8

Arm
! The man who gets angry, at the right things, with the right people, in the right
way, at the right time and for the right length of time is commended!
—Aristotle

INTRODUCTION
The arm extends from the shoulder joint till the elbow
joint. The skeleton of the arm is a ‘solo’ bone, the
humerus. Medial and lateral intermuscular septa divide
the arm into an anterior or flexor compartment and a
posterior or extensor compartment, to give each
compartment its individuality and freedom of action.
Since the structures in the front of arm continue across
the elbow joint into the cubital fossa, the cubital fossa
is also included in this chapter. The arm is called
brachium, so most of the structures in this chapter are
named accordingly, like brachialis, coracobrachialis and
brachial artery.

SURFACE LANDMARKS

The following landmarks can be felt in the living subject.

1 The greater tubercle of the humerus is the most lateral
bony point in the shoulder region. It can be felt just Fig. 8.1: Surface landmarks—front of upper arm
below the acromion process, deep to the deltoid
when the arm is by the side of the trunk (Fig. 8.1). the lower one-fourth of the arm as upward
2 The shaft of the humerus is felt only indistinctly continuations of the epicondyles.
because it is surrounded by muscles in its upper 6 The deltoid forms the rounded contour of the
half. In the lower half, the humerus is covered shoulder. The apex of the muscle is attached to the
anteriorly by the biceps brachii and brachialis, and deltoid tuberosity located at the middle of the
posteriorly by the triceps brachii. anterolateral surface of the humerus.
3 The medial epicondyle of the humerus is a prominent 7 The coracobrachialis forms an inconspicuous rounded
bony projection on the medial side of the elbow. It ridge in the upper part of the medial side of the arm.
is best seen and felt in a mid-flexed elbow. Pulsations of the brachial artery can be felt in the
4 The lateral epicondyle of the humerus is less prominent depression behind it.
than the medial. It can be felt in the upper part of 8 The biceps brachii muscle is overlapped above by the
the depression on the posterolateral aspect of the pectoralis major and by the deltoid. Below these
elbow in the extended position of the forearm. muscles, the biceps forms a conspicuous elevation
5 The medial and lateral supracondylar ridges are better on the front of the arm. Upon flexing the elbow, the
defined in the lower portions of the medial and contracting muscle becomes still more prominent.
lateral borders of the humerus. They can be felt in The tendon of the biceps can be felt in front of the
94
 ARM
95

elbow. The tendon is a guide to the brachial artery Two additional septa are present in the anterior
which lies on its medial side. compartment of the arm. The transverse septum
9 The brachial artery can be felt in front of the elbow separates the biceps from the brachialis and encloses
joint just medial to the tendon of the biceps brachii. the musculocutaneous nerve. The anteroposterior septum
Brachial pulsations are used for recording the blood separates the brachialis from the muscles attached to
pressure. the lateral supracondylar ridge; it encloses the radial
10 The ulnar nerve can be rolled by the palpating finger nerve and the anterior descending branch of the
behind the medial epicondyle of the humerus. During profunda brachii artery.
leprosy, this nerve becomes thick and enlarged.
11 The superficial cubital veins can be made more Competency achievement: The student should be able to:
prominent by applying tight pressure round the arm AN 11.1 Describe and demonstrate muscle groups of upper arm
and then contracting the forearm muscles by with emphasis on biceps and triceps brachii.1
clenching and releasing the fist a few times. The
cephalic vein runs upwards along the lateral border
of the biceps. The basilic vein can be seen along the ANTERIOR COMPARTMENT
lower half of the medial border of the biceps. The
cephalic and basilic veins are connected together in MUSCLES
front of the elbow by the median cubital vein which Muscles of the anterior compartment of the arm are
runs obliquely upwards and medially. the coracobrachialis, the biceps brachii and the
brachialis. They are described in Tables 8.1 and 8.2.
COMPARTMENTS OF THE ARM Morphological Importance of Coracobrachialis
The arm is divided into anterior and posterior Morphologically, the muscle is very important for
compartments by extension of deep fascia which are following reasons.
called the medial and lateral intermuscular septa The coracobrachialis represents the medial compart-
(Fig. 8.2). These septa provide additional surface for the ment, which is so well developed in the thigh.
attachment of muscles. They also form planes along In some animals, it is a tricipital muscle. In human,
which nerves and blood vessels travel. The septa are well the upper two heads have fused and musculocutaneous
nerve passes between the two, and the lowest third head
defined only in the lower half of the arm and are attached
has disappeared. Persistence of the lower head in
to the medial and lateral borders and supracondylar
human is associated with the presence of ‘ligament of
ridges of the humerus. The medial septum is pierced by
Struthers’, which is a fibrous band extending from the
the ulnar nerve and the superior ulnar collateral artery;
trochlear spine to the medial epicondyle of the humerus,
the lateral septum is pierced by the radial nerve and
to which the third head of the coracobrachialis is
radial collateral artery or the anterior descending branch
inserted, and from the lower part of which the pronator
of the profunda brachii artery (Fig. 8.7).
teres muscle takes origin. Beneath the ligament pass the
median nerve or brachial artery or both.
The front or anterior compartment of the arm is
homologous with flexor and medial compartments of
the thigh. The flexor compartment of thigh lies

Upper Limb
posteriorly because the lower limb bud rotates medially.

