Upper limb
















Upper limb




  • A

    surface anatomy


  • B

    muscles


  • C

    bones






  • 1

    Arm


  • 2

    Deltoid


  • 3

    Elbow joint


  • 4

    Forearm


  • 5

    Hand


  • 6

    Interphalangeal joint


  • 7

    Scapula


  • 8

    Shoulder joint


  • 9

    Wrist joint






Accessory ossicles






Left scapula










  • A

    dorsal surface


  • B

    costal surface



  • 1

    Acromial angle


  • 2

    Acromion


  • 3

    Coracoid process


  • 4

    Inferior angle


  • 5

    Infraspinous fossa


  • 6

    Lateral border


  • 7

    Margin of glenoid cavity


  • 8

    Medial border


  • 9

    Neck (and spinoglenoid notch on dorsal surface)


  • 10

    Spine


  • 11

    Subscapular fossa


  • 12

    Superior angle


  • 13

    Superior border


  • 14

    Suprascapular notch


  • 15

    Supraspinous fossa




The spine (A10) of the scapula projects from its dorsal surface with the acromion (A2) at the lateral end of the spine.





Left scapula





  • attachments






    • A

      dorsal surface


    • B

      costal surface


Blue lines, epiphysial lines (physis); green lines, capsular attachments of shoulder joint; pale green lines, ligament attachments

  • 1

    Conoid ligament of coracoclavicular ligament


  • 2

    Coracoacromial ligament


  • 3

    Coracobrachialis and short head of biceps


  • 4

    Deltoid


  • 5

    Inferior belly of omohyoid


  • 6

    Infraspinatus


  • 7

    Latissimus dorsi


  • 8

    Levator scapulae


  • 9

    Long head of triceps


  • 10

    Pectoralis minor


  • 11

    Rhomboid major


  • 12

    Rhomboid minor


  • 13

    Serratus anterior


  • 14

    Subscapularis


  • 15

    Superior transverse scapular ligament


  • 16

    Supraspinatus


  • 17

    Teres major


  • 18

    Teres minor and intervening groove for circumflex scapular artery


  • 19

    Trapezius


  • 20

    Trapezoid ligament of coracoclavicular ligament




The suprascapular notch is bridged by the superior transverse scapular ligament (15).


The conoid (1) and trapezoid (20) ligaments together form the coracoclavicular ligament, which attaches the coracoid process of the scapula to the under-surface of the lateral end of the clavicle.


The coracoacromial ligament (2) passes between the coracoid process and the acromion, forming with these bony processes an arch above the shoulder joint.






Left scapula








  • from the lateral side



  • 1

    Acromion


  • 2

    Coracoid process


  • 3

    Glenoid cavity


  • 4

    Inferior angle


  • 5

    Infraglenoid tubercle


  • 6

    Infraspinous fossa


  • 7

    Lateral border


  • 8

    Spine


  • 9

    Supraglenoid tubercle


  • 10

    Supraspinous fossa






Left scapula and clavicle





  • articulation, from above



  • 1

    Acromial end of clavicle


  • 2

    Acromioclavicular joint


  • 3

    Acromion


  • 4

    Coracoid process


  • 5

    Shaft of clavicle


  • 6

    Spine of scapula


  • 7

    Sternal end of clavicle


  • 8

    Supraspinous fossa






Left clavicle





  • from below



  • 1

    Acromial end with articular surface (arrow)


  • 2

    Conoid tubercle


  • 3

    Groove for subclavius muscle


  • 4

    Impression for costoclavicular ligament


  • 5

    Sternal end with articular surface (arrow)


  • 6

    Trapezoid line




The sternal end of the clavicle (B7, C5) is bulbous; the acromial end (B1, C1) is flattened. The shaft is convex towards the front in its medial two-thirds, and the groove for the subclavius muscle is on the inferior surface (C3).






