Illustrative Practice Manual of Surface and Radiological Anatomy Anita Tuli, Shashi Raheja, Sneh Agarwal
INDEX
×
Chapter Notes

Save Clear


Upper Limb2

 
LANDMARKS OF UPPER LIMB (FIGS. 1 AND 2)
  1. Clavicle: Long bone placed horizontally at the junction of neck and thorax and is palpable throughout.
  2. Sternal end of clavicle.
  3. Coracoid process: It is felt in the infraclavicular fossa 2.5 cm below the clavicle.
  4. Acromion: Subcutaneous, lies at the top of the shoulder.
  5. Crest of the spine of scapula: It extends from the acromion medially till the medial border of scapula.
  6. Greater tubercle of humerus: Lateral most bony projection in shoulder region.
  7. Axilla: Hollow of armpit.
  8. Head of humerus: Rounded upper end of humerus.
  9. Medial epicondyle of humerus: Projection on medial side of elbow.
  10. Lateral epicondyle of humerus: It lies at the depression on the posterolateral aspect of elbow.
  11. Head of radius: It is a depression on the posterolateral aspect of extended elbow and lies distal to lateral epicondyle. It can be felt to rotate in pronation and supination.
  12. Deltoid tuberosity: It lies midway on the lateral side of arm.
  13. Root of the spine of scapula: At the level of third thoracic spine. Superior angle overlies 2nd rib and Inferior angle overlies 7th rib or the 7th intercostal space.
  14. Olecranon process of ulna: Bony prominence at the back of elbow.
  15. Biceps brachii muscle forms a prominent elevation on the front of arm. Its tendon can be felt in the cubital fossa when arm is flexed against resistance.
  16. Head of ulna: It forms a rounded elevation on the ulnar side of dorsal aspect of pronated wrist.
  17. Styloid process of ulna: Place the tip of your finger medial to the head of ulna and bring the hand to supine position. Styloid process of ulna can be felt medial to the tendon of extensor carpi ulnaris.
  18. Dorsal tubercle of radius: It is seen and felt as an ill-defined elevation at the back of the distal end of the radius in line with the cleft between the index and middle fingers in pronated and fully flexed wrist.3
    zoom view
    Fig. 1: Landmarks of upper limb from the back.
    4
    5
    6
  19. Styloid process of radius: It is felt in the proximal part of the floor of the anatomical snuff box. It is 1 cm distal to the styloid process of ulna.
  20. Pisiform: Felt on the palmar aspect of the wrist on the medial side of the proximal border of hypothenar eminence.
  21. Hook of Hamate: Felt on deep palpation 2.5 cm distal to pisiform in line with radial border of the ring finger.
  22. Tubercle of scaphoid: It is felt on the medial side of proximal border of thenar eminence.
  23. Crest of Trapezium: Distal and lateral to tubercle of scaphoid.
  24. Two transverse creases are seen on the front of the wrist. Proximal transverse crease lies at the level of the wrist joint. Distal transverse crease corresponds to the proximal border of flexor retinaculum.
  25. Thenar eminence is a fleshy elevation on the lateral side of the hollow of the palm at the base of thumb.
  26. Hypothenar eminence is a small fleshy elevation on the medial side of the hollow of palm.
  27. Anatomical snuff box is a triangular hollow space on the back of root of extended thumb. It is bounded medially by tendon of extensor pollicis longus and laterally by tendons of abductor pollicis longus and extensor pollicis brevis. Styloid process of radius and base of 1st metacarpal bone are felt in its floor.
  28. Heads of metacarpal bones form the knuckles when fist is made.
  29. Posterior border of ulna: It is subcutaneous and is felt in the back of fully flexed forearm.
 
THE BACK
Median furrow of the back (Fig. 1) Feel the spines of the vertebrae in these furrows.
 
RELATIONSHIP OF VERTEBRAL SPINES WITH OTHER LANDMARKS
Spine
Level
Second cervical
Uppermost spine felt in the back of the neck
Seventh cervical (vertebrae prominens)
It is the upper of the two prominences seen at the root of the neck at the back
First thoracic
Lower prominence seen at the root of the neck at the back
Third thoracic
At the point where crest of spine and medial border of scapula meet
Seventh thoracic
Inferior angle of scapula
Twelfth thoracic
Midway between inferior angle of scapula and level of upper border of iliac crest
Fourth lumbar
Highest part of iliac crest
Second sacral
Posterior superior iliac spine underlying a dimple 4 cm lateral to second spinous tubercle, above the medial part of buttock
Third sacral
Lies at the upper end of natal cleft
7
zoom view
Fig. 2: Landmarks of upper limb from the front.
8
9
10
 
