6/9/2017 Forearm and Hand ­ FRCEM Success

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You answered 22 correct out of 102 questions.
Your answers are shown below:

You have been asked to review a patient with a Monteggia fracture. The proximal radioulnar
joint is primarily supported by which of the following ligaments:

a) Ulnar collateral ligament

b) Radial collateral ligament
c) Annular ligament
d) Deltoid ligament
e) Transverse humeral ligament
Something wrong?

Answer
The proximal radioulnar joint is a pivot type synovial joint occurring between the head of the radius and the radial
notch of the ulnar. The radial head is held in position by the annular ligament of the radius. The radial and ulnar
collateral ligaments support the elbow joint. The transverse humeral ligament spans the intertubercular sulcus of the
proximal humerus. The deltoid ligament supports the ankle joint.

Notes
The radioulnar joints allow pronation and supination of the forearm.

Movement Muscles Involved

Pronation Pronator quadratus, pronator teres

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Supination Supinator, biceps brachii

The proximal radioulnar joint is a pivot type synovial joint occurring between the head of the radius and the radial
notch of the ulnar. The radial head is held in position by the annular ligament of the radius.

Joint Proximal radioulnar joint

Type Synovial pivot

Articulations Head of radius with radial notch of ulna

Stabilising factors Annular ligament

Movements Pronation and supination

The distal radioulnar joint is a pivot type synovial joint occurring between the head of the ulnar and the ulnar notch on
the radius.

Joint Distal radioulnar joint

Type Synovial pivot

Articulations Head of ulna with ulnar notch of radius

Movements Pronation and supination

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By OpenStax College [CC BY 3.0 (http://creativecommons.org/licenses/by/3.0)], via Wikimedia Commons

A 43 year old artist presents to the ED complaining of numbness in his ngertips. On

examination you note loss of sensation to the palmar aspect and ngertips of the lateral three and
a half digits. Which of the following nerves is most likely affected:

a) The super cial branch of the radial nerve

b) The palmar cutaneous branch of the median nerve
c) The palmar cutaneous branch of the ulnar nerve
d) The super cial branch of the ulnar nerve
e) The palmar digital branch of the median nerve
Something wrong?

Answer
The palmar digital branch of the median nerve supplies the skin over the palmar surface and the ngertips of the lateral
three and a half digits.

Notes

Nerve Origin Skin supplied

Lateral supraclavicular nerve Cervical plexus (C3, Upper half of deltoid muscle
C4)

Superior lateral cutaneous nerve Axillary nerve Lower half of deltoid muscle
of the arm

Inferior lateral cutaneous nerve of Radial nerve Lateral arm below deltoid muscle
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Inferior lateral cutaneous nerve of Radial nerve Lateral arm below deltoid muscle
the arm

Medial cutaneous nerve of the Brachial plexus (C8, Medial arm

arm T1)

Intercostobrachial nerve Second intercostal Axilla

nerve (T2)

Posterior cutaneous nerve of the Radial nerve Posterior arm

arm

Medial cutaneous nerve of the Brachial plexus (C8, Medial forearm

forearm T1)

Posterior cutaneous nerve of the Radial nerve Posterior forearm

forearm

Lateral cutaneous nerve of the Musculocutaneous Lateral forearm

forearm nerve

Super cial branch of radial nerve Radial nerve Lateral dorsum of hand and lateral three and a
half digits

Palmar cutaneous branch of ulnar Ulnar nerve Medial half of palm

nerve

Dorsal cutaneous branch of ulnar Ulnar nerve Medial dorsum of hand and medial one and a half
nerve ngers

Super cial branch of ulnar nerve Ulnar nerve Palmar surface of medial one and a half digits

Palmar cutaneous branch of Median nerve Lateral half of palm

median nerve

Palmar digital branch of median Median nerve Palmar surface and ngertips of lateral three and
nerve a half digits

Arm:

The lateral supraclavicular nerve, branch of the cervical plexus, supplies the skin over the upper half of the
deltoid muscle.
The superior lateral cutaneous nerve of the arm, branch of the axillary nerve, supplies the skin over the lower
half of the deltoid muscle (regimental badge area).
The inferior lateral cutaneous nerve of the arm, branch of the radial nerve, supplies the skin over the lateral
side of the arm below the deltoid muscle.
The medial cutaneous nerve of the arm, branch of the brachial plexus, supplies skin over the medial arm.
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The medial cutaneous nerve of the arm, branch of the brachial plexus, supplies skin over the medial arm.
The intercostobrachial nerve, branch of the second intercostal nerve, supplies the skin of the axilla.
The posterior cutaneous nerve of the arm, branch of the radial nerve, supplies the skin over the posterior arm.

Forearm:

The medial cutaneous nerve of the forearm, branch of the brachial plexus, supplies the skin over the medial
aspect of the forearm.
The posterior cutaneous nerve of the forearm, branch of the radial nerve, supplies the skin over the posterior
forearm.
The lateral cutaneous nerve of the forearm, branch of the musculocutaneous nerve, supplies the skin over the
lateral aspect of the forearm.

Hand:

The super cial branch of the radial nerve supplies the skin over the lateral dorsum of the hand and the lateral
three and a half digits.
The palmar cutaneous branch of the ulnar nerve supplies the skin over the medial half of the palm.
The dorsal cutaneous branch of the ulnar nerve supplies the skin over medial dorsum of the hand and the
dorsum of the medial one and a half ngers.
The super cial branch of the ulnar nerve supplies the skin over the palmar surface of the medial one and a half
ngers.
The palmar cutaneous branch of the median nerve supplies the skin over the lateral half of the palm.
The palmar digital branch of the median nerve supplies the skin over the palmar surface and the ngertips of
the lateral three and a half digits.

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Modi ed by FRCEM Success. Original by Henry Vandyke Carter [Public domain], via Wikimedia Commons

You have been asked to give a tutorial to a group of medical students about upper limb
neurology. You decide to cover the sensory supply to the upper limb. The skin over the medial half
of the palm is supplied by which of the following nerves:

a) The super cial branch of the radial nerve

b) The palmar cutaneous branch of the median nerve
c) The palmar cutaneous branch of the ulnar nerve
d) The super cial branch of the ulnar nerve
e) The palmar digital branch of the median nerve
Something wrong?

Answer
The palmar cutaneous branch of the ulnar nerve supplies the skin over the medial half of the palm.

Notes

Nerve Origin Skin supplied

Lateral supraclavicular nerve Cervical plexus (C3, Upper half of deltoid muscle
C4)

Superior lateral cutaneous nerve Axillary nerve Lower half of deltoid muscle
of the arm

Inferior lateral cutaneous nerve of Radial nerve Lateral arm below deltoid muscle
the arm

Medial cutaneous nerve of the Brachial plexus (C8, Medial arm

arm T1)

Intercostobrachial nerve Second intercostal Axilla

nerve (T2)

Posterior cutaneous nerve of the Radial nerve Posterior arm

arm

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Medial cutaneous nerve of the Brachial plexus (C8, Medial forearm

forearm T1)

Posterior cutaneous nerve of the Radial nerve Posterior forearm

forearm

Lateral cutaneous nerve of the Musculocutaneous Lateral forearm

forearm nerve

Super cial branch of radial nerve Radial nerve Lateral dorsum of hand and lateral three and a
half digits

Palmar cutaneous branch of ulnar Ulnar nerve Medial half of palm

nerve

Dorsal cutaneous branch of ulnar Ulnar nerve Medial dorsum of hand and medial one and a half
nerve ngers

Super cial branch of ulnar nerve Ulnar nerve Palmar surface of medial one and a half digits

Palmar cutaneous branch of Median nerve Lateral half of palm

median nerve

Palmar digital branch of median Median nerve Palmar surface and ngertips of lateral three and
nerve a half digits

Arm:

The lateral supraclavicular nerve, branch of the cervical plexus, supplies the skin over the upper half of the
deltoid muscle.
The superior lateral cutaneous nerve of the arm, branch of the axillary nerve, supplies the skin over the lower
half of the deltoid muscle (regimental badge area).
The inferior lateral cutaneous nerve of the arm, branch of the radial nerve, supplies the skin over the lateral
side of the arm below the deltoid muscle.
The medial cutaneous nerve of the arm, branch of the brachial plexus, supplies skin over the medial arm.
The intercostobrachial nerve, branch of the second intercostal nerve, supplies the skin of the axilla.
The posterior cutaneous nerve of the arm, branch of the radial nerve, supplies the skin over the posterior arm.

Forearm:

The medial cutaneous nerve of the forearm, branch of the brachial plexus, supplies the skin over the medial
aspect of the forearm.
The posterior cutaneous nerve of the forearm, branch of the radial nerve, supplies the skin over the posterior
forearm.
The lateral cutaneous nerve of the forearm, branch of the musculocutaneous nerve, supplies the skin over the
lateral aspect of the forearm.
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Hand:

The super cial branch of the radial nerve supplies the skin over the lateral dorsum of the hand and the lateral
three and a half digits.
The palmar cutaneous branch of the ulnar nerve supplies the skin over the medial half of the palm.
The dorsal cutaneous branch of the ulnar nerve supplies the skin over medial dorsum of the hand and the
dorsum of the medial one and a half ngers.
The super cial branch of the ulnar nerve supplies the skin over the palmar surface of the medial one and a half
ngers.
The palmar cutaneous branch of the median nerve supplies the skin over the lateral half of the palm.
The palmar digital branch of the median nerve supplies the skin over the palmar surface and the ngertips of
the lateral three and a half digits.

Modi ed by FRCEM Success. Original by Henry Vandyke Carter [Public domain], via Wikimedia Commons

A 54 year old woman presents to the ED complaining of pain and swelling over the site of her
recent carpal tunnel decompression. Which of the following structures passes into the hand
anterior to the exor retinaculum:

a) Flexor carpi radialis tendon

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a) Flexor carpi radialis tendon
b) Flexor pollicis longus tendon
c) Median nerve
d) Flexor digitorum super cialis tendon
e) Ulnar artery
Something wrong?

Answer
The ulnar artery, ulnar nerve, and tendon of the palmaris longus pass into the hand anterior to the exor retinaculum,
and therefore do not pass through the carpal tunnel.

Notes
The exor retinaculum (transverse carpal ligament) is a thickened band of brous connective tissue on the volar aspect
of the hand which forms the roof of the carpal tunnel. The exor retinaculum holds the exor tendons in place at the
wrist and prevents them from bowstringing.

It is attached laterally to the scaphoid and trapezium and medially to the pisiform and the hook of the hamate.

The thenar and hypothenar muscles arise from the exor retinaculum.

The ulnar artery, ulnar nerve, and tendon of the palmaris longus pass into the hand anterior to the exor retinaculum,
and therefore do not pass through the carpal tunnel.

The exor carpi radialis tendon passes through the lateral aspect of the exor retinaculum into the hand.

The four tendons of the exor digitorum profundus, the four tendons of the exor digitorum super cialis, the tendon of
the exor pollicis longus and the median nerve pass into the hand posterior to the exor retinaculum, within the carpal
tunnel.

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By Henry Vandyke Carter [Public domain], via Wikimedia Commons

A 34 year old man presents to ED having sustained a laceration to the ngernail of his
little  nger whilst opening a tin. You note the laceration extends through his nailbed, and your
consultant asks you to perform a ring block in order to suture the wound. Which of the following
nerves would need to be anaesthetised for painless wound closure:

a) Super cial branch of the ulnar nerve

b) Palmar digital branch of the median nerve
c) Recurrent branch of the median nerve
d) Super cial branch of the radial nerve
e) Palmar cutaneous branch of the ulnar nerve
Something wrong?

Answer
The digits are supplied by four digital nerves. The palmar digital nerves innervate the palmar aspect of the digit and the
nailbed, and the dorsal nerves innervate the dorsum of the digit. The common palmar digital nerves of the ulnar nerve
arise from the super cial branch of the ulnar nerve, and innervate the medial one and a half ngers. The common
palmar digital nerves of the median nerve innervate the lateral three and a half ngers. The super cial branch of the
radial nerve supplies the dorsum of the lateral three and a half ngers. The dorsal cutaneous branch of the ulnar nerve
supplies the dorsum of the medial one and a half ngers.

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Modi ed by FRCEM Success. Original by Henry Vandyke Carter [Public domain], via Wikimedia Commons

Notes
The ulnar nerve is a continuation of the medial cord of the brachial plexus, containing bres from the C8 – T1 nerve
roots.

Nerve Ulnar nerve

Nerve C8 – T1
roots

Plexus Medial cord

cords

Motor All the intrinsic muscles of the hand (except for the thenar muscles and the lateral two lumbricals), the
Supply exor carpi ulnaris and the medial half of the exor digitorum profundus

Sensory Medial half of palm, palmar and dorsal surface of medial one and a half ngers and lateral dorsum of
supply hand

Anatomical course

The ulnar nerve descends down the medial side of the upper arm and passes posterior to the medial epicondyle (where
it is susceptible to damage) before entering the anterior compartment of the forearm by passing between the two
heads of the exor carpi ulnaris. It continues down the medial aspect of the forearm. The ulnar nerve emerges from
beneath the exor carpi ulnaris and becomes super cial just proximal to the wrist where it passes super cial to the
exor retinaculum, together with the ulnar artery, to enter the hand through a groove between the pisiform and the
hook of the hamate where it bifurcates into its terminal branches.

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By Henry Vandyke Carter [Public domain], via Wikimedia Commons

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Branches

Branches of Origin Supply

Ulnar Nerve

Muscular Forearm Flexor carpi ulnaris, medial half of exor digitorum profundus
branch

Palmar Forearm Skin of medial half of palm

cutaneous
branch

Dorsal Forearm Skin of dorsum of medial one and a half ngers and associated dorsal hand area
cutaneous
branch

Deep branch Hand Hypothenar muscles (abductor digiti minimi, exor digiti minimi, opponens digiti
minimi), medial two lumbricals, adductor pollicis and interossei

Super cial Hand Skin of palmar surface of medial one and a half ngers
branch

The ulnar nerve gives off no major branches in the arm, but three branches arise in the forearm:

The muscular branch innervating the exor carpi ulnaris and the medial half of the exor digitorum profundus
The palmar cutaneous branch supplying the skin of the medial half of the palm
The dorsal cutaneous branch supplying the skin of the medial dorsum of the hand and the dorsal surface of the
medial one and a half ngers

The ulnar nerve terminates by bifurcating into:

A deep branch innervating the hypothenar muscles, the medial two lumbricals, the adductor pollicis and the
interossei
A super cial branch supplying the skin of the palmar surface of the medial one and a half ngers

Clinical implications

Lesion Proximal (at elbow) Distal (at wrist)

Mechanism Fracture of medial epicondyle Laceration at wrist

Motor Loss Wrist exion and adduction, nger abduction and adduction, exion Finger abduction and
of ring and little nger, abduction and opposition of little nger, thumb adduction, exion of ring
adduction, extension of IPJs of all digits (less so at index and middle and little nger,
nger due to sparing of lateral two lumbricals) abduction and
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nger due to sparing of lateral two lumbricals) abduction and
opposition of little
nger, thumb adduction,
extension at IPJs

Sensory Medial half of palm, palmar and dorsal surface of medial one and a half Palmar surface of medial
Loss ngers and medial dorsum of hand one and a half ngers

Signs Hand held in abduction (due to unopposed action of exor carpi Claw hand (unopposed
radialis), Froment’s sign (patient is asked to hold a piece of paper extension at MCPJ and
between thumb and at palm as paper is pulled away, patient will ex unopposed exion at
thumb at IPJ to maintain hold – tests adductor pollicis muscle), IPJs of ring and little
hypothenar eminence wasting, N.B. claw hand not typically seen due nger), hypothenar
to paralysis of the exor digitorum profundus eminence wasting,
Froment’s sign

The ulnar nerve is most likely to be injured proximally by a medial epicondyle fracture and results in:

There is weak wrist exion and adduction due to paralysis of the exor carpi ulnaris and the medial half of the
exor digitorum profundus; the hand may be held in abduction (due to unopposed action of the exor carpi
radialis).
There is loss of abduction and adduction of the ngers due to paralysis of the interossei.
There is loss of exion at the MCPJ of the ring and little nger due to paralysis of the medial two lumbricals and
the exor digiti minimi.
There is loss of exion at the DIPJ of the ring and little nger due to paralysis of the medial half of the exor
digitorum profundus (but exion at the PIPJ is likely preserved as this is a function of the exor digitorum
super cialis).
There is weakened extension at the IPJs of the ring and little nger due to paralysis of the interossei and medial
two lumbricals (and to a lesser extent at the IPJs of the index and middle nger).
There is loss of abduction and opposition of the little nger due to paralysis of the hypothenar muscles
(hypothenar wasting may be seen).
There is loss of adduction of the thumb due to paralysis of the adductor pollicis (Froment’s sign).
There is loss of sensation to skin over the medial half of the palm, the palmar and dorsal surface of the medial
one and a half ngers and the medial dorsum of the hand.
There is not typically a claw hand appearance (as may be seen in a lesion at the wrist) due to paralysis of the
exor digitorum profundus.

A distal lesion most commonly occurs due to laceration at the wrist. Only intrinsic hand muscles are affected (the exor
carpi ulnaris and medial half of the exor digitorum profundus are spared). A loss of sensation will only affect the
palmar surface of the medial one and a half ngers (the medial palm and the dorsum of the hand are spared). A claw
hand deformity may be seen due to unopposed extension at the MCPJ (by the extensor digitorum) and unopposed
exion at the IPJs (by the FDP and FDS) of the ring and little nger.

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Froment’s sign (right hand). Copyright FRCEM

Success.

Claw hand deformity. By Mcstrother (Own work)

[CC BY 3.0
(http://creativecommons.org/licenses/by/3.0)], via
Wikimedia Commons

A 67 year old woman presents to the ED after falling onto an outstretched hand. You x-ray her
left wrist and note no fracture. You discuss the case with your consultant, he advises you to test for
anatomical snuffbox tenderness. The anatomical snuffbox is bounded medially by the tendon of
which of the following muscles:

a) Extensor pollicis longus

b) Extensor pollicis brevis
c) Abductor pollicis longus
d) Adductor pollicis
e) Abductor pollicis brevis
Something wrong?

Answer
The anatomical snuffbox is bounded medially by the tendon of the extensor pollicis longus.

Notes
The anatomical snuffbox is the triangular depression formed on the posterolateral side of the dorsal wrist and 1st
metacarpal by the extensor tendons passing into the thumb.

Anatomical Structure
Boundaries

Medial border Tendon of extensor pollicis longus

Lateral border Tendons of the abductor pollicis longus and extensor pollicis brevis

Proximal border Radial styloid process

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Distal border 1st metacarpal

Floor Scaphoid and trapezium bones

Roof Skin

Contents Radial artery, terminal portion of the super cial branch of the radial nerve, cephalic
vein

It is bounded laterally by the tendons of the abductor pollicis longus and the extensor pollicis brevis and medially by
the tendon of the extensor pollicis longus.

The oor of the anatomical snuffbox is formed by the scaphoid and trapezium carpal bones. The radial styloid process
can be palpated proximally and the 1st metacarpal can be palpated distally.

The radial artery crosses the oor of the anatomical snuffbox. Subcutaneously terminal parts of the super cial branch
of the radial nerve and the origin of the cephalic vein pass over the anatomical snuffbox.

The anatomical snuffbox is important clinically as the scaphoid is palpable within the snuffbox; localised pain and
tenderness of the anatomical snuffbox is most likely due to a scaphoid fracture.

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By Grant, John Charles Boileau (An atlas of anatomy, / by regions 1962) [Public domain], via
Wikimedia Commons

A 54 year old carpenter has sustained a laceration to his left hand with a stanley knife. He is
unable to ex the proximal interphalangeal joint of his middle nger which is held in extension.
Which of the following structures has most likely been injured:

a) Tendon of the exor digitorum super cialis

b) Tendon of the exor digitorum profundus
c) Lumbrical muscle
d) Interosseous muscle
e) Digital branch of the median nerve
Something wrong?

