Blue Box Stuff from Moore
The Upper Limb digitorum profundus and hypothenar muscles).
The structure of the scapula: anterior – subscapular
fossa; posterior – supraspinatous and infraspinatous fossae;
articulates with the clavicle at the acromion; has a coracoid
process where several muscles (coracobrachialis, pectoralis
minor) attach.
The structure of the humerus: the head goes into the
glenoid fossa of the scapula, just inferior to the acromion.
There is the greater tubercle, which is lateral and serves as
the attachment for the supraspinatus, infraspinatus, and
teres minor muscles. The lesser tubercle is anteromedial and
is the attachment for the other muscle of the rotator cuff, the
subscapularis. There are tuberosities, which serve as
attachments for the deltoid and brachialis muscles, more distal
on the anteromedial surface of the bone. At the distal end are
the lateral and medial epicondyles. The humeroulnar and
humeroradial joint facets are made up of the capitulum, on
the radial / lateral side, and the trochlea, on the ulnar / medial
side. Posteriorly the olecranon fossa lies in-between
epicondyles.
The structure of the ulna: The coronoid process is on
the proximal, anterior surface, while the olecranon process
is on the proximal, posterior surface. It looks like a wrench,
sort of. Distally lies the styloid process of the ulna, which
actually attaches on the medial surface of the radius (the
styloid process of the ulna articulates with the wrist).
The structure of the radius: The head of the radius
articulates with the capitulum of the humerus, while its styloid
process is attached to the wrist.
The clavicle is most commonly fractured in the
lateral third, medial to the coracoclavicular ligament. The
sternocleidomastoid contracts and elevates the medial
fragment, while the latissimus dorsi and pectoralis contract
and bring the lateral fragment medially. The arm sags because
the trapezius supports all of its weight. Patients with broken
clavicles present with upper limb supported / in a sling.
Nerves
The radial nerve runs on the posterior aspect of the
arm, runs anteriorly around the lateral epicondyle, then wraps
back posteriorly in the forearm, piercing the supinator, to
become the posterior interosseous nerve. It branches into the
deep (motor) and superficial (sensory) radial nerves. Injury
results in anesthesia to the lateral half of the dorsum of the
hand, and in loss of extension and abduction of wrist and
extension of fingers  wrist drop.
The ulnar nerve runs on the medial aspect of the
arm, wraps posteriorly around the medial epicondyle, where it
is liable to be bumped, then passes between the two heads of
the flexor carpi ulnaris,. It too divides into superficial and
deep branches. Injury results in impaired flexion and
adduction of the wrist, and loss of abduction / adduction of
the fingers, especially the fifth digit (hypothenar
compartment). Loss of sensation occurs to the hypothenar
compartment and the medial half of the dorsum of the hand.
Patients presenting with ulnar nerve damage cannot flex their
fourth and fifth fingers (paralysis of medial half of flexor
The median nerve pretty much runs as its name
implies, passes through the two heads of the pronator teres
muscle, then dives in between the flexor digitorum
superficialis and the flexor digitorum profundum in the
forearm. Injury to this nerve results in loss of sensation to the
lateral palmar side of the hand and paralysis of wrist and
finger flexors, especially thenar muscles and the second and
third digits. This is due to the fact that the median nerve
innervates only the lateral half of the flexor digitorum
profundus. It can also get trapped between the two heads of
the pronator teres, causing pain in the proximal anterior
portion of the forearm.
Injuries to the brachial plexus are many and
complex.
Injuries to the superior parts of the plexus usually
result from separation of the neck and shoulder. The roots of
C5 and C6 may be pulled out of the spinal cord. The
suprascapular, axillary, and musculocutaneous nerves do not
function. The supraspinatus and infraspinatus (lateral
rotation of arm), deltoid and teres minor (abduction), and
biceps brachii and brachialis (flexion) are paralyzed. This
disorder, known as Erb’s palsy, results in a characteristic
“waiter’s tip” presentation of the patient – pronated, medially
rotated, and extended. The lateral aspect [lateral antebrachial
cutaneous] of the arm is numb.
Poorly fitting crutches may injure the posterior cord
of the plexus, damaging the radial nerve. The triceps and
extensors of the wrist are paralyzed, and unopposed flexion
causes characteristic “wrist drop.” Patient also cannot
extend their elbow, wrist, or digits.
Injury to the inferior roots of the plexus may occur if
an infant’s shoulder is pulled during birth or if someone grabs
something to stop a fall. The inferior trunk is damaged, and
the ulnar nerve loses function. This results in impaired
finger flexion, abduction, and thumb adduction. Also the
median brachial and antebrachial cutaneous nerves lose
function, resulting in numbness of the medial aspect of the
arm, forearm, and hand.
Injury to the long thoracic nerve can result from a
stab wound, mastectomy, weight lifting, surgery, or carrying a
heavy object on the shoulder. The serratus anterior
[protraction of scapula] loses function, resulting in wing
scapula, where the medial edge of the scapula protrudes
posteriorly, away from the thoracic wall. The patient cannot
abduct the arm above horizontal, nor can they push with
their arm.
Injury to the axillary nerve can result from fracture
