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ARM IN ARM
A Partial Survey of the Bones, Muscles, Nerves and Blood Vessels of the Arm and Elbow
Having finished the pectoral girdle, were now off to view the upper arm and elbow. Recall that the upper arm is one large single bone, the humerus. The elbow is the articular region between the humerus and two smaller bones, the radius and the ulna. There are many muscles that move the arm and some of them were introduced to you during the shoulder exercise. Today we will examine these muscles in more detail and we will also discuss pertinent nerves and blood vessels associated with the upper arm and elbow region.

Part I: Bones
Now we will continue our survey of the humerus by examining the distal region of this bone. To appreciate points of insertion for many of the arm muscles, we will also examine the proximal end of the bones of the forearm, the radius and ulna. A. Humerus (Martini, figure 7.6 & 7.7, page 186 & 187; Calais-Germain, page 111). Recall that the humerus is a long bone with a proximal and distal epiphyseal region. Lets begin with a midpoint of the diaphysis we recently studied, the rough surface called the deltoid tuberosity. This region is the point of insertion for the deltoid muscle. At the distal end of the humerus, we find two protruding bumps just above the smooth region of the joint. These bumps are the medial and lateral epicondyles. The medial epicondyle is the same side as head of the humerus, but on the opposite end. It is more pronounced than the lateral epicondyle, which rests on the lateral side of the humerus. Epi means above; condyle means knuckle. The medial and lateral epicondyles are of interest to us because they are points of origin for several muscles of the forearm which will be discussed in the next exercise. For now, just be able to recognize and distinguish between the epicondyles. Lets get back to the condyles of the humerus. First we must ask what constitutes a condyle? Most smooth surfaces of long bones are condyles, but they are not always called condyles and the condyles of the humerus are no exception. The condyles of the humerus are called the trochlea and capitulum. Lets examine them. If we examine the condyles we see that there is one that juts out of the epiphysis. Further examination reveals that this condyle resembles a pulley. Indeed, this is yet another trochlea, named for its pulley-like appearance. Lateral to the trochlea rests a rounded condyle, the capitulum. Capitulum means little head and it does resemble the cranium of a very small skull. So

2 much for the condyles; lets examine the depressions. There are three depressions (fossa) of interest on the distal end of the humerus. On the anterior side are two shallow fossae; a large deep fossa rests on the posterior side. This is one way to tell the anterior and posterior regions of the humerus apart, and it will also help in telling the left humerus form the right. Lets look at the anterior side first. The medial most fossa is a relatively deep one called the coronoid fossa. It is a depression that articulates with the coronoid process of the ulna which we will study soon. The radial fossa is a shallow, lateral depression. It articulates with the head of the radius, another region that will be described shortly. Now lets examine the posterior side of the humerus. The deep depression at the distal epiphysis is called the olecranon fossa. Olecranon is Greek for elbow, so I guess you know where this is going. This means that the elbow, per se, is not on the humerus, but on the ulna, one of the forearm bones. The olecranon process of the ulna (the bump we recognize as the elbow) articulates with the olecranon fossa (no surprise). Before we leave the humerus, pick up a humerus at random and see if you can tell if its the right or left humerus. This would make a good test question. What landmarks should you look for? Time for review? B. Bones of the Forearm We are now ready to examine the bones of the forearm, the radius and the ulna. Note that the radius is associated 2. Ulna (Martini, figure 7.7 pages 188189; Calais-Germain, pages 133-134) with the thumb. It is a lateral bone of the forearm in anatomical position. The ulna is associated with the little finger and is the medial bone of the forearm in anatomical position. Note, too, that the proximal end of the radius is narrow and the distal end is broad. The opposite is true for the ulna. The heads of these bones are the narrow regions, so these two bones rest next to each other in the forearm like sardines in a can. 1. Radius (Martini, figure 7.7 pages 188189; Calais-Germain, pages 133-134) Radius comes from the Latin word for rod or bar. Once again, you will find this bone thumb side. Today we will restrict ourselves to the proximal end of the radius. First examine the round head that resembles a radial tire. Note that the head of the radius inserts nicely into the radial fossa of the humerus allow it to roll in rotation Examine the assembled arm to see this association. See how this works? The head of the radius also articulates with the radial notch of the ulna. Well get to that soon. Below the head of the radius is the radial tuberosity. This tuberosity is a prominent bump on the medial side of the radius. The radial tuberosity is the point of insertion for the biceps brachii muscle which we will discuss shortly. Between the head of the radius and the radial tuberosity is the neck of the radius (again, no surprise).