Acromioclavicular separation







Left scapula








  • attachments, from the lateral side

Blue lines, epiphysial lines (physis); green lines, capsular attachments of shoulder joint; pale green lines, ligament attachments

  • 1

    Coracoacromial ligament


  • 2

    Coracobrachialis and short head of biceps


  • 3

    Coracohumeral ligament


  • 4

    Deltoid


  • 5

    Infraspinatus


  • 6

    Long head of biceps


  • 7

    Long head of triceps


  • 8

    Serratus anterior


  • 9

    Subscapularis


  • 10

    Teres major


  • 11

    Teres minor (with intervening groove for circumflex scapular artery)






Left scapula and clavicle





  • articulation, from above

Blue lines, epiphysial lines (physis); green lines, capsular attachments of sternoclavicular and acromioclavicular joints; pale green lines, ligament attachments

  • 1

    Coracoacromial ligament


  • 2

    Coracobrachialis and short head of biceps


  • 3

    Deltoid


  • 4

    Inferior belly of omohyoid


  • 5

    Levator scapulae


  • 6

    Pectoralis major


  • 7

    Sternocleidomastoid


  • 8

    Superior transverse scapular ligament


  • 9

    Supraspinatus


  • 10

    Trapezius






Left clavicle





  • attachments, from below

Blue lines, epiphysial lines (physis); green lines, capsular attachments of sternoclavicular and acromioclavicular joints; pale green lines, ligament attachments

  • 1

    Conoid ligament


  • 2

    Costoclavicular ligament


  • 3

    Deltoid


  • 4

    Pectoralis major


  • 5

    Sternohyoid


  • 6

    Subclavius and clavipectoral fascia


  • 7

    Trapezius


  • 8

    Trapezoid ligament






Fractured clavicle





Fractured scapula






Right humerus








  • upper end



    • A

      from the front


    • B

      from behind


    • C

      from the medial side


    • D

      from the lateral side


    • E

      from above




  • 1

    Anatomical neck


  • 2

    Deltoid tuberosity


  • 3

    Greater tubercle


  • 4

    Groove for radial nerve


  • 5

    Head


  • 6

    Intertubercular groove


  • 7

    Lateral lip of intertubercular groove


  • 8

    Lesser tubercle


  • 9

    Medial lip of intertubercular groove


  • 10

    Surgical neck




The intertubercular (bicipital) groove (A6) is on the front of the upper end and is occupied by the tendon of the long head of biceps. (For attachments see page 121 .)






Dislocation of humerus






Right humerus








  • attachments, upper end



    • A

      from the front


    • B

      from behind


    • C

      from the medial side


    • D

      from the lateral side


    • E

      from above


Blue lines, epiphysial lines (physis); green lines, capsular attachment of shoulder joint

  • 1

    Brachialis


  • 2

    Coracobrachialis


  • 3

    Deltoid


  • 4

    Infraspinatus


  • 5

    Lateral head of triceps


  • 6

    Latissimus dorsi


  • 7

    Medial head of triceps


  • 8

    Pectoralis major


  • 9

    Subscapularis


  • 10

    Supraspinatus


  • 11

    Teres major


  • 12

    Teres minor




    Intraosseous vascular access






Deltoid is attached to the V-shaped deltoid tuberosity (A3 and D3) on the lateral surface of the middle of the shaft.


Coracobrachialis is attached to the medial surface of the middle of the shaft (C2) (opposite the deltoid tuberosity).


Note the relative positions of the epiphysial and capsular lines: the epiphysis is partly intracapsular and partly extracapsular at the upper end of the humerus.





Right humerus








  • lower end



    • A

      from the front


    • B

      from behind


    • C

      from below


    • D

      from the medial side


    • E

      from the lateral side




  • 1

    Anterior surface


  • 2

    Capitulum


  • 3

    Coronoid fossa


  • 4

    Lateral edge of capitulum


  • 5

    Lateral epicondyle


  • 6

    Lateral supracondylar ridge


  • 7

    Medial epicondyle


  • 8

    Medial supracondylar ridge


  • 9

    Medial surface of trochlea


  • 10

    Olecranon fossa


  • 11

    Posterior surface


  • 12

    Radial fossa


  • 13

    Trochlea




The medial epicondyle (7) is more prominent than the lateral (5).


The medial part of the trochlea (13) is more prominent than the lateral part.


The olecranon fossa (10) on the posterior surface is deeper than the radial and coronoid fossae on the anterior surface (12 and 3).