Competency achievement: The student should be able to:

AN 11.2 Identify and describe origin, course, relations, branches
(or tributaries), termination of important nerves and vessels in arm.2

NERVES
Musculocutaneous Nerve
1

The musculocutaneous nerve is the main nerve of the

Section

front of the arm, and continues below the elbow as the

lateral cutaneous nerve of the forearm (see Fig. 7.1a).
It is a branch of the lateral cord of the brachial plexus,
Fig. 8.2: Transverse section through the distal one-third of the arising at the lower border of the pectoralis minor (see
arm, showing the intermuscular septa and the compartments Fig. 4.14) in the axilla.
 UPPER LIMB
96

Table 8.1: Attachments of muscles

Muscle Origin Insertion
1. Coracobrachialis • The medial aspect of tip of the coracoid process with • The middle 5 cm of the medial border of
(see Fig. 2.8) the short head of the biceps brachii (Fig. 8.3a) the humerus
2. Biceps brachii It has two heads of origin: • Posterior rough part of the radial tuberosity.
(Fig. 8.3b) • The short head arises with coracobrachialis from the The tendon is twisted; the anterior fibres
lateral aspect of tip of the coracoid process become lateral and posterior fibres become
• The long head arises from the supraglenoid tubercle medial. The tendon is separated from the
of the scapula and from the glenoidal labrum. The anterior part of the tuberosity by a bursa
tendon is intracapsular (Fig. 8.4)
• The tendon gives off an extension called
the bicipital aponeurosis which extends to
ulna and it separates median cubital vein
from brachial artery
3. Brachialis • Lower half of the front of the humerus, including both • Coronoid process and ulnar tuberosity
(Fig. 8.5) the anteromedial and anterolateral surfaces and the • Rough anterior surface of the coronoid
anterior border process of the ulna
Superiorly the origin embraces the insertion of the
deltoid
• Medial and lateral intermuscular septa

Table 8.2: Nerve supply and actions of muscles

Muscle Nerve supply Actions
1. Coracobrachialis Musculocutaneous nerve (C5–C7) Flexes the arm at the shoulder joint
(Fig. 8.3a)
2. Biceps brachii Musculocutaneous nerve (C5–C6) • It is strong supinator when the forearm is flexed
(Figs 8.3b and c, All screwing movements are done with it
8.6, 8.7) • It is a flexor of the elbow
• The short head is a flexor of the arm
• The long head prevents upwards displacement of the
head of the humerus
• It can be tested against resistance as shown in Fig. 8.8
3. Brachialis • Musculocutaneous nerve is motor Flexes forearm at the elbow joint
• Radial nerve is proprioceptive

Root Value Relations

Upper Limb

The root value of musculocutaneous nerve is ventral In the lower part of the axilla: It accompanies the third
rami of C5–C7 segments of spinal cord. part of the axillary artery and has the following relations.
Anteriorly: Pectoralis major.
Origin, Course and Termination
Posteriorly: Subscapularis.
Musculocutaneous nerve arises from the lateral cord
of brachial plexus in the lower part of the axilla. It Medially: Axillary artery and lateral root of the median
nerve (see Fig. 4.9).
accompanies the third part of the axillary artery. It then
enters the front of arm, where it pierces coracobrachialis Laterally: Coracobrachialis (see Fig. 4.9).
muscle. Musculocutaneous nerve leaves the axilla, and enters
1

Musculocutaneous nerve runs downwards and the front of the arm by piercing the coracobrachialis
Section

laterally between biceps brachii and brachialis muscles (Fig. 8.6).

to reach the lateral side of the tendon of biceps brachii. In the arm: It runs downward and laterally between
It terminates by continuing as the lateral cutaneous the biceps brachii and brachialis to reach the lateral side
nerve of forearm 2 cm above the bend of the elbow of the tendon of the biceps. It ends by piercing the fascia
(Fig. 8.6). 2 cm above the bend of the forearm.
 ARM
97

