Shoulder & Arm and Forearm & Hand — Comprehensive Study Notes

Shoulder & Arm

• Learning objectives (shoulder and arm)

  • Recognize the surface anatomy including skin and fascial structures of the shoulder and arm.
  • Palpate the bones and bony landmarks of the shoulder and arm and recognize the connections between them and soft tissue.
  • Palpate the shoulder and arm landmarks that identify the location of underlying nerves, blood vessels, and lymph nodes to be cautious of when practicing manual therapies.
  • Describe the relationships between the topographical contours and underlying musculoskeletal structures, as well as the texture, thickness, and mobility of the skin and fascial structures in the shoulder and arm.
  • Name and locate the bones, bony landmarks, and joints for the shoulder and arm and describe the connections between them and the soft tissues of the shoulder and arm.
  • Name and locate major joint structures of the shoulder and arm, including ligaments and bursae that are common sites of pain and injury in the region.

• Surface features visible on the shoulder and arm (anterior, anterior/lateral, posterior views)

  • Anterior view features include clavicle, humerus, scapula, acromion, coracoid process, sternoclavicular (S/C) joint, acromioclavicular (A/C) joint, glenohumeral (G/H) joint, sternum, ribs.
  • Anterior/lateral view features and posterior view features similarly highlight surface contours and landmarks used for palpation.

• Bones of the shoulder and arm (anterior view)

  • Humerus
  • Scapula
  • Cervical vertebra (C-
    -7)
  • Clavicle
  • Sternoclavicular (S/C) joint
  • Acromioclavicular (A/C) joint
  • Glenohumeral joint
  • Sternum
  • Ribs

• Bony landmarks of the shoulder and arm (scapula-focused)

  • Superior angle
  • Supraspinous fossa
  • Acromion
  • Supraglenoid tubercle
  • Glenoid cavity
  • Infraglenoid tubercle
  • Coracoid process
  • Superior notch
  • Superior angle
  • Lateral border
  • Spine of the scapula
  • Medial border
  • Infraspinous fossa
  • Subscapular fossa
  • Inferior angle
  • Additional scapular landmarks appearing in other views: Acromial angle, Midline borders, etc.

• Review questions

  • What 3 bones comprise the shoulder complex? $ext{Humerus}, ext{Scapula}, ext{Clavicle}$
  • Which joint is the attachment between the appendicular and axial skeleton? $S ext{/}C ext{ joint (Sternoclavicular joint)}$

• Shoulder & Arm – Acromion and scapular landmarks (specific views)

  • Acromion
  • Spine of scapula
  • Superior angle
  • Inferior angle
  • Coracoid process
  • Supraglenoid tubercle
  • Infraglenoid tubercle
  • Glenoid cavity
  • Supraspinous fossa
  • Infraspinous fossa
  • Subscapular fossa

• Shoulder & Arm – Clavicle landmarks (bony landmarks)

  • Clavicle features include: Acromial end (lateral), Sternal end (medial), Trapezoid line, Conoid tubercle, Groove for subclavius, and relations to the sternum and shoulder girdle.
  • Lateral 1/3 of clavicle is a common palpation landmark.

• Shoulder & Arm – Humerus landmarks and joints (anterior view)

  • Greater tubercle
  • Head of the humerus
  • Crest of greater tubercle
  • Lesser tubercle
  • Deltoid tuberosity
  • Lateral supra-condylar ridge
  • Lateral condyle
  • Lateral epicondyle
  • Radial fossa
  • Capitulum
  • Intertubercular groove
  • Crest of lesser tubercle
  • Medial supra-condylar ridge
  • Medial condyle
  • Medial epicondyle
  • Coronoid fossa
  • Trochlea
  • Medial supra-condylar ridge
  • Olecranon fossa
  • Groove for ulnar nerve
  • Groove for radial nerve
  • Groove for ulna nerve

• Rotator cuff and related shoulder muscles

  • Rotator cuff muscles (Group #2): Supraspinatus, Infraspinatus, Teres Minor, Subscapularis
  • Supraspinatus
  • A: Abduct the shoulder (glenohumeral joint); Stabilize head of humerus in glenoid cavity
  • O: Supraspinous fossa of the scapula
  • I: Greater tubercle of the humerus
  • N: Suprascapular nerve $C4,5,6$
  • Infraspinatus
  • A: Laterally rotate the shoulder (glenohumeral joint); Adduct the shoulder; Stabilize head of humerus
  • O: Infraspinous fossa of the scapula
  • I: Greater tubercle of the humerus
  • N: Suprascapular nerve $C4,5,6$
  • Teres Minor
  • A: Laterally rotate the shoulder; Adduct the shoulder; Stabilize head of humerus
  • O: Upper two-thirds of lateral border of the scapula
  • I: Greater tubercle of the humerus
  • N: Axillary nerve $C5,6$
  • Subscapularis
  • A: Medially rotate the shoulder; Stabilize head of humerus
  • O: Subscapular fossa of the scapula
  • I: Lesser tubercle of the humerus
  • N: Upper and lower subscapular nerves $C5,6,7$
  • Supraspinatus, Infraspinatus, Teres Minor, Subscapularis tendons (jointly stabilize GH joint; rotator cuff group)