Avulsion medial epicondyle





Supracondylar spur






Right humerus








  • attachments, lower end



    • A

      from the front


    • B

      from behind


    • C

      from below


    • D

      from the medial side


    • E

      from the lateral side


Blue lines, epiphysial lines (physis); green lines, capsular attachments of elbow joint

  • 1

    Anconeus


  • 2

    Brachialis


  • 3

    Brachioradialis


  • 4

    Common extensor origin


  • 5

    Common flexor origin


  • 6

    Coronoid fossa


  • 7

    Extensor carpi radialis longus


  • 8

    Medial head of triceps


  • 9

    Olecranon fossa


  • 10

    Pronator teres, humeral head


  • 11

    Radial fossa





Right radius








  • upper end



    • A

      from the front


    • B

      from behind


    • C

      from the medial side


    • D

      from the lateral side




  • 1

    Anterior border


  • 2

    Anterior oblique line


  • 3

    Anterior surface


  • 4

    Head


  • 5

    Interosseous border


  • 6

    Lateral surface


  • 7

    Neck


  • 8

    Posterior border


  • 9

    Posterior surface


  • 10

    Rough area for pronator teres


  • 11

    Tuberosity





Right radius





  • lower end



    • E

      from the front


    • F

      from behind


    • G

      from the medial side


    • H

      from the lateral side




  • 1

    Anterior surface


  • 2

    Dorsal tubercle


  • 3

    Groove for abductor pollicis longus


  • 4

    Groove for extensor carpi radialis brevis


  • 5

    Groove for extensor carpi radialis longus


  • 6

    Groove for extensor digitorum and extensor indicis


  • 7

    Groove for extensor pollicis brevis


  • 8

    Groove for extensor pollicis longus


  • 9

    Interosseous border


  • 10

    Lateral surface


  • 11

    Posterior surface


  • 12

    Styloid process


  • 13

    Ulnar notch




The lower end of the radius is concave anteriorly (at the lower label 1 in E), with the ulnar notch medially (G13) and the dorsal tubercle on the posterior surface (F2).





Right ulna








  • upper end



    • A

      from the front


    • B

      from behind


    • C

      from the medial side


    • D

      from the lateral side




  • 1

    Anterior border


  • 2

    Anterior surface


  • 3

    Coronoid process


  • 4

    Interosseous border


  • 5

    Medial surface


  • 6

    Olecranon


  • 7

    Posterior border


  • 8

    Posterior surface


  • 9

    Radial notch


  • 10

    Supinator crest


  • 11

    Trochlear notch


  • 12

    Tuberosity




The trochlear notch (11) faces forwards, with the radial notch (9) on the lateral side.





Right ulna





  • lower end



    • E

      from the front


    • F

      from behind


    • G

      from the medial side


    • H

      from the lateral side




  • 1

    Anterior surface


  • 2

    Groove for extensor carpi ulnaris


  • 3

    Head


  • 4

    Interosseous border


  • 5

    Medial surface


  • 6

    Posterior surface


  • 7

    Styloid process






Right radius and ulna








  • upper ends, from above and in front



  • 1

    Coronoid process of ulna


  • 2

    Head of radius


  • 3

    Neck of radius


  • 4

    Olecranon of ulna


  • 5

    Trochlear notch of ulna


  • 6

    Tuberosity of radius


  • 7

    Tuberosity of ulna






Right radius and ulna





  • lower ends, from below



  • 1

    Attachment of articular disc


  • 2

    Dorsal tubercle


  • 3

    Groove for extensor carpi radialis brevis


  • 4

    Groove for extensor carpi radialis longus


  • 5

    Groove for extensor carpi ulnaris


  • 6

    Groove for extensor digitorum and extensor indicis


  • 7

    Groove for extensor pollicis longus


  • 8

    Styloid process of radius


  • 9

    Styloid process of ulna


  • 10

    Surface for disc


  • 11

    Surface for lunate


  • 12

    Surface for scaphoid





Right humerus, radius and ulna





  • articulation



    • C

      from the front


    • D

      from behind




  • 1

    Capitulum of humerus


  • 2

    Coronoid process of ulna


  • 3

    Head of radius


  • 4

    Lateral epicondyle of humerus


  • 5

    Medial epicondyle of humerus


  • 6

    Olecranon of ulna


  • 7

    Radial notch of ulna


  • 8

    Trochlea of humerus




The elbow joint and the proximal radio-ulnar joint share a common synovial cavity.