Answer
The exor digitorum super cialis is primarily responsible for exion at the proximal interphalangeal joint and thus
separation of this tendon from its attachment on the middle phalanx of the nger will result in loss of this movement.
The exor digitorum profundus exes the distal interphalangeal joint. Flexion at the metacarpophalangeal joint is
primarily produced by the lumbrical muscles with assistance from the interossei and the exor digitorum profundus
and super cialis. Abduction and adduction of the ngers at the metacarpophalangeal joint is produced by the
interossei.

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Notes
Hand movements are complex. The table below shows an overview of hand and thumb movements and the main
muscles bringing about these movements.

Hand movements Primary muscle (assisting muscles)

Flexion of MCPJ of digits 2 – 5 Lumbricals ( exor digitorum super cialis, exor digitorum profundus, exor
digiti minimi, interossei)

Flexion of PIPJ of digits 2 – 5 Flexor digitorum super cialis ( exor digitorum profundus)

Flexion of DIPJ of digits 2 – 5 Flexor digitorum profundus

Extension of MCPJ of digits 2 – Extensor digitorum, extensor indicis, extensor digiti minimi
5

Extension of PIPJ and DIPJ of Lumbricals and interossei (extensor digitorum)

digits 2 – 5

Adduction of digits 2 – 5 Palmar interossei

Abduction of digits 2 – 4 Dorsal interossei

Abduction of little nger Abductor digiti minimi

Opposition of little nger Opponens digiti minimi

Thumb movements Primary muscle(s)

Flexion of thumb at MCPJ Flexor pollicis longus and brevis

Flexion of thumb at IPJ Flexor pollicis longus

Extension of thumb at CMCJ and MCPJ Extensor pollicis longus and brevis

Extension of thumb at IPJ Extensor pollicis longus

Abduction of thumb Abductor pollicis longus and brevis

Adduction of thumb Adductor pollicis

Opposition of thumb Opponens pollicis

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Original by By OpenStax [CC BY 4.0 (http://creativecommons.org/licenses/by/4.0)], via Wikimedia

Commons

You have been asked to review a wound on the hand of a 42 year old gardener. He sustained a
deep laceration to the right palm whilst cutting down a bush. You are concerned by the depth of the
wound and consider if there has been damage to any underlying structures. The palmar
aponeurosis originates from which of the following structures:

a) Tendon of the exor carpi ulnaris

b) Tendon of the palmaris longus
c) Tendon of the exor carpi radialis
d) Tendon of the exor digitorum super cialis
e) Tendon of the exor digitorum profundus
Something wrong?

Answer
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Answer
The palmar aponeurosis is continuous with the palmaris longus tendon.

Notes
The palmar aponeurosis is a thickened area of palmar fascia which is continuous proximally with the palmaris longus
tendon and the exor retinaculum. Distally, the palmar aponeurosis fans out into four slips which become the brous
digital sheaths.

The palmar aponeurosis protects the underlying soft tissue and long exor tendons. The brous digital sheaths cover
the synovial sheaths which contain the exor tendons, maintaining the tension and preventing bowstringing.

By Henry Vandyke Carter [Public domain], via Wikimedia Commons

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A 30 year old man attends ED with a deep knife wound to his distal forearm. He is unable to
hold a piece of paper between his ngers and is complaining of loss of sensation over the medial
side of his hand and little nger. Which of the following nerves is most likely to have been affected:

a) Radial nerve
b) Median nerve
c) Ulnar nerve
d) Posterior interosseous nerve
e) Anterior interosseous nerve
Something wrong?

Answer
The ulnar nerve innervates all of the intrinsic muscles of the hand (except for the thenar muscles and the lateral two
lumbricals, innervated by the median nerve). Adduction of the ngers is required to hold a piece of paper between the
ngers, which is produced by the palmar interossei. The ulnar nerve supplies sensation to the dorsal and palmar aspect
of the medial hand and the medial one and a half ngers.

Notes
The ulnar nerve is a continuation of the medial cord of the brachial plexus, containing bres from the C8 – T1 nerve
roots.

Nerve Ulnar nerve

Nerve C8 – T1
roots

Plexus Medial cord

cords

Motor All the intrinsic muscles of the hand (except for the thenar muscles and the lateral two lumbricals), the
Supply exor carpi ulnaris and the medial half of the exor digitorum profundus

Sensory Medial half of palm, palmar and dorsal surface of medial one and a half ngers and lateral dorsum of
supply hand

Anatomical course

The ulnar nerve descends down the medial side of the upper arm and passes posterior to the medial epicondyle (where
it is susceptible to damage) before entering the anterior compartment of the forearm by passing between the two
heads of the exor carpi ulnaris. It continues down the medial aspect of the forearm. The ulnar nerve emerges from
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heads of the exor carpi ulnaris. It continues down the medial aspect of the forearm. The ulnar nerve emerges from
beneath the exor carpi ulnaris and becomes super cial just proximal to the wrist where it passes super cial to the
exor retinaculum, together with the ulnar artery, to enter the hand through a groove between the pisiform and the
hook of the hamate where it bifurcates into its terminal branches.

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By Henry Vandyke Carter [Public domain], via Wikimedia Commons

Branches

Branches of Origin Supply

Ulnar Nerve

Muscular Forearm Flexor carpi ulnaris, medial half of exor digitorum profundus
branch

Palmar Forearm Skin of medial half of palm

cutaneous
branch

Dorsal Forearm Skin of dorsum of medial one and a half ngers and associated dorsal hand area
cutaneous
branch

Deep branch Hand Hypothenar muscles (abductor digiti minimi, exor digiti minimi, opponens digiti
minimi), medial two lumbricals, adductor pollicis and interossei

Super cial Hand Skin of palmar surface of medial one and a half ngers
branch

The ulnar nerve gives off no major branches in the arm, but three branches arise in the forearm:

The muscular branch innervating the exor carpi ulnaris and the medial half of the exor digitorum profundus
The palmar cutaneous branch supplying the skin of the medial half of the palm
The dorsal cutaneous branch supplying the skin of the medial dorsum of the hand and the dorsal surface of the
medial one and a half ngers

The ulnar nerve terminates by bifurcating into:

A deep branch innervating the hypothenar muscles, the medial two lumbricals, the adductor pollicis and the
interossei
A super cial branch supplying the skin of the palmar surface of the medial one and a half ngers

Clinical implications

Lesion Proximal (at elbow) Distal (at wrist)

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Lesion Proximal (at elbow) Distal (at wrist)

Mechanism Fracture of medial epicondyle Laceration at wrist

Motor Loss Wrist exion and adduction, nger abduction and adduction, exion Finger abduction and
of ring and little nger, abduction and opposition of little nger, thumb adduction, exion of ring
adduction, extension of IPJs of all digits (less so at index and middle and little nger,
nger due to sparing of lateral two lumbricals) abduction and
opposition of little
nger, thumb adduction,
extension at IPJs

Sensory Medial half of palm, palmar and dorsal surface of medial one and a half Palmar surface of medial
Loss ngers and medial dorsum of hand one and a half ngers

Signs Hand held in abduction (due to unopposed action of exor carpi Claw hand (unopposed
radialis), Froment’s sign (patient is asked to hold a piece of paper extension at MCPJ and
between thumb and at palm as paper is pulled away, patient will ex unopposed exion at
thumb at IPJ to maintain hold – tests adductor pollicis muscle), IPJs of ring and little
hypothenar eminence wasting, N.B. claw hand not typically seen due nger), hypothenar
to paralysis of the exor digitorum profundus eminence wasting,
Froment’s sign

The ulnar nerve is most likely to be injured proximally by a medial epicondyle fracture and results in:

There is weak wrist exion and adduction due to paralysis of the exor carpi ulnaris and the medial half of the
exor digitorum profundus; the hand may be held in abduction (due to unopposed action of the exor carpi
radialis).
There is loss of abduction and adduction of the ngers due to paralysis of the interossei.
There is loss of exion at the MCPJ of the ring and little nger due to paralysis of the medial two lumbricals and
the exor digiti minimi.
There is loss of exion at the DIPJ of the ring and little nger due to paralysis of the medial half of the exor
digitorum profundus (but exion at the PIPJ is likely preserved as this is a function of the exor digitorum
super cialis).
There is weakened extension at the IPJs of the ring and little nger due to paralysis of the interossei and medial
two lumbricals (and to a lesser extent at the IPJs of the index and middle nger).
There is loss of abduction and opposition of the little nger due to paralysis of the hypothenar muscles
(hypothenar wasting may be seen).
There is loss of adduction of the thumb due to paralysis of the adductor pollicis (Froment’s sign).
There is loss of sensation to skin over the medial half of the palm, the palmar and dorsal surface of the medial
one and a half ngers and the medial dorsum of the hand.
There is not typically a claw hand appearance (as may be seen in a lesion at the wrist) due to paralysis of the
exor digitorum profundus.

A distal lesion most commonly occurs due to laceration at the wrist. Only intrinsic hand muscles are affected (the exor
carpi ulnaris and medial half of the exor digitorum profundus are spared). A loss of sensation will only affect the
palmar surface of the medial one and a half ngers (the medial palm and the dorsum of the hand are spared). A claw
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hand deformity may be seen due to unopposed extension at the MCPJ (by the extensor digitorum) and unopposed
exion at the IPJs (by the FDP and FDS) of the ring and little nger.

Froment’s sign (right hand). Copyright FRCEM

Success.

Claw hand deformity. By Mcstrother (Own work)

[CC BY 3.0
(http://creativecommons.org/licenses/by/3.0)], via
Wikimedia Commons

A 20 year old woman sustains an injury to the median nerve at the wrist after self harming.
Which of the following clinical features would you least expect to see:

a) Loss of abduction and opposition of the thumb

b) Loss of sensation over lateral half of palm
c) Loss of sensation to skin over palmar surface of lateral 3 and a half digits
d) Weakness of exion of the index and middle nger
e) Thenar eminence wasting
Something wrong?

Answer
In a wrist lesion, typically the palmar cutaneous nerve is spared as this arises in the forearm, thus you would not expect
loss of sensation over the lateral half of the palm. Loss of sensation over the palmar surface of the lateral three and a
half digits may occur. Weakness of opposition and abduction of the thumb occur due to paralysis of the thenar muscles.
Thenar eminence wasting may occur.

Notes
The median nerve is formed from the medial and lateral brachial plexus cords and contains bres from all ve roots (C5
– T1).

Nerve Median nerve

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Nerve C5 – T1
roots

Plexus Medial and lateral cords

cords

Motor All the anterior forearm muscles (except for the exor carpi ulnaris and the medial half of the exor
Supply digitorum profundus), the thenar muscles ( exor pollicis brevis, abductor pollicis brevis, opponens
pollicis) and the lateral two lumbricals

Sensory Lateral aspect of palm and palmar surface and ngertips of lateral three and a half digits
supply

Anatomical course

The median nerve originates in the axilla before passing down the medial side of the arm (initially lateral to the brachial
artery before crossing over to the medial side of the brachial artery). It enters the anterior compartment of the
forearm via the antecubital fossa, travelling between the exor digitorum profundus and exor digitorum super cialis
muscles, before entering the hand via the carpal tunnel and bifurcating into its terminal branches.

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By Henry Vandyke Carter [Public domain], via Wikimedia Commons

Branches

Branches of Origin Supply

Median Nerve

Median nerve Axilla Super cial and intermediate compartment of anterior forearm (pronator teres,
exor carpi radialis, palmaris longus, exor digitorum super cialis, NOT exor
carpi ulnaris)

Anterior Forearm Deep compartment of anterior forearm ( exor pollicis longus, pronator
interosseous quadratus, lateral half of exor digitorum profundus)
nerve

Palmar Forearm Skin over the lateral aspect of the palm

cutaneous
branch

Recurrent Hand Thenar muscles ( exor pollicis brevis, abductor pollicis brevis, opponens pollicis)
branch of
median nerve

Palmar digital Hand Lateral two lumbricals and skin over the palmar surface and ngertips of the
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Palmar digital Hand Lateral two lumbricals and skin over the palmar surface and ngertips of the
branch lateral three and a half digits

The median nerve directly innervates the pronator teres, the exor carpi radialis, the palmaris longus and the exor
digitorum super cialis. It gives off no major branches in the arm, but gives rise to the anterior interosseous nerve
(innervating the exor pollicis longus, the pronator quadratus, and the lateral half of the exor digitorum profundus)
and the palmar cutaneous nerve (innervating the lateral aspect of the palm) in the forearm.

In the hand the median nerve bifurcates into the recurrent branch of the median nerve (innervating the thenar
muscles) and the palmar digital branch (innervating the lateral two lumbricals and the skin over the palmar surface and
ngertips of the lateral three and a half digits).

Clinical implications

Lesion Proximal (arm, elbow, proximal forearm) Distal (wrist)

Mechanisms Supracondylar fracture, stab wound to arm or forearm Lacerations just

proximal to exor
retinaculum, carpal
tunnel syndrome

Motor Loss Forearm pronation, wrist exion and abduction, index and middle nger Thumb exion,
exion, thumb exion, abduction and opposition abduction and
opposition, exion of
index and middle
nger MCPJ

Sensory Lateral aspect of palm and palmar surface and ngertips of lateral three Palmar surface and
Loss and a half digits ngertips of lateral
three and a half digits

Signs Forearm rests in supination with wrist in ulnar deviation and thumb Thenar eminence
extended, thenar eminence wasting, hand of Benediction (when asked wasting
to make a st, the patient will be able to ex the little and ring ngers
but not the index and middle ngers)

A proximal median nerve lesion at the elbow may occur due to supracondylar fracture of the humerus or from deep
penetrating wounds to the arm or forearm and may result in:

Pronation of the forearm and exion and abduction of the wrist are lost due to paralysis of the exors and
pronators in the forearm. The forearm thus often rests in supination with ulnar deviation of the wrist (due to
unopposed action of the exor carpi ulnaris).
Flexion, abduction and opposition of the thumb at the MCPJ and IPJ are lost due to paralysis of the thenar
muscles and the exor pollicis longus.
Flexion of the index and middle ngers at the IPJs is lost due to paralysis of the exor digitorum super cialis
and the lateral half of the exor digitorum profundus.
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Flexion of the MCPJ of the index and middle ngers is lost due to paralysis of the lateral two lumbrical muscles.
N.B. Flexion of the ring and little ngers at the MCPJ and DIPJ are preserved as these are functions of the
medial half of the exor digitorum profundus and the medial two lumbrical muscles, innervated by the ulnar
nerve (there may be weakness of exion at the PIPJ of these ngers due to paralysis of the exor digitorum
super cialis).
There is loss of sensation over the lateral aspect of the palm, and the skin over the palmar surface and
ngertips of the lateral three and a half digits.

Medial nerve lesion at the wrist often occurs due to lacerations just proximal to the exor retinaculum or to
compression of the median nerve in the carpal tunnel. Only the intrinsic hand muscles are affected. Loss of opposition,
abduction and exion of the MCPJ of the thumb occurs due to paralysis of the thenar muscles. Loss of exion at the
MCPJ of the index and middle nger occurs due to paralysis of the lateral two lumbricals. There is loss of sensation to
the palmar surface and ngertips of the lateral three and a half digits only (the palmar region is spared).

You are giving a tutorial regarding forearm injuries to a group of nal year medical students.
You are discussing Galeazzi fractures. Which of the following synovial joint types best describes
the radioulnar joints:

a) Synovial plane joints

b) Synovial modi ed hinge joints
c) Synovial saddle joints
d) Synovial condyloid joints
e) Synovial pivot joints
Something wrong?

Answer

The radioulnar joints are synovial pivot joints.

Notes
The radioulnar joints allow pronation and supination of the forearm.

Movement Muscles Involved

Pronation Pronator quadratus, pronator teres

Supination Supinator, biceps brachii

The proximal radioulnar joint is a pivot type synovial joint occurring between the head of the radius and the radial
notch of the ulnar. The radial head is held in position by the annular ligament of the radius.

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Joint Proximal radioulnar joint

Type Synovial pivot

Articulations Head of radius with radial notch of ulna

Stabilising factors Annular ligament

Movements Pronation and supination

The distal radioulnar joint is a pivot type synovial joint occurring between the head of the ulnar and the ulnar notch on
the radius.

Joint Distal radioulnar joint

Type Synovial pivot

Articulations Head of ulna with ulnar notch of radius

Movements Pronation and supination

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By OpenStax College [CC BY 3.0 (http://creativecommons.org/licenses/by/3.0)], via Wikimedia Commons

A patient presents to ED complaining of pins and needles over the lateral three and a half
digits. You suspect carpal tunnel syndrome. Which of the following clinical features would you
most expect to see on examination:

a) Atrophy of the adductor pollicis muscle

b) Inability to abduct the index nger
c) Inability to ex the distal interphalangeal joint of the index nger
d) Inability to ex the interphalangeal joint of the thumb
e) Inability to touch the pad of the little nger with the thumb
Something wrong?

Answer
Compression of the median nerve in the carpal tunnel will result in weakness and atrophy of the thenar muscles –
resulting in weakness of opposition, abduction and exion of the thumb at the metacarpophalangeal joint and
anaesthesia or paraesthesia over the distribution of the palmar digital branch of the median nerve (skin over the
palmar surface and ngertips of the lateral three and a half digits). The adductor pollicis muscle is innervated by the
ulnar nerve, and abduction of the ngers is produced by the interossei, also innervated by the ulnar nerve. Flexion of
the interphalangeal joint of the thumb is produced by the exor pollicis longus, and exion of the distal interphalangeal
joint of the index nger is produced by the exor digitorum profundus. Median nerve injury at the wrist will not affect
the long exors of the forearm as these are innervated by the anterior interosseous nerve which arises in the proximal
forearm.

Notes
The median nerve is formed from the medial and lateral brachial plexus cords and contains bres from all ve roots (C5
– T1).

Nerve Median nerve

Nerve C5 – T1
roots

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Plexus Medial and lateral cords

cords

Motor All the anterior forearm muscles (except for the exor carpi ulnaris and the medial half of the exor
Supply digitorum profundus), the thenar muscles ( exor pollicis brevis, abductor pollicis brevis, opponens
pollicis) and the lateral two lumbricals

Sensory Lateral aspect of palm and palmar surface and ngertips of lateral three and a half digits
supply

Anatomical course

The median nerve originates in the axilla before passing down the medial side of the arm (initially lateral to the brachial
artery before crossing over to the medial side of the brachial artery). It enters the anterior compartment of the
forearm via the antecubital fossa, travelling between the exor digitorum profundus and exor digitorum super cialis
muscles, before entering the hand via the carpal tunnel and bifurcating into its terminal branches.

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By Henry Vandyke Carter [Public domain], via Wikimedia Commons

Branches

Branches of Origin Supply

Median Nerve

Median nerve Axilla Super cial and intermediate compartment of anterior forearm (pronator teres,
exor carpi radialis, palmaris longus, exor digitorum super cialis, NOT exor
carpi ulnaris)

Anterior Forearm Deep compartment of anterior forearm ( exor pollicis longus, pronator
interosseous quadratus, lateral half of exor digitorum profundus)
nerve

Palmar Forearm Skin over the lateral aspect of the palm

cutaneous
branch

Recurrent Hand Thenar muscles ( exor pollicis brevis, abductor pollicis brevis, opponens pollicis)
branch of
median nerve

Palmar digital Hand Lateral two lumbricals and skin over the palmar surface and ngertips of the
branch lateral three and a half digits

The median nerve directly innervates the pronator teres, the exor carpi radialis, the palmaris longus and the exor
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digitorum super cialis. It gives off no major branches in the arm, but gives rise to the anterior interosseous nerve
(innervating the exor pollicis longus, the pronator quadratus, and the lateral half of the exor digitorum profundus)
and the palmar cutaneous nerve (innervating the lateral aspect of the palm) in the forearm.

