The hand as a mechanical tool

One of the major functions of the hand is to grip and manipulate objects. Gripping objects generally involves flexing the fingers against the thumb. Depending on the type of grip, muscles in the hand act to:

The hand as a sensory tool

The hand is used to discriminate between objects on the basis of touch. The pads on the palmar aspect of the fingers contain a high density of somatic sensory receptors. Also, the sensory cortex of the brain devoted to interpreting information from the hand, particularly from the thumb, is disproportionately large relative to that for many other regions of skin.

Muscles

Some muscles of the shoulder, such as the trapezius, levator scapulae, and rhomboids, connect the scapula and clavicle to the trunk. Other muscles connect the clavicle, scapula, and body wall to the proximal end of the humerus. These include the pectoralis major, pectoralis minor, latissimus dorsi, teres major, and deltoid (Fig. 7.9A,B). The most important of these muscles are the four rotator cuff muscles—the subscapularis, supraspinatus, infraspinatus, and teres minor muscles—which connect the scapula to the humerus and provide support for the glenohumeral joint (Fig. 7.9C).

Muscles in the arm and forearm are separated into anterior (flexor) and posterior (extensor) compartments by layers of fascia, bones, and ligaments (Fig. 7.10).

The anterior compartment of the arm lies anteriorly in position and is separated from muscles of the posterior compartment by the humerus and by medial and lateral intermuscular septa. These intermuscular septa are continuous with the deep fascia enclosing the arm and attach to the sides of the humerus.

In the forearm, the anterior and posterior compartments are separated by a lateral intermuscular septum, the radius, the ulna, and an interosseous membrane, which joins adjacent sides of the radius and ulna (Fig. 7.10).

Muscles in the arm act mainly to move the forearm at the elbow joint, while those in the forearm function predominantly to move the hand at the wrist joint and the fingers and thumb.

Muscles found entirely in the hand, the intrinsic muscles, generate delicate movements of the digits of the hand and modify the forces produced by tendons coming into the fingers and thumb from the forearm. Included among the intrinsic muscles of the hand are three small thenar muscles, which form a soft tissue mound, called the thenar eminence, over the palmar aspect of metacarpal I. The thenar muscles allow the thumb to move freely relative to the other fingers.

Back and thoracic wall

Muscles that attach the bones of the shoulder to the trunk are associated with the back and the thoracic wall and include the trapezius, levator scapulae, rhomboid major, rhomboid minor, and latissimus dorsi (Fig. 7.12).

The breast on the anterior thoracic wall has a number of significant relationships with the axilla and upper limb. It overlies the pectoralis major muscle, which forms most of the anterior wall of the axilla and attaches the humerus to the chest wall (Fig. 7.13). Often, part of the breast known as the axillary process extends around the lateral margin of the pectoralis major into the axilla.

Lymphatic drainage from lateral and superior parts of the breast is predominantly into lymph nodes in the axilla. Several arteries and veins that supply or drain the gland also originate from, or drain into, major axillary vessels.

Nerves related to bone

Three important nerves are directly related to parts of the humerus (Fig. 7.17):

Fractures of the humerus in any one of these three regions can endanger the related nerve.

Superficial veins

Large veins embedded in the superficial fascia of the upper limb are often used to access a patient’s vascular system and to withdraw blood. The most significant of these veins are the cephalic, basilic, and median cubital veins (Fig. 7.18).

The cephalic and basilic veins originate from the dorsal venous network on the back of the hand.

The cephalic vein originates over the anatomical snuffbox at the base of the thumb, passes laterally around the distal forearm to reach the anterolateral surface of the limb, and then continues proximally. It crosses the elbow, then passes up the arm into a triangular depression—the clavipectoral triangle (deltopectoral triangle)—between the pectoralis major muscle, deltoid muscle, and clavicle. In this depression, the vein passes into the axilla by penetrating deep fascia just inferior to the clavicle.

The basilic vein originates from the medial side of the dorsal venous network of the hand and passes proximally up the posteromedial surface of the forearm. It passes onto the anterior surface of the limb just inferior to the elbow and then continues proximally to penetrate deep fascia about midway up the arm.