3 The ulna is the bone of the forearm that rests on the side of the little finger. The name ulna means elbow in Latin, taking all the mystery out of where to find it. To me, the ulna resembles a pipe wrench, and it is the pipe wrench end (the proximal diaphysis) that we will study today. First lets look at the notch in the wrench. This notch holds the trochlea of the humerus. Can you guess what its called? If you said trochlear notch, thats more points toward the Buick. There are two processes that reside above and below the trochlear notch. The superior process is the olecranon process or simply the olecranon (again, elbow in Greek). Recall that the olecranon is the little bony projection that we know as our elbow. The lip-like process inferior to the trochlear notch is the coronoid process, again because it has a point on it like a crown. I suppose if we put all the coronoid process of the skeleton together, wed have a crown. Wed also have a very strange skeleton. On the lateral side of the coronoid process rests the radial notch. Here the head of the radius rests. A small ligament, one of the many annular ligaments, holds the head of the radius in place. Finally, inferior and medial to the radial notch is the ulnar tuberosity. This rough surface is the point of insertion for the brachialis muscle, a muscle we will visit soon.

Part II: The Elbow Joint (Martini, figure 8.12, page 228; Calais-Germain, page 135)
At the elbow joint, radius and the ulna form two kinds of diarthrosis. Because the radius can rotate 1800 over the ulna, the elbow joint is a pivot joint. Because the forearm can flex and extend at the elbow, this diarthrosis also a hinge joint. We dont have models of this joint, but a few details are worth mentioning. The joint is wrapped by a strong articular capsule. On the side of the ulna are two strong ulnar collateral ligaments and similar ligaments may be found on the radial side. The radial head is also connected to the ulna by the previously mentioned annular ligament that allows for rotation. The term annular means ring. One final note, the radius and ulna are held together by a connective tissue sheath called the antebrachial interosseous membrane (also known as the bicipital aponeurosis). This fascious membrane of areolar connective tissue helps hold the radius and ulna together during rotation of the forearm. This is, of course, a syndesmosis.

Part III: Muscles of the Arm

4 The following is a summary of the muscles that move the arm, many of which have been mentioned in the previous exercise. When examining the origins of these muscles, it is a good time to review the upper humerus, the clavicle and the scapula. 1. Rotator cuffs (Martini, figure11.5, page 296; Calais-Germain, page 120-121) While the four rotator cuff muscles are found directly on the scapula, they insert into the humerus. The following is a brief description of them. a. Subscapularis Covering the entire anterior side of the scapula is the subscapularis muscle. The point of origin for this muscle is the subscapular fossa; the subscapularis inserts in the lesser tubercle of the humerus. The subscapularis also has an interesting location. It rests over the serratus anterior muscles and ribs. To ensure free movement of the scapula in general, fatty tissue lies between the serratus anterior and subscapularis muscles acting as a protecting barrier and providing a certain lubricating effect. The purpose of this rotator cuff muscle is to provide support for the glenohumeral joint, but to also assist the latissimus dorsi, pectoralis major, teres major and anterior deltoid muscles in medial rotation of the arm. The subscapularis also assists the pectoralis major and latissimus dorsi in adduction of the arm (see Calais-Germain, pages 128-9). b. Supraspinatus Resting snugly in the supraspinous fossa is the body of the supraspinatus. Its insertion is the apex of the greater tubercule of the humerus. To form its insertion, the tendon of the supraspinatus must travel beneath the acromioclavicular joint which accounts for the gap between the acromion process and the glenoid cavity. It is synergistic to the deltoid muscle in abduction of the arm (see Calais-Germain, page 128). c. Infraspinatus Below the spine of the scapula rests the large infraspinatus muscle. The infraspinatus has its origin in the infraspinous fossa and it inserts posteriorly and inferiorly into the greater tubercule of the humerus, below the tendon of the supraspinatus. This rotator cuff muscle laterally rotates the arm, assisting the teres minor and posterior deltoid muscle (see CalaisGermain, page 128). . d. Teres minor The final rotator cuff muscle is the teres minor. It is located inferiorly and laterally to the infraspinatus muscle and the two perform the same task, lateral rotation of the arm. Once again, the point of insertion is the greater tubercle of the humerus, but at a point inferior to the insertion of the tendon of the infraspinatus (see Calais-Germain, page 128). . 2. Coracobrachialis (Martini, figure 11.5, page 296; Calais-Germain, page 122) As the name implies the coracobrachialis origins at the coracoid process of the scapula and inserts on the