In the hand the median nerve bifurcates into the recurrent branch of the median nerve (innervating the thenar
muscles) and the palmar digital branch (innervating the lateral two lumbricals and the skin over the palmar surface and
ngertips of the lateral three and a half digits).

Clinical implications

Lesion Proximal (arm, elbow, proximal forearm) Distal (wrist)

Mechanisms Supracondylar fracture, stab wound to arm or forearm Lacerations just

proximal to exor
retinaculum, carpal
tunnel syndrome

Motor Loss Forearm pronation, wrist exion and abduction, index and middle nger Thumb exion,
exion, thumb exion, abduction and opposition abduction and
opposition, exion of
index and middle
nger MCPJ

Sensory Lateral aspect of palm and palmar surface and ngertips of lateral three Palmar surface and
Loss and a half digits ngertips of lateral
three and a half digits

Signs Forearm rests in supination with wrist in ulnar deviation and thumb Thenar eminence
extended, thenar eminence wasting, hand of Benediction (when asked wasting
to make a st, the patient will be able to ex the little and ring ngers
but not the index and middle ngers)

A proximal median nerve lesion at the elbow may occur due to supracondylar fracture of the humerus or from deep
penetrating wounds to the arm or forearm and may result in:

Pronation of the forearm and exion and abduction of the wrist are lost due to paralysis of the exors and
pronators in the forearm. The forearm thus often rests in supination with ulnar deviation of the wrist (due to
unopposed action of the exor carpi ulnaris).
Flexion, abduction and opposition of the thumb at the MCPJ and IPJ are lost due to paralysis of the thenar
muscles and the exor pollicis longus.
Flexion of the index and middle ngers at the IPJs is lost due to paralysis of the exor digitorum super cialis
and the lateral half of the exor digitorum profundus.
Flexion of the MCPJ of the index and middle ngers is lost due to paralysis of the lateral two lumbrical muscles.
N.B. Flexion of the ring and little ngers at the MCPJ and DIPJ are preserved as these are functions of the
medial half of the exor digitorum profundus and the medial two lumbrical muscles, innervated by the ulnar
nerve (there may be weakness of exion at the PIPJ of these ngers due to paralysis of the exor digitorum
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nerve (there may be weakness of exion at the PIPJ of these ngers due to paralysis of the exor digitorum
super cialis).
There is loss of sensation over the lateral aspect of the palm, and the skin over the palmar surface and
ngertips of the lateral three and a half digits.

Medial nerve lesion at the wrist often occurs due to lacerations just proximal to the exor retinaculum or to
compression of the median nerve in the carpal tunnel. Only the intrinsic hand muscles are affected. Loss of opposition,
abduction and exion of the MCPJ of the thumb occurs due to paralysis of the thenar muscles. Loss of exion at the
MCPJ of the index and middle nger occurs due to paralysis of the lateral two lumbricals. There is loss of sensation to
the palmar surface and ngertips of the lateral three and a half digits only (the palmar region is spared).

You are asked to review a 62 year old woman who presents with a numb left arm. On
examination you note she lacks sensation to the skin over the medial aspect of the forearm. The
skin over the medial aspect of the forearm is supplied by which of the following nerves:

a) Medial cutaneous nerve of the forearm, branch of the musculocutaneous nerve

b) Medial cutaneous nerve of the forearm, branch of the radial nerve
c) Medial cutaneous nerve of the forearm, branch of the median nerve
d) Medial cutaneous nerve of the forearm, branch of the ulnar nerve
e) Medial cutaneous nerve of the forearm from the brachial plexus
Something wrong?

Answer
The medial cutaneous nerve of the forearm, branch of the brachial plexus, supplies the skin over the medial aspect of
the forearm.

Notes

Nerve Origin Skin supplied

Lateral supraclavicular nerve Cervical plexus (C3, Upper half of deltoid muscle
C4)

Superior lateral cutaneous nerve Axillary nerve Lower half of deltoid muscle
of the arm

Inferior lateral cutaneous nerve of Radial nerve Lateral arm below deltoid muscle
the arm

Medial cutaneous nerve of the Brachial plexus (C8, Medial arm

arm T1)

Intercostobrachial nerve Second intercostal Axilla

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Intercostobrachial nerve Second intercostal Axilla
nerve (T2)

Posterior cutaneous nerve of the Radial nerve Posterior arm

arm

Medial cutaneous nerve of the Brachial plexus (C8, Medial forearm

forearm T1)

Posterior cutaneous nerve of the Radial nerve Posterior forearm

forearm

Lateral cutaneous nerve of the Musculocutaneous Lateral forearm

forearm nerve

Super cial branch of radial nerve Radial nerve Lateral dorsum of hand and lateral three and a
half digits

Palmar cutaneous branch of ulnar Ulnar nerve Medial half of palm

nerve

Dorsal cutaneous branch of ulnar Ulnar nerve Medial dorsum of hand and medial one and a half
nerve ngers

Super cial branch of ulnar nerve Ulnar nerve Palmar surface of medial one and a half digits

Palmar cutaneous branch of Median nerve Lateral half of palm

median nerve

Palmar digital branch of median Median nerve Palmar surface and ngertips of lateral three and
nerve a half digits

Arm:

The lateral supraclavicular nerve, branch of the cervical plexus, supplies the skin over the upper half of the
deltoid muscle.
The superior lateral cutaneous nerve of the arm, branch of the axillary nerve, supplies the skin over the lower
half of the deltoid muscle (regimental badge area).
The inferior lateral cutaneous nerve of the arm, branch of the radial nerve, supplies the skin over the lateral
side of the arm below the deltoid muscle.
The medial cutaneous nerve of the arm, branch of the brachial plexus, supplies skin over the medial arm.
The intercostobrachial nerve, branch of the second intercostal nerve, supplies the skin of the axilla.
The posterior cutaneous nerve of the arm, branch of the radial nerve, supplies the skin over the posterior arm.

Forearm:

The medial cutaneous nerve of the forearm, branch of the brachial plexus, supplies the skin over the medial
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aspect of the forearm.

The posterior cutaneous nerve of the forearm, branch of the radial nerve, supplies the skin over the posterior
forearm.
The lateral cutaneous nerve of the forearm, branch of the musculocutaneous nerve, supplies the skin over the
lateral aspect of the forearm.

Hand:

The super cial branch of the radial nerve supplies the skin over the lateral dorsum of the hand and the lateral
three and a half digits.
The palmar cutaneous branch of the ulnar nerve supplies the skin over the medial half of the palm.
The dorsal cutaneous branch of the ulnar nerve supplies the skin over medial dorsum of the hand and the
dorsum of the medial one and a half ngers.
The super cial branch of the ulnar nerve supplies the skin over the palmar surface of the medial one and a half
ngers.
The palmar cutaneous branch of the median nerve supplies the skin over the lateral half of the palm.
The palmar digital branch of the median nerve supplies the skin over the palmar surface and the ngertips of
the lateral three and a half digits.

Modi ed by FRCEM Success. Original by Henry Vandyke Carter [Public domain], via Wikimedia Commons

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Which of the following features would you most expect to see in a patient who has sustained
an ulnar nerve injury at the wrist following deliberate self harm:

a) Weakness of wrist exion

b) Claw hand appearance
c) Loss of abduction of the thumb
d) Loss of sensation to the skin over the dorsal and palmar aspect of the medial one and a half digits
e) Loss of exion of the index and ring ngers
Something wrong?

Answer
Claw hand appearance may be seen in a distal ulnar nerve injury due to unopposed extension at MCPJ and unopposed
exion at IPJ of ring and little nger.

Notes
The ulnar nerve is a continuation of the medial cord of the brachial plexus, containing bres from the C8 – T1 nerve
roots.

Nerve Ulnar nerve

Nerve C8 – T1
roots

Plexus Medial cord

cords

Motor All the intrinsic muscles of the hand (except for the thenar muscles and the lateral two lumbricals), the
Supply exor carpi ulnaris and the medial half of the exor digitorum profundus

Sensory Medial half of palm, palmar and dorsal surface of medial one and a half ngers and lateral dorsum of
supply hand

Anatomical course

The ulnar nerve descends down the medial side of the upper arm and passes posterior to the medial epicondyle (where
it is susceptible to damage) before entering the anterior compartment of the forearm by passing between the two
heads of the exor carpi ulnaris. It continues down the medial aspect of the forearm. The ulnar nerve emerges from
beneath the exor carpi ulnaris and becomes super cial just proximal to the wrist where it passes super cial to the
exor retinaculum, together with the ulnar artery, to enter the hand through a groove between the pisiform and the
hook of the hamate where it bifurcates into its terminal branches.

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By Henry Vandyke Carter [Public domain], via Wikimedia Commons

Branches

Branches of Origin Supply

Ulnar Nerve

Muscular Forearm Flexor carpi ulnaris, medial half of exor digitorum profundus
branch

Palmar Forearm Skin of medial half of palm

cutaneous
branch

Dorsal Forearm Skin of dorsum of medial one and a half ngers and associated dorsal hand area
cutaneous
branch

Deep branch Hand Hypothenar muscles (abductor digiti minimi, exor digiti minimi, opponens digiti
minimi), medial two lumbricals, adductor pollicis and interossei

Super cial Hand Skin of palmar surface of medial one and a half ngers
branch

The ulnar nerve gives off no major branches in the arm, but three branches arise in the forearm:

The muscular branch innervating the exor carpi ulnaris and the medial half of the exor digitorum profundus
The palmar cutaneous branch supplying the skin of the medial half of the palm
The dorsal cutaneous branch supplying the skin of the medial dorsum of the hand and the dorsal surface of the
medial one and a half ngers

The ulnar nerve terminates by bifurcating into:

A deep branch innervating the hypothenar muscles, the medial two lumbricals, the adductor pollicis and the
interossei
A super cial branch supplying the skin of the palmar surface of the medial one and a half ngers

Clinical implications

Lesion Proximal (at elbow) Distal (at wrist)

Mechanism Fracture of medial epicondyle Laceration at wrist

Motor Loss Wrist exion and adduction, nger abduction and adduction, exion Finger abduction and
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Motor Loss Wrist exion and adduction, nger abduction and adduction, exion Finger abduction and
of ring and little nger, abduction and opposition of little nger, thumb adduction, exion of ring
adduction, extension of IPJs of all digits (less so at index and middle and little nger,
nger due to sparing of lateral two lumbricals) abduction and
opposition of little
nger, thumb adduction,
extension at IPJs

Sensory Medial half of palm, palmar and dorsal surface of medial one and a half Palmar surface of medial
Loss ngers and medial dorsum of hand one and a half ngers

Signs Hand held in abduction (due to unopposed action of exor carpi Claw hand (unopposed
radialis), Froment’s sign (patient is asked to hold a piece of paper extension at MCPJ and
between thumb and at palm as paper is pulled away, patient will ex unopposed exion at
thumb at IPJ to maintain hold – tests adductor pollicis muscle), IPJs of ring and little
hypothenar eminence wasting, N.B. claw hand not typically seen due nger), hypothenar
to paralysis of the exor digitorum profundus eminence wasting,
Froment’s sign

The ulnar nerve is most likely to be injured proximally by a medial epicondyle fracture and results in:

There is weak wrist exion and adduction due to paralysis of the exor carpi ulnaris and the medial half of the
exor digitorum profundus; the hand may be held in abduction (due to unopposed action of the exor carpi
radialis).
There is loss of abduction and adduction of the ngers due to paralysis of the interossei.
There is loss of exion at the MCPJ of the ring and little nger due to paralysis of the medial two lumbricals and
the exor digiti minimi.
There is loss of exion at the DIPJ of the ring and little nger due to paralysis of the medial half of the exor
digitorum profundus (but exion at the PIPJ is likely preserved as this is a function of the exor digitorum
super cialis).
There is weakened extension at the IPJs of the ring and little nger due to paralysis of the interossei and medial
two lumbricals (and to a lesser extent at the IPJs of the index and middle nger).
There is loss of abduction and opposition of the little nger due to paralysis of the hypothenar muscles
(hypothenar wasting may be seen).
There is loss of adduction of the thumb due to paralysis of the adductor pollicis (Froment’s sign).
There is loss of sensation to skin over the medial half of the palm, the palmar and dorsal surface of the medial
one and a half ngers and the medial dorsum of the hand.
There is not typically a claw hand appearance (as may be seen in a lesion at the wrist) due to paralysis of the
exor digitorum profundus.

A distal lesion most commonly occurs due to laceration at the wrist. Only intrinsic hand muscles are affected (the exor
carpi ulnaris and medial half of the exor digitorum profundus are spared). A loss of sensation will only affect the
palmar surface of the medial one and a half ngers (the medial palm and the dorsum of the hand are spared). A claw
hand deformity may be seen due to unopposed extension at the MCPJ (by the extensor digitorum) and unopposed
exion at the IPJs (by the FDP and FDS) of the ring and little nger.

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Froment’s sign (right hand). Copyright FRCEM

Success.

Claw hand deformity. By Mcstrother (Own work)

[CC BY 3.0
(http://creativecommons.org/licenses/by/3.0)], via
Wikimedia Commons

A 34 year old man sustains an injury to the proximal median nerve following a stab wound to
the forearm. Which of the following muscles would you least expect to be affected:

a) Pronator teres
b) Flexor digitorum profundus
c) Flexor pollicis longus
d) Abductor pollicis brevis
e) Flexor digiti minimi
Something wrong?

Answer
The  exor digiti minimi is innervated by the ulnar nerve, together with the medial half of the digitorum profundus.

Notes
The median nerve is formed from the medial and lateral brachial plexus cords and contains bres from all ve roots (C5
– T1).

Nerve Median nerve

Nerve C5 – T1
roots

Plexus Medial and lateral cords

cords

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Motor All the anterior forearm muscles (except for the exor carpi ulnaris and the medial half of the exor
Supply digitorum profundus), the thenar muscles ( exor pollicis brevis, abductor pollicis brevis, opponens
pollicis) and the lateral two lumbricals

Sensory Lateral aspect of palm and palmar surface and ngertips of lateral three and a half digits
supply

Anatomical course

The median nerve originates in the axilla before passing down the medial side of the arm (initially lateral to the brachial
artery before crossing over to the medial side of the brachial artery). It enters the anterior compartment of the
forearm via the antecubital fossa, travelling between the exor digitorum profundus and exor digitorum super cialis
muscles, before entering the hand via the carpal tunnel and bifurcating into its terminal branches.

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By Henry Vandyke Carter [Public domain], via Wikimedia Commons

Branches

Branches of Origin Supply

Median Nerve

Median nerve Axilla Super cial and intermediate compartment of anterior forearm (pronator teres,
exor carpi radialis, palmaris longus, exor digitorum super cialis, NOT exor
carpi ulnaris)

Anterior Forearm Deep compartment of anterior forearm ( exor pollicis longus, pronator
interosseous quadratus, lateral half of exor digitorum profundus)
nerve

Palmar Forearm Skin over the lateral aspect of the palm

cutaneous
branch

Recurrent Hand Thenar muscles ( exor pollicis brevis, abductor pollicis brevis, opponens pollicis)
branch of
median nerve

Palmar digital Hand Lateral two lumbricals and skin over the palmar surface and ngertips of the
branch lateral three and a half digits

The median nerve directly innervates the pronator teres, the exor carpi radialis, the palmaris longus and the exor
digitorum super cialis. It gives off no major branches in the arm, but gives rise to the anterior interosseous nerve
(innervating the exor pollicis longus, the pronator quadratus, and the lateral half of the exor digitorum profundus)
and the palmar cutaneous nerve (innervating the lateral aspect of the palm) in the forearm.
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In the hand the median nerve bifurcates into the recurrent branch of the median nerve (innervating the thenar
muscles) and the palmar digital branch (innervating the lateral two lumbricals and the skin over the palmar surface and
ngertips of the lateral three and a half digits).

Clinical implications

Lesion Proximal (arm, elbow, proximal forearm) Distal (wrist)

Mechanisms Supracondylar fracture, stab wound to arm or forearm Lacerations just

proximal to exor
retinaculum, carpal
tunnel syndrome

Motor Loss Forearm pronation, wrist exion and abduction, index and middle nger Thumb exion,
exion, thumb exion, abduction and opposition abduction and
opposition, exion of
index and middle
nger MCPJ

Sensory Lateral aspect of palm and palmar surface and ngertips of lateral three Palmar surface and
Loss and a half digits ngertips of lateral
three and a half digits

Signs Forearm rests in supination with wrist in ulnar deviation and thumb Thenar eminence
extended, thenar eminence wasting, hand of Benediction (when asked wasting
to make a st, the patient will be able to ex the little and ring ngers
but not the index and middle ngers)

A proximal median nerve lesion at the elbow may occur due to supracondylar fracture of the humerus or from deep
penetrating wounds to the arm or forearm and may result in:

Pronation of the forearm and exion and abduction of the wrist are lost due to paralysis of the exors and
pronators in the forearm. The forearm thus often rests in supination with ulnar deviation of the wrist (due to
unopposed action of the exor carpi ulnaris).
Flexion, abduction and opposition of the thumb at the MCPJ and IPJ are lost due to paralysis of the thenar
muscles and the exor pollicis longus.
Flexion of the index and middle ngers at the IPJs is lost due to paralysis of the exor digitorum super cialis
and the lateral half of the exor digitorum profundus.
Flexion of the MCPJ of the index and middle ngers is lost due to paralysis of the lateral two lumbrical muscles.
N.B. Flexion of the ring and little ngers at the MCPJ and DIPJ are preserved as these are functions of the
medial half of the exor digitorum profundus and the medial two lumbrical muscles, innervated by the ulnar
nerve (there may be weakness of exion at the PIPJ of these ngers due to paralysis of the exor digitorum
super cialis).
There is loss of sensation over the lateral aspect of the palm, and the skin over the palmar surface and
ngertips of the lateral three and a half digits.
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ngertips of the lateral three and a half digits.

Medial nerve lesion at the wrist often occurs due to lacerations just proximal to the exor retinaculum or to
compression of the median nerve in the carpal tunnel. Only the intrinsic hand muscles are affected. Loss of opposition,
abduction and exion of the MCPJ of the thumb occurs due to paralysis of the thenar muscles. Loss of exion at the
MCPJ of the index and middle nger occurs due to paralysis of the lateral two lumbricals. There is loss of sensation to
the palmar surface and ngertips of the lateral three and a half digits only (the palmar region is spared).

A 65 year old woman presents to the ED complaining of paresthesia in the left arm. On
examination you note she has no sensation over the lateral aspect of the forearm. The skin over the
lateral aspect of the forearm is supplied by which of the following nerves:

a) The lateral cutaneous nerve of the forearm, branch of the musculocutaneous nerve
b) The lateral cutaneous nerve of the forearm, branch of the radial nerve
c) The lateral cutaneous nerve of the forearm, branch of the ulnar nerve
d) The lateral cutaneous nerve of the forearm, branch of the median nerve
e) The lateral cutaneous nerve of the forearm, from the brachial plexus
Something wrong?

Answer
The lateral cutaneous nerve of the forearm, branch of the musculocutaneous nerve, supplies the skin over the lateral
aspect of the forearm.