• Shoulder muscle group #1 and other movers

  • Deltoid
  • A: All fibers abduct the shoulder (G/H joint)
    • Anterior fibers: flex the shoulder; medially rotate; horizontally adduct
    • Middle fibers: abduct the shoulder
    • Posterior fibers: extend the shoulder; laterally rotate; horizontally abduct
  • O: Lateral 1/3 of clavicle, acromion, and spine of scapula
  • I: Deltoid tuberosity
  • N: Axillary nerve $C5,6$
  • Trapezius (Upper, Middle, Lower fibers)
  • A: Head/neck actions; elevate, up. rotate scapula; adduct; stabilize; depress and upwardly rotate scapula
  • O: External occipital protuberance, medial superior nuchal line, ligamentum nuchae, spinous processes C-7 through T-12
  • I: Lateral 1/3 of clavicle, acromion, spine of the scapula
  • N: Spinal portion of cranial nerve XI (accessory) and ventral rami C2,3,4
  • Latissimus Dorsi
  • A: Extend, adduct, and medially rotate the shoulder
  • O: Inferior angle of the scapula; spinous processes of last $6$ thoracic vertebrae, last $3$ or $4$ ribs; thoracolumbar fascia; posterior iliac crest
  • I: Intertubercular groove of the humerus
  • N: Thoracodorsal nerve $C6,7,8$
  • Teres Major
  • A: Extend, adduct, and medially rotate the shoulder
  • O: Inferior angle and lower one-third of the lateral border of the scapula
  • I: Crest of the lesser tubercle of the humerus
  • N: Lower subscapular nerve $C5,6,7$

• Axilla and shoulder ligaments/joints

  • Axilla structures (structures of the axilla to palpate and beware of during manual therapies):
  • Coracobrachialis, biceps brachii, triceps brachii, pectoralis major, serratus anterior, latissimus dorsi, subscapularis
  • Median nerve, brachial artery, medial antebrachial cutaneous nerve, ulnar nerve, basilic vein, cephalic veins (as listed in the diagram)
  • Sternoclavicular joint components
  • Anterior sternoclavicular ligament
  • Interclavicular ligament
  • Articular disc
  • Clavicle
  • First and second ribs with their costal cartilages
  • Joint cavity
  • Costoclavicular ligament
  • Sternocostal synchondrosis
  • Manubrium
  • Radiate ligament
  • Sternocostal joints
  • Ligaments of the shoulder
  • Coracoclavicular ligaments: trapezoid and conoid
  • Acromioclavicular ligament
  • Coracoacromial ligament
  • Coracohumeral ligament
  • Tendons: Supraspinatus and Subscapularis (tendons shown, some cut in diagrams)
  • Biceps brachii tendon (long head shown, sometimes cut in diagrams)
  • Humerus, Coracoid process, Glenohumeral joint and capsule, Scapula

• Subacromial and glenohumeral joint structures

  • Subacromial bursa
  • Supraspinatus tendon; Acromion; Clavicle; Head of humerus
  • Glenohumeral joint capsule; Synovial membrane (cut in diagrams); Inferior glenohumeral ligament; Supraspinatus, infraspinatus, and teres minor tendons (often shown cut and reflected)
  • Glenoid labrum; Glenoid cavity; Cartilage of glenoid cavity
  • Joint articulation relationships: Acromioclavicular joint and ligament; Middle glenohumeral ligament; Anterior sternoclavicular ligament; etc.

• Forearm & Hand

• Forearm & Hand – Learning objectives

  • Recognize surface anatomy of forearm and hand; palpate bones and landmarks; connections to soft tissue.
  • Identify landmarks for underlying nerves and vessels; be cautious during manual therapies.
  • Describe relationships between topographical contours and musculoskeletal structures; discuss texture and mobility of skin and fascia.
  • Name and locate bones, joints, and soft tissues of forearm and hand; describe connections between them and soft tissues.
  • Name and locate major joint structures (ligaments and bursae) in the forearm and hand; common sites of pain and injury.