Dislocation of the elbow





Supracondylar fracture of the humerus






Right radius and ulna








  • attachments



    • A

      from the front


    • B

      from behind


Blue lines, epiphysial lines (physis); green lines, capsular attachments of elbow and wrist joints

  • 1

    Abductor pollicis longus


  • 2

    Anconeus


  • 3

    Aponeurotic attachment of flexor digitorum profundus, flexor carpi ulnaris and extensor carpi ulnaris


  • 4

    Biceps


  • 5

    Brachialis


  • 6

    Brachioradialis


  • 7

    Extensor indicis


  • 8

    Extensor pollicis brevis


  • 9

    Extensor pollicis longus


  • 10

    Flexor digitorum profundus


  • 11

    Flexor digitorum superficialis, radial head


  • 12

    Flexor digitorum superficialis, ulnar head


  • 13

    Flexor pollicis longus


  • 14

    Pronator quadratus


  • 15

    Pronator teres, ulnar head


  • 16

    Pronator teres


  • 17

    Supinator


  • 18

    Triceps




Abductor pollicis longus (1) and extensor pollicis brevis (8) are the only two muscles to have an origin from the posterior surface of the radius (although both extend on to the interosseous membrane and the abductor also has an origin from the posterior surface of the ulna). These muscles remain companions as they wind round the lateral side of the radius ( page 161 ) and form the radial boundary of the anatomical snuffbox ( pages 162 and 176 ).


In the young subject, the radius sometimes fractures across the lower epiphysis following an injury to the wrist. In the adult the term “Colles’ fracture” ( page 129 ) refers to a transverse break across the lower radius within about 2.5 cm of the lower end of the bone. The ulnar styloid process is also often fractured.






Traction of forearm fractures






Bones of the right hand







  • A

    palmar surface


  • B

    from the lateral side


  • C

    hamate from the medial side


  • D

    scaphoid, palmar surface




The scaphoid, lunate, triquetral and pisiform bones form the proximal row of carpal bones.


The trapezium, trapezoid, capitate and hamate bones form the distal row of carpal bones.


The tubercle (33) and waist (35) are the non-articular parts of the scaphoid and therefore contain nutrient foramina. A fracture across the waist may therefore interfere with the blood supply of the proximal pole of the bone and lead to avascular necrosis (see page 173 ). The waist of the scaphoid lies in the anatomical snuffbox; the tubercle may be palpated in front of the radial boundary of the snuffbox.



  • 1

    Base of fifth metacarpal


  • 2

    Base of first metacarpal


  • 3

    Base of middle phalanx of middle finger


  • 4

    Base of proximal phalanx of ring finger


  • 5

    Capitate


  • 6

    Distal phalanx of ring finger


  • 7

    Distal phalanx of thumb


  • 8

    Groove for deep branch of ulnar nerve


  • 9

    Hamate


  • 10

    Head of fifth metacarpal


  • 11

    Head of first metacarpal


  • 12

    Head of middle phalanx of middle finger


  • 13

    Head of proximal phalanx of ring finger


  • 14

    Hook of hamate


  • 15

    Lunate


  • 16

    Palmar surface, hamate


  • 17

    Pisiform


  • 18

    Proximal phalanx of index finger


  • 19

    Proximal phalanx of little finger


  • 20

    Proximal phalanx of thumb


  • 21

    Scaphoid


  • 22

    Shaft of second metacarpal


  • 23

    Shaft of fifth metacarpal


  • 24

    Shaft of first metacarpal


  • 25

    Shaft of middle phalanx of middle finger


  • 26

    Shaft of proximal phalanx of ring finger


  • 27

    Surface for capitate


  • 28

    Surface for lunate


  • 29

    Surface for triquetral


  • 30

    Trapezium


  • 31

    Trapezoid


  • 32

    Triquetral


  • 33

    Tubercle of scaphoid


  • 34

    Tubercle of trapezium


  • 35

    Waist of scaphoid





Bones of the right hand








  • dorsal surface



  • 1

    Base of first metacarpal


  • 2

    Capitate


  • 3

    Distal phalanx of middle finger


  • 4

    Distal phalanx of thumb


  • 5

    Fifth metacarpal


  • 6

    Hamate


  • 7

    Head of first metacarpal


  • 8

    Lunate


  • 9

    Middle phalanx of middle finger


  • 10

    Proximal phalanx of middle finger


  • 11

    Proximal phalanx of thumb


  • 12

    Scaphoid


  • 13

    Shaft of first metacarpal


  • 14

    Styloid process of radius


  • 15

    Styloid process of ulna


  • 16

    Third metacarpal


  • 17

    Trapezium


  • 18

    Trapezoid


  • 19

    Triquetral




The wrist joint (properly called the radiocarpal joint) is the joint between (proximally) the lower end of the radius and the interarticular disc which holds the lower ends of the radius and the ulna together, and (distally) the scaphoid, lunate and triquetral bones.