Notes

Nerve Origin Skin supplied

Lateral supraclavicular nerve Cervical plexus (C3, Upper half of deltoid muscle
C4)

Superior lateral cutaneous nerve Axillary nerve Lower half of deltoid muscle
of the arm

Inferior lateral cutaneous nerve of Radial nerve Lateral arm below deltoid muscle
the arm

Medial cutaneous nerve of the Brachial plexus (C8, Medial arm

arm T1)

Intercostobrachial nerve Second intercostal Axilla

nerve (T2)

Posterior cutaneous nerve of the Radial nerve Posterior arm

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arm

Medial cutaneous nerve of the Brachial plexus (C8, Medial forearm

forearm T1)

Posterior cutaneous nerve of the Radial nerve Posterior forearm

forearm

Lateral cutaneous nerve of the Musculocutaneous Lateral forearm

forearm nerve

Super cial branch of radial nerve Radial nerve Lateral dorsum of hand and lateral three and a
half digits

Palmar cutaneous branch of ulnar Ulnar nerve Medial half of palm

nerve

Dorsal cutaneous branch of ulnar Ulnar nerve Medial dorsum of hand and medial one and a half
nerve ngers

Super cial branch of ulnar nerve Ulnar nerve Palmar surface of medial one and a half digits

Palmar cutaneous branch of Median nerve Lateral half of palm

median nerve

Palmar digital branch of median Median nerve Palmar surface and ngertips of lateral three and
nerve a half digits

Arm:

The lateral supraclavicular nerve, branch of the cervical plexus, supplies the skin over the upper half of the
deltoid muscle.
The superior lateral cutaneous nerve of the arm, branch of the axillary nerve, supplies the skin over the lower
half of the deltoid muscle (regimental badge area).
The inferior lateral cutaneous nerve of the arm, branch of the radial nerve, supplies the skin over the lateral
side of the arm below the deltoid muscle.
The medial cutaneous nerve of the arm, branch of the brachial plexus, supplies skin over the medial arm.
The intercostobrachial nerve, branch of the second intercostal nerve, supplies the skin of the axilla.
The posterior cutaneous nerve of the arm, branch of the radial nerve, supplies the skin over the posterior arm.

Forearm:

The medial cutaneous nerve of the forearm, branch of the brachial plexus, supplies the skin over the medial
aspect of the forearm.
The posterior cutaneous nerve of the forearm, branch of the radial nerve, supplies the skin over the posterior
forearm.
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The lateral cutaneous nerve of the forearm, branch of the musculocutaneous nerve, supplies the skin over the
lateral aspect of the forearm.

Hand:

The super cial branch of the radial nerve supplies the skin over the lateral dorsum of the hand and the lateral
three and a half digits.
The palmar cutaneous branch of the ulnar nerve supplies the skin over the medial half of the palm.
The dorsal cutaneous branch of the ulnar nerve supplies the skin over medial dorsum of the hand and the
dorsum of the medial one and a half ngers.
The super cial branch of the ulnar nerve supplies the skin over the palmar surface of the medial one and a half
ngers.
The palmar cutaneous branch of the median nerve supplies the skin over the lateral half of the palm.
The palmar digital branch of the median nerve supplies the skin over the palmar surface and the ngertips of
the lateral three and a half digits.

Modi ed by FRCEM Success. Original by Henry Vandyke Carter [Public domain], via Wikimedia Commons

A 26 year old woman presents to ED having sustained a deep laceration to the dorsum of her
ring nger whilst cooking. Her proximal interphalangeal joint is xed in exion and the distal
interphalangeal joint is hyperextended. Which of the following structures in the digit has most
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interphalangeal joint is hyperextended. Which of the following structures in the digit has most
likely been injured:

a) Terminal insertion of the extensor tendon

b) Super cial branch of the radial nerve
c) Insertion of the exor digitorum profundus
d) Insertion of the exor digitorum super cialis
e) Insertion of the central slip of the extensor tendon
Something wrong?

Answer
Damage to the central slip of the extensor digitorum tendon would result in loss of extension at the proximal
interphalangeal joint resulting in a xed exion deformity of this joint, and hyperextension of the distal interphalangeal
joint due to a loss of balancing forces. This is called the Boutonniere deformity.

Notes
The tendons of the extensor digitorum (and extensor pollicis longus) pass onto the dorsal aspect of the digits and
expand over the proximal phalanges to form complex extensor hoods. The central slip inserts into the base of the
middle phalanx, and distally the tendon inserts into the distal phalanx of each digit.

Division of the central slip of the extensor tendon will result in the Boutonniere deformity, with loss of extension of the
proximal interphalangeal joint and loss of exion of the distal interphalangeal joint. The middle phalanx is held in
forced exion, with hyperextension of the distal phalanx.

Division of the terminal extensor tendon will result in the Mallet deformity, with loss of extension at the distal
interphalangeal joint as in this case; the distal phalanx is held in forced exion due to unopposed action of the exor
digitorum profundus muscle.

Structure Terminal extensor tendon Central slip of extensor tendon

Attachment Distal phalanx Middle phalanx

Movements Loss of extension at distal Loss of extension at proximal interphalangeal joint and
affected in interphalangeal joint exion at distal interphalangeal joint
injury

Deformity in Mallet deformity: Distal Boutonniere deformity: Middle phalanx held in xed
injury phalanx held in xed exion exion with hyperextension of distal phalanx

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Modi ed by FRCEM Success. Original by Henry Vandyke Carter [Public domain], via Wikimedia
Commons

A patient presents to ED complaining of pain and paraesthesia in her right hand which
becomes worse at night. Her symptoms have been ongoing for about 6 months. You suspect carpal
tunnel syndrome. Which of the following muscles would you most expect to be atrophied on
examination:

a) Hypothenar muscles
b) Dorsal interossei
c) Thenar muscles
d) Palmar interossei
e) Medial two lumbricals
Something wrong?

Answer
Carpal tunnel syndrome results from compression of the median nerve in the carpal tunnel. Typically there is pain and
paraesthesia in the cutaneous distribution of the median nerve (palmar surface and ngertips of lateral three and a half
digits – lateral palm is spared), and weakness and wasting of the thenar muscles with weak thumb grip. Symptoms may
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be reproduced by performing Phalen’s test (with sustained exion of the wrist) or Tinel’s test (by tapping lightly over
the median nerve at the wrist). The hypothenar muscles, interossei and medial two lumbricals are all innervated by the
ulnar nerve.

Notes
The median nerve is formed from the medial and lateral brachial plexus cords and contains bres from all ve roots (C5
– T1).

Nerve Median nerve

Nerve C5 – T1
roots

Plexus Medial and lateral cords

cords

Motor All the anterior forearm muscles (except for the exor carpi ulnaris and the medial half of the exor
Supply digitorum profundus), the thenar muscles ( exor pollicis brevis, abductor pollicis brevis, opponens
pollicis) and the lateral two lumbricals

Sensory Lateral aspect of palm and palmar surface and ngertips of lateral three and a half digits
supply

Anatomical course

The median nerve originates in the axilla before passing down the medial side of the arm (initially lateral to the brachial
artery before crossing over to the medial side of the brachial artery). It enters the anterior compartment of the
forearm via the antecubital fossa, travelling between the exor digitorum profundus and exor digitorum super cialis
muscles, before entering the hand via the carpal tunnel and bifurcating into its terminal branches.

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By Henry Vandyke Carter [Public domain], via Wikimedia Commons

Branches

Branches of Origin Supply

Median Nerve

Median nerve Axilla Super cial and intermediate compartment of anterior forearm (pronator teres,
exor carpi radialis, palmaris longus, exor digitorum super cialis, NOT exor
carpi ulnaris)

Anterior Forearm Deep compartment of anterior forearm ( exor pollicis longus, pronator
interosseous quadratus, lateral half of exor digitorum profundus)
nerve
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nerve

Palmar Forearm Skin over the lateral aspect of the palm

cutaneous
branch

Recurrent Hand Thenar muscles ( exor pollicis brevis, abductor pollicis brevis, opponens pollicis)
branch of
median nerve

Palmar digital Hand Lateral two lumbricals and skin over the palmar surface and ngertips of the
branch lateral three and a half digits

The median nerve directly innervates the pronator teres, the exor carpi radialis, the palmaris longus and the exor
digitorum super cialis. It gives off no major branches in the arm, but gives rise to the anterior interosseous nerve
(innervating the exor pollicis longus, the pronator quadratus, and the lateral half of the exor digitorum profundus)
and the palmar cutaneous nerve (innervating the lateral aspect of the palm) in the forearm.

In the hand the median nerve bifurcates into the recurrent branch of the median nerve (innervating the thenar
muscles) and the palmar digital branch (innervating the lateral two lumbricals and the skin over the palmar surface and
ngertips of the lateral three and a half digits).

Clinical implications

Lesion Proximal (arm, elbow, proximal forearm) Distal (wrist)

Mechanisms Supracondylar fracture, stab wound to arm or forearm Lacerations just

proximal to exor
retinaculum, carpal
tunnel syndrome

Motor Loss Forearm pronation, wrist exion and abduction, index and middle nger Thumb exion,
exion, thumb exion, abduction and opposition abduction and
opposition, exion of
index and middle
nger MCPJ

Sensory Lateral aspect of palm and palmar surface and ngertips of lateral three Palmar surface and
Loss and a half digits ngertips of lateral
three and a half digits

Signs Forearm rests in supination with wrist in ulnar deviation and thumb Thenar eminence
extended, thenar eminence wasting, hand of Benediction (when asked wasting
to make a st, the patient will be able to ex the little and ring ngers
but not the index and middle ngers)

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A proximal median nerve lesion at the elbow may occur due to supracondylar fracture of the humerus or from deep
penetrating wounds to the arm or forearm and may result in:

Pronation of the forearm and exion and abduction of the wrist are lost due to paralysis of the exors and
pronators in the forearm. The forearm thus often rests in supination with ulnar deviation of the wrist (due to
unopposed action of the exor carpi ulnaris).
Flexion, abduction and opposition of the thumb at the MCPJ and IPJ are lost due to paralysis of the thenar
muscles and the exor pollicis longus.
Flexion of the index and middle ngers at the IPJs is lost due to paralysis of the exor digitorum super cialis
and the lateral half of the exor digitorum profundus.
Flexion of the MCPJ of the index and middle ngers is lost due to paralysis of the lateral two lumbrical muscles.
N.B. Flexion of the ring and little ngers at the MCPJ and DIPJ are preserved as these are functions of the
medial half of the exor digitorum profundus and the medial two lumbrical muscles, innervated by the ulnar
nerve (there may be weakness of exion at the PIPJ of these ngers due to paralysis of the exor digitorum
super cialis).
There is loss of sensation over the lateral aspect of the palm, and the skin over the palmar surface and
ngertips of the lateral three and a half digits.

Medial nerve lesion at the wrist often occurs due to lacerations just proximal to the exor retinaculum or to
compression of the median nerve in the carpal tunnel. Only the intrinsic hand muscles are affected. Loss of opposition,
abduction and exion of the MCPJ of the thumb occurs due to paralysis of the thenar muscles. Loss of exion at the
MCPJ of the index and middle nger occurs due to paralysis of the lateral two lumbricals. There is loss of sensation to
the palmar surface and ngertips of the lateral three and a half digits only (the palmar region is spared).

A 67 year old woman presents to the ED after falling onto an outstretched hand. You x-ray her
left wrist and note no fracture. You discuss the case with your consultant, he advises you to test for
anatomical snuffbox tenderness. The anatomical snuffbox is bounded laterally by the tendons of
which of the following muscles:

a) Abductor pollicis brevis and extensor pollicis longus

b) Extensor pollicis longus and extensor pollicis brevis
c) Abductor pollicis longus and extensor pollicis brevis
d) Abductor pollicis longus and extensor pollicis longus
e) Abductor pollicis brevis and extensor pollicis brevis
Something wrong?

Answer
The anatomical snuffbox is bounded laterally by the tendons of the abductor pollicis longus and the extensor pollicis
brevis.

Notes

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The anatomical snuffbox is the triangular depression formed on the posterolateral side of the dorsal wrist and 1st
metacarpal by the extensor tendons passing into the thumb.

Anatomical Structure
Boundaries

Medial border Tendon of extensor pollicis longus

Lateral border Tendons of the abductor pollicis longus and extensor pollicis brevis

Proximal border Radial styloid process

Distal border 1st metacarpal

Floor Scaphoid and trapezium bones

Roof Skin

Contents Radial artery, terminal portion of the super cial branch of the radial nerve, cephalic
vein

It is bounded laterally by the tendons of the abductor pollicis longus and the extensor pollicis brevis and medially by
the tendon of the extensor pollicis longus.

The oor of the anatomical snuffbox is formed by the scaphoid and trapezium carpal bones. The radial styloid process
can be palpated proximally and the 1st metacarpal can be palpated distally.

The radial artery crosses the oor of the anatomical snuffbox. Subcutaneously terminal parts of the super cial branch
of the radial nerve and the origin of the cephalic vein pass over the anatomical snuffbox.

The anatomical snuffbox is important clinically as the scaphoid is palpable within the snuffbox; localised pain and
tenderness of the anatomical snuffbox is most likely due to a scaphoid fracture.

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By Grant, John Charles Boileau (An atlas of anatomy, / by regions 1962) [Public domain], via
Wikimedia Commons

A 17 year old footballer sustains an injury to the proximal ulnar nerve after fracturing his
elbow. Which of the following muscles would you least expect to be affected:

a) Medial two lumbricals

b) Interossei muscles
c) Flexor digitorum super cialis
d) Flexor digitorum profundus
e) Adductor pollicis
Something wrong?

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Answer
The  exor digitorum super cialis is innervated by the median nerve, together with the lateral half of the exor
digitorum profundus.

Notes
The ulnar nerve is a continuation of the medial cord of the brachial plexus, containing bres from the C8 – T1 nerve
roots.

Nerve Ulnar nerve

Nerve C8 – T1
roots

Plexus Medial cord

cords

Motor All the intrinsic muscles of the hand (except for the thenar muscles and the lateral two lumbricals), the
Supply exor carpi ulnaris and the medial half of the exor digitorum profundus

Sensory Medial half of palm, palmar and dorsal surface of medial one and a half ngers and lateral dorsum of
supply hand

Anatomical course

The ulnar nerve descends down the medial side of the upper arm and passes posterior to the medial epicondyle (where
it is susceptible to damage) before entering the anterior compartment of the forearm by passing between the two
heads of the exor carpi ulnaris. It continues down the medial aspect of the forearm. The ulnar nerve emerges from
beneath the exor carpi ulnaris and becomes super cial just proximal to the wrist where it passes super cial to the
exor retinaculum, together with the ulnar artery, to enter the hand through a groove between the pisiform and the
hook of the hamate where it bifurcates into its terminal branches.

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By Henry Vandyke Carter [Public domain], via Wikimedia Commons

Branches

Branches of Origin Supply

Ulnar Nerve

Muscular Forearm Flexor carpi ulnaris, medial half of exor digitorum profundus
branch
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branch

Palmar Forearm Skin of medial half of palm

cutaneous
branch

Dorsal Forearm Skin of dorsum of medial one and a half ngers and associated dorsal hand area
cutaneous
branch

Deep branch Hand Hypothenar muscles (abductor digiti minimi, exor digiti minimi, opponens digiti
minimi), medial two lumbricals, adductor pollicis and interossei

Super cial Hand Skin of palmar surface of medial one and a half ngers
branch

The ulnar nerve gives off no major branches in the arm, but three branches arise in the forearm:

The muscular branch innervating the exor carpi ulnaris and the medial half of the exor digitorum profundus
The palmar cutaneous branch supplying the skin of the medial half of the palm
The dorsal cutaneous branch supplying the skin of the medial dorsum of the hand and the dorsal surface of the
medial one and a half ngers

The ulnar nerve terminates by bifurcating into:

A deep branch innervating the hypothenar muscles, the medial two lumbricals, the adductor pollicis and the
interossei
A super cial branch supplying the skin of the palmar surface of the medial one and a half ngers

Clinical implications

Lesion Proximal (at elbow) Distal (at wrist)

Mechanism Fracture of medial epicondyle Laceration at wrist

Motor Loss Wrist exion and adduction, nger abduction and adduction, exion Finger abduction and
of ring and little nger, abduction and opposition of little nger, thumb adduction, exion of ring
adduction, extension of IPJs of all digits (less so at index and middle and little nger,
nger due to sparing of lateral two lumbricals) abduction and
opposition of little
nger, thumb adduction,
extension at IPJs

Sensory Medial half of palm, palmar and dorsal surface of medial one and a half Palmar surface of medial
Loss ngers and medial dorsum of hand one and a half ngers

Signs Hand held in abduction (due to unopposed action of exor carpi Claw hand (unopposed
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Signs Hand held in abduction (due to unopposed action of exor carpi Claw hand (unopposed
radialis), Froment’s sign (patient is asked to hold a piece of paper extension at MCPJ and
between thumb and at palm as paper is pulled away, patient will ex unopposed exion at
thumb at IPJ to maintain hold – tests adductor pollicis muscle), IPJs of ring and little
hypothenar eminence wasting, N.B. claw hand not typically seen due nger), hypothenar
to paralysis of the exor digitorum profundus eminence wasting,
Froment’s sign

The ulnar nerve is most likely to be injured proximally by a medial epicondyle fracture and results in:

There is weak wrist exion and adduction due to paralysis of the exor carpi ulnaris and the medial half of the
exor digitorum profundus; the hand may be held in abduction (due to unopposed action of the exor carpi
radialis).
There is loss of abduction and adduction of the ngers due to paralysis of the interossei.
There is loss of exion at the MCPJ of the ring and little nger due to paralysis of the medial two lumbricals and
the exor digiti minimi.
There is loss of exion at the DIPJ of the ring and little nger due to paralysis of the medial half of the exor
digitorum profundus (but exion at the PIPJ is likely preserved as this is a function of the exor digitorum
super cialis).
There is weakened extension at the IPJs of the ring and little nger due to paralysis of the interossei and medial
two lumbricals (and to a lesser extent at the IPJs of the index and middle nger).
There is loss of abduction and opposition of the little nger due to paralysis of the hypothenar muscles
(hypothenar wasting may be seen).
There is loss of adduction of the thumb due to paralysis of the adductor pollicis (Froment’s sign).
There is loss of sensation to skin over the medial half of the palm, the palmar and dorsal surface of the medial
one and a half ngers and the medial dorsum of the hand.
There is not typically a claw hand appearance (as may be seen in a lesion at the wrist) due to paralysis of the
exor digitorum profundus.

A distal lesion most commonly occurs due to laceration at the wrist. Only intrinsic hand muscles are affected (the exor
carpi ulnaris and medial half of the exor digitorum profundus are spared). A loss of sensation will only affect the
palmar surface of the medial one and a half ngers (the medial palm and the dorsum of the hand are spared). A claw
hand deformity may be seen due to unopposed extension at the MCPJ (by the extensor digitorum) and unopposed
exion at the IPJs (by the FDP and FDS) of the ring and little nger.

Froment’s sign (right hand). Copyright FRCEM

Success.

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Claw hand deformity. By Mcstrother (Own work)
[CC BY 3.0
(http://creativecommons.org/licenses/by/3.0)], via
Wikimedia Commons

A 16 year old girl presents complaining of weakness of her left hand following an injury to her
left arm. On examination she has weakness of exion of the metacarpophalangeal joint of the ring
nger, and inability to adduct that same nger. Which of the following muscles is most likely
affected:

a) Flexor pollicis profundus

b) Flexor pollicis super cialis
c) Lumbrical
d) Dorsal interosseous
e) Palmar interosseus
Something wrong?

Answer
The interossei muscles assist the lumbricals with exion of the ngers at the metacarpophalangeal joints and extension
at the interphalangeal joints. The palmar interossei cause adduction of the ngers and the dorsal interossei cause
abduction of the ngers. The exor digitorum profundus and super cialis are involved in exion at the
metacarpophalangeal joint but have no function in adduction of the ngers.

Notes
Hand movements are complex. The table below shows an overview of hand and thumb movements and the main
muscles bringing about these movements.