• Forearm & Hand – Surface features visible (forearm and hand, anterior view; lateral view)

  • Forearm and hand surface features include landmarks for palpation of nerves and vessels; lateral epicondyle of humerus noted in dorsal view as surface landmark.

• Forearm & Hand – Bones of the forearm and hand (anterior view)

  • Ulna
  • Radius
  • Humerus (proximal landmarks used for the forearm)
  • Head of radius; Neck of radius; Radial tuberosity
  • Olecranon process (posterior surface)
  • Trochlear notch; Coronoid process; Radial notch of ulna
  • Ulnar tuberosity
  • Styloid processes of ulna and radius
  • Lister's tubercle (a notable distal radius landmark)
  • Distal carpals and metacarpals; Eight carpal bones (posterior view often shown)
  • Metacarpals and phalanges

• Forearm & Hand – Forearm muscles (origin–insertion–action–nerve) – overview

  • Brachialis
  • A: Flex the elbow (humeroulnar joint)
  • O: Distal half of the anterior surface of the humerus
  • I: Tuberosity and coronoid process of ulna
  • N: Musculocutaneous, with a small radial contribution
  • Biceps Brachii
  • A: Flex the elbow; Supinate the forearm; Flex the shoulder
  • O: Short head from coracoid process; Long head from supraglenoid tubercle of scapula
  • I: Tuberosity of the radius and bicipital aponeurosis
  • N: Musculocutaneous $C5,6$
  • Brachioradialis
  • A: Flex the elbow; assist to pronate/supinate when resisted
  • O: Proximal two-thirds of the lateral supracondylar ridge of the humerus
  • I: Styloid process of the radius
  • N: Radial $C5,6$
  • Pronator Teres
  • A: Pronate the forearm; assist to flex the elbow
  • O: Common flexor tendon from the medial epicondyle of humerus and coronoid process of ulna
  • I: Middle of the lateral surface of the radius
  • N: Median $C6,7$
  • Pronator Quadratus
  • A: Pronate the forearm
  • O: Medial, anterior surface of distal ulna
  • I: Lateral, anterior surface of distal radius
  • N: Median $C7,8, T1$
  • Supinator
  • A: Supinate the forearm
  • O: Lateral epicondyle of humerus, radial collateral ligament, annular ligament, supinator crest of ulna
  • I: Anterior, lateral surface of proximal one-third of radial shaft
  • N: Radial $C5,6,7$

• Extensors of the forearm and hand (selected major muscles)

  • Extensor Carpi Radialis Longus
  • A: Extend the wrist; Abduct the wrist; Assist to flex the elbow
  • O: Distal one-third of the lateral supracondylar ridge of humerus
  • I: Base of the second metacarpal
  • N: Radial $C5,6,7,8$
  • Extensor Carpi Radialis Brevis
  • A: Extend the wrist; Abduct the wrist; Assist to flex the elbow
  • O: Common extensor tendon from lateral epicondyle of humerus
  • I: Base of the third metacarpal
  • N: Radial $C6,7,8$
  • Extensor Carpi Ulnaris
  • A: Extend the wrist; Adduct the wrist
  • O: Common extensor tendon from lateral epicondyle
  • I: Base of the fifth metacarpal
  • N: Radial $C6,7,8$
  • Extensor Digitorum (Communis, EDC)
  • A: Extend the 2nd–5th digits; assist to extend the wrist
  • O: Common extensor tendon from lateral epicondyle
  • I: Bases of middle and distal phalanges of 2nd–5th fingers
  • N: Radial $C6,7,8$
  • Extensor Indicis
  • A: Extend the 2nd finger; may assist to extend the wrist
  • O: Posterior surface of distal shaft of ulna and interosseous membrane
  • I: Tendon of the extensor digitorum at the level of the 2nd metacarpal
  • N: Radial $C6,7,8$

• Forearm & Hand – Flexors of the wrist and fingers (selected important muscles)