Fig. 8.3a: Short head of biceps brachii and coacobrachialis

muscles

Fig. 8.3b: The biceps brachii muscle in extended elbow

Upper Limb
1Section

Fig. 8.3c: Intracapsular course of long head of biceps brachii muscle

 UPPER LIMB
98

Branches and Distribution

Muscular branches: It supplies the following muscles of
the front of the arm.
i. Coracobrachialis
ii. Biceps brachii, long and short heads
iii. Brachialis (Figs 8.6 and 8.7).
Cutaneous branches: Through the lateral cutaneous nerve
of the forearm, it supplies the skin of the lateral side of
the forearm from the elbow to the wrist including the
ball of the thumb (see Fig. 7.1a).
Articular branches:
i. The elbow joint through its branch to the brachialis.
Fig. 8.4: The precise mode of insertion of the biceps brachii ii. The shoulder joint through a separate branch which
muscle enters the humerus along with its nutrient artery.
Communicating branches: The musculocutaneous nerve
through lateral cutaneous nerve of forearm
communicates with the neighbouring nerves, namely
the superficial branch of the radial nerve, the posterior
cutaneous nerve of the forearm, and the palmar
cutaneous branch of the median nerve.
Upper Limb
1
Section

Fig. 8.5: The origin and insertion of the brachialis muscle Fig. 8.6: The course of the musculocutaneous nerve
 ARM
99

Fig. 8.7: Transverse section passing through the lower one-third of the arm

Median Nerve DISSECTION

Median nerve is closely related to the brachial artery Make an incision in the middle of deep fascia of the
throughout its course in the arm (Fig. 8.9). upper arm right down up to the elbow joint. Reflect the
In the upper part, it is lateral to the artery; in the flaps sideways.
middle of the arm, it crosses the artery from lateral to The most prominent muscle seen is the biceps
the medial side; and remains on the medial side of the brachii. Deep to this, another muscle called brachialis
artery right up to the elbow. is seen easily. In the fascial septum between the two
In the arm, the median nerve gives off a branch to muscles lies the musculocutaneous nerve (a branch of
the pronator teres just above the elbow and vascular the lateral cord of brachial plexus). Trace the tendinous
branches to the brachial artery. long head of biceps arising from the supraglenoid
An articular branch to the elbow joint arises at the tubercle and the short head arising from the tip of the
elbow. coracoid process of scapula. Identify coracobrachialis
muscle on the medial side of biceps brachii. This muscle
Ulnar Nerve is easily identified as it is pierced by musculocutaneous
nerve. Clean the branches of the nerve supplying all
Ulnar nerve runs on the medial side of the brachial
the three muscles dissected (refer to BDC App).
artery up to the level of insertion of the coraco-
brachialis, where it pierces the medial intermuscular
septum and enters the posterior compartment of the CLINICAL ANATOMY
arm. It is accompanied by the superior ulnar collateral Physician holds the patient’s wrist firmly, not letting it
vessels. move. Patient is requested to flex the elbow against
At the elbow, it passes behind the medial epicondyle
Upper Limb
the resistance offered by physician’s hand. One can see
where it can be palpated with a finger (Fig. 8.13a). and palpate hardening biceps brachii muscle (Fig. 8.8).

Radial Nerve
At the beginning of the brachial artery, the radial nerve
lies posterior to the artery (see Fig. 4.9). Soon the nerve
leaves the artery by entering the radial (spiral) groove
on the back of the arm where it is accompanied by the
profunda brachii artery (Fig. 8.13a).
1

In the lower part of the arm, the nerve appears

Section

again on the front of the arm where it lies between

the brachialis (medially); and the brachioradialis
and extensor carpi radialis longus (laterally)
(Fig. 8.17). Its branches will be discussed with the Fig. 8.8: Testing biceps brachii against resistance
back of the arm.
 UPPER LIMB
100

Biceps reflex: Musculocutaneous nerve is tested by downwards and laterally in the front of arm and crosses
biceps reflex. Tap the tendon of biceps with forearm the elbow joint. It ends at the level of the neck of radius
pronated and partially extended at the elbow. in the cubital fossa by dividing into its two terminal
Normal reflex is jerk-like flexion of elbow joint. branches, the radial and ulnar arteries.
Relations
Competency achievement: The student should be able to: 1 It runs downwards and laterally, from the medial
AN 11.2 Identify and describe origin, course, relations, branches (or side of the arm to the front of the elbow.
tributaries), and termination of important nerves and vessels in arm.3
2 It is superficial throughout its extent and is
accompanied by two venae comitantes.
BRACHIAL ARTERY
3 Anteriorly, in the middle of the arm, it is crossed by
Features the median nerve from the lateral to the medial side;
Brachial artery is the continuation of the axillary artery. and in front of the elbow, it is covered by the bicipital
It extends from the lower border of the teres major aponeurosis and the median cubital vein (Fig. 8.9).
muscle to a point in front of the elbow, at the level of 4 Posteriorly, it is related to:
the neck of the radius, just medial to the tendon of the
i. The triceps brachii
biceps brachii.
ii. The radial nerve and the profunda brachii artery.
Beginning, Course and Termination 5 Medially, in the upper part, it is related to the ulnar
Brachial artery begins at the lower border of teres major nerve and the basilic vein, and in the lower part to
muscle as continuation of axillary artery. It runs the median nerve (Figs 8.9a and b).
Upper Limb
1
Section