Hand movements Primary muscle (assisting muscles)

Flexion of MCPJ of digits 2 – 5 Lumbricals ( exor digitorum super cialis, exor digitorum profundus, exor
digiti minimi, interossei)

Flexion of PIPJ of digits 2 – 5 Flexor digitorum super cialis ( exor digitorum profundus)

Flexion of DIPJ of digits 2 – 5 Flexor digitorum profundus

Extension of MCPJ of digits 2 – Extensor digitorum, extensor indicis, extensor digiti minimi
5

Extension of PIPJ and DIPJ of Lumbricals and interossei (extensor digitorum)

digits 2 – 5
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digits 2 – 5

Adduction of digits 2 – 5 Palmar interossei

Abduction of digits 2 – 4 Dorsal interossei

Abduction of little nger Abductor digiti minimi

Opposition of little nger Opponens digiti minimi

Thumb movements Primary muscle(s)

Flexion of thumb at MCPJ Flexor pollicis longus and brevis

Flexion of thumb at IPJ Flexor pollicis longus

Extension of thumb at CMCJ and MCPJ Extensor pollicis longus and brevis

Extension of thumb at IPJ Extensor pollicis longus

Abduction of thumb Abductor pollicis longus and brevis

Adduction of thumb Adductor pollicis

Opposition of thumb Opponens pollicis

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Original by By OpenStax [CC BY 4.0 (http://creativecommons.org/licenses/by/4.0)], via Wikimedia

Commons

A 48 year old presents to ED having sustained a deep laceration to his right upper limb. On
examination he is unable to extend the interphalangeal joints of the fourth and fth digits and
extension of the interphalangeal joints of the second and third digits is very weak. Extension at the
metacarpophalangeal joints is preserved in all digits. Which of the following nerves has most likely
been injured:

a) Super cial branch of the ulnar nerve

b) Deep branch of the ulnar nerve
c) Anterior interosseous nerve
d) Posterior interosseous nerve
e) Recurrent branch of the median nerve
Something wrong?

Answer
The deep branch of the ulnar nerve innervates the medial two lumbricals and all of the interossei. There is loss of
extension at the IPJs of the fourth and fth digits due to paralysis of the medial two lumbricals and the interossei.
Extension at the IPJs of the second and third digits are only weakened as the lateral two lumbricals are spared
(innervated by the median nerve). Extension at the MCPJs of all ve digits is a function of the radial nerve. The
super cial branch of the ulnar nerve has only cutaneous function.

Notes
The ulnar nerve is a continuation of the medial cord of the brachial plexus, containing bres from the C8 – T1 nerve
roots.

Nerve Ulnar nerve

Nerve C8 – T1
roots

Plexus Medial cord

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Plexus Medial cord
cords

Motor All the intrinsic muscles of the hand (except for the thenar muscles and the lateral two lumbricals), the
Supply exor carpi ulnaris and the medial half of the exor digitorum profundus

Sensory Medial half of palm, palmar and dorsal surface of medial one and a half ngers and lateral dorsum of
supply hand

Anatomical course

The ulnar nerve descends down the medial side of the upper arm and passes posterior to the medial epicondyle (where
it is susceptible to damage) before entering the anterior compartment of the forearm by passing between the two
heads of the exor carpi ulnaris. It continues down the medial aspect of the forearm. The ulnar nerve emerges from
beneath the exor carpi ulnaris and becomes super cial just proximal to the wrist where it passes super cial to the
exor retinaculum, together with the ulnar artery, to enter the hand through a groove between the pisiform and the
hook of the hamate where it bifurcates into its terminal branches.

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By Henry Vandyke Carter [Public domain], via Wikimedia Commons

Branches

Branches of Origin Supply

Ulnar Nerve

Muscular Forearm Flexor carpi ulnaris, medial half of exor digitorum profundus
branch

Palmar Forearm Skin of medial half of palm

cutaneous
branch

Dorsal Forearm Skin of dorsum of medial one and a half ngers and associated dorsal hand area
cutaneous
branch

Deep branch Hand Hypothenar muscles (abductor digiti minimi, exor digiti minimi, opponens digiti
minimi), medial two lumbricals, adductor pollicis and interossei

Super cial Hand Skin of palmar surface of medial one and a half ngers
branch

The ulnar nerve gives off no major branches in the arm, but three branches arise in the forearm:

The muscular branch innervating the exor carpi ulnaris and the medial half of the exor digitorum profundus
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The muscular branch innervating the exor carpi ulnaris and the medial half of the exor digitorum profundus
The palmar cutaneous branch supplying the skin of the medial half of the palm
The dorsal cutaneous branch supplying the skin of the medial dorsum of the hand and the dorsal surface of the
medial one and a half ngers

The ulnar nerve terminates by bifurcating into:

A deep branch innervating the hypothenar muscles, the medial two lumbricals, the adductor pollicis and the
interossei
A super cial branch supplying the skin of the palmar surface of the medial one and a half ngers

Clinical implications

Lesion Proximal (at elbow) Distal (at wrist)

Mechanism Fracture of medial epicondyle Laceration at wrist

Motor Loss Wrist exion and adduction, nger abduction and adduction, exion Finger abduction and
of ring and little nger, abduction and opposition of little nger, thumb adduction, exion of ring
adduction, extension of IPJs of all digits (less so at index and middle and little nger,
nger due to sparing of lateral two lumbricals) abduction and
opposition of little
nger, thumb adduction,
extension at IPJs

Sensory Medial half of palm, palmar and dorsal surface of medial one and a half Palmar surface of medial
Loss ngers and medial dorsum of hand one and a half ngers

Signs Hand held in abduction (due to unopposed action of exor carpi Claw hand (unopposed
radialis), Froment’s sign (patient is asked to hold a piece of paper extension at MCPJ and
between thumb and at palm as paper is pulled away, patient will ex unopposed exion at
thumb at IPJ to maintain hold – tests adductor pollicis muscle), IPJs of ring and little
hypothenar eminence wasting, N.B. claw hand not typically seen due nger), hypothenar
to paralysis of the exor digitorum profundus eminence wasting,
Froment’s sign

The ulnar nerve is most likely to be injured proximally by a medial epicondyle fracture and results in:

There is weak wrist exion and adduction due to paralysis of the exor carpi ulnaris and the medial half of the
exor digitorum profundus; the hand may be held in abduction (due to unopposed action of the exor carpi
radialis).
There is loss of abduction and adduction of the ngers due to paralysis of the interossei.
There is loss of exion at the MCPJ of the ring and little nger due to paralysis of the medial two lumbricals and
the exor digiti minimi.
There is loss of exion at the DIPJ of the ring and little nger due to paralysis of the medial half of the exor
digitorum profundus (but exion at the PIPJ is likely preserved as this is a function of the exor digitorum
super cialis).
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super cialis).
There is weakened extension at the IPJs of the ring and little nger due to paralysis of the interossei and medial
two lumbricals (and to a lesser extent at the IPJs of the index and middle nger).
There is loss of abduction and opposition of the little nger due to paralysis of the hypothenar muscles
(hypothenar wasting may be seen).
There is loss of adduction of the thumb due to paralysis of the adductor pollicis (Froment’s sign).
There is loss of sensation to skin over the medial half of the palm, the palmar and dorsal surface of the medial
one and a half ngers and the medial dorsum of the hand.
There is not typically a claw hand appearance (as may be seen in a lesion at the wrist) due to paralysis of the
exor digitorum profundus.

A distal lesion most commonly occurs due to laceration at the wrist. Only intrinsic hand muscles are affected (the exor
carpi ulnaris and medial half of the exor digitorum profundus are spared). A loss of sensation will only affect the
palmar surface of the medial one and a half ngers (the medial palm and the dorsum of the hand are spared). A claw
hand deformity may be seen due to unopposed extension at the MCPJ (by the extensor digitorum) and unopposed
exion at the IPJs (by the FDP and FDS) of the ring and little nger.

Froment’s sign (right hand). Copyright FRCEM

Success.

Claw hand deformity. By Mcstrother (Own work)

[CC BY 3.0
(http://creativecommons.org/licenses/by/3.0)], via
Wikimedia Commons

A patient sustains an injury to the radial nerve through a midshaft humeral fracture. Which of
the following clinical ndings would you least expect to see in this patient:

a) Wrist drop
b) Loss of extension of the forearm
c) Loss of extension of the ngers
d) Weakness of supination
e) Loss of sensation over the dorsum of the lateral three and a half digits.
Something wrong?

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Answer
The radial nerve innervates the triceps brachii and the posterior compartment of the forearm. The radial nerve in the
arm is most susceptible to midshaft fractures of the humerus due to its course in the spiral groove. Extension of the
forearm is not affected as the triceps brachii is spared. There is loss of extension of the wrist and MCPJs of the ngers
and weakness of supination of the forearm. The cutaneous branches of the arm and forearm have already arisen and
sensation loss occurs only on the dorsum of the lateral hand and three and a half digits.

Notes
The radial nerve is a continuation of the posterior cord, containing bres from C5 – T1.

Nerve Radial nerve

Nerve C5 – T1
roots

Plexus Posterior cord

cords

Motor Triceps brachii, posterior compartment of forearm: super cial muscles (brachioradialis, extensor carpi
Supply radialis longus and brevis, extensor digitorum, extensor digiti minimi, extensor carpi ulnaris) and deep
muscles (supinator, abductor pollicis longus, extensor pollicis longus and brevis, extensor indicis)

Sensory Lower lateral arm, posterior arm, posterior forearm, dorsum of lateral hand and three and a half
supply ngers

Anatomical course

The radial nerve enters the arm by crossing the lower margin of the teres major muscle, where it lies posterior to the
brachial artery. It enters the posterior compartment of the arm, where it descends obliquely passing from medial to
lateral in the radial (spiral) groove of the humerus. After emerging from the spiral groove, the radial nerve pierces the
lateral intermuscular septum and enters the anterior compartment of the arm, descending into the cubital fossa where
it lies between the brachialis and brachioradialis muscles. The radial nerve enters the forearm after passing over the
lateral epicondyle of the humerus. Within the proximal forearm the nerve terminates by bifurcating into the deep
branch and the super cial branch. N.B. Once the deep branch of the radial nerve penetrates between the two heads of
the supinator muscle to access the posterior compartment of the arm, it becomes known as the posterior interosseous
nerve.

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By Henry Vandyke Carter [Public domain], via Wikimedia

Commons

Branches

Branches of Radial Origin Supply

Nerve

Radial nerve Axilla Triceps brachii, extensor carpi radialis longus, brachioradialis

Posterior Axilla Skin of posterior arm

cutaneous nerve of
the arm

Inferior lateral Arm Skin over lateral aspect of lower arm

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Inferior lateral Arm Skin over lateral aspect of lower arm
cutaneous nerve of
the arm

Posterior Arm Strip of skin down middle of posterior forearm

cutaneous nerve of
the forearm

Deep branch which Forearm Posterior compartment of forearm: super cial muscles (extensor carpi radialis
continues as the brevis, extensor digitorum, extensor digiti minimi, extensor carpi ulnaris) and
posterior deep muscles (supinator, abductor pollicis longus, extensor pollicis longus and
interosseous nerve brevis, extensor indicis)

Super cial branch Forearm Skin of dorsum of the hand and lateral three and a half ngers

In the arm, the radial nerve directly innervates the triceps brachii, the extensor carpi radialis longus and the
brachioradialis. In the forearm, the deep branch, which continues as the posterior interosseous nerve, innervates the
muscles of the posterior compartment of the forearm and the super cial branch supplies the skin of the dorsum of the
hand and lateral three and a half ngers.

The radial nerve also gives rise to several cutaneous branches; the posterior cutaneous nerve of the arm originating in
the axilla, and the inferior lateral cutaneous nerve of the arm and the posterior cutaneous nerve of the forearm
originating in the arm. These cutaneous branches supply skin over the posterior surface of the arm, the lateral aspect
of the arm and the skin down the middle of the posterior forearm respectively.

Clinical implications

Lesion In axilla In spiral groove In forearm In forearm (deep

(super cial branch) branch)

Mechanism Glenohumeral joint Fracture of midshaft Stabbing/laceration Fracture of

dislocation, fracture of of humerus of forearm radial head or
proximal humerus, ‘Saturday posterior
night syndrome’ dislocation
of radius

Motor Loss Loss of extension at elbow, Loss of extension at None Weakness of

wrist and ngers wrist and ngers extension at
(triceps brachii wrist and
spared) ngers (extensor
carpi radialis
spared)

Sensory Lower lateral arm, posterior Dorsum of lateral Dorsum of lateral None
Loss arm, posterior forearm, hand and three and a hand and three and
dorsum of lateral hand and half ngers a half ngers
three and a half ngers (cutaneous branches
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three and a half ngers (cutaneous branches
of arm and forearm
spared)

Signs Wrist drop (unopposed Wrist drop, weak None Wrist drop not
wrist exion), weakness of hand grip typically seen
hand grip ( nger exion is (extensor carpi
weak as the long exor radialis spared)
tendons are not under
tension)

Radial nerve injury at the axilla may occur in glenohumeral joint dislocation, in fractures of the proximal humerus,
through incorrect use of axillary crutches, or due to ‘Saturday Night’ palsy. There is loss of extension of the forearm
due to paralysis of the triceps brachii and loss of extension of the wrist and ngers (predominantly MCPJs, as extension
at the IPJs is primarily a function of the lumbrical and interosseous muscles) and weakness of supination due to
paralysis of the muscles of the posterior compartment of the forearm. All four cutaneous branches of the radial nerve
are affected and there is loss of sensation over the lateral and posterior arm, the posterior forearm and the dorsal
surface of the hand and lateral three and a half digits. There is unopposed wrist exion, giving the appearance of wrist
drop.

The radial nerve in the arm is most susceptible to midshaft fractures of the humerus due to its course in the spiral
groove. Extension of the forearm is not affected as the triceps brachii is spared. There is loss of extension of the wrist
and MCPJs of the ngers and weakness of supination of the forearm. The cutaneous branches of the arm and forearm
have already arisen and sensation loss occurs only on the dorsum of the lateral hand and three and a half digits.

Radial nerve damage in the forearm may present as super cial branch or deep branch damage. The super cial branch is
most commonly damaged by stabbing or laceration to the forearm and results in loss of sensation over the dorsum of
the lateral hand and three and a half digits. The deep branch may be damaged by fracture of the radial head or
posterior dislocation of the radius and results in weakness of extension of the wrist and ngers, but not typically with
wrist drop (as the extensor carpi radialis is spared).

A 35 year old man attends ED having been thrown off his mountain bike and fallen onto his
right arm. You note numerous abrasions and bruises. He is unable to extend his right wrist, ngers
and thumb, although can extend his elbow. Sensation is abnormal on the lateral dorsum of his right
hand. Which of the following nerves has most likely been affected, and at which level:

a) Radial nerve, axilla

b) Median nerve, arm
c) Radial nerve, midhumerus
d) Super cial branch of radial nerve, forearm
e) Ulnar nerve, forearm
Something wrong?

Answer
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Answer
The radial nerve innervates the posterior muscles in the arm and forearm, which primarily act to produce extension of
the forearm, wrist and ngers. In injury to the radial nerve in the axilla, you would expect the triceps brachii muscle to
also be affected, and thus extension at the elbow to be lost in association with loss of sensation over the inferior lateral
arm and posterior arm and forearm. In injury at the mid-humerus the triceps brachii muscle and the cutaneous
branches of the arm and forearm are usually spared. The super cial branch of the radial nerve has no motor supply and
thus cannot solely be affected in this case.

Notes
The radial nerve is a continuation of the posterior cord, containing bres from C5 – T1.

Nerve Radial nerve

Nerve C5 – T1
roots

Plexus Posterior cord

cords

Motor Triceps brachii, posterior compartment of forearm: super cial muscles (brachioradialis, extensor carpi
Supply radialis longus and brevis, extensor digitorum, extensor digiti minimi, extensor carpi ulnaris) and deep
muscles (supinator, abductor pollicis longus, extensor pollicis longus and brevis, extensor indicis)

Sensory Lower lateral arm, posterior arm, posterior forearm, dorsum of lateral hand and three and a half
supply ngers

Anatomical course

The radial nerve enters the arm by crossing the lower margin of the teres major muscle, where it lies posterior to the
brachial artery. It enters the posterior compartment of the arm, where it descends obliquely passing from medial to
lateral in the radial (spiral) groove of the humerus. After emerging from the spiral groove, the radial nerve pierces the
lateral intermuscular septum and enters the anterior compartment of the arm, descending into the cubital fossa where
it lies between the brachialis and brachioradialis muscles. The radial nerve enters the forearm after passing over the
lateral epicondyle of the humerus. Within the proximal forearm the nerve terminates by bifurcating into the deep
branch and the super cial branch. N.B. Once the deep branch of the radial nerve penetrates between the two heads of
the supinator muscle to access the posterior compartment of the arm, it becomes known as the posterior interosseous
nerve.

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By Henry Vandyke Carter [Public domain], via Wikimedia

Commons

Branches

Branches of Radial Origin Supply

Nerve

Radial nerve Axilla Triceps brachii, extensor carpi radialis longus, brachioradialis

Posterior Axilla Skin of posterior arm

cutaneous nerve of
the arm

Inferior lateral
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Inferior lateral Arm Skin over lateral aspect of lower arm
cutaneous nerve of
the arm

Posterior Arm Strip of skin down middle of posterior forearm

cutaneous nerve of
the forearm

Deep branch which Forearm Posterior compartment of forearm: super cial muscles (extensor carpi radialis
continues as the brevis, extensor digitorum, extensor digiti minimi, extensor carpi ulnaris) and
posterior deep muscles (supinator, abductor pollicis longus, extensor pollicis longus and
interosseous nerve brevis, extensor indicis)

Super cial branch Forearm Skin of dorsum of the hand and lateral three and a half ngers

In the arm, the radial nerve directly innervates the triceps brachii, the extensor carpi radialis longus and the
brachioradialis. In the forearm, the deep branch, which continues as the posterior interosseous nerve, innervates the
muscles of the posterior compartment of the forearm and the super cial branch supplies the skin of the dorsum of the
hand and lateral three and a half ngers.

The radial nerve also gives rise to several cutaneous branches; the posterior cutaneous nerve of the arm originating in
the axilla, and the inferior lateral cutaneous nerve of the arm and the posterior cutaneous nerve of the forearm
originating in the arm. These cutaneous branches supply skin over the posterior surface of the arm, the lateral aspect
of the arm and the skin down the middle of the posterior forearm respectively.

Clinical implications

Lesion In axilla In spiral groove In forearm In forearm (deep

(super cial branch) branch)

Mechanism Glenohumeral joint Fracture of midshaft Stabbing/laceration Fracture of

dislocation, fracture of of humerus of forearm radial head or
proximal humerus, ‘Saturday posterior
night syndrome’ dislocation
of radius

Motor Loss Loss of extension at elbow, Loss of extension at None Weakness of

wrist and ngers wrist and ngers extension at
(triceps brachii wrist and
spared) ngers (extensor
carpi radialis
spared)

Sensory Lower lateral arm, posterior Dorsum of lateral Dorsum of lateral None
Loss arm, posterior forearm, hand and three and a hand and three and
dorsum of lateral hand and half ngers a half ngers
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three and a half ngers (cutaneous branches

of arm and forearm
spared)

Signs Wrist drop (unopposed Wrist drop, weak None Wrist drop not
wrist exion), weakness of hand grip typically seen
hand grip ( nger exion is (extensor carpi
weak as the long exor radialis spared)
tendons are not under
tension)

Radial nerve injury at the axilla may occur in glenohumeral joint dislocation, in fractures of the proximal humerus,
through incorrect use of axillary crutches, or due to ‘Saturday Night’ palsy. There is loss of extension of the forearm
due to paralysis of the triceps brachii and loss of extension of the wrist and ngers (predominantly MCPJs, as extension
at the IPJs is primarily a function of the lumbrical and interosseous muscles) and weakness of supination due to
paralysis of the muscles of the posterior compartment of the forearm. All four cutaneous branches of the radial nerve
are affected and there is loss of sensation over the lateral and posterior arm, the posterior forearm and the dorsal
surface of the hand and lateral three and a half digits. There is unopposed wrist exion, giving the appearance of wrist
drop.