At the elbow, the cephalic and basilic veins are connected by the median cubital vein, which crosses the roof of the cubital fossa.

Orientation of the thumb

The thumb is positioned at right angles to the orientation of the index, middle, ring, and little fingers (Fig. 7.19). As a result, movements of the thumb occur at right angles to those of the other digits. For example, flexion brings the thumb across the palm, whereas abduction moves it away from the fingers at right angles to the palm.

Importantly, with the thumb positioned at right angles to the palm, only a slight rotation of metacarpal I on the wrist brings the pad of the thumb into a position directly facing the pads of the other fingers. This opposition of the thumb is essential for normal hand function.

Clavicle

The clavicle is the only bony attachment between the trunk and the upper limb. It is palpable along its entire length and has a gentle S-shaped contour, with the forward-facing convex part medial and the forward-facing concave part lateral. The acromial (lateral) end of the clavicle is flat, whereas the sternal (medial) end is more robust and somewhat quadrangular in shape (Fig. 7.20).

The acromial end of the clavicle has a small oval facet on its surface for articulation with a similar facet on the medial surface of the acromion of the scapula.

The sternal end has a much larger facet for articulation mainly with the manubrium of the sternum, and to a lesser extent, with the first costal cartilage.

The inferior surface of the lateral third of the clavicle possesses a distinct tuberosity consisting of a tubercle (the conoid tubercle) and lateral roughening (the trapezoid line), for attachment of the important coracoclavicular ligament.

In addition, the surfaces and margins of the clavicle are roughened by the attachment of muscles that connect the clavicle to the thorax, neck, and upper limb. The superior surface is smoother than the inferior surface.

Scapula

The scapula is a large, flat triangular bone with:

 three angles (lateral, superior, and inferior),

 three borders (superior, lateral, and medial),

 two surfaces (costal and posterior), and

 three processes (acromion, spine, and coracoid process) (Fig. 7.21).

The lateral angle of the scapula is marked by a shallow, somewhat comma-shaped glenoid cavity, which articulates with the head of the humerus to form the glenohumeral joint (Fig. 7.21B,C).

A large triangular-shaped roughening (the infraglenoid tubercle) inferior to the glenoid cavity is the site of attachment for the long head of the triceps brachii muscle.

A less distinct supraglenoid tubercle is located superior to the glenoid cavity and is the site of attachment for the long head of the biceps brachii muscle.

A prominent spine subdivides the posterior surface of the scapula into a small, superior supraspinous fossa and a much larger, inferior infraspinous fossa (Fig. 7.21A).

The acromion, which is an anterolateral projection of the spine, arches over the glenohumeral joint and articulates, via a small oval facet on its distal end, with the clavicle.

The region between the lateral angle of the scapula and the attachment of the spine to the posterior surface of the scapula is the greater scapular notch (spinoglenoid notch).

Unlike the posterior surface, the costal surface of the scapula is unremarkable, being characterized by a shallow concave subscapular fossa over much of its extent (Fig. 7.21B). The costal surface and margins provide for muscle attachment, and the costal surface, together with its related muscle (subscapularis), moves freely over the underlying thoracic wall.

The lateral border of the scapula is strong and thick for muscle attachment, whereas the medial border and much of the superior border is thin and sharp.

The superior border is marked on its lateral end by:

The spine and acromion can be readily palpated on a patient, as can the tip of the coracoid process, the inferior angle, and much of the medial border of the scapula.

Proximal humerus

The proximal end of the humerus consists of the head, the anatomical neck, the greater and lesser tubercles, the surgical neck, and the superior half of the shaft of the humerus (Fig. 7.22).

The head is half-spherical in shape and projects medially and somewhat superiorly to articulate with the much smaller glenoid cavity of the scapula.

The anatomical neck is very short and is formed by a narrow constriction immediately distal to the head. It lies between the head and the greater and lesser tubercles laterally, and between the head and the shaft more medially.

Sternoclavicular joint

The sternoclavicular joint occurs between the proximal end of the clavicle and the clavicular notch of the manubrium of the sternum together with a small part of the first costal cartilage (Fig. 7.23). It is synovial and saddle shaped. The articular cavity is completely separated into two compartments by an articular disc. The sternoclavicular joint allows movement of the clavicle, predominantly in the anteroposterior and vertical planes, although some rotation also occurs.