Figs 8.9a and b: The course and relations of the brachial artery
 ARM
101

Figs 8.10a and b: Anastomoses around the elbow joint

6 Laterally, it is related to the coracobrachialis, Anastomoses around the Elbow Joint

the biceps brachii and the median nerve in its upper Anastomoses around the elbow joint link the brachial
part; and to the tendon of the biceps brachii at the artery with the upper ends of the radial and ulnar arteries.
elbow (Figs 8.9a and b). They supply the ligaments and bones of the joint. The
7 At the elbow, the structures from the medial to the anastomoses can be subdivided into the following parts.
lateral side are: In front of the lateral epicondyle of the humerus, the
i. Median nerve anterior descending (radial collateral) branch of the
ii. Brachial artery profunda brachii anastomoses with the radial recurrent
iii. Biceps brachii tendon branch of the radial artery (Figs 8.10a and b).
iv. Radial nerve on a deeper plane (MBBR). Behind the lateral epicondyle of the humerus, the
posterior descending branch of the profunda brachii
Branches artery (middle collateral) anastomoses with the
1 Unnamed muscular branches. interosseous recurrent branch of the posterior

Upper Limb
2 The profunda brachii artery arises just below the teres interosseous artery.
major and accompanies the radial nerve. In front of the medial epicondyle of the humerus, the
3 The superior ulnar collateral branch arises in the upper inferior ulnar collateral branch of the brachial artery
part of the arm and accompanies the ulnar nerve anastomoses with the anterior ulnar recurrent branch
(Figs 8.10a and b). of the ulnar artery.
4 A nutrient artery is given off to the humerus. Behind the medial epicondyle of the humerus, the
5 The inferior ulnar collateral (or supratrochlear) branch superior ulnar collateral branch of the brachial artery
arises in the lower part and takes part in the anastomoses with the posterior ulnar recurrent branch
of the ulnar artery.
1

anastomoses around the elbow joint.

6 The artery ends by dividing into two terminal
Section

branches, the radial and ulnar arteries. DISSECTION

Dissect the brachial artery as it lies on the medial side
Competency achievement: The student should be able to: of the upper part of the arm medial to median nerve
AN 11.6 Describe the anastomoses around the elbow joint.4 and lateral to ulnar nerve (Figs 8.9a and b).
 UPPER LIMB
102

In the lower half of the upper arm, the brachial artery

is seen lateral to the median nerve as the nerve crosses
the brachial artery from lateral to medial side. Note that
the median nerve and brachial artery are forming
together a neurovascular bundle (refer to BDC App).
Ulnar nerve accompanied by the superior ulnar
collateral branch of the brachial artery will be dissected
later as it reaches the posterior (extensor) compartment
of the upper arm after piercing the medial intermuscular
septum (refer to BDC App).
Look for the radial nerve on the posterior aspect of
artery before it enters the radial groove.
Clean the branches of brachial artery and identify
other arteries which take part in the arterial
anastomoses around the elbow joint.
Fig. 8.11: Blood pressure being taken

CLINICAL ANATOMY
• Brachial pulsations are felt or auscultated in front
of the elbow just medial to the tendon of biceps
for recording the blood pressure (Fig. 8.11).
Figure 8.12 shows other palpable arteries.
• Although the brachial artery can be compressed
anywhere along its course, it can be compressed
most favourably in the middle of the arm, where
it lies on the tendon of the coracobrachialis.
• Blood for blood gas analysis is collected from
brachial artery.

Changes at the Level of Insertion of Coracobrachialis

1 Bone: The circular shaft becomes triangular below
this level.
2 Fascial septa: The medial and lateral intermuscular
septa become better defined from this level down
(Fig. 8.5).
3 Muscles:
i. Deltoid and coracobrachialis are inserted at this level
(Fig. 8.3a).
ii. Upper end of origin of brachialis.
Upper Limb

iii. Upper end of origin of the medial head of triceps

brachii.
4 Arteries:
i. The brachial artery passes from the medial side
of the arm to its anterior aspect.
ii. The profunda brachii artery runs in the spiral
groove and divides into its anterior descending/
radial collateral artery and posterior descending/
middle collateral branches (Fig. 8.9). Fig. 8.12: Palpable arteries in the body
1

iii. The superior ulnar collateral artery originates

Section

from the brachial artery, and pierces the medial ii. Two venae comitantes of the brachial artery may
intermuscular septum along with the ulnar nerve. unite to form one brachial vein.
iv. The nutrient artery of the humerus enters the bone. 6 Nerves:
5 Veins: i. The median nerve crosses the brachial artery from
i. The basilic vein pierces the deep fascia (Fig. 8.13b). the lateral to the medial side (Fig. 8.9).
 ARM
103