5 medial surface of the humerus, about half way down the diaphysis. It is a small synergist muscle which assist the anterior deltoid and pectoralis major in flexing the arm. It also assists the latissimus dorsi, teres major and pectoralis major in adducting the arm (see Calais-Germain, pages 127-8). 3. Biceps brachii (Martini, figure 11.5 page 296; Calais-Germain, page 123) The name biceps means two heads. The two heads of the biceps brachii are its points of origin and they are named the long and short heads. The origin of the short head is the coracoid process of the scapula; the origin of the long head is the superior tubercle of the glenoid cavity. Recall that the tendon of the long head of the biceps brachii travels through the intertubercular groove of the humerus which helps to stabilize this tendon. The point of insertion of the biceps brachii is the radial tuberosity of the radius and the proximal region of the interosseous membrane (bicipital aponeurosis), the fascious membrane between the radius and the ulna. As you might have guessed, the biceps brachii is an important muscle. Its primary task is to flex the arm at the elbow. The long head is involved in abducting the arm and the short head is involved in adducting the arm. The long head then assists the deltoids and supraspinatus muscles in abduction; the short head assists the latissimus dorsi, pectoralis major, and teres major in adduction, along with the coracobrachialis. The coracobrachialis and the short head of the biceps brachii have fused tendons at their points of origin. We would expect similar actions from them and we are not disappointed. 4. Triceps brachii (Martini, figure 11.5 page 296; Calais-Germain, page 140) One of the great agonist/antagonist relationships in the muscle world is the relationship between the biceps brachii and our next muscle, the triceps brachii. I suppose the oneup-manship began when the triceps developed three heads, but lets not toy with evolution. While the biceps brachii flexes the arm, the triceps performs the opposite action, extension. In addition the triceps helps to adduct the arm, while the biceps abducts it. There just is no love lost here. The triceps brachii has its origin in three regions: its lateral head originates at the superior lateral margin of the humerus, but its long head originates at the infraglenoid tubercle of the scapula. Recall that the biceps brachii has the origin for its long head in the supraglenoid tubercle. I guess thats one point for the biceps. The medial head has its region on the posterior surface on the humerus. All three heads insert on the olecranon of the ulna. We will visit the triceps brachii briefly when we visit the forearm muscles. Just remember it as the primary extensor of the forearm, and also as a muscle that assists the deltoid and supraspinatus in adduction. For now, well send the triceps home packing. 5. Pectoralis major (Martini, figure 11.5 page 296; Calais-Germain, page 124) Pectoralis major muscle is very easy to find. It is the main muscle we see when we view the chest. This muscle has

