirely sensory, descends lateral tot he radial artery in the forearm
Under brachioradialis
Curves aroudn the lateral aspect of the radius
Pierces deep fascia to supply skin on the dorm of the wrist hand, thumb and lateral 1.5 digits

Deep branch
Largest branch is PIN
Pierces interosseous membrane
Passes between heads of supinator, curves around lateral head of radius
Enters posteiror compartment and continues distally to dorsum of wrist

Supplies all extensors of forearm, BR, ECRB, supinator

Variations
May accompany axillary nerve through the quadrangular space
May communicate with ulnar n in arm
May supply sensation to ulnar half of hand or middle and index fingers through PIN
Superificial branch may be doubled

Write short notes on the anatomy of the lymph nodes of the upper limb.
All lymphatics from the upper limb drain into the axillary LNs
Lymphatic drainage are divided into superficial and deep groups by the deep fascia

Lymph from the hand and forearm drain from lymphatic plexus via the superficial channels that
accompany the basilic and cephalic veins to ta series of nodes around the elbow
- superificial and deep cubital nodes
- epi/supratrochlear nodes - one to five nodes lying medial to the brachial vein just superior to the
medial epicondyle
- drain to the lateral group of axillary nodes

Deep channels accompany the arteries and drain to the lateral group of axillary nodes

Lymph then drains up the arm, pasting through a few deep brachial LNs and deltopectoral nodes in
with the cephalic veins at the deltopectoral groove before draining into

Infraclavicialar nodes - predominately lateral upper limb and lateral two digits (cephalic)
Axillary nodes - predominately medial upper limb and three medial digits (basilic)
Larger lymph vessels do not tend to unite into larger trunks but run individual courses directly
towards the axilla

Axillary nodal groups

Anterior (pectoral)
Posterior (subscap)
Lateral
Central
Apical - receives lymph from all groups and drains to subclavian trunk > thoracic or right
lymphatic trunk

Write short notes on the arterial supply of the left upper limb and normal variants.

Brachial artery is the principal supply to the arm

Continuation of axillary artery at the inferior border of teres major

Runs inferiorly and slightly laterally on medial side of biceps brachii
Crossed by median nerve in mid arm
Crosses humerus to lie anterior to it and crosses the elbow midway between the medial and lateral
epicondyles
In the elbow it lies immediately medial to the biceps tendon

Terminates at bifurcation into radial and ulnar arteries under the cover of the bicipital aponeurosiss
distal to the elbow opposite the neck of the radius

Branches
Deep artery of the arm > branches from posteromedial aspect below teres major and passes
posterior ly through triangular inlet with radial n to lie along the radial groove of the humerus
- gives off middle collateral artery and continues as radial collateral artery which becomes the
radial recurrent which joins the radial artery

Nutreint humeral artery

Superior ulnar collateral

Inferior ulnar collateral

Relations
Ant - biceps, coracobrachialis
Post - long then medial head of triceps
Lateral - biceps, medial n in upper arm
MEdial - ulnar n in upper arm then median distally

Radial artery

Arises as one of the terminal branches of the brachia artery in the cubital fossa
Terminates as the deep palmar arch of the hand

Course
Descends along the radial side of the forearm anteriorly
Under cover of BR
Lies on pronator teres, FDS and FPL
In distal forearm, emerges from cover of BR and lies between border of radius and FCR tendon
Gives off a superficial branch at wrist
Winds aroudn lateral aspect wrist entering the anatomical snuff box
Gives off branches to thumb and index finger
Enter palm between two heads of adductor pollicis
Forms deep palmar arch

Branches

Foream
- recurrent radial
- Palmar carpal branch
- Superficial palmar branch - anastomoses with superficial arch

Wrist
- Doral carpal branch
- First dorsal metacarpal

Hand
- Deep palmar arch
- Arteies to pollicis and indices

Relations
Ant - BR, brachialis
Lateral - superficial branch of radial n, APL, EPB, biceps tendon
Lies on - PT, FDS, FDL, PQ, Lower radius, EPL

Ulnar artery
Begins at neck of radius medial to the biceps tendon as one of the terminal branches of the
brachial artery

Ends at the superficial palmar arch in the hand

Course
Runs down ulnar aspect of forearm
Leaves cubital fossa by passing deep to PT
Passes through the forearm in fascial plane between the FCU and FDP
Lateral to ulnar nerve distally
Leaves the arm by passing through Guyons canal with ulnar n, superficial to the flexure
retinaculum

Divides into superficial and deep branches - main contributor to superficial palmar arch and joins
deep palmar arch from radial a

Branches
Common interosseous > Anterior and posterior interosseus aa > from level of PT
Anterior and posterior ulnar recurrent aa
Muscular branches
Dorsal carpal branch >contributes to dorsal carpal arch
Palmar carpal branch
Branch to deep palmar arch
Superficial palmar arch - supplies hypothenar eminence and gives off the palmar digital arteries

Variants
Branchial a doubled during part or all of its course
Ulnar a may be a branch of profunda
Ulnar a doubled
High division of brachial
Proximal origin of radial
Radial may cross over the adductors of thumb (not under)
Variable radial a branches
No profunda

Write short notes on the anatomy of the arterial supply of the hand including normal
variants.
Bloods supply to the hand is via the radial and ulnar arteries which form two interconnected
vascular arches in the palm
Vessels to the digits, muscles and joints originate from the arches and parent arteries