Figs 8.13a and b: Changes in positions of nerve, veins and arteries

ii. The ulnar nerve pierces the medial intermuscular

septum with the superior ulnar collateral artery
and goes to the posterior compartment (Fig. 8.9).
iii. The radial nerve pierces the lateral intermuscular
septum with the anterior descending (radial
collateral) branch of the profunda brachii artery
and passes from the posterior to the anterior
compartment (Fig. 8.13a).
iv. The medial cutaneous nerve of the arm pierces
the deep fascia (Fig. 8.13b).
v. The medial cutaneous nerve of the forearm
pierces the deep fascia (Fig. 8.13b).
Competency achievement: The student should be able to:

Upper Limb
AN 11.5 Identify and describe boundaries and contents of cubital
fossa.5

CUBITAL FOSSA

Features
Cubital (Latin cubitus, elbow) fossa is a triangular hollow
situated on the front of the elbow. (It is homologous Fig. 8.14: Boundaries of the right cubital fossa
1

with the popliteal fossa of the lower limb situated on

the back of the knee.)
Section

Medially – Lateral border of the pronator teres.

Boundaries Base – It is directed upwards, and is represented
Laterally – Medial border of the brachioradialis by an imaginary line joining the front of
(Fig. 8.14). two epicondyles of the humerus.
 UPPER LIMB
104

Apex – It is directed downwards, and is formed

by the area where brachioradialis crosses
the pronator teres muscle.

Roof
The roof of the cubital fossa (Fig. 8.15) is formed by:
a. Skin
b. Superficial fascia containing the median cubital vein
joining the cephalic and basilic veins. The lateral
cutaneous nerve of the forearm lies along with
cephalic vein and the medial cutaneous nerve of the
forearm along with basilic vein.
c. Deep fascia
d. Bicipital aponeurosis

Floor
It is formed by:
i. Brachialis (Figs 8.16a and b)
ii. Supinator surrounding the upper part of radius

Contents
The fossa is actually very narrow. The contents
described are seen after retracting the boundaries. From
medial to the lateral side, the contents are as follows:
1 The median nerve: It gives branches to flexor carpi
radialis, palmaris longus, flexor digitorum
superficialis and leaves the fossa by passing between Figs 8.16a and b: The floor of the cubital fossa is formed by
the two heads of pronator teres (Fig. 8.18). the brachialis and supinator muscles: (a) Surface view, and
(b) cross-sectional view
Upper Limb
1

Fig. 8.17: Contents of the right cubital fossa; mnemonic—MBBR

Section

2 The termination of the brachial artery, and the beginning

of the radial and ulnar arteries lie in the fossa.
The radial artery is smaller and more superficial than
Fig. 8.15: Structures in the roof of the right cubital fossa the ulnar artery. It gives off the radial recurrent branch.
 ARM
105

4 The radial nerve: It descends medial to lateral

epicondyle to enter cubital fossa. In the fossa, it gives
off the posterior interosseous nerve or deep branch
of the radial nerve which gives branches to extensor
capri radialis brevis and supinator. Then it leaves
the fossa by piercing the supinator muscle (Fig. 8.18).
The remaining superficial branch runs in the front
of forearm for some distance.

DISSECTION
Identify the structures (see text) present in the roof of a
shallow cubital fossa located on the front of the elbow.
Separate the lateral and medial boundaries formed
respectively by the brachioradialis and pronator teres
muscles (Figs 8.14 and 8.19). Clean the contents:
i. Median nerve on the medial side of brachial artery.
ii. Terminal part of brachial artery bifurcating into radial
Fig. 8.18: Contents of right cubital fossa (schematic) and ulnar arteries (refer to BDC App).
iii. The tendon of biceps brachii muscle between the
brachial artery and radial nerve.
The ulnar artery goes deep to both heads of pronator iv. The radial nerve on a deeper plane on the lateral
teres and runs downwards and medially, being side of biceps tendon.
separated from the median nerve by the deep head Identify brachialis and supinator muscles, forming
of the pronator teres (Fig. 8.19). the floor of cubital fossa.
Ulnar artery gives off the anterior ulnar recurrent,
the posterior ulnar recurrent, and the common
CLINICAL ANATOMY
interosseous branches (Fig. 8.10).
The common interosseous branch divides into the • The cubital region is important for the following
anterior and posterior interosseous arteries, and reasons:
latter gives off the interosseous recurrent branch. a. The median cubital vein is often the vein of
3 The tendon of the biceps brachii (Fig. 8.17). choice for intravenous injections (see Fig. 7.8).
It is used for introducing cardiac catheters to
get sample of blood from various chambers of
heart.
b. The blood pressure is universally recorded by
auscultating the brachial artery in front of the
elbow (Fig. 8.11).
• The anatomy of the cubital fossa is useful while
dealing with the fracture around the elbow, like

Upper Limb
the supracondylar fracture of the humerus.