The midcarpal joint is the joint between the proximal and distal rows of carpal bones (see the note on pages 173 and 177 ).


The carpometacarpal joint of the thumb is the joint between the trapezium and the base of the first metacarpal.






Bar room fracture





Colles’ fracture





Dislocation of the finger





Smith’s fracture






Bones of the right hand








  • attachments



    • A

      palmar surface


    • B

      dorsal surface


Pale green lines, ligament attachments

  • 1

    Abductor digiti minimi


  • 2

    Abductor pollicis brevis


  • 3

    Abductor pollicis longus


  • 4

    Extensor carpi radialis brevis


  • 5

    Extensor carpi radialis longus


  • 6

    Extensor carpi ulnaris


  • 7

    Extensor expansion


  • 8

    Extensor pollicis brevis


  • 9

    Extensor pollicis longus


  • 10

    First dorsal interosseous


  • 11

    First palmar interosseous


  • 12

    Flexor carpi radialis


  • 13

    Flexor carpi ulnaris


  • 14

    Flexor digiti minimi brevis


  • 15

    Flexor digitorum profundus


  • 16

    Flexor digitorum superficialis


  • 17

    Flexor pollicis brevis


  • 18

    Flexor pollicis longus


  • 19

    Fourth dorsal interosseous


  • 20

    Fourth palmar interosseous


  • 21

    Oblique head of adductor pollicis


  • 22

    Opponens digiti minimi


  • 23

    Opponens pollicis


  • 24

    Pisohamate ligament


  • 25

    Pisometacarpal ligament


  • 26

    Second dorsal interosseous


  • 27

    Second palmar interosseous


  • 28

    Third dorsal interosseous


  • 29

    Third palmar interosseous


  • 30

    Transverse head of adductor pollicis




The metacarpophalangeal joints are the joints between the heads of the metacarpals and the bases of the proximal phalanges.


The interphalangeal joints are the joints between the head of one phalanx and the base of the adjoining phalanx.


The pisiform is a sesamoid bone in the tendon of flexor carpi ulnaris and is anchored by the pisohamate and pisometacarpal ligaments (24 and 25).


Dorsal interossei arise from the sides of two adjacent metacarpal bones (as at 26, from the sides of the second and third metacarpals); palmar interossei arise only from the metacarpal of their own finger (as at 27, from the second metacarpal). Compare with dissection B on page 176 and note that when looking at the palm, parts of the dorsal interossei can be seen as well as the palmar interossei, but when looking at the dorsum of the hand (as on page 176 ) only dorsal interossei are seen.






Digital development abnormality





Fractured hamate






Right upper limb bones








  • secondary centres of ossification



    • A

      scapula, upper lateral part


    • B

      clavicle, sternal end


    • C D

      humerus, upper and lower ends


    • E F

      radius, upper and lower ends


    • G H

      ulna, upper and lower ends


    • I

      first metacarpal and phalanges of thumb


    • J

      second metacarpal and phalanges of index finger


Figures in years after birth, commencement of ossification → fusion. (P, puberty)


The first figure indicates the approximate date when ossification begins in the secondary centre, and the second figure (beyond the arrowhead) when the centre finally becomes fused with the rest of the bone. Single average dates have been given (both here and for the lower limb bone centres on pages 322 and 323 ) and although there may be considerable individual variations, the ‘growing end’ of the bone (when fusion occurs last) is constant. The dates in females are often a year or more earlier than in males.




Apart from the acromial, coracoid and subcoracoid centres illustrated (A), the scapula usually has other centres for the inferior angle, medial border, and the lower part of the rim of the glenoid cavity (all P → 20; see page 143 ).