of the humerus, or dislocation of the shoulder joint. The
deltoid atrophies, leaving flatness on the lateral proximal side
of the arm. The patient cannot abduct the arm.
Injury to the thoracodorsal nerve can result from
operations of the axilla. Injury results in paralysis of the
latissimus dorsi.
Arteries and veins
The subclavian artery first sends off a vertebral
branch superiorly, then a thyrocervical trunk superiorly and
an internal thoracic artery inferiorly. Once it crosses the first
rib, it is named the axillary artery.
The first branch of the axillary artery is the supreme
intercostal [1st and 2nd intercostal spaces]. It is followed by the
thoracoacromial artery [deltoid, pectorales, and various other
areas.] The next branch is the lateral thoracic artery [lateral
portion of the breast], then the subscapular artery [anterior
surface of the scapula], and the posterior and anterior
circumflex humeral arteries [head and neck of humerus].
*The posterior circumflex humeral and axillary nerve both
enter the quadrangular space of the arm.
The axillary vein is large and lies anterior to the
axillary artery. These two, along with the brachial plexus, are
enclosed in the axillary sheath.
Anastamosis: If the axillary artery is ligated in
between the thyrocervical trunk and the subscapular, blood
can still flow distally through anastomoses. Blood flows from
the dorsal scapular branches of the transverse cervical artery
[a branch of the thyrocervical trunk] into the first few
intercostal arteries, which anastomose with the circumflex
scapular branch of the subscapular. Blood flows up through
the subscapular artery into the rest of the axillary.
Laceration of the brachial artery can result from a
broken elbow. This is an emergency because the damage to the
flexors of the fingers can be irreversible, resulting in
formation of scar tissue and permanent contracture of the
digits. The brachial artery divides into the ulnar and radial
artery, with the ulnar artery branching into the ulnar and
common interosseous arteries. The common interosseous
artery branches further into anterior and posterior interosseous
arteries.
The hand
A fall on the hand may fracture the distal end of
the radius, resulting in a “Colle’s fracture.” The distal
fragment of the ulna is displaced posteriorly and the hand
looks sort of like a fork. The scaphoid bone is also often
fractured breaking a fall, and results in tenderness of the base
of the anatomical snuff box. The “anatomical snuff box:”
bounded by the tendons of the extensor pollicis longus
superiorly, extensor pollicis brevis and abductor pollicis
longs inferiorly. Within it are contained the radial artery and
the superficial radial nerve.
Tendinitis of the common flexor tendon can result
from repetitive use of the flexors, and pain is experienced on
the anteromedial side of the elbow, where the flexor tendon is
located. Patients will have trouble flexing their fingers against
resistance. Tendinitis of the common extensor tendon,
located on the posterolateral aspect of the elbow, results in
pain when supinating and extending the digits. Patients will
have difficulty extending their fingers against resistance.
. they are about to release the ball; i.e. when their shoulder is
Infections in the hand are limited to the compartment
they begin in, unless they break through intercompartmental
septa. Thus, most are localized to the thenar, hypothenar, or
adductor compartments of the hand. They can, however,
spread distally through the wrist into the forearm. Infections of
a tendinous sheath of one finger will generally stay in that
sheath unless neglected.
The abductor pollicis brevis/ digiti minimi is most
lateral / medial (respectively) and superficial. Medial / lateral
to that is the flexor pollicis brevis / digiti minimi, and deep to
both is the opponens pollicis / digiti minimi. The lumbricals
are innervated by either the median (II and III) or ulnar (IV
and V) nerves, and flex the metacarpophalangeal joints /
extend the interphalangeal joints. The interossei are
innervated by the ulnar nerve and adduct (palmar) or abduct
(dorsal) the fingers about the middle finger.
Carpal tunnel syndrome is characterized by
compression of the median nerve within the carpal tunnel.
Patients present with tingling of the lateral aspect of their
hand, and a loss of coordination of the thumb due to weakness
of the muscles of the thenar compartment. The second and
third fingers, too, may lose function the disorder is severe
enough.
The shoulder area
The sternoclavicular joint is the only attachment of
the upper limb to the axial skeleton. It is enclosed in an
articular capsule, and like the temporomandibular joint,
contains an articular disc which gives it freedom of rotation. It
is anchored to the first rib by the costoclavicular ligament
laterally and the sternoclavicular ligament medially. The
joint is very sturdy and the clavicle will break before the joint
dislocates.
The acromioclavicular joint is also enclosed in an
articular capsule. It is anchored by the coracoacromial,
acromioclavicular, and coracoclavicular ligaments. When
these ligaments rupture from a hard fall on the shoulder, the
joint can dislocate. The shoulder will fall away from the
clavicle due to the weight of the upper limb.
The shoulder joint is made up of the articular
surface of the humerus and the glenoid fossa of the scapula.
The fossa is very shallow but is deepened somewhat by a rim
of fibrocartilage named the glenoid labrum. The four rotator
cuff muscles provide most of the stability for this joint, which
is prone to dislocation and other injuries due to its degree of