SURFACE MARKING (FIG. 3)
Axillary artery (Fig. 3): Abduct the arm at right angles. Mark three points and join by two parallel lines:
  • a. Midpoint of the lower border of clavicle
  • b. Below coracoid process in infraclavicular fossa
  • c. At the pulsation of axillary artery just beyond anterior axillary fold in living and at bicipital groove in cadavers.
Axillary vein: Mark along the medial side of axillary artery.
Brachial artery (Fig. 4): Mark two points:
  • c. Termination of axillary artery
  • d. 1 cm below middle of line joining two epicondyles medial to the tendon of biceps brachii. This point lies at the neck of radius and marks the termination of brachial artery into radial and ulnar arteries.
Radial artery (Fig. 4): Mark the following points:
  • d. Termination of brachial artery: At the neck of radius 1 cm below middle of line joining two epicondyles
  • e. Between flexor carpi radialis tendon and lower end of radius
  • f. Anatomical snuff box
  • g. Proximal end of 1st intermetacarpal space.
Join points d, e, f, g to mark radial artery, d-f marks radial artery in forearm and f-g marks at wrist.
Ulnar artery (Fig. 4): Join the following points to mark the ulnar artery:
  • d. Termination of brachial artery: At the neck of radius 1 cm below middle of line joining two epicondyles
  • h. Junction of upper 1/3 and lower 2/3 of medial border of forearm.
  • i. Lateral to pisiform bone.11
zoom view
Fig. 3: Axilla from the front.
zoom view
Fig. 4: View of upper limb from the front.
12
13
14
Superficial palmar arch (Fig. 5): Mark the following points:
  1. Lateral to pisiform
  2. Hook of hamate
  3. Middle of thenar eminence
Join a, b, c points with convexity towards the fingers level with distal border of extended thumb.
Deep palmar arch (Fig. 5): Draw a horizontal line 4 cm from a point just distal to hook of hamate. It lies 1 cm proximal to superficial palmar arch.
 
NERVES OF THE UPPER LIMB
Axillary nerve (Fig. 6): Draw a line from tip of acromion to deltoid tuberosity.
  1. A transverse line 2 cm above the midpoint of this line represents axillary nerve.
Musculocutaneous nerve (Fig. 6): Mark two points:
  • b. Inferolateral to coracoid process of scapula.
  • c. Lateral to tendon of biceps brachii in cubital fossa.
Join b and c points.15
zoom view
Fig. 5: View of hand from the front.
zoom view
Fig. 6: View of upper limb from the front.
16
17
18
Radial nerve (Fig. 7):
I. In the arm: Mark 3 points:
  1. Termination of axillary artery
  2. Junction of upper 2/3rd and lower 1/3rd of a line joining acromion and lateral epicondyle of the humerus.
  3. 1 cm lateral to tendon of biceps brachii at the level of lateral epicondyle of the humerus.
Join a and b points across the back of arm to mark radial nerve in radial groove. Line joining points a, b, c represent radial nerve in the arm.
II. In the forearm: Mark 3 points:
  • c. 1 cm lateral to tendon of biceps brachii at the level of lateral epicondyle of the humerus.
  • d. Junction of upper 2/3rd and lower 1/3rd of a line joining lateral epicondyle of the humerus to styloid process of radius.
  • e. Proximal part of anatomical snuff box.
Line joining points c, d, e represent superficial terminal branch of radial nerve.
Posterior interosseous nerve (Fig. 7): Mark 3 points:
  • c. 1 cm lateral to tendon of biceps brachii at the level of lateral epicondyle of the humerus.
  • f. At the junction of upper 1/3rd and lower 2/3rd of a line joining head of radius and dorsal tubercle of radius on the back of wrist.
  • g. 1 cm distal to line joining the head of ulna and the dorsal tubercle of radius on the dorsum of wrist.
Join c, f, g by dotted line to mark the course of posterior interosseous nerve.
Ulnar nerve (Fig. 8): Mark 4 points:
  1. Inferolateral to coracoid process
  2. Midpoint of medial border of arm
  3. Behind the medial epicondyle of the humerus
  4. Lateral to pisiform bone
Line joining points a, b, c represent ulnar nerve in the arm and c, d in the forearm.19
zoom view
Fig. 7: View of upper limb from the front.
zoom view
Fig. 8: View of upper limb from the front.
20
21
22
Median nerve (Fig. 9): Mark the following points:
  1. Inferolateral to coracoid process.
  2. Medial to termination of brachial artery in the cubital fossa.
  3. Medial to tendon of flexor carpi radialis in front of the wrist.
Line joining points a, b represent median nerve in axilla and arm and b, c in the forearm.
 
PALPABLE PULSES OF UPPER LIMB
Axillary artery: Pulsations can be felt against lateral wall of lower part of the axilla.
Brachial artery: Its pulsations can be felt throughout its length against the humerus. Brachial artery is medial to humerus in its upper half and in front of it in its lower half. The best place to compress the artery is about the middle of arm, where the artery lies on the tendon of coracobrachialis on the medial side of the humerus.
Radial artery: It can be felt pulsating against the front of distal end of radius lateral to the tendon of flexor carpi radialis. Its pulsations are also felt in the floor of anatomical snuff box.
Ulnar artery: It may be felt pulsating in front of the wrist lateral to the pisiform bone.
 
PALPABLE NERVES OF UPPER LIMB
Ulnar nerve: It can be palpated at the back of medial epicondyle of the humerus in slightly flexed arm. It feels like a rounded cord and, on compression, sends pins and needle sensation along the medial side of the hand.
 
RETINACULA
Flexor retinaculum (Fig. 10): It is a transverse band anterior to wrist with concave proximal and distal borders, about the size of a postage stamp.
Proximal border: Marked by joining points a and b:
  1. Tubercle of scaphoid
  2. Pisiform bone
Distal border: Marked by joining points c and d:
  • c. Hook of hamate
  • d. Crest of trapezium23
zoom view
Fig. 9: View of upper limb from the front.
zoom view
Fig. 10: View of palm.
24
25
26
Extensor retinaculum (Fig. 11): Mark the following:
  1. Anterior border of radius
  2. Triquetral and pisiform
Join points a and b obliquely with 2 cm wide band across the back of the wrist.27
zoom view
Fig. 11: Dorsal view of hand.
28