  • Flexor Carpi Radialis
  • A: Flex the wrist; Abduct the wrist; Assist to flex the elbow
  • O: Common flexor tendon from medial epicondyle of humerus
  • I: Bases of 2nd and 3rd metacarpals
  • N: Median $C6,7,8$
  • Palmaris Longus
  • A: Tens the palmar fascia; Flex the wrist; Assist to flex the elbow
  • O: Common flexor tendon from medial epicondyle of humerus
  • I: Flexor retinaculum and palmar aponeurosis
  • N: Median $C(6),7,8,T1$
  • Flexor Carpi Ulnaris
  • A: Flex the wrist; Adduct the wrist; Assist to flex the elbow
  • O: Humeral head—common flexor tendon from medial epicondyle; Ulnar head—posterior surface of proximal two-thirds of ulna
  • I: Pisiform, hook of hamate, and base of 5th metacarpal
  • N: Ulnar $C7,8,T1$
  • Flexor Digitorum Superficialis
  • A: Flex 2nd–5th fingers; flex the wrist
  • O: Common flexor tendon from medial epicondyle; ulnar collateral ligament; coronoid process of ulna; interosseous membrane; proximal shaft of radius
  • I: Sides of middle phalanges of 2nd–5th fingers
  • N: Median $C7,8,T1$
  • Flexor Digitorum Profundus
  • A: Flex 2nd–5th fingers; assist to flex the wrist
  • O: Anterior and medial surfaces of proximal three-quarters of ulna
  • I: Bases of distal phalanges; palmar surface of 2nd–5th fingers
  • N: 2nd–3rd fingers: Median $C7,8,T1$; 4th–5th fingers: Ulnar $C7,8,T1$

• Forearm & Hand – Thumb muscles (long/extrinsic and intrinsic groups)

  • Long muscles of the thumb
  • Abductor Pollicis Longus
    • A: Abduct the thumb; Extend the thumb; Abduct the wrist
    • O: Posterior surface of radius and ulna, and interosseous membrane
    • I: Base of first metacarpal
    • N: Radial $C6,7,8$
  • Extensor Pollicis Longus
    • A: Extend the thumb (IP joint); Extend the thumb (MCP and CMC joints); Abduct the wrist
    • O: Posterior surface of ulna and interosseous membrane
    • I: Base of distal phalanx of thumb
    • N: Radial $C6,7,8$
  • Extensor Pollicis Brevis
    • A: Extend the thumb (MCP and CMC); Abduct the wrist
    • O: Posterior surface of radius and interosseous membrane
    • I: Base of proximal phalanx of thumb
    • N: Radial $C6,7,8$
  • Flexor Pollicis Longus
    • A: Flex the thumb (IP, MCP, CMC joints); Assist to flex the wrist
    • O: Anterior surface of radius and interosseous membrane
    • I: Base of distal phalanx of thumb
    • N: Median $C6,7,8,T1$
  • Thenar Eminence (intrinsic muscles of the thumb)
  • Abductor Pollicis Brevis
    • A: Abduct the thumb; Assist in opposition
    • O: Flexor retinaculum, trapezium, and scaphoid tubercles
    • I: Base of proximal phalanx of thumb
    • N: Median $C6,7,8,T1$
  • Flexor Pollicis Brevis
    • A: Flex the thumb; Assist in opposition
    • O: Superficial head—Flexor retinaculum; Deep head—Trapezium, trapezoid, capitate
    • I: Base of proximal phalanx of thumb
    • N: Superficial head—Median; Deep head—Ulnar $C8,T1$
  • Opponens Pollicis
    • A: Opposition of the thumb at the CMC joint
    • O: Flexor retinaculum and tubercle of trapezium
    • I: Entire length of first metacarpal bone, radial surface
    • N: Median $C6,7,8,T1$
  • Adductor Pollicis
    • A: Adduct the thumb at the CMC and MCP joints; Assist to flex MCP
    • O: Capitate, 2nd and 3rd metacarpals
    • I: Base of proximal phalanx of thumb
    • N: Ulnar $C8,T1$
  • Interossei and Lumbricals (intrinsic hand muscles)
  • Lumbricals
    • A: Extend the 2nd–5th fingers at IP joints; Flex the 2nd–5th fingers at MCP joints
    • O: Surfaces of flexor digitorum profundus tendons
    • I: Extensor aponeurosis on the dorsal surface of phalanges
    • N: 2nd–3rd fingers: Median $C6,7,8,T1$; 4th–5th fingers: Ulnar $C7,8,T1$
  • Palmar Interossei
    • A: Adduct the 1st, 3rd, and 5th fingers toward the 3rd finger; Assist to flex MCP joints; Assist to extend IP joints
    • O: Base of 1st, 2nd, 4th, and 5th metacarpals
    • I: Base of proximal phalanx of related finger; extensor aponeurosis
    • N: Ulnar $C8,T1$
  • Dorsal Interossei
    • A: Abduct the 2nd–4th fingers; Assist to flex MCP joints; Assist to extend IP joints
    • O: Adjacent sides of all metacarpals
    • I: Base of proximal phalanx of 2nd–4th fingers; extensor aponeurosis
    • N: Ulnar $C8,T1$
  • Hypothenar Eminence
  • Abductor Digiti Minimi
  • Flexor Digiti Minimi Brevis
  • Opponens Digiti Minimi
  • A, O, I, N details follow the intrinsic hand muscle patterns (ulnar nerve) with emphasis on little finger motion