POSTERIOR COMPARTMENT

Features
The region contains the triceps muscle, the radial nerve
and the profunda brachii artery. The nerve and artery
run through the muscle. The ulnar nerve runs through
1

the lower part of this compartment.

Section

Competency achievement: The student should be able to:

AN 11.1 Describe and demonstrate muscle groups of upper arm
with emphasis on biceps and triceps brachii.
Fig. 8.19: Contents of the cubital fossa seen in cross-section Biceps has been discribed in Tables 8.1 and 8.2.6
 UPPER LIMB
106

TRICEPS BRACHII MUSCLE medial head is inserted partly into the superficial
Origin tendon, and partly into the olecranon process. Although
the medial head is separated from the capsule of the
Triceps brachii muscle arises by the following three elbow joint by a small bursa, a few of its fibres are
heads (Figs 8.20a and b). inserted into this part of the capsule: This prevents
1 The long head arises from the infraglenoid tubercle nipping of the capsule during extension of the arm.
of the scapula; it is the longest of the three heads These fibres are referred to as the articularis cubiti, or as
(Fig. 8.21). the subanconeus.
2 The lateral head arises from an oblique ridge on the
upper part of the posterior surface of the humerus, Nerve Supply
corresponding to the lateral lip of the radial (spiral) Each head receives a separate branch from the radial
groove (Fig. 8.20a and b). nerve (C7, C8). The branches arise in the axilla and in
3 The medial head arises from a large triangular area on the radial groove.
the posterior surface of the humerus below the
radial groove, as well as from the medial and lateral Actions
intermuscular septa. At the level of the radial The triceps is a powerful active extensor of the elbow.
groove, the medial head is medial to the lateral head The long head causes extension and adduction of arm
(see Figs 2.14a and b). at shoulder joint. It supports the head of the humerus
in the abducted position of the arm. Gravity extends
Insertion the elbow passively.
The long and lateral heads converge and fuse to form a Electromyography has shown that the medial head
superficial flattened tendon which covers the medial of the triceps is active in all forms of extension, and the
head and are inserted into the posterior part of the actions of the long and lateral heads are minimal, except
superior surface of the olecranon process (Fig. 8.20). The when acting against resistance.
Upper Limb
1
Section

Figs 8.20a and b: The triceps brachii muscle

 ARM
107

Fig. 8.21: Transverse section through the arm a little below the insertion of the coracobrachialis and deltoid showing arrangement
of three heads of the triceps, and the radial nerve in the radial groove

DISSECTION
Reflect the skin of back of arm to view the triceps brachii
muscle. Define its attachments and separate the long
head of the muscle from its lateral head.
Radial nerve will be seen passing between the long
head of triceps and medial border of the humerus. Note
the continuity of radial nerve up to axilla. Carefully cut
through the lateral head of triceps to expose radial nerve
along with profunda brachii vessels. Note that the radial
nerve lies in the radial groove, on the back of humerus,
passing between the lateral head of triceps above and
its medial head below. In the lower part of arm, the radial
nerve lies on the front of elbow just lateral to the
brachialis, dividing into two terminal branches in the Fig. 8.22: Testing triceps brachii against resistance
cubital fossa (refer to BDC App).
The ulnar nerve (which was seen in the anterior
compartment of arm till its middle) pierces the medial Origin, Course and Termination
intermuscular septum with its accompanying vessels, Radial nerve is given off from the posterior cord in the
reaches the back of elbow and may easily be palpated lower part of axilla.
on the back of medial epicondyle of humerus. 1 It runs behind third part of axillary artery (see

Upper Limb
Figs 4.7c and d).
CLINICAL ANATOMY 2 In the arm, it lies behind the brachial artery (Fig. 8.9a).
3 Leaves the brachial artery to enter the lower
• In radial nerve injuries in the arm, the triceps triangular space to reach the oblique radial sulcus
brachii usually escapes complete paralysis because on the back of humerus (Fig. 8.13a).
the two nerves supplying it, arise in the axilla. 4 The nerve reaches the lateral side of arm 5 cm below
• Physician holds the flexed forearm firmly. Patient deltoid tuberosity, pierces lateral intermuscular
is requested to extend his elbow against the septum to enter the anterior compartment of arm on
resistance of the physician’s hand. The contracting its lateral aspect (Fig. 8.13a).
1

triceps brachii is felt (Fig. 8.22). 5 It descends down medial to the lateral epicondyle
Section

into cubital fossa.