mobility. There are many bursae in the region but Moore
especially mentions the subacromial bursa, which lies in
between the acromion and the tendon of the supraspinatus on
the superior aspect of the joint. Inflammation of this bursa
(bursitis) causes pain only when the arm is abducted – the
tendon is in contact with the acromion only then.
Anterior dislocation of the shoulder joint is caused
by excessive extension and lateral rotation of the humerus.
The head of the humerus is driven anteriorly and the joint
capsule and glenoid labrum are torn off the fossa.
Quarterbacks who are hit forcefully on the arm as
fully abducted, will tear the joint capsule so that the humeral
head will lie inferior to the glenoid cavity. Patients will
present with the injured arm rotated anterosuperiorly
(forward, medially rotated) under the coracoid process,
holding the nonfunctional arm with their other arm. One
must suspect damage to the axillary nerve in a shoulder
dislocation because it lies very close to the inferior aspect of
the joint capsule.
The elbow joint
This joint is not stable in children due to incomplete
ossification. Separation of humeral, ulnar, or radial epiphyses
can occur when a child falls on his / her elbow. Dislocations
tend to occur posteriorly because the humerus is pushed
through the weaker anterior portion of the humeroradial /
humeroulnar joint capsule [think this one through].
The medial epicondyle of the humerus also ossifies
late, and can be avulsed in a fall. It will be pulled distally due
to traction of the ulnar collateral ligament. Since the ulnar
nerve passes through this region, avulsion of the medial
epicondyle can also stretch this nerve and cause difficulties
flexing digits IV and V and adducting the wrist.
If someone is holding a child’s hand and suddenly
tugs it, an injury known as subluxation is likely to occur. The
sudden force on the forearm tears the distal attachment of the
annular ligament of the radius. The head of the radius is
then pulled distally, out of the torn ligament. The poor child
will present with his / her elbow flexed and forearm
pronated.
The wrist and hand
I have no good mnemonic for the eight carpals. I tend
to remember starting from the “Thumb Side” – the most
lateral carpals are the Trapezium and the Scaphoid.
Proceeding medially from the trapezium are the trapezoid,
capitate, and hamate. Doing the same from the scaphoid are
the lunate, triquetrum, and the pisiform. I guess you can also
remember that the Pisiform is on the Pinky side of the hand. I
dunno, whatever works best for you.
A broken scaphoid bone results in tenderness of
the anatomical snuff box.
With the exception of the thumb, digits have one
metacarpal and three phalanges. The metacarpophalangeal
joints are capable of flexion / extension, ab / adduction, and
rotation. The interphalangeal joints can only flex / extend. The
carpometacarpal joint in the thumb is the joint capable of fl /
ex, ab / ad, and rotation, while the metacarpophalangeal and
interphalangeal joint fl / ex.
would probably also have lack of finger abduction strength
(dorsal interossei), impaired flexion of digits IV and V (medial
flexor digitorum profundus), and impaired wrist flexion and
abduction (flexor carpi ulnaris). Prognosis for recovery is
good, as the nerve was not severed.
6-4: Wrist-drop and lack of sensation to the lateral
half of the dorsum of the hand is screaming “Radial nerve
damage!!” Elbow flexion would be impaired if the forearm
was midway between supination and pronation, as the
brachioradialis (“hand shake muscle”) is responsible for elbow
flexion in this situation; it is innervated by the radial nerve.
The humerus is shortened because the biceps, brachialis, and
triceps contract to immobilize the ends of the broken bone.
The radial nerve is prone to injury at the lateral aspect of the
arm, midway down, because it lies right next to the humerus
6-5: The trapezium and scaphoid lie in the floor of
the snuff box, along with the distal end of the radius. The
scaphoid was most probably fractured.
6-6: The tendon of the palmaris longus was probably
severed, as well as the flexor carpi radialis. Her median nerve
was definitely severed; the lack of thumb opposition, fine
control of digits II and III, and lack of sensation over the
lateral half of the palm demonstrate deficits in median nerve
function [opponens pollicis, the first two lumbricals, and
sensory innervation to the lateral palm are provided by the
median n.] Her superficial radial artery was probably severed;
wrist flexion would be affected a bit by the severing of her
palmaris longus, which attaches to the palmar aponeurosis.
Her wrist will probably adduct when she flexes it, due to the
unopposed action of the flexor carpi ulnaris.
6-7: The lady’s ulna styloid process was probably
fractured, and with muscle contraction, brought to the same
level as the radial styloid process, which makes the wrist look
like a fork (Colle’s fracture). The scaphoid, again, was
probably fractured in this fall.

Sudden tension on an extensor tendon may avulse

part of its attachment. Patient will present being unable to
extend the distal interphalangeal joint.

Case Studies
6-1 … Check the description of injuries of the
brachial plexus.
6-2 … Check the description of a dislocated
acromioclavicular joint.

6-3: The lack of response to pinprick on digit V and

medial border of palm indicates that the ulnar nerve, which
supplies sensation to this area, is damaged. This is
corroborated by the lack of finger adduction strength in the
boy’s hand (caused by impaired palmar interossei). The boy