The clavicle is the first bone in the body to start to ossify (fifth week of gestation). It ossifies in membrane, but the ends of the bone have a cartilaginous phase of ossification; a secondary centre appearing at the sternal end (B) unites with the body at about the 25th year.


The centre illustrated at the upper end of the humerus (C) is the result of the union at 6 years of centres for the head (1 year), greater tubercle (3 years) and lesser tubercle (5 years).


At the lower end of the humerus (D) the centres for the capitulum, trochlea and lateral epicondyle fuse together before uniting with the shaft.


All the phalanges (as in J), and the first metacarpal (I) have a secondary centre at their proximal ends; the other metacarpals (as in J) have one at their distal ends.


All the carpal bones are cartilaginous at birth and none has a secondary centre. The largest, the capitate, is the first to begin to ossify (in the second month after birth), followed in a month or so by the hamate, with the triquetral at 3 years, lunate at 4 years, scaphoid, trapezoid and trapezium at 5 years and the pisiform last at 9 years or later. There are often variations in the above common pattern.





Right shoulder








  • surface markings, from the front

The clavicle is subcutaneous throughout its length. Its acromial end (1) at the acromioclavicular joint (2) lies at a slightly higher level than the acromion of the scapula (3). At the most lateral part of the shoulder, the deltoid overlies the humerus; the acromion of the scapula does not extend so far laterally. Compare the positions of the features noted here with the dissection on the next page.

  • 1

    Acromial end of clavicle


  • 2

    Acromioclavicular joint


  • 3

    Acromion


  • 4

    Anterior margin of deltoid


  • 5

    Areola


  • 6

    Biceps


  • 7

    Deltoid overlying greater tubercle of humerus


  • 8

    Deltopectoral groove and cephalic vein


  • 9

    Infraclavicular fossa


  • 10

    Lower margin of pectoralis major


  • 11

    Nipple


  • 12

    Serratus anterior


  • 13

    Supraclavicular fossa


  • 14

    Trapezius


  • 15

    Upper margin of pectoralis major




The nipple in the male (11) normally lies at the level of the fourth intercostal space.


The lower border of pectoralis major (10) forms the anterior axillary fold.


Note that the most lateral bony point in the shoulder is the greater tubercle (7).






Dislocation of humerus





Sternoclavicular dislocation






Right shoulder








  • superficial dissection

Removal of skin and fascia displays the anterior musculature of the shoulder and thoracic wall.

  • 1

    Anterior layer of rectus sheath


  • 2

    Anterior perforating branches of intercostal neurovascular bundle


  • 3

    Biceps brachii muscle (long head)


  • 4

    Brachioradialis muscle


  • 5

    Cephalic vein


  • 6

    Cephalic vein in deltopectoral groove


  • 7

    Clavicle


  • 8

    Deltoid muscle


  • 9

    Latissimus dorsi muscle


  • 10

    Pectoralis major muscle, abdominal head


  • 11

    Pectoralis major muscle, clavicular head


  • 12

    Pectoralis major muscle, sternal head


  • 13

    Serratus anterior muscle


  • 14

    Triceps brachii muscle (lateral head)




    Intraosseous vascular access







Right shoulder








  • superficial dissection, from the front

Removal of skin and fascia displays branches of the supraclavicular nerve (6) crossing the clavicle (9), and the cephalic vein (7) lying in the deltopectoral groove between deltoid (13) and pectoralis major (11).

  • 1

    A superficial venous plexus


  • 2

    Accessory nerve


  • 3

    Acromial end of clavicle


  • 4

    Acromioclavicular joint


  • 5

    Acromion of scapula


  • 6

    Branches of supraclavicular nerves


  • 7

    Cephalic vein


  • 8

    Cervical nerve to trapezius


  • 9

    Clavicle


  • 10

    Clavicular head of sternocleidomastoid


  • 11

    Clavicular part of pectoralis major


  • 12

    Clavipectoral fascia


  • 13

    Deltoid


  • 14

    Sternal head of sternocleidomastoid


  • 15

    Sternocostal part of pectoralis major


  • 16

    Trapezius




The position of the acromioclavicular joint (4) is indicated by the small ‘step down’ between the acromial end of the clavicle (3) and the acromion (5); compare with the surface feature 2 on page 132 . This is the normal appearance; when the joint is dislocated, with the acromion being forced below the end of the clavicle, the ‘step’ is much exaggerated.