The radial nerve in the arm is most susceptible to midshaft fractures of the humerus due to its course in the spiral
groove. Extension of the forearm is not affected as the triceps brachii is spared. There is loss of extension of the wrist
and MCPJs of the ngers and weakness of supination of the forearm. The cutaneous branches of the arm and forearm
have already arisen and sensation loss occurs only on the dorsum of the lateral hand and three and a half digits.

Radial nerve damage in the forearm may present as super cial branch or deep branch damage. The super cial branch is
most commonly damaged by stabbing or laceration to the forearm and results in loss of sensation over the dorsum of
the lateral hand and three and a half digits. The deep branch may be damaged by fracture of the radial head or
posterior dislocation of the radius and results in weakness of extension of the wrist and ngers, but not typically with
wrist drop (as the extensor carpi radialis is spared).

A 21 year old man presents to ED with multiple lacerations to his right upper limb, after falling
through a ground oor window during a ght. He is unable to ex the distal interphalangeal joints
of the fourth and fth digits. Which of the following muscles is most likely affected:

a) Flexor digitorum super cialis

b) Flexor digitorum profundus
c) Lumbricals
d) Flexor carpi ulnaris
e) Interossei
Something wrong?

Answer
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Answer

The ulnar nerve runs a super cial course and is vulnerable to laceration. The exor digitorum profundus, innervated by
the ulnar nerve medially and the median nerve laterally, acts to ex the distal interphalangeal joints and the
metacarpophalangeal joints of the medial four ngers. The exor digitorum super cialis, innervated by the deeper
median nerve, acts to ex the proximal interphalangeal joints and the metacarpophalangeal joints of the medial four
ngers. The exor carpi ulnaris acts to ex and adduct the wrist. The interossei mainly act to adduct and abduct the
ngers. The lumbricals act to ex the medial four ngers at the metacarpophalangeal joints and extend them at the
interphalangeal joints.

Notes
Hand movements are complex. The table below shows an overview of hand and thumb movements and the main
muscles bringing about these movements.

Hand movements Primary muscle (assisting muscles)

Flexion of MCPJ of digits 2 – 5 Lumbricals ( exor digitorum super cialis, exor digitorum profundus, exor
digiti minimi, interossei)

Flexion of PIPJ of digits 2 – 5 Flexor digitorum super cialis ( exor digitorum profundus)

Flexion of DIPJ of digits 2 – 5 Flexor digitorum profundus

Extension of MCPJ of digits 2 – Extensor digitorum, extensor indicis, extensor digiti minimi
5

Extension of PIPJ and DIPJ of Lumbricals and interossei (extensor digitorum)

digits 2 – 5

Adduction of digits 2 – 5 Palmar interossei

Abduction of digits 2 – 4 Dorsal interossei

Abduction of little nger Abductor digiti minimi

Opposition of little nger Opponens digiti minimi

Thumb movements Primary muscle(s)

Flexion of thumb at MCPJ Flexor pollicis longus and brevis

Flexion of thumb at IPJ Flexor pollicis longus

Extension of thumb at CMCJ and MCPJ

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Extension of thumb at CMCJ and MCPJ Extensor pollicis longus and brevis

Extension of thumb at IPJ Extensor pollicis longus

Abduction of thumb Abductor pollicis longus and brevis

Adduction of thumb Adductor pollicis

Opposition of thumb Opponens pollicis

Original by By OpenStax [CC BY 4.0 (http://creativecommons.org/licenses/by/4.0)], via Wikimedia

Commons

Your consultant asks you to perform a neurological assessment of a trauma patient. The
patient fell approximately 4 metres on a building site. Your consultant has arranged imaging that
shows a possible injury of the C6, C7 and T1 vertebrae. The C6 dermatome is best tested at which
of the following landmarks:

a) On the lateral side of the antecubital fossa

b)
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b) On the medial side of the antecubital fossa

c) Dorsum of middle nger
d) Dorsum of little nger
e) Dorsum of thumb
Something wrong?

Answer

The C6 dermatome is best tested on the dorsal surface of the proximal phalanx of the thumb.

Notes

Dermatome Landmark

C2 Occipital Protuberance

C3 Supraclavicular Fossa

C4 Acromioclavicular Joint

C5 Lateral Antecubital Fossa

C6 Thumb

C7 Middle Finger

C8 Little Finger

T1 Medial Antecubital Fossa

T2 Apex of Axilla

The C2 dermatome is best tested at least one cm lateral to the occipital protuberance at the base of the skull.
Alternately, it can be located at least 3 cm behind the ear.
The C3 dermatome is best tested in the supraclavicular fossa, at the midclavicular line.
The C4 dermatome is best tested over the acromioclavicular joint.
The C5 dermatome is best tested on the lateral (radial) side of the antecubital fossa just proximal to the elbow.
The C6 dermatome is best tested on the dorsal surface of the proximal phalanx of the thumb.
The C7 dermatome is best tested on the dorsal surface of the proximal phalanx of the middle nger.
The C8 dermatome is best tested on the dorsal surface of the proximal phalanx of the little nger.
The T1 dermatome is best tested on the medial (ulnar) side of the antecubital fossa, just proximal to the medial
epicondyle of the humerus.
The T2 dermatome is best tested at the apex of the axilla.

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By Grant, John Charles Boileau (An atlas of anatomy, / by regions 1962) [Public domain], via
Wikimedia Commons

A 32 year old electrician presents to the ED after sustaining a laceration to the forearm. On

examination of the hand you note loss of sensation to the lateral dorsal surface. The skin over the
lateral dorsum of the hand and the dorsum of the lateral three and a half digits is supplied by which
of the following nerves:

a) The super cial branch of the radial nerve

b) The deep branch of the radial nerve
c) The dorsal cutaneous branch of the ulnar nerve
d) The super cial branch of the ulnar nerve
e) The digital branch of the median nerve
Something wrong?

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Answer
The super cial branch of the radial nerve supplies the skin over the lateral dorsum of the hand and the lateral three and
a half digits.

Notes

Nerve Origin Skin supplied

Lateral supraclavicular nerve Cervical plexus (C3, Upper half of deltoid muscle
C4)

Superior lateral cutaneous nerve Axillary nerve Lower half of deltoid muscle
of the arm

Inferior lateral cutaneous nerve of Radial nerve Lateral arm below deltoid muscle
the arm

Medial cutaneous nerve of the Brachial plexus (C8, Medial arm

arm T1)

Intercostobrachial nerve Second intercostal Axilla

nerve (T2)

Posterior cutaneous nerve of the Radial nerve Posterior arm

arm

Medial cutaneous nerve of the Brachial plexus (C8, Medial forearm

forearm T1)

Posterior cutaneous nerve of the Radial nerve Posterior forearm

forearm

Lateral cutaneous nerve of the Musculocutaneous Lateral forearm

forearm nerve

Super cial branch of radial nerve Radial nerve Lateral dorsum of hand and lateral three and a
half digits

Palmar cutaneous branch of ulnar Ulnar nerve Medial half of palm

nerve

Dorsal cutaneous branch of ulnar Ulnar nerve Medial dorsum of hand and medial one and a half
nerve ngers

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Super cial branch of ulnar nerve Ulnar nerve Palmar surface of medial one and a half digits

Palmar cutaneous branch of Median nerve Lateral half of palm

median nerve

Palmar digital branch of median Median nerve Palmar surface and ngertips of lateral three and
nerve a half digits

Arm:

The lateral supraclavicular nerve, branch of the cervical plexus, supplies the skin over the upper half of the
deltoid muscle.
The superior lateral cutaneous nerve of the arm, branch of the axillary nerve, supplies the skin over the lower
half of the deltoid muscle (regimental badge area).
The inferior lateral cutaneous nerve of the arm, branch of the radial nerve, supplies the skin over the lateral
side of the arm below the deltoid muscle.
The medial cutaneous nerve of the arm, branch of the brachial plexus, supplies skin over the medial arm.
The intercostobrachial nerve, branch of the second intercostal nerve, supplies the skin of the axilla.
The posterior cutaneous nerve of the arm, branch of the radial nerve, supplies the skin over the posterior arm.

Forearm:

The medial cutaneous nerve of the forearm, branch of the brachial plexus, supplies the skin over the medial
aspect of the forearm.
The posterior cutaneous nerve of the forearm, branch of the radial nerve, supplies the skin over the posterior
forearm.
The lateral cutaneous nerve of the forearm, branch of the musculocutaneous nerve, supplies the skin over the
lateral aspect of the forearm.

Hand:

The super cial branch of the radial nerve supplies the skin over the lateral dorsum of the hand and the lateral
three and a half digits.
The palmar cutaneous branch of the ulnar nerve supplies the skin over the medial half of the palm.
The dorsal cutaneous branch of the ulnar nerve supplies the skin over medial dorsum of the hand and the
dorsum of the medial one and a half ngers.
The super cial branch of the ulnar nerve supplies the skin over the palmar surface of the medial one and a half
ngers.
The palmar cutaneous branch of the median nerve supplies the skin over the lateral half of the palm.
The palmar digital branch of the median nerve supplies the skin over the palmar surface and the ngertips of
the lateral three and a half digits.

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Modi ed by FRCEM Success. Original by Henry Vandyke Carter [Public domain], via Wikimedia Commons

You are examining the arm of a 23 year old electrician who has sustained a fracture of the
humerus following a fall. On examination he nds exion of the wrist painful. The exor muscles of
the anterior forearm all originate from which of the following structures:

a) The medial epicondyle of the humerus

b) The lateral epicondyle of the humerus
c) The lesser trochanter of the humerus
d) The greater trochanter of the humerus
e) The intertubercular groove of the humerus
Something wrong?

Answer
All of the muscles in the anterior forearm are innervated by the median nerve, except for the exor carpi ulnaris and
the medial half of the exor digitorum profundus which are innervated by the ulnar nerve.

Notes
The anterior forearm is divided into:

The super cial compartment consisting of the exor carpi ulnaris, exor carpi radialis, palmaris longus and the
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The super cial compartment consisting of the exor carpi ulnaris, exor carpi radialis, palmaris longus and the
pronator teres
The intermediate compartment consisting of the exor digitorum super cialis
The deep compartment consisting of the exor digitorum profundus, exor pollicis longus and pronator
quadratus

All of the muscles in the anterior forearm are innervated by the median nerve, except for the exor carpi ulnaris and
the medial half of the exor digitorum profundus which are innervated by the ulnar nerve.

Muscle Action Innervation

Flexor carpi ulnaris Flexion and adduction of wrist Ulnar nerve

Flexor carpi radialis Flexion and abduction of wrist Median nerve

Palmaris longus Flexion of wrist Median nerve

Pronator teres Pronation of forearm Median nerve

Flexor digitorum Flexion of MCPJ and PIPJ of all four digits, Median nerve
super cialis exion of wrist

Flexor pollicis longus Flexion of MCPJ and IPJ of thumb Median nerve

Flexor digitorum Flexion of MCPJ and DIPJ of all four digits, Lateral half by median nerve, medial half
profundus exion of wrist by ulnar nerve

Pronator quadratus Pronation of forearm Median nerve

The exor muscles of the anterior forearm all originate from the medial humeral epicondyle. A detailed knowledge of
the distal attachments of the exor tendons is important to allow understanding of the clinical effects of division/injury
at any given level of the nger.

The exor pollicis longus is attached distally to the base of the distal phalanx of the thumb.
The exor digitorum profundus is attached distally to the palmar surface of the distal phalanges of all four
ngers.
The exor digitorum super cialis is attached distally to the palmar surface of the middle phalanges of all four
ngers.
The exor carpi ulnaris is attached distally to the pisiform, hook of hamate and 5th metacarpal.
The exor carpi radialis is attached distally to the base of the 2nd and 3rd metacarpal.
The palmaris longus distally blends with the bres of the exor retinaculum which is continuous with the
palmar aponeurosis.

Flexor tendon Distal attachment

Flexor pollicis longus Base of distal phalanx of thumb

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Flexor pollicis longus Base of distal phalanx of thumb

Flexor digitorum profundus Distal phalanges of all four digits

Flexor digitorum super cialis Middle phalanges of all four digits

Flexor carpi ulnaris Pisiform, hook of hamate and 5th metacarpal

Flexor carpi radialis Base of 2nd and 3rd metacarpal

Palmaris longus Palmar aponeurosis

By Henry Vandyke Carter [Public

domain], via Wikimedia Commons

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By Henry Vandyke Carter [Public domain], via

Wikimedia Commons

A patient presents to ED complaining of weakness in her right hand. After examination, you
suspect weakness of the lumbrical muscles. Regarding the lumbrical muscles, which of the
following statements is CORRECT:

a) The lumbrical muscles originate from the tendons of the exor digitorum super cialis muscle.
b) The lumbrical muscles insert into the distal phalanges of the medial four ngers.
c) The lumbrical muscles act to ex the ngers at the metacarpophalangeal joints.
d) The lumbrical muscles are all innervated by the ulnar nerve.
e) The lumbrical muscles act to ex the ngers at the interphalangeal joints.
Something wrong?

Answer

The lumbrical muscles act to ex these ngers at the metacarpophalangeal joints (MCPJs) and extend them at the
interphalangeal joints (IPJs).

Notes
The lumbrical muscles originate from the tendons of the exor digitorum profundus in the palm and insert into the
extensor hoods of the medial four ngers.

The lumbrical muscles act to ex these ngers at the metacarpophalangeal joints (MCPJs) and extend them at the
interphalangeal joints (IPJs).

The medial two lumbricals are innervated by the ulnar nerve and the lateral two lumbricals are innervated by the
median nerve.

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Modi ed by FRCEM Success. Original by CFCF (Own work) [CC BY-SA 4.0
(http://creativecommons.org/licenses/by-sa/4.0)], via Wikimedia Commons

A 67 year old patient complains of weakness of abduction and adduction of his ngers. You
suspect weakness of the interossei. Regarding the interosseous muscles, which of the following
statements is INCORRECT:

a) The interossei lie between and attached to the metacarpals.

b) The interossei insert into the extensor hoods of the ngers.
c) There are three palmar and four dorsal interossei.
d) The interossei are innervated by the ulnar nerve.
e) The dorsal interossei adduct the ngers.
Something wrong?

Answer
The four dorsal interossei act to abduct the index, middle and ring ngers, and the three palmar interossei act to
adduct the thumb, index, ring and little ngers. (DAB, PAD).

Notes
The interosseous muscles originate from and lie between the metacarpal bones. The dorsal interossei insert into the
extensor hoods and proximal phalanges of the index, middle and ring nger. The palmar interossei insert into the
extensor hoods of the index, ring and little nger.

The four dorsal interossei act to abduct the index, middle and ring ngers, and the three palmar interossei act to
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The four dorsal interossei act to abduct the index, middle and ring ngers, and the three palmar interossei act to
adduct the index, ring and little ngers. (DAB, PAD). Because the interosseous muscles insert into the extensor hoods,
they also contribute to the complex exion and extension movements of the interphalangeal joints of the digits.

The interosseous muscles are all innervated by the ulnar nerve.

Muscle Action Innervation

Dorsal interossei Abduction of ngers at MCPJ Ulnar nerve

Palmar interossei Adduction of ngers at MCPJ Ulnar nerve

Modi ed by FRCEM Success. Original by By OpenStax [CC BY 4.0

(http://creativecommons.org/licenses/by/4.0)], via Wikimedia Commons

A 16 year old boy sustains a supracondylar fracture falling off his skateboard. He is unable to
ex the distal interphalangeal joint of his index nger. Which of the following clinical nding are
you most likely to see on further examination:

a) Inability to ex the distal interphalangeal joint of the ring nger

b) Loss of supination of the forearm
c) Loss of sensation over the lateral dorsum of the hand.
d) Inability to oppose the thumb
e) Inability to abduct the ngers
Something wrong?

Answer

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A supracondylar fracture is most commonly associated with damage to the median nerve. Paralysis of the lateral half of
the exor digitorum profundus would cause loss of exion at the distal interphalangeal joint of the index nger but not
the ring nger, as the medial half is innervated by the ulnar nerve. Median nerve injury results in paralysis of the thenar
muscles with loss of opposition of the thumb.

Notes
The median nerve is formed from the medial and lateral brachial plexus cords and contains bres from all ve roots (C5
– T1).

Nerve Median nerve

Nerve C5 – T1
roots

Plexus Medial and lateral cords

cords

Motor All the anterior forearm muscles (except for the exor carpi ulnaris and the medial half of the exor
Supply digitorum profundus), the thenar muscles ( exor pollicis brevis, abductor pollicis brevis, opponens
pollicis) and the lateral two lumbricals

Sensory Lateral aspect of palm and palmar surface and ngertips of lateral three and a half digits
supply

Anatomical course

The median nerve originates in the axilla before passing down the medial side of the arm (initially lateral to the brachial
artery before crossing over to the medial side of the brachial artery). It enters the anterior compartment of the
forearm via the antecubital fossa, travelling between the exor digitorum profundus and exor digitorum super cialis
muscles, before entering the hand via the carpal tunnel and bifurcating into its terminal branches.

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By Henry Vandyke Carter [Public domain], via Wikimedia Commons

Branches

Branches of Origin Supply

Median Nerve

Median nerve Axilla Super cial and intermediate compartment of anterior forearm (pronator teres,
exor carpi radialis, palmaris longus, exor digitorum super cialis, NOT exor
carpi ulnaris)

Anterior Forearm Deep compartment of anterior forearm ( exor pollicis longus, pronator
interosseous quadratus, lateral half of exor digitorum profundus)
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interosseous quadratus, lateral half of exor digitorum profundus)
nerve

Palmar Forearm Skin over the lateral aspect of the palm

cutaneous
branch

Recurrent Hand Thenar muscles ( exor pollicis brevis, abductor pollicis brevis, opponens pollicis)
branch of
median nerve

Palmar digital Hand Lateral two lumbricals and skin over the palmar surface and ngertips of the
branch lateral three and a half digits

The median nerve directly innervates the pronator teres, the exor carpi radialis, the palmaris longus and the exor
digitorum super cialis. It gives off no major branches in the arm, but gives rise to the anterior interosseous nerve
(innervating the exor pollicis longus, the pronator quadratus, and the lateral half of the exor digitorum profundus)
and the palmar cutaneous nerve (innervating the lateral aspect of the palm) in the forearm.

In the hand the median nerve bifurcates into the recurrent branch of the median nerve (innervating the thenar
muscles) and the palmar digital branch (innervating the lateral two lumbricals and the skin over the palmar surface and
ngertips of the lateral three and a half digits).

Clinical implications

Lesion Proximal (arm, elbow, proximal forearm) Distal (wrist)

Mechanisms Supracondylar fracture, stab wound to arm or forearm Lacerations just

proximal to exor
retinaculum, carpal
tunnel syndrome

Motor Loss Forearm pronation, wrist exion and abduction, index and middle nger Thumb exion,
exion, thumb exion, abduction and opposition abduction and
opposition, exion of
index and middle
nger MCPJ

Sensory Lateral aspect of palm and palmar surface and ngertips of lateral three Palmar surface and
Loss and a half digits ngertips of lateral
three and a half digits

Signs Forearm rests in supination with wrist in ulnar deviation and thumb Thenar eminence
extended, thenar eminence wasting, hand of Benediction (when asked wasting
to make a st, the patient will be able to ex the little and ring ngers
but not the index and middle ngers)
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A proximal median nerve lesion at the elbow may occur due to supracondylar fracture of the humerus or from deep
penetrating wounds to the arm or forearm and may result in:

Pronation of the forearm and exion and abduction of the wrist are lost due to paralysis of the exors and
pronators in the forearm. The forearm thus often rests in supination with ulnar deviation of the wrist (due to
unopposed action of the exor carpi ulnaris).
Flexion, abduction and opposition of the thumb at the MCPJ and IPJ are lost due to paralysis of the thenar
muscles and the exor pollicis longus.
Flexion of the index and middle ngers at the IPJs is lost due to paralysis of the exor digitorum super cialis
and the lateral half of the exor digitorum profundus.
Flexion of the MCPJ of the index and middle ngers is lost due to paralysis of the lateral two lumbrical muscles.
N.B. Flexion of the ring and little ngers at the MCPJ and DIPJ are preserved as these are functions of the
medial half of the exor digitorum profundus and the medial two lumbrical muscles, innervated by the ulnar
nerve (there may be weakness of exion at the PIPJ of these ngers due to paralysis of the exor digitorum
super cialis).
There is loss of sensation over the lateral aspect of the palm, and the skin over the palmar surface and
ngertips of the lateral three and a half digits.