RADIAL NERVE OR MUSCULOSPIRAL NERVE Radial nerve terminates by dividing into a superficial
Radial nerve is the largest branch of the posterior cord and a deep branch (posterior interosseous nerve) just
of the brachial plexus with a root value of C5–C8 and below the level of lateral epicondyle. These are seen in
T1 (see Fig. 4.14). the cubital fossa (Fig. 8.18).
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Relations It then enters the radial groove with the profunda

a. In the lower part of the axilla, radial nerve passes vessels (see Fig. 6.11).
downwards and has the following relations. c. In the radial groove, the nerve runs downwards and
Anteriorly: Third part of the axillary artery (see Fig. 4.8). laterally between the lateral and medial heads of the
triceps brachii, in contact with the humerus (Fig. 8.13a).
Posteriorly: Subscapularis, latissimus dorsi and teres
At the lower end of the groove, 5 cm below the deltoid
major.
tuberosity, the nerve pierces the lateral intermuscular
Laterally: Axillary nerve and coracobrachialis. septum and passes into the anterior compartment of
Medially: Axillary vein (see Fig. 4.9). the arm (Fig. 8.17) to reach the cubital fossa where it
b. In the upper part of the arm, it continues behind the ends by dividing into superficial and deep branches.
brachial artery, and passes posterolaterally (with the
profunda brachii vessels) through the lower Branches and Distribution
triangular space, below the teres major, and between Various branches of radial nerve are shown in
the long head of the triceps brachii and the humerus. Figs 8.23a–c.
Upper Limb
1
Section

Figs 8.23a and b: Distribution of right radial nerve

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109

or even the pressure of the crutch (crutch

paralysis) (Figs 8.24a and b).
b. Fractures of the shaft of the humerus. This
results in the weakness and loss of power of
extension at the wrist (wrist drop) (Fig. 8.25)
and sensory loss over a narrow strip on the back
of forearm, and on the lateral side of the dorsum
of the hand (Fig. 8.26).
• Wrist drop is quite disabling, because the patient
cannot grip any object firmly in the hand without
the synergistic action of the extensors.

Fig. 8.23c: Distribution of radial nerve (schematic)

Muscular
1 Before entering the spiral groove, radial nerve supplies
the long and medial heads of the triceps brachii.
2 In the spiral groove, it supplies the lateral and medial
heads of the triceps brachii and the anconeus.
3 Below the radial groove, on the front of the arm, it
supplies the brachialis with proprioceptive fibres.
The brachioradialis and extensor carpi radialis Figs 8.24a and b: Injury to radial nerve: (a) Saturday night
longus are supplied with motor fibres (Fig. 8.23a). palsy, and (b) crutch paralysis

Cutaneous Branches
1 In the axilla, radial nerve gives off the posterior
cutaneous nerve of the arm which supplies the skin
on the back of the arm (see Fig. 7.1b).
2 In the radial groove, the radial nerve gives off the
lower lateral cutaneous nerves of the arm and the
posterior cutaneous nerve of the forearm.
Upper Limb
Articular branches: The articular branches near the
elbow supply the elbow joint.

Competency achievement: The student should be able to:

AN 11.4 Describe the anatomical basis of Saturday night paralysis.7
AN 12.13 Describe the anatomical basis of wrist drop.8

CLINICAL ANATOMY
1

• The radial nerve is very commonly damaged in

Section

the region of the radial (spiral) groove. The

common causes of injury are as follows.
a. Sleeping in an armchair with the limb hanging
by the side of the chair (Saturday night palsy), Fig. 8.25: Wrist drop
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Mnemonics
Cubital fossa contents MBBR
From medial to lateral:
• Median nerve
• Brachial artery
• Tendon of Biceps
• Radial nerve
Biceps brachii muscle: Origins
“You walk shorter to a street corner. You ride longer
on a superhighway”
Short head originates from coracoid process.
Long head originates from the supraglenoid tubercle.

FACTS TO REMEMBER
Fig. 8.26: Sensory loss over back of forearm and dorsum of • Medial root of median nerve crosses the axillary
hand artery in front to join lateral root to form the
median nerve.
PROFUNDA BRACHII ARTERY • The order of structures from medial to lateral side
in the cubital fossa is median nerve, brachial artery,
Profunda brachii artery is a large branch, arising just
tendon of biceps brachii and radial nerve.
below the teres major. It accompanies the radial nerve
through the radial groove, and before piercing the • Triceps brachii is the only active extensor of elbow
lateral intermuscular septum, it divides into the anterior joint. Gravity extends the joint passively.
and posterior descending branches which take part in • Biceps brachii is a strong supinator of the flexed
the anastomoses around the elbow joint (Fig. 8.10). elbow, besides being its flexor.