The sternoclavicular joint is surrounded by a joint capsule and is reinforced by four ligaments:

Acromioclavicular joint

The acromioclavicular joint is a 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 (Fig. 7.24, also see Fig. 7.31). It allows movement in the anteroposterior and vertical planes together with some axial rotation.

The acromioclavicular joint is surrounded by a joint capsule and is reinforced by:

Glenohumeral joint

The glenohumeral joint is a synovial ball and socket articulation between the head of the humerus and the glenoid cavity of the scapula (Fig. 7.25). It is multiaxial with a wide range of movements provided at the cost of skeletal stability. Joint stability is provided, instead, by the rotator cuff muscles, the long head of the biceps brachii muscle, related bony processes, and extracapsular ligaments. Movements at the joint include flexion, extension, abduction, adduction, medial rotation, lateral rotation, and circumduction.

The articular surfaces of the glenohumeral joint are the large spherical head of the humerus and the small glenoid cavity of the scapula (Fig. 7.25). Each of the surfaces is covered by hyaline cartilage.

The glenoid cavity is deepened and expanded peripherally by a fibrocartilaginous collar (the glenoid labrum), which attaches to the margin of the fossa. Superiorly, this labrum is continuous with the tendon of the long head of the biceps brachii muscle, which attaches to the supraglenoid tubercle and passes through the articular cavity superior to the head of the humerus.

The synovial membrane attaches to the margins of the articular surfaces and lines the fibrous membrane of the joint capsule (Fig. 7.26). The synovial membrane is loose inferiorly. This redundant region of synovial membrane and related fibrous membrane accommodates abduction of the arm.

The synovial membrane protrudes through apertures in the fibrous membrane to form bursae, which lie between the tendons of surrounding muscles and the fibrous membrane. The most consistent of these is the subtendinous bursa of the subscapularis, which lies between the subscapularis muscle and the fibrous membrane. The synovial membrane also folds around the tendon of the long head of the biceps brachii muscle in the joint and extends along the tendon as it passes into the intertubercular sulcus. All these synovial structures reduce friction between the tendons and adjacent joint capsule and bone.

In addition to bursae that communicate with the articular cavity through apertures in the fibrous membrane, other bursae are associated with the joint but are not connected to it. These occur:

The fibrous membrane of the joint capsule attaches to the margin of the glenoid cavity, outside the attachment of the glenoid labrum and the long head of the biceps brachii muscle, and to the anatomical neck of the humerus (Fig. 7.27).

On the humerus, the medial attachment occurs more inferiorly than the neck and extends onto the shaft. In this region, the fibrous membrane is also loose or folded in the anatomical position. This redundant area of the fibrous membrane accommodates abduction of the arm.

Openings in the fibrous membrane provide continuity of the articular cavity with bursae that occur between the joint capsule and surrounding muscles and around the tendon of the long head of the biceps brachii muscle in the intertubercular sulcus.

The fibrous membrane of the joint capsule is thickened:

Joint stability is provided by surrounding muscle tendons and a skeletal arch formed superiorly by the coracoid process and acromion and the coraco-acromial ligament (Fig. 7.28).

Tendons of the rotator cuff muscles (the supraspinatus, infraspinatus, teres minor, and subscapularis muscles) blend with the joint capsule and form a musculotendinous collar that surrounds the posterior, superior, and anterior aspects of the glenohumeral joint (Figs. 7.28 and 7.29). This cuff of muscles stabilizes and holds the head of the humerus in the glenoid cavity of the scapula without compromising the arm’s flexibility and range of motion. The tendon of the long head of the biceps brachii muscle passes superiorly through the joint and restricts upward movement of the humeral head on the glenoid cavity.

Vascular supply to the glenohumeral joint is predominantly through branches of the anterior and posterior circumflex humeral and suprascapular arteries.

The glenohumeral joint is innervated by branches from the posterior cord of the brachial plexus, and from the suprascapular, axillary, and lateral pectoral nerves.