The cephalic vein (7) runs in the deltopectoral groove between deltoid (13) and pectoralis major (11) and pierces the clavipectoral fascia (12) to drain into the axillary vein.





Right shoulder











  • deeper dissection, from the front

Most of deltoid (10) and pectoralis major (20) have been removed to show the underlying pectoralis minor (21) and its associated vessels and nerves. The clavipectoral fascia which passes between the clavicle (7) and the upper (medial) border of the pectoralis minor (21) has also been removed to show the axillary vein (3) receiving the cephalic vein (6) and continuing as the subclavian vein (27) as it crosses the first rib (11).

  • 1

    Anterior circumflex humeral artery and musculocutaneous nerve


  • 2

    Axillary lymph nodes (enlarged)


  • 3

    Axillary vein


  • 4

    Branches of medial pectoral nerve


  • 5

    Branches of lateral pectoral nerve


  • 6

    Cephalic vein


  • 7

    Clavicle


  • 8

    Coracobrachialis


  • 9

    Coracoid process and acromial branch of thoracoacromial artery


  • 10

    Deltoid


  • 11

    First rib


  • 12

    Inferior belly of omohyoid (displaced upwards)


  • 13

    Intercostobrachial nerve


  • 14

    Internal jugular vein


  • 15

    Lateral thoracic artery


  • 16

    Long thoracic nerve (to serratus anterior)


  • 17

    Median nerve


  • 18

    Nerve to sternothyroid


  • 19

    Pectoral branch of thoracoacromial artery


  • 20

    Pectoralis major


  • 21

    Pectoralis minor


  • 22

    Phrenic nerve overlying scalenus anterior


  • 23

    Scalenus medius


  • 24

    Short head of biceps


  • 25

    Sternohyoid


  • 26

    Sternothyroid


  • 27

    Subclavian vein


  • 28

    Subclavius


  • 29

    Subscapularis


  • 30

    Suprascapular nerve


  • 31

    Tendon of long head of biceps


  • 32

    Trapezius


  • 33

    Trunks of brachial plexus





Shoulder arthroscopy





This shows the arthroscopic view of the right shoulder seen from behind. The supraspinatus tendon and the long head of biceps is in pristine condition. The anterior edge of the glenoid labrum shows some wear.





Klumpke’s paralysis






Right shoulder








  • surface markings, from behind

The arm is slightly abducted, and the inferior angle of the scapula (5) has been made to project backwards by attempting to flex the shoulder joint against resistance. Compare the features noted with the dissection opposite.

  • 1

    Acromial end of clavicle


  • 2

    Acromioclavicular joint


  • 3

    Acromion


  • 4

    Deltoid


  • 5

    Inferior angle of scapula


  • 6

    Infraspinatus


  • 7

    Latissimus dorsi


  • 8

    Level of axillary nerve behind humerus


  • 9

    Long head of triceps


  • 10

    Spine of scapula


  • 11

    Teres major


  • 12

    Trapezius


  • 13

    Vertebral (medial) border of scapula




The inferior angle of the scapula (5) usually lies at the level of the seventh intercostal space. It is overlapped by the upper margin of latissimus dorsi ( page 138 , 9).


The axillary nerve (8) runs transversely under cover of deltoid (4) behind the shaft of the humerus at a level 5–6 cm below the acromion (3). This must be remembered when giving intramuscular injections into the deltoid.


Latissimus dorsi (7; page 138 , 7) and teres major (11; page 138 , 16) form the lower boundary of the posterior wall of the axilla.





Right shoulder











  • superficial dissection, from behind




The triangle of auscultation (12) is bounded by the trapezius, latissimus dorsi and the medial border of the scapula; its floor is partly formed by rhomboid major. If the arms are brought forwards, the sixth intercostal space becomes available for auscultation.