Branches
CLINICOANATOMICAL PROBLEM
1 The radial collateral (anterior descending) artery is one
of the terminal branches, and represents the In a motorcycle accident, there was injury to the
continuation of the profunda artery. It accompanies middle of back of arm.
the radial nerve, and ends by anastomosing with the • What nerve is likely to be injured?
radial recurrent artery in front of the lateral • What muscles are affected? Name five of them.
epicondyle of the humerus (Fig. 8.10). • What is the effect of injury?
2 The middle collateral (posterior descending) artery is the
largest terminal branch, which descends in the Ans: Due to injury to the middle of back of arm, the
substance of the medial head of the triceps. It ends radial nerve gets injured. The muscles of arm affected
by anastomosing with the interosseous recurrent partially are lateral and medial heads of triceps
artery, behind the lateral epicondyle of the humerus brachii. A part of muscle escapes paralysis as it gets
Upper Limb

(Fig. 8.10). It usually gives a branch which supplied in the axilla.

accompanies the nerve to the anconeus. The other muscles affected are the extensors of
3 The deltoid (ascending) branch ascends between the forearm. These are brachioradialis, extensor carpi
long and lateral heads of the triceps, and radialis longus and brevis, extensor digitorum and
anastomoses with the descending branch of the extensor pollicis longus.
posterior circumflex humeral artery. The effect of injury is ‘wrist drop’.
4 The nutrient artery to the humerus is often present. It
enters the bone in the radial groove just behind the FURTHER READING
1

deltoid tuberosity. However, it may be remembered • Jayakumari S, Rath G, Arora J. Unilateral double axillary and
that the main artery to the humerus is a branch of
Section

double brachial arteries. Embryological basis and clinical

the brachial artery. implications. Int J Morph 2006;24(3):463–68.
1–8
From Medical Council of India, Competency based Undergraduate Curriculum for the Indian Medical Graduate, 2018;1:44–80.
 ARM
111

1. Describe musculocutaneous nerve under following 3. Write short notes on:

headings: a. Changes at the level of insertion of coraco-
a. Root value b. Course brachialis
c. Branches d. Relations b. Anastomoses around the elbow joint
e. Clinical anatomy
c. Origin and insertion of triceps brachii muscle
2. Enumerate all the boundaries and contents of
cubital fossa. Give the clinical importance of the d. Branches of deep branch of radial nerve. What
fossa. is the effect of its injury?

1. Which event does not occur at the insertion of 5. Lateral boundary of cubital fossa is formed by
coracobrachialis? which muscle?
a. Median nerve crosses brachial artery from the a. Biceps brachii b. Brachioradialis
lateral to the medial side c. Brachialis d. Extensor carpi radialis
b. Ulnar nerve pierces medial intermuscular septum longus
c. Lateral cutaneous nerve of forearm pierces the 6. Fracture of humerus at mid-shaft is likely to cause
deep fascia injury to which of the following nerves?
d. Radial nerve pierces lateral intermuscular septum
a. Median b. Radial
2. Interosseous recurrent artery is a branch of which c. Ulnar d. Musculocutaneous
artery?
7. Correct order of structures from medial side to
a. Ulnar
lateral side in cubital fossa is:
b. Common interosseous
a. Median nerve, brachial artery, biceps tendon and
c. Anterior interosseous
radial nerve
d. Posterior interosseous
b. Median nerve, biceps tendon, radial nerve,
3. Which nerve is felt behind medial epicondyle of branchial artery
humerus? c. Median nerve, brachial artery, radial nerve and
a. Radial biceps tendon
b. Median d. Brachial artery, median nerve, biceps tendon,
c. Musculocutaneous radial nerve
d. Ulnar 8. Which are the heads of triceps brachii muscle?
4. Which of the following nerve injury leads to wrist a. Long, medial and posterior
drop? b. Long, lateral and medial
a. Ulnar b. Radial c. Long, lateral and posterior
Upper Limb
c. Median d. Axillary d. Lateral, medial and posterior

1. c 2. d 3. d 4. b 5. b 6. b 7. a 8. b
1Section

• How many compartments are there in the upper • Name the events occurring at the level of insertion
arm? of coracobrachialis.
• Name the root value of musculocutaneous nerve. • What is name of its cutaneous branch?
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• Name the muscles supplied by musculocutaneous • Enumerate the structures forming its roof.
nerve. • Name the muscles forming floor of the fossa.
• Which muscle does coracobrachialis correspond to • What are the main contents of the fossa?
in lower limb?
• Name the branches of median nerve in the fossa.
• Name the branches of brachial artery.
• What is the clinical importance of brachial artery? • Name the branches of brachial artery in the fossa.
• Name the nerves present on the medial side of • Name the branches of radial nerve in the fossa.
brachial artery in its course in upper part and in • What is the clinical importance of bicipital
lower part of arm. aponeurosis?
• How is median nerve formed? Why is it called • What is clinical importance of cubital fossa?
median nerve? • Name the heads of triceps brachii muscle and show
• Name the branches of median nerve in the arm. their origins and insertion.
• Name the branches of radial nerve in the axilla. • Name the regions through which radial nerve passes.
• Which movement will be affected in paralysis of the • Name the branches of radial nerve in all these regions.
musculocutaneous nerve?
• What is wrist drop?
CUBITAL FOSSA • What is the course of profunda brachii artery? Name
• What muscle forms lateral boundary of cubital fossa? its branches.
• What muscle forms its medial boundary? • What does word ‘profunda’ mean?
Upper Limb
1
Section