In the clinic

Fractures of the clavicle and dislocations of the acromioclavicular and sternoclavicular joints

The clavicle provides osseous continuity between the upper limb and thorax. Given its relative size and the potential forces that it transmits from the upper limb to the trunk, it is not surprising that it is often fractured. The typical site of fracture is the middle third (Fig. 7.30). The medial and lateral thirds are rarely fractured.

The acromial end of the clavicle tends to dislocate at the acromioclavicular joint with trauma (Fig. 7.31). The outer third of the clavicle is joined to the scapula by the conoid and trapezoid ligaments of the coracoclavicular ligament.

A minor injury tends to tear the fibrous joint capsule and ligaments of the acromioclavicular joint, resulting in acromioclavicular separation on a plain radiograph. More severe trauma will disrupt the conoid and trapezoid ligaments of the coracoclavicular ligament, which results in elevation and upward subluxation of the clavicle.

The typical injury at the medial end of the clavicle is an anterior or posterior dislocation of the sternoclavicular joint. Importantly, a posterior dislocation of the clavicle may impinge on the great vessels in the root of the neck and compress or disrupt them.

In the clinic

Dislocations of the glenohumeral joint

The glenohumeral joint is extremely mobile, providing a wide range of movement at the expense of stability. The relatively small bony glenoid cavity, supplemented by the less robust fibrocartilaginous glenoid labrum and the ligamentous support, make it susceptible to dislocation.

Anterior dislocation (Fig. 7.32) occurs most frequently and is usually associated with an isolated traumatic incident (clinically, all anterior dislocations are anteroinferior). In some cases, the anteroinferior glenoid labrum is torn with or without a small bony fragment. Once the joint capsule and cartilage are disrupted, the joint is susceptible to further (recurrent) dislocations. When an anteroinferior dislocation occurs, the axillary nerve may be injured by direct compression of the humeral head on the nerve inferiorly as it passes through the quadrangular space. Furthermore, the “lengthening” effect of the humerus may stretch the radial nerve, which is tightly bound within the radial groove, and produce a radial nerve paralysis. Occasionally, an anteroinferior dislocation is associated with a fracture, which may require surgical reduction.

Posterior dislocation is extremely rare; when seen, the clinician should focus on its cause, the most common being extremely vigorous muscle contractions, which may be associated with an epileptic seizure caused by electrocution.

In the clinic

Rotator cuff disorders

The two main disorders of the rotator cuff are impingement and tendinopathy. The muscle most commonly involved is supraspinatus as it passes beneath the acromion and the acromioclavicular ligament. This space, beneath which the supraspinatus tendon passes, is of fixed dimensions. Swelling of the supraspinatus muscle, excessive fluid within the subacromial/subdeltoid bursa, or subacromial bony spurs may produce significant impingement when the arm is abducted.

The blood supply to the supraspinatus tendon is relatively poor. Repeated trauma, in certain circumstances, makes the tendon susceptible to degenerative change, which may result in calcium deposition, producing extreme pain.

When the supraspinatus tendon has undergone significant degenerative change, it is more susceptible to trauma, and partial- or full-thickness tears may develop (Fig. 7.33). These tears are most common in older patients and may result in considerable difficulty in carrying out normal activities of daily living such as combing hair. However, complete tears may be entirely unsymptomatic.

In the clinic

Inflammation of the subacromial (subdeltoid) bursa

Between the supraspinatus and deltoid muscles laterally and the acromion medially, there is a bursa referred to clinically as the subacromial or subdeltoid bursa. In patients who have injured the shoulder or who have supraspinatus tendinopathy, this bursa may become inflamed, making movements of the glenohumeral joint painful. These inflammatory changes may be treated by injection of a corticosteroid and local anesthetic agent (Fig. 7.34).

Trapezius

The trapezius muscle has an extensive origin from the axial skeleton, which includes sites on the skull and the vertebrae, from CI to TXII (Fig. 7.36). From CI to CVII, the muscle attaches to the vertebrae through the ligamentum nuchae. The muscle inserts onto the skeletal framework of the shoulder along the inner margins of a continuous U-shaped line of attachment oriented in the horizontal plane, with the bottom of the U directed laterally. Together, the left and right trapezius muscles form a diamond or trapezoid shape, from which the name is derived.

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