• Forearm & Hand – Ligaments, retinacula, and palmar aponeurosis

  • Retinacula of the wrist and palmar aponeurosis
  • Flexor Retinaculum
  • Extensor Retinaculum
  • Palmar Aponeurosis
  • Arteries
  • Radial artery
  • Ulnar artery
  • Joints and ligaments
  • Radiocarpal joints ligaments (palmar radiocarpal ligaments: radioscapholunate part, radiotriquetral part, radiocapitate part)
  • Dorsal radioulnar ligament
  • Palmar radioulnar ligament
  • Ulnar collateral ligament
  • Intercarpal ligaments (palmar and dorsal intercarpal ligaments)
  • Pisohamate ligament; Distal intercarpal ligaments; Radiate carpal ligaments
  • Palmar ulnocarpal ligament (ulnolunate and ulnotriquetral parts)
  • Carpometacarpal and metacarpal joints; Interphalangeal joints with deep transverse metacarpal ligaments

• Forearm & Hand – Reached the Summit (closing pages)

  • Final summary prompts and review prompts to help consolidate the forearm and hand anatomy and functions.

• Connections to practice

  • Pain and injury sites are commonly at the rotator cuff tendons, acromioclavicular joint, glenohumeral capsule, and the ligaments of the shoulder.
  • The axillary- and brachial plexus-related nerves and vessels traverse the axilla and arm; careful palpation and awareness during manual therapy are essential to avoid nerve or vessel injury.
  • The forearm and hand sections emphasize the interplay between flexors and extensors, abductors and adductors, and the reflexive actions required for daily hand use and fine motor tasks.

• Summary of key nerve roots and innervation (select examples)

  • Suprascapular nerve: $C4,5,6$
  • Axillary nerve: $C5,6$
  • Thoracodorsal nerve: $C6,7,8$ (Latissimus Dorsi)
  • Dorsal scapular nerve: $C4,5$ (Rhomboids / Levator scapulae areas)
  • Median nerve: $C6,7,8,T1$ (forearm flexors; some intrinsic hand muscles)
  • Ulnar nerve: $C7,8,T1$ (many intrinsic hand muscles; hypothenar group)
  • Radial nerve: $C5,6,7,8$ (posterior arm/forearm compartments)

• Notable anatomical references and features to remember

  • Greater and lesser tubercles of the humerus; intertubercular groove
  • Crest of greater tubercle; supraglenoid tubercle and infraglenoid tubercle
  • Cervical and thoracic vertebrae relationships to scapular and shoulder girdle muscles
  • S/C joint, A/C joint, and glenohumeral joint as key articulations of the shoulder
  • Sternal end vs. acromial end of the clavicle; conoid and trapezoid ligaments (part of coracoclavicular ligament)
  • Retinacula, tendon sheaths, and bursae around the wrist and hand (e.g., subacromial bursa around the GH joint)

• LaTeX-ready numerical references used in this outline

  • Nerves: $C5,6$, $C4,5,6$, $C6,7,8$, $C7,8,T1$, $C8,T1$, $C5,6,7,8$
  • Skeletal/vertebral references: $C<em>7$, $T</em>2\text{ to } T<em>5$, $T</em>{12}$, $T<em>7\text{–}T</em>{12}$
  • Muscular insertions/landmarks: e.g., $G/H$ for glenohumeral, $CMC$ (carpometacarpal), $IP$ (interphalangeal), $MCP$ (metacarpophalangeal), and joint designations such as $GH ext{ joint}$, $S/C ext{ joint}$, $A/C ext{ joint}$.

• Probing questions for quick review

  • Which three main bones form the shoulder complex?
  • What joint serves as the sole articulation between the upper limb and the axial skeleton?
  • Name the rotator cuff muscles and give their primary actions.
  • Which nerve innervates the deltoid and teres minor, and what are their primary actions?
  • Identify the major ligaments stabilizing the AC joint and the GH joint.
  • List the major forearm flexors and extensors and their primary actions.
  • What are the intrinsic muscles of the thumb and hand, and what nerves innervate them?
  • What are the primary retinacula and palmar aponeurosis, and what is their functional role?

• Note: All numerical references (e.g., nerve roots, vertebral levels, and joint designations) follow the format shown in the source slides and are presented here in LaTeX-ready form where appropriate for study purposes.