6 a long region of insertion, traveling from the costal cartilages of ribs 2-6 to the edge of the body of the sternum and into the inferior medial region of the clavicle. Having two bones for regions of origin makes this a two headed muscle as well. The heads are called the clavicular head and the sternocostal head. Both heads insert in the greater tubercle and the lateral lip of the intertubercular groove of the humerus, but the fibers of the clavicular head inserts inferiorly to the sternocostal head. The principle action of the pectoralis major, when both heads are working together, is to adduct and medially rotate the arm. The heads are antagonist to one another when they operate alone. The clavicular head flexes an extended shoulder, while the sternocostal head extends a flexed shoulder (as in pull-ups). See Calais Germain page 124. 6. Latissimus dorsi (Martini, figure 11.5 page 296; Calais-Germain, page 125) Although this muscle is the widest muscle of the back, it really serves the arm. The latissimus dorsi is a superficial back muscle, originating from the sacral and iliac crests, the fascia of the small of the back, the spinous processes of T7-T12 and the posterior surfaces of the false ribs. Its insertion is the intertubercular groove of the humerus. The function of the latissimus dorsi is to extend the arm along with the posterior deltoid and the teres major. It also adducts the arm along with the pectoralis major and teres major, and provides a mechanism for medial rotation, along with the subscapularis, pectoralis major, teres major and the anterior deltoid. Incidentally, latissimus refers to the broadness of this muscle and the fact that it is lateral to the axis of the body; the dorsi bit comes from the fact that this muscles inserts on the back. 7. Teres major (Martini, figure 11.5 page 296; Calais-Germain, page 125) Teres major is a short, fat muscle that rests in the axillary region. It originates in the posterior surface of the inferior angle of the scapula and inserts next to the tendon of the latissimus dorsi on the floor of the intertubercular groove. As you may have gathered from reading the description of the latissimus dorsi, the principle job of the teres major is to assist the latissimus dorsi. They perform the same actions. Think of the teres major as the latissimus dorsis little buddy, both out to adduct, extend and medially rotate the world (or was that the arm?). 8. Deltoid (Martini, figure 11.5 page 296; Calais-Germain, page 126) The final and most obvious muscle of the shoulder is the deltoid. The deltoid is also called the shoulder cap because of its position. Its fibers are rounded which gives this muscle some shock-absorbing prosperities. It originates from the spine of the scapula including the acromion process. It inserts on a long, rough surface, deltoid tuberosity of the humerus. The fibers of this muscle can really be separated into two groups, the anterior fibers and posterior fibers. When all of the deltoids fibers work as a unit, they serve as the principle abductor of the arm at the shoulder. But when they contract separately, the anterior and posterior

7 fibers can act as antagonists to one another as well. The anterior fibers of the deltoid are key players in medial rotation and flexion, but the posterior fibers are key players in lateral rotation and extension. Recall that a similar situation exist in the pectoralis major. The anterior fibers then can be assisted by the pectoralis major and coracobrachialis flexing the arm. The posterior fibers can be assisted by the latissimus dorsi and teres major in extending the arm, (see Calais-Germain, p. 127). When all the fibers work together, the supraspinatus assits them in extension (see CalaisGermain, p. 128).

Part IV: Nerves

We are thankfully beyond the brachial plexus, but we should examine the position of some of the branches that can be found in the vicinity of the humerus. The musculocutaneous has inserted itself into the biceps brachii muscle about of the way down the humerus. The median nerve has joined the brachial artery and vein in a neurovascular bundle that will continue just past the antecubital region of the elbow joint. The radial nerve is traveling solo below the median nerve, and the ulnar nerve continues its lateral descent downward some distance from the actual bone. We will continue our discussion of the nerves of the arm in the next exercise.

Summary of Muscular Innervation

1. Axillary Nerve: Deltoid and Teres minor. 2. Musculocutaneous Nerve: Biceps brachii, brachialis, coracobrachilais. 3. Radial nerve: triceps brachii, anconeus.

Part V: Blood Vessels

A. Arteries The principle artery in the region of the humerus is the brachial artery. This artery will leave the neurovascular bundle when it splits into the radial artery and the ulnar artery at the antecubital region of the elbow joint. We

8 will follow the course of these arteries in the next exercise. B. Veins Two brachial veins are accompanying the brachial artery down the arm as part of the neurovascular bundle. These veins will also leave the neurovascular bundle and join other veins and follow the ulnar and radial arteries down the forearm. The cephalic vein and the basilic vein will be joined together by a short vein at the antecubital region of the elbow. This short connecting vein is the median cubital vein and is the vein from which blood is typically drawn. This vein is missing in some people. In such cases, a rather a short median cephalic vein and median basilic vein meet in the middle to form an M. The cephalic vein travels in the superficial grove between the fibers of the deltoid muscle. The basilic vein, by contrast, branches off the axillary vein and travels medially down the arm.