Medial nerve lesion at the wrist often occurs due to lacerations just proximal to the exor retinaculum or to
compression of the median nerve in the carpal tunnel. Only the intrinsic hand muscles are affected. Loss of opposition,
abduction and exion of the MCPJ of the thumb occurs due to paralysis of the thenar muscles. Loss of exion at the
MCPJ of the index and middle nger occurs due to paralysis of the lateral two lumbricals. There is loss of sensation to
the palmar surface and ngertips of the lateral three and a half digits only (the palmar region is spared).

A 28 year old man presents to ED having falling off his bike. Imaging shows fracture of the
medial epicondyle and ulnar nerve injury. Which of the following muscles will most likely be
affected:

a) Flexor digitorum super cialis

b) Supinator
c) Brachialis
d) Brachioradialis
e) Flexor digitorum profundus
Something wrong?

Answer
The ulnar nerve innervates the medial half of the exor digitorum profundus and the exor carpi ulnaris in the forearm
and most of the intrinsic muscles of the hand (except for the lateral two lumbricals, and the thenar muscles, innervated
by the median nerve). The exor digitorum super cialis is innervated by the median nerve. The brachialis is innervated
by the musculocutaneous nerve. The brachioradialis and the supinator are innervated by the radial nerve.

Notes
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Notes
The ulnar nerve is a continuation of the medial cord of the brachial plexus, containing bres from the C8 – T1 nerve
roots.

Nerve Ulnar nerve

Nerve C8 – T1
roots

Plexus Medial cord

cords

Motor All the intrinsic muscles of the hand (except for the thenar muscles and the lateral two lumbricals), the
Supply exor carpi ulnaris and the medial half of the exor digitorum profundus

Sensory Medial half of palm, palmar and dorsal surface of medial one and a half ngers and lateral dorsum of
supply hand

Anatomical course

The ulnar nerve descends down the medial side of the upper arm and passes posterior to the medial epicondyle (where
it is susceptible to damage) before entering the anterior compartment of the forearm by passing between the two
heads of the exor carpi ulnaris. It continues down the medial aspect of the forearm. The ulnar nerve emerges from
beneath the exor carpi ulnaris and becomes super cial just proximal to the wrist where it passes super cial to the
exor retinaculum, together with the ulnar artery, to enter the hand through a groove between the pisiform and the
hook of the hamate where it bifurcates into its terminal branches.

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By Henry Vandyke Carter [Public domain], via Wikimedia Commons

Branches

Branches of Origin Supply

Ulnar Nerve

Muscular Forearm Flexor carpi ulnaris, medial half of exor digitorum profundus
branch

Palmar Forearm Skin of medial half of palm

cutaneous
branch

Dorsal Forearm Skin of dorsum of medial one and a half ngers and associated dorsal hand area
cutaneous
branch
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branch

Deep branch Hand Hypothenar muscles (abductor digiti minimi, exor digiti minimi, opponens digiti
minimi), medial two lumbricals, adductor pollicis and interossei

Super cial Hand Skin of palmar surface of medial one and a half ngers
branch

The ulnar nerve gives off no major branches in the arm, but three branches arise in the forearm:

The muscular branch innervating the exor carpi ulnaris and the medial half of the exor digitorum profundus
The palmar cutaneous branch supplying the skin of the medial half of the palm
The dorsal cutaneous branch supplying the skin of the medial dorsum of the hand and the dorsal surface of the
medial one and a half ngers

The ulnar nerve terminates by bifurcating into:

A deep branch innervating the hypothenar muscles, the medial two lumbricals, the adductor pollicis and the
interossei
A super cial branch supplying the skin of the palmar surface of the medial one and a half ngers

Clinical implications

Lesion Proximal (at elbow) Distal (at wrist)

Mechanism Fracture of medial epicondyle Laceration at wrist

Motor Loss Wrist exion and adduction, nger abduction and adduction, exion Finger abduction and
of ring and little nger, abduction and opposition of little nger, thumb adduction, exion of ring
adduction, extension of IPJs of all digits (less so at index and middle and little nger,
nger due to sparing of lateral two lumbricals) abduction and
opposition of little
nger, thumb adduction,
extension at IPJs

Sensory Medial half of palm, palmar and dorsal surface of medial one and a half Palmar surface of medial
Loss ngers and medial dorsum of hand one and a half ngers

Signs Hand held in abduction (due to unopposed action of exor carpi Claw hand (unopposed
radialis), Froment’s sign (patient is asked to hold a piece of paper extension at MCPJ and
between thumb and at palm as paper is pulled away, patient will ex unopposed exion at
thumb at IPJ to maintain hold – tests adductor pollicis muscle), IPJs of ring and little
hypothenar eminence wasting, N.B. claw hand not typically seen due nger), hypothenar
to paralysis of the exor digitorum profundus eminence wasting,
Froment’s sign

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The ulnar nerve is most likely to be injured proximally by a medial epicondyle fracture and results in:

There is weak wrist exion and adduction due to paralysis of the exor carpi ulnaris and the medial half of the
exor digitorum profundus; the hand may be held in abduction (due to unopposed action of the exor carpi
radialis).
There is loss of abduction and adduction of the ngers due to paralysis of the interossei.
There is loss of exion at the MCPJ of the ring and little nger due to paralysis of the medial two lumbricals and
the exor digiti minimi.
There is loss of exion at the DIPJ of the ring and little nger due to paralysis of the medial half of the exor
digitorum profundus (but exion at the PIPJ is likely preserved as this is a function of the exor digitorum
super cialis).
There is weakened extension at the IPJs of the ring and little nger due to paralysis of the interossei and medial
two lumbricals (and to a lesser extent at the IPJs of the index and middle nger).
There is loss of abduction and opposition of the little nger due to paralysis of the hypothenar muscles
(hypothenar wasting may be seen).
There is loss of adduction of the thumb due to paralysis of the adductor pollicis (Froment’s sign).
There is loss of sensation to skin over the medial half of the palm, the palmar and dorsal surface of the medial
one and a half ngers and the medial dorsum of the hand.
There is not typically a claw hand appearance (as may be seen in a lesion at the wrist) due to paralysis of the
exor digitorum profundus.

A distal lesion most commonly occurs due to laceration at the wrist. Only intrinsic hand muscles are affected (the exor
carpi ulnaris and medial half of the exor digitorum profundus are spared). A loss of sensation will only affect the
palmar surface of the medial one and a half ngers (the medial palm and the dorsum of the hand are spared). A claw
hand deformity may be seen due to unopposed extension at the MCPJ (by the extensor digitorum) and unopposed
exion at the IPJs (by the FDP and FDS) of the ring and little nger.

Froment’s sign (right hand). Copyright FRCEM

Success.

Claw hand deformity. By Mcstrother (Own work)

[CC BY 3.0
(http://creativecommons.org/licenses/by/3.0)], via
Wikimedia Commons

A 72 year old man is brought to the ED by his daughter. He is complaining of a numbness in his
right arm. On examination you note he has lost sensation to the posterior forearm. The skin over
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right arm. On examination you note he has lost sensation to the posterior forearm. The skin over
the posterior forearm is supplied by which of the following nerves:

a) The posterior cutaneous nerve of the forearm, branch of the ulnar nerve
b) The posterior cutaneous nerve of the forearm, branch of the median nerve
c) The posterior cutaneous nerve of the forearm, branch of the radial nerve
d) The posterior cutaneous nerve of the forearm, branch of the musculocutaneous nerve
e) The posterior cutaneous nerve of the forearm, from the brachial plexus
Something wrong?

Answer
The posterior cutaneous nerve of the forearm, branch of the radial nerve, supplies the skin over the posterior forearm.

Notes

Nerve Origin Skin supplied

Lateral supraclavicular nerve Cervical plexus (C3, Upper half of deltoid muscle
C4)

Superior lateral cutaneous nerve Axillary nerve Lower half of deltoid muscle
of the arm

Inferior lateral cutaneous nerve of Radial nerve Lateral arm below deltoid muscle
the arm

Medial cutaneous nerve of the Brachial plexus (C8, Medial arm

arm T1)

Intercostobrachial nerve Second intercostal Axilla

nerve (T2)

Posterior cutaneous nerve of the Radial nerve Posterior arm

arm

Medial cutaneous nerve of the Brachial plexus (C8, Medial forearm

forearm T1)

Posterior cutaneous nerve of the Radial nerve Posterior forearm

forearm

Lateral cutaneous nerve of the Musculocutaneous Lateral forearm

forearm nerve

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Super cial branch of radial nerve Radial nerve Lateral dorsum of hand and lateral three and a
half digits

Palmar cutaneous branch of ulnar Ulnar nerve Medial half of palm

nerve

Dorsal cutaneous branch of ulnar Ulnar nerve Medial dorsum of hand and medial one and a half
nerve ngers

Super cial branch of ulnar nerve Ulnar nerve Palmar surface of medial one and a half digits

Palmar cutaneous branch of Median nerve Lateral half of palm

median nerve

Palmar digital branch of median Median nerve Palmar surface and ngertips of lateral three and
nerve a half digits

Arm:

The lateral supraclavicular nerve, branch of the cervical plexus, supplies the skin over the upper half of the
deltoid muscle.
The superior lateral cutaneous nerve of the arm, branch of the axillary nerve, supplies the skin over the lower
half of the deltoid muscle (regimental badge area).
The inferior lateral cutaneous nerve of the arm, branch of the radial nerve, supplies the skin over the lateral
side of the arm below the deltoid muscle.
The medial cutaneous nerve of the arm, branch of the brachial plexus, supplies skin over the medial arm.
The intercostobrachial nerve, branch of the second intercostal nerve, supplies the skin of the axilla.
The posterior cutaneous nerve of the arm, branch of the radial nerve, supplies the skin over the posterior arm.

Forearm:

The medial cutaneous nerve of the forearm, branch of the brachial plexus, supplies the skin over the medial
aspect of the forearm.
The posterior cutaneous nerve of the forearm, branch of the radial nerve, supplies the skin over the posterior
forearm.
The lateral cutaneous nerve of the forearm, branch of the musculocutaneous nerve, supplies the skin over the
lateral aspect of the forearm.

Hand:

The super cial branch of the radial nerve supplies the skin over the lateral dorsum of the hand and the lateral
three and a half digits.
The palmar cutaneous branch of the ulnar nerve supplies the skin over the medial half of the palm.
The dorsal cutaneous branch of the ulnar nerve supplies the skin over medial dorsum of the hand and the
dorsum of the medial one and a half ngers.
The super cial branch of the ulnar nerve supplies the skin over the palmar surface of the medial one and a half
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The super cial branch of the ulnar nerve supplies the skin over the palmar surface of the medial one and a half
ngers.
The palmar cutaneous branch of the median nerve supplies the skin over the lateral half of the palm.
The palmar digital branch of the median nerve supplies the skin over the palmar surface and the ngertips of
the lateral three and a half digits.

Modi ed by FRCEM Success. Original by Henry Vandyke Carter [Public domain], via Wikimedia Commons

You have been asked to review a 43 year old man who presents with weakness to the right
arm after falling. You perform a neurological examination of the upper limbs, including testing the
strength of the upper limb muscles. Which of the following muscles is innervated by the median
nerve:

a) Interossei muscles
b) Adductor pollicis
c) Flexor carpi ulnaris
d) Flexor carpi radialis
e) Medial two lumbricals
Something wrong?

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Answer

The exor carpi radialis is innervated by the median nerve. The adductor pollicis, exor carpi ulnaris, medial two
lumbricals and interossei muscles are innervated by the ulnar nerve.

Notes
The median nerve is formed from the medial and lateral brachial plexus cords and contains bres from all ve roots (C5
– T1).

Nerve Median nerve

Nerve C5 – T1
roots

Plexus Medial and lateral cords

cords

Motor All the anterior forearm muscles (except for the exor carpi ulnaris and the medial half of the exor
Supply digitorum profundus), the thenar muscles ( exor pollicis brevis, abductor pollicis brevis, opponens
pollicis) and the lateral two lumbricals

Sensory Lateral aspect of palm and palmar surface and ngertips of lateral three and a half digits
supply

Anatomical course

The median nerve originates in the axilla before passing down the medial side of the arm (initially lateral to the brachial
artery before crossing over to the medial side of the brachial artery). It enters the anterior compartment of the
forearm via the antecubital fossa, travelling between the exor digitorum profundus and exor digitorum super cialis
muscles, before entering the hand via the carpal tunnel and bifurcating into its terminal branches.

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By Henry Vandyke Carter [Public domain], via Wikimedia Commons

Branches

Branches of Origin Supply

Median Nerve

Median nerve Axilla Super cial and intermediate compartment of anterior forearm (pronator teres,
exor carpi radialis, palmaris longus, exor digitorum super cialis, NOT exor
carpi ulnaris)

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Anterior Forearm Deep compartment of anterior forearm ( exor pollicis longus, pronator
interosseous quadratus, lateral half of exor digitorum profundus)
nerve

Palmar Forearm Skin over the lateral aspect of the palm

cutaneous
branch

Recurrent Hand Thenar muscles ( exor pollicis brevis, abductor pollicis brevis, opponens pollicis)
branch of
median nerve

Palmar digital Hand Lateral two lumbricals and skin over the palmar surface and ngertips of the
branch lateral three and a half digits

The median nerve directly innervates the pronator teres, the exor carpi radialis, the palmaris longus and the exor
digitorum super cialis. It gives off no major branches in the arm, but gives rise to the anterior interosseous nerve
(innervating the exor pollicis longus, the pronator quadratus, and the lateral half of the exor digitorum profundus)
and the palmar cutaneous nerve (innervating the lateral aspect of the palm) in the forearm.

In the hand the median nerve bifurcates into the recurrent branch of the median nerve (innervating the thenar
muscles) and the palmar digital branch (innervating the lateral two lumbricals and the skin over the palmar surface and
ngertips of the lateral three and a half digits).

Clinical implications

Lesion Proximal (arm, elbow, proximal forearm) Distal (wrist)

Mechanisms Supracondylar fracture, stab wound to arm or forearm Lacerations just

proximal to exor
retinaculum, carpal
tunnel syndrome

Motor Loss Forearm pronation, wrist exion and abduction, index and middle nger Thumb exion,
exion, thumb exion, abduction and opposition abduction and
opposition, exion of
index and middle
nger MCPJ

Sensory Lateral aspect of palm and palmar surface and ngertips of lateral three Palmar surface and
Loss and a half digits ngertips of lateral
three and a half digits

Signs Forearm rests in supination with wrist in ulnar deviation and thumb Thenar eminence
extended, thenar eminence wasting, hand of Benediction (when asked wasting
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to make a st, the patient will be able to ex the little and ring ngers
but not the index and middle ngers)

A proximal median nerve lesion at the elbow may occur due to supracondylar fracture of the humerus or from deep
penetrating wounds to the arm or forearm and may result in:

Pronation of the forearm and exion and abduction of the wrist are lost due to paralysis of the exors and
pronators in the forearm. The forearm thus often rests in supination with ulnar deviation of the wrist (due to
unopposed action of the exor carpi ulnaris).
Flexion, abduction and opposition of the thumb at the MCPJ and IPJ are lost due to paralysis of the thenar
muscles and the exor pollicis longus.
Flexion of the index and middle ngers at the IPJs is lost due to paralysis of the exor digitorum super cialis
and the lateral half of the exor digitorum profundus.
Flexion of the MCPJ of the index and middle ngers is lost due to paralysis of the lateral two lumbrical muscles.
N.B. Flexion of the ring and little ngers at the MCPJ and DIPJ are preserved as these are functions of the
medial half of the exor digitorum profundus and the medial two lumbrical muscles, innervated by the ulnar
nerve (there may be weakness of exion at the PIPJ of these ngers due to paralysis of the exor digitorum
super cialis).
There is loss of sensation over the lateral aspect of the palm, and the skin over the palmar surface and
ngertips of the lateral three and a half digits.

Medial nerve lesion at the wrist often occurs due to lacerations just proximal to the exor retinaculum or to
compression of the median nerve in the carpal tunnel. Only the intrinsic hand muscles are affected. Loss of opposition,
abduction and exion of the MCPJ of the thumb occurs due to paralysis of the thenar muscles. Loss of exion at the
MCPJ of the index and middle nger occurs due to paralysis of the lateral two lumbricals. There is loss of sensation to
the palmar surface and ngertips of the lateral three and a half digits only (the palmar region is spared).

You are part of the trauma team caring for a 18 year old horse rider who fell when jumping a
fence. She is complaining of pain in her neck. Whilst awaiting imaging your consultant asks you to
perform a brief neurological assessment. She is tender over the C7 and T1 vertebrae. The C7
dermatome is best tested at which of the following landmarks:

a) Dorsum of middle nger

b) Dorsum of little nger
c) Dorsum of thumb
d) Medial antecubital fossa
e) Lateral antecubital fossa
Something wrong?

Answer
The C7 dermatome is best tested on the dorsal surface of the proximal phalanx of the middle nger.

Notes
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Notes

Dermatome Landmark

C2 Occipital Protuberance

C3 Supraclavicular Fossa

C4 Acromioclavicular Joint

C5 Lateral Antecubital Fossa

C6 Thumb

C7 Middle Finger

C8 Little Finger

T1 Medial Antecubital Fossa

T2 Apex of Axilla

The C2 dermatome is best tested at least one cm lateral to the occipital protuberance at the base of the skull.
Alternately, it can be located at least 3 cm behind the ear.
The C3 dermatome is best tested in the supraclavicular fossa, at the midclavicular line.
The C4 dermatome is best tested over the acromioclavicular joint.
The C5 dermatome is best tested on the lateral (radial) side of the antecubital fossa just proximal to the elbow.
The C6 dermatome is best tested on the dorsal surface of the proximal phalanx of the thumb.
The C7 dermatome is best tested on the dorsal surface of the proximal phalanx of the middle nger.
The C8 dermatome is best tested on the dorsal surface of the proximal phalanx of the little nger.
The T1 dermatome is best tested on the medial (ulnar) side of the antecubital fossa, just proximal to the medial
epicondyle of the humerus.
The T2 dermatome is best tested at the apex of the axilla.

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By Grant, John Charles Boileau (An atlas of anatomy, / by regions 1962) [Public domain], via
Wikimedia Commons

A patient presents with pain in the wrist and a tingling in the hand. On examination Tinel’s
test is positive and you diagnose carpal tunnel syndrome. Regarding the carpal tunnel, which of the
following statements is INCORRECT:

a)
The tendons of the exor digitorum profundus, exor digitorum super cialis and exor pollicis longus lie within a
single synovial sheath.
b) The median nerve lies anterior to the tendons in the carpal tunnel.
c) The ulnar nerve and ulnar artery pass over, not through, the carpal tunnel.
d) The oor of the carpal tunnel is formed medially by the pisiform and hook of the hamate.
e) The exor retinaculum forms the roof of the carpal tunnel.
Something wrong?

Answer
Free movement of the tendons in the carpal tunnel is facilitated by synovial sheaths, which surround the tendons. All of
the tendons of the FDP and FDS are contained within a single synovial sheath with a separate sheath enclosing the
tendon of the FPL.