  • 1

    Acromion


  • 2

    Branches of circumflex scapular artery


  • 3

    Deltoid muscle


  • 4

    Infraspinatus fascia


  • 5

    Lateral cutaneous branches of dorsal rami of thoracic nerves


  • 6

    Latissimus dorsi muscle


  • 7

    Long head of triceps brachii muscle


  • 8

    Posterior cutaneous nerve to the arm


  • 9

    Teres major muscle


  • 10

    Teres minor muscle


  • 11

    Trapezius muscle


  • 12

    Triangle of auscultation






Intramuscular injection – deltoid






Right shoulder











  • from behind, trapezius reflected



  • 1

    Acromion


  • 2

    Branches of circumflex scapular artery


  • 3

    Deep branch of transverse cervical artery


  • 4

    Deltoid muscle


  • 5

    Erector spinae muscle


  • 6

    Infraspinatus muscle


  • 7

    Latissimus dorsi muscle


  • 8

    Levator scapulae muscle


  • 9

    Medial border of scapula


  • 10

    Rhomboid major muscle


  • 11

    Rhomboid minor muscle


  • 12

    Spinal accessory nerve


  • 13

    Spine of scapula


  • 14

    Splenius capitis muscle


  • 15

    Supraspinatus muscle


  • 16

    Teres major muscle


  • 17

    Teres minor muscle


  • 18

    Thoracic part of thoracolumbar fascia


  • 19

    Trapezius muscle (cut and reflected)






Shoulder joint injection







Right shoulder











  • from above and behind



  • 1

    Acromion


  • 2

    Branches of circumflex scapular artery anastomosing with suprascapular artery


  • 3

    Deltoid muscle (cut and reflected)


  • 4

    Erector spinae muscle


  • 5

    Infraspinous fossa


  • 6

    Infraspinatus muscle (cut and reflected)


  • 7

    Latissimus dorsi muscle


  • 8

    Levator scapulae muscle


  • 9

    Long head of triceps brachii muscle


  • 10

    Medial border of scapula


  • 11

    Omohyoid muscle


  • 12

    Posterior cutaneous nerve to the arm


  • 13

    Rhomboid major muscle


  • 14

    Rhomboid minor muscle


  • 15

    Serratus posterior superior muscle


  • 16

    Spine of the scapula


  • 17

    Splenius capitis muscle


  • 18

    Superior transverse scapular ligament


  • 19

    Suprascapular artery


  • 20

    Suprascapular nerve


  • 21

    Supraspinous fossa


  • 22

    Supraspinatus muscle (cut and reflected)


  • 23

    Teres major muscle


  • 24

    Teres minor muscle


  • 25

    Thoracic part of thoracolumbar fascia


  • 26

    Trapezius muscle (cut and reflected)






Right shoulder and upper arm








  • from the right

Deltoid (7) extends over the tip of the shoulder to its attachment halfway down the lateral side of the shaft of the humerus. Biceps brachii (3) is on the front of the arm below pectoralis major (8) and triceps (11 and 12) is at the back.

  • 1

    Acromion


  • 2

    Anconeus


  • 3

    Biceps brachii


  • 4

    Brachialis


  • 5

    Brachioradialis


  • 6

    Cephalic vein


  • 7

    Deltoid


  • 8

    Pectoralis major


  • 9

    Radial nerve


  • 10

    Radial nerve, posterior cutaneous branch to the forearm


  • 11

    Triceps, lateral head


  • 12

    Triceps, long head


  • 13

    Triceps, tendon






Posterior dislocation of the shoulder






Right shoulder








  • deep dissection of scapular region



  • 1

    Acromion


  • 2

    Branches of circumflex scapular artery


  • 3

    Deltoid muscle (cut and reflected)


  • 4

    Erector spinae muscle


  • 5

    Infraspinatus muscle (cut and reflected)


  • 6

    Latissimus dorsi muscle


  • 7

    Levator scapulae muscle


  • 8

    Long head of triceps brachii muscle


  • 9

    Medial border of scapula


  • 10

    Posterior cutaneous nerve to the arm


  • 11

    Rhomboid major muscle


  • 12

    Rhomboid minor muscle


  • 13

    Suprascapular artery


  • 14

    Suprascapular nerve


  • 15

    Supraspinatus muscle (cut and reflected)


  • 16

    Teres major muscle


  • 17

    Teres minor muscle


  • 18

    Thoracic part of thoracolumbar fascia


  • 19

    Trapezius muscle (cut and reflected)





Right shoulder deep dissection of scapular region



Nov 8, 2019 | Posted by in GENERAL & FAMILY MEDICINE | Comments Off on Upper limb
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