Superficial palmar arch

Ulnar artery and nerve enter hand in Guyons canal on medial side of wrist between palmaris brevis
and Flexor retinaculum
Swings laterally and forming the superficial palmar arch which is superficial to the long flexors
tendons of the digits, deep to the aponeurosis
Communicates with the superficial branch of the palmar artery
Lies at level of extended thumb in palm of hand

Branches
- ulnar digital a to medial little finger
- 3-4 common palmar digital arteries which divide into proper palmar digital aa

Deep palmar arch

Direct continuation of the radial a as it passes between two heads of the first dorsal interossei and
adductor policies heads
Deep branch of ulnar a penetrates the hypothenar muscles to anastomose with the deep palmar
arch

Courses deep to the flexor tendons in the deep plane of the the palm in contact with the
metacarpal bases
Proximal to the superficial arch

Branches
Common palmar digital branches which divide into proper palmar digital aa
Dorsal carpal branch
First dorsal metacarpal aaa
Priceps pollicis and radialis incidis

Variations
Superficial arch may be formed by ulnar alone
Incomplete arches
Common trunk for pollicis and indicies branches
Dublpicated arch

Write short notes on the anatomy of the venous drainage of the left upper limb.

Divided into superficial and deep systems

Superficial and deep palmar venous arches

Dorsal digital veins
- drain into 3 dorsal metacarpal veins
- unite to form the dorsal venous network

Medially become basilic vein> joins brachial vein in upper arm

Laterally become cephalic vein >passes in deltopectoral groove draining into axillary
Connected by medial cephalic in cubital fossa

Deep veins
Radial, ulnar > brachial >axillary > subclavian runs anterior to ant scalene muscle at 1t rib
and drains into BCV

Write short notes on the anatomy of the left subclavian artery. (see thorax)

Axillary artery

Begins at the lateral border of the 1st rib behind the midpoint of the clavicle as the continuation of
the subclavian artery

Course
Enters the apex of the axilla passing over the first digitation of serrates anterior at anterior border
of 1st rib

Divided into three parts by the pectoralis minor

1st part
Btw lateral border of 1st rib and medial border of pec minor
Branches
- superior thoracic > serratus anterior and 1,2nd intercostal spaces

2nd part
Lies posterior to pec minor
Branches
- thoracoacromial > divides deep to clavicular head of pec major into acromial, deltoid, pectoral
and clavicular branches
- lateral thoracic > descends along pec minor and supplies pec muscles, axillary LNxx and
breast

3rd part - from lateral border of pec minor to interior border of teres major
- subscapular > descends on lateral border of subscap, divides into circumflex scapular and
thracodorsal (lat dorsi)
- anterior circumflex humeral
- posterior circumplex humeral > passes through quadrangular space in posterior wall of axilla

Ends at the inferior border of trees major (posterior to pec major) into the arm

Relations
Ant - clavicle, pec major, lateral pectoral n and cephalic v
Post - long thoracic nerve, serrates anterior
Lateral - BrPl and then surrounds artery, biceps, humerus
Medial ulnar n, axillary v.

Cubital fossa
Triangular fossa in anterior aspect of elbow

Boundaries
Sup - imaginary line connecting lat and med epicondyle
Med - PT
Lat - BR
Floor - brachialis, supinator, deep and superficial branches of radial n
Roof - deep fascia, bicipital aponeurosis, sub cut, median cubital v, medial an lateral cutanous
nerves of foream, skin

Contnets (m to l)
Median n
Brachial artery and bifurcation
Brachial vv
Biceps tendon
Deep branch of radial n
Radial n

Axilla
Roughly pyramidal space at the junction of the arm and thorax
passeage way for nerves and vessels

borders
ant pec major and minor and clavicle
post - latissimus dorsi and teres major and subscapularis
medial - ribs, costal cartilages and serratus anterior
Lateral intertuburcular groove of humerus
Base faces inferiorly - fascia and skin
Apex - directly at root of neck (clavicle, scapula, 1st rib

Brachial plexus
Muculocutanous n, axillary n
Muscles in forearm and arm
Muscles in hand
Clavicle, humerus, radius, ulna

Quadrangular space
Passageway for nerves and vessels passing btw the axilla and posterior scapular and deltoid
regions
Sup - subscab
Lat - humerus neck
Med - long head of triceps
Inf - Teres major superior border
Contents - axillary nerve; posterior circumflex humeral artery and vein

Triagular space
Supmed - subscap
Lat - long head of triceps
Inf - teres major
Contents - circumflex scapular artery

Triangular interval
Sup - inferior border of trees major
Med- lateral margin of long head of triceps
Lat - humeral shaft
Contents - radial n, profunda radial a

Write short notes on the anatomy of the glenohumeral articulation

Write short notes on the anatomy of the shoulder joint
Write short notes on the anatomy of the venous drainage of the left upper limb.
Write short notes on the anatomy of the elbow joint.
Write short notes on the anatomy of the wrist joint.

Write short notes on the anatomy of the shoulder joint

Write short notes on the anatomy of the lunate bone
Write short notes on the arterial supply to the hand
Write short notes on the anatomy of the venous drainage of the left upper limb
13 Write short notes on the anatomy of the rotator cuff of the shoulder.