Notes

Anatomical Structure
Boundaries
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Roof Flexor retinaculum

Carpal arch Pisiform and hook of the hamate medially, tubercles of the scaphoid and trapezium laterally

Contents Four tendons of exor digitorum profundus, four tendons of exor digitorum super cialis,
tendon of exor pollicis longus, median nerve

The carpal tunnel is formed by a deep carpal arch and a super cial exor retinaculum. The base of the carpal tunnel is
formed medially by the pisiform and the hook of the hamate and laterally by the tubercles of the scaphoid and
trapezium. The exor retinaculum is a thickened band of brous connective tissue on the volar aspect of the hand,
which bridges the gap between these carpal bones and forms the roof of the carpal tunnel.

The following structures pass through the carpal tunnel:

the four tendons of the exor digitorum profundus (FDP)

the four tendons of the exor digitorum super cialis (FDS)
the tendon of the exor pollicis longus (FPL)
the median nerve.

Free movement of the tendons in the carpal tunnel is facilitated by synovial sheaths, which surround the tendons. All of
the tendons of the FDP and FDS are contained within a single synovial sheath with a separate sheath enclosing the
tendon of the FPL. The median nerve lies anterior to the tendons in the carpal tunnel.

Carpal tunnel syndrome is caused by compression of the median nerve within the carpal tunnel.

Modi ed by FRCEM Success. Original by Henry Vandyke Carter [Public domain], via Wikimedia
Commons

A 47 year old secretary presents to the ED complaining of pain in the left wrist. After
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A 47 year old secretary presents to the ED complaining of pain in the left wrist. After
examination you suspect carpal tunnel syndrome. Which of the following structures passes
through the carpal tunnel:

a) Tendon of the exor carpi radialis

b) Ulnar artery
c) Ulnar nerve
d) Tendon of the palmaris longus
e) Tendon of the exor pollicis longus
Something wrong?

Answer
The tendons of the exor pollicis longus, exor digitorum super cialis and exor digitorum profundus pass through the
carpal tunnel. The ulnar nerve and ulnar artery pass into the hand anterior to the exor retinaculum and carpal tunnel.

Notes

Anatomical Structure
Boundaries

Roof Flexor retinaculum

Carpal arch Pisiform and hook of the hamate medially, tubercles of the scaphoid and trapezium laterally

Contents Four tendons of exor digitorum profundus, four tendons of exor digitorum super cialis,
tendon of exor pollicis longus, median nerve

The carpal tunnel is formed by a deep carpal arch and a super cial exor retinaculum. The base of the carpal tunnel is
formed medially by the pisiform and the hook of the hamate and laterally by the tubercles of the scaphoid and
trapezium. The exor retinaculum is a thickened band of brous connective tissue on the volar aspect of the hand,
which bridges the gap between these carpal bones and forms the roof of the carpal tunnel.

The following structures pass through the carpal tunnel:

the four tendons of the exor digitorum profundus (FDP)

the four tendons of the exor digitorum super cialis (FDS)
the tendon of the exor pollicis longus (FPL)
the median nerve.

Free movement of the tendons in the carpal tunnel is facilitated by synovial sheaths, which surround the tendons. All of
the tendons of the FDP and FDS are contained within a single synovial sheath with a separate sheath enclosing the
tendon of the FPL. The median nerve lies anterior to the tendons in the carpal tunnel.

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Carpal tunnel syndrome is caused by compression of the median nerve within the carpal tunnel.

Modi ed by FRCEM Success. Original by Henry Vandyke Carter [Public domain], via Wikimedia
Commons

A 29 year old woman presents to ED after injuring her left elbow. She is complaining of weak
grip in her left hand. You ask her to hold onto a piece of paper with both hands as you try to pull it
away from her. She is unable to hold onto the piece of paper in her left hand without exing the
distal joint of the thumb. Which of the following nerves is most likely to be damaged:

a) Axillary
b) Median
c) Musculocutaneous
d) Radial
e) Ulnar
Something wrong?

Answer
This is a positive Froment’s sign, which is seen in ulnar neuropathy, caused by weakness of the adductor pollicis muscle.

Notes
The ulnar nerve is a continuation of the medial cord of the brachial plexus, containing bres from the C8 – T1 nerve
roots.

Nerve Ulnar nerve

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Nerve C8 – T1
roots

Plexus Medial cord

cords

Motor All the intrinsic muscles of the hand (except for the thenar muscles and the lateral two lumbricals), the
Supply exor carpi ulnaris and the medial half of the exor digitorum profundus

Sensory Medial half of palm, palmar and dorsal surface of medial one and a half ngers and lateral dorsum of
supply hand

Anatomical course

The ulnar nerve descends down the medial side of the upper arm and passes posterior to the medial epicondyle (where
it is susceptible to damage) before entering the anterior compartment of the forearm by passing between the two
heads of the exor carpi ulnaris. It continues down the medial aspect of the forearm. The ulnar nerve emerges from
beneath the exor carpi ulnaris and becomes super cial just proximal to the wrist where it passes super cial to the
exor retinaculum, together with the ulnar artery, to enter the hand through a groove between the pisiform and the
hook of the hamate where it bifurcates into its terminal branches.

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By Henry Vandyke Carter [Public domain], via Wikimedia Commons

Branches

Branches of Origin Supply

Ulnar Nerve

Muscular Forearm Flexor carpi ulnaris, medial half of exor digitorum profundus
branch

Palmar Forearm Skin of medial half of palm

cutaneous
branch

Dorsal Forearm Skin of dorsum of medial one and a half ngers and associated dorsal hand area
cutaneous
branch

Deep branch Hand Hypothenar muscles (abductor digiti minimi, exor digiti minimi, opponens digiti
minimi), medial two lumbricals, adductor pollicis and interossei

Super cial Hand Skin of palmar surface of medial one and a half ngers
branch
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branch

The ulnar nerve gives off no major branches in the arm, but three branches arise in the forearm:

The muscular branch innervating the exor carpi ulnaris and the medial half of the exor digitorum profundus
The palmar cutaneous branch supplying the skin of the medial half of the palm
The dorsal cutaneous branch supplying the skin of the medial dorsum of the hand and the dorsal surface of the
medial one and a half ngers

The ulnar nerve terminates by bifurcating into:

A deep branch innervating the hypothenar muscles, the medial two lumbricals, the adductor pollicis and the
interossei
A super cial branch supplying the skin of the palmar surface of the medial one and a half ngers

Clinical implications

Lesion Proximal (at elbow) Distal (at wrist)

Mechanism Fracture of medial epicondyle Laceration at wrist

Motor Loss Wrist exion and adduction, nger abduction and adduction, exion Finger abduction and
of ring and little nger, abduction and opposition of little nger, thumb adduction, exion of ring
adduction, extension of IPJs of all digits (less so at index and middle and little nger,
nger due to sparing of lateral two lumbricals) abduction and
opposition of little
nger, thumb adduction,
extension at IPJs

Sensory Medial half of palm, palmar and dorsal surface of medial one and a half Palmar surface of medial
Loss ngers and medial dorsum of hand one and a half ngers

Signs Hand held in abduction (due to unopposed action of exor carpi Claw hand (unopposed
radialis), Froment’s sign (patient is asked to hold a piece of paper extension at MCPJ and
between thumb and at palm as paper is pulled away, patient will ex unopposed exion at
thumb at IPJ to maintain hold – tests adductor pollicis muscle), IPJs of ring and little
hypothenar eminence wasting, N.B. claw hand not typically seen due nger), hypothenar
to paralysis of the exor digitorum profundus eminence wasting,
Froment’s sign

The ulnar nerve is most likely to be injured proximally by a medial epicondyle fracture and results in:

There is weak wrist exion and adduction due to paralysis of the exor carpi ulnaris and the medial half of the
exor digitorum profundus; the hand may be held in abduction (due to unopposed action of the exor carpi
radialis).
There is loss of abduction and adduction of the ngers due to paralysis of the interossei.
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There is loss of abduction and adduction of the ngers due to paralysis of the interossei.
There is loss of exion at the MCPJ of the ring and little nger due to paralysis of the medial two lumbricals and
the exor digiti minimi.
There is loss of exion at the DIPJ of the ring and little nger due to paralysis of the medial half of the exor
digitorum profundus (but exion at the PIPJ is likely preserved as this is a function of the exor digitorum
super cialis).
There is weakened extension at the IPJs of the ring and little nger due to paralysis of the interossei and medial
two lumbricals (and to a lesser extent at the IPJs of the index and middle nger).
There is loss of abduction and opposition of the little nger due to paralysis of the hypothenar muscles
(hypothenar wasting may be seen).
There is loss of adduction of the thumb due to paralysis of the adductor pollicis (Froment’s sign).
There is loss of sensation to skin over the medial half of the palm, the palmar and dorsal surface of the medial
one and a half ngers and the medial dorsum of the hand.
There is not typically a claw hand appearance (as may be seen in a lesion at the wrist) due to paralysis of the
exor digitorum profundus.

A distal lesion most commonly occurs due to laceration at the wrist. Only intrinsic hand muscles are affected (the exor
carpi ulnaris and medial half of the exor digitorum profundus are spared). A loss of sensation will only affect the
palmar surface of the medial one and a half ngers (the medial palm and the dorsum of the hand are spared). A claw
hand deformity may be seen due to unopposed extension at the MCPJ (by the extensor digitorum) and unopposed
exion at the IPJs (by the FDP and FDS) of the ring and little nger.

Froment’s sign (right hand). Copyright FRCEM

Success.

Claw hand deformity. By Mcstrother (Own work)

[CC BY 3.0
(http://creativecommons.org/licenses/by/3.0)], via
Wikimedia Commons

A patient sustains an injury to the proximal median nerve after falling through a glass door.
Which of the following muscles would you not expect to be affected:

a) Flexor carpi ulnaris

b) Flexor carpi radialis
c) Flexor digitorum super cialis
d) Flexor digitorum profundus
e) Flexor pollicis longus
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e) Flexor pollicis longus
Something wrong?

Answer
All of the muscles in the anterior forearm are innervated by the median nerve, except for the exor carpi ulnaris and
the medial half of the exor digitorum profundus which are innervated by the ulnar nerve.

Notes
The anterior forearm is divided into:

The super cial compartment consisting of the exor carpi ulnaris, exor carpi radialis, palmaris longus and the
pronator teres
The intermediate compartment consisting of the exor digitorum super cialis
The deep compartment consisting of the exor digitorum profundus, exor pollicis longus and pronator
quadratus

All of the muscles in the anterior forearm are innervated by the median nerve, except for the exor carpi ulnaris and
the medial half of the exor digitorum profundus which are innervated by the ulnar nerve.

Muscle Action Innervation

Flexor carpi ulnaris Flexion and adduction of wrist Ulnar nerve

Flexor carpi radialis Flexion and abduction of wrist Median nerve

Palmaris longus Flexion of wrist Median nerve

Pronator teres Pronation of forearm Median nerve

Flexor digitorum Flexion of MCPJ and PIPJ of all four digits, Median nerve
super cialis exion of wrist

Flexor pollicis longus Flexion of MCPJ and IPJ of thumb Median nerve

Flexor digitorum Flexion of MCPJ and DIPJ of all four digits, Lateral half by median nerve, medial half
profundus exion of wrist by ulnar nerve

Pronator quadratus Pronation of forearm Median nerve

The exor muscles of the anterior forearm all originate from the medial humeral epicondyle. A detailed knowledge of
the distal attachments of the exor tendons is important to allow understanding of the clinical effects of division/injury
at any given level of the nger.

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The exor pollicis longus is attached distally to the base of the distal phalanx of the thumb.
The exor digitorum profundus is attached distally to the palmar surface of the distal phalanges of all four
ngers.
The exor digitorum super cialis is attached distally to the palmar surface of the middle phalanges of all four
ngers.
The exor carpi ulnaris is attached distally to the pisiform, hook of hamate and 5th metacarpal.
The exor carpi radialis is attached distally to the base of the 2nd and 3rd metacarpal.
The palmaris longus distally blends with the bres of the exor retinaculum which is continuous with the
palmar aponeurosis.

Flexor tendon Distal attachment

Flexor pollicis longus Base of distal phalanx of thumb

Flexor digitorum profundus Distal phalanges of all four digits

Flexor digitorum super cialis Middle phalanges of all four digits

Flexor carpi ulnaris Pisiform, hook of hamate and 5th metacarpal

Flexor carpi radialis Base of 2nd and 3rd metacarpal

Palmaris longus Palmar aponeurosis

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By Henry Vandyke Carter [Public

domain], via Wikimedia Commons

By Henry Vandyke Carter [Public domain], via

Wikimedia Commons

A 43 year old man sustains an injury to the proximal ulnar nerve after falling through a
greenhouse door. Which of the following muscles would you not expect to be affected:

a) Opponens digiti minimi

b) Abductor digiti minimi
c) Flexor digiti minimi
d) Extensor digiti minimi
e) Flexor carpi ulnaris
Something wrong?

Answer
The hypothenar muscles (opponens digiti minimi, abductor digiti minimi and exor digiti minimi) are all innervated by
the ulnar nerve. The exor carpi ulnaris in the anterior forearm is also innervated by the ulnar nerve. The extensor
digiti minimi in the posterior forearm is innervated by the radial nerve.

Notes

The hypothenar muscles are the opponens digiti minimi, the abductor digiti minimi and the exor digiti minimi, all
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The hypothenar muscles are the opponens digiti minimi, the abductor digiti minimi and the exor digiti minimi, all
innervated by the ulnar nerve.

Muscle Action Innervation

Opponens digiti minimi (blue) Laterally rotates little nger Ulnar nerve

Abductor digiti minimi (green) Abducts little nger at MCPJ Ulnar nerve

Flexor digiti minimi brevis (red) Flexes little nger at MCPJ Ulnar nerve

Modi ed by FRCEM Success. Original by By OpenStax [CC BY 4.0

(http://creativecommons.org/licenses/by/4.0)], via Wikimedia Commons

A 42 year old construction worker has sustained a penetrating injury to his left forearm. On
examination, he is unable to form the ‘ok’ sign between his thumb and index nger due to weak
exion of the distal interphalangeal joints of these ngers. He is able to touch the pad of his little
nger with his thumb. Which of the following nerves has most likely been affected:

a) Recurrent branch of median nerve

b) Anterior interosseous nerve
c) Posterior interosseous nerve
d) Palmar digital branch of the median nerve
e) Deep branch of the ulnar nerve
Something wrong?

Answer
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The anterior interosseous nerve, branch of the median nerve, innervates the exor pollicis longus and the lateral half of
the exor digitorum profundus muscles which are responsible for exion at the distal interphalangeal joint of the
thumb and index nger respectively. Opposition is preserved, as this is controlled by the thenar muscles, innervated by
the recurrent branch of the median nerve.

Notes
The median nerve is formed from the medial and lateral brachial plexus cords and contains bres from all ve roots (C5
– T1).

Nerve Median nerve

Nerve C5 – T1
roots

Plexus Medial and lateral cords

cords

Motor All the anterior forearm muscles (except for the exor carpi ulnaris and the medial half of the exor
Supply digitorum profundus), the thenar muscles ( exor pollicis brevis, abductor pollicis brevis, opponens
pollicis) and the lateral two lumbricals

Sensory Lateral aspect of palm and palmar surface and ngertips of lateral three and a half digits
supply

Anatomical course

The median nerve originates in the axilla before passing down the medial side of the arm (initially lateral to the brachial
artery before crossing over to the medial side of the brachial artery). It enters the anterior compartment of the
forearm via the antecubital fossa, travelling between the exor digitorum profundus and exor digitorum super cialis
muscles, before entering the hand via the carpal tunnel and bifurcating into its terminal branches.

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By Henry Vandyke Carter [Public domain], via Wikimedia Commons

Branches

Branches of Origin Supply

Median Nerve

Median nerve Axilla Super cial and intermediate compartment of anterior forearm (pronator teres,
exor carpi radialis, palmaris longus, exor digitorum super cialis, NOT exor
carpi ulnaris)

Anterior Forearm Deep compartment of anterior forearm ( exor pollicis longus, pronator
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Anterior Forearm Deep compartment of anterior forearm ( exor pollicis longus, pronator
interosseous quadratus, lateral half of exor digitorum profundus)
nerve

Palmar Forearm Skin over the lateral aspect of the palm

cutaneous
branch

Recurrent Hand Thenar muscles ( exor pollicis brevis, abductor pollicis brevis, opponens pollicis)
branch of
median nerve

Palmar digital Hand Lateral two lumbricals and skin over the palmar surface and ngertips of the
branch lateral three and a half digits

The median nerve directly innervates the pronator teres, the exor carpi radialis, the palmaris longus and the exor
digitorum super cialis. It gives off no major branches in the arm, but gives rise to the anterior interosseous nerve
(innervating the exor pollicis longus, the pronator quadratus, and the lateral half of the exor digitorum profundus)
and the palmar cutaneous nerve (innervating the lateral aspect of the palm) in the forearm.

In the hand the median nerve bifurcates into the recurrent branch of the median nerve (innervating the thenar
muscles) and the palmar digital branch (innervating the lateral two lumbricals and the skin over the palmar surface and
ngertips of the lateral three and a half digits).

Clinical implications

Lesion Proximal (arm, elbow, proximal forearm) Distal (wrist)

Mechanisms Supracondylar fracture, stab wound to arm or forearm Lacerations just

proximal to exor
retinaculum, carpal
tunnel syndrome

Motor Loss Forearm pronation, wrist exion and abduction, index and middle nger Thumb exion,
exion, thumb exion, abduction and opposition abduction and
opposition, exion of
index and middle
nger MCPJ

Sensory Lateral aspect of palm and palmar surface and ngertips of lateral three Palmar surface and
Loss and a half digits ngertips of lateral
three and a half digits

Signs Forearm rests in supination with wrist in ulnar deviation and thumb Thenar eminence
extended, thenar eminence wasting, hand of Benediction (when asked wasting
to make a st, the patient will be able to ex the little and ring ngers
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but not the index and middle ngers)

A proximal median nerve lesion at the elbow may occur due to supracondylar fracture of the humerus or from deep
penetrating wounds to the arm or forearm and may result in:

Pronation of the forearm and exion and abduction of the wrist are lost due to paralysis of the exors and
pronators in the forearm. The forearm thus often rests in supination with ulnar deviation of the wrist (due to
unopposed action of the exor carpi ulnaris).
Flexion, abduction and opposition of the thumb at the MCPJ and IPJ are lost due to paralysis of the thenar
muscles and the exor pollicis longus.
Flexion of the index and middle ngers at the IPJs is lost due to paralysis of the exor digitorum super cialis
and the lateral half of the exor digitorum profundus.
Flexion of the MCPJ of the index and middle ngers is lost due to paralysis of the lateral two lumbrical muscles.
N.B. Flexion of the ring and little ngers at the MCPJ and DIPJ are preserved as these are functions of the
medial half of the exor digitorum profundus and the medial two lumbrical muscles, innervated by the ulnar
nerve (there may be weakness of exion at the PIPJ of these ngers due to paralysis of the exor digitorum
super cialis).
There is loss of sensation over the lateral aspect of the palm, and the skin over the palmar surface and
ngertips of the lateral three and a half digits.

Medial nerve lesion at the wrist often occurs due to lacerations just proximal to the exor retinaculum or to
compression of the median nerve in the carpal tunnel. Only the intrinsic hand muscles are affected. Loss of opposition,
abduction and exion of the MCPJ of the thumb occurs due to paralysis of the thenar muscles. Loss of exion at the
MCPJ of the index and middle nger occurs due to paralysis of the lateral two lumbricals. There is loss of sensation to
the palmar surface and ngertips of the lateral three and a half digits only (the palmar region is spared).

A 76 year old man presents to the ED complaining of weakness in the right wrist. On
examination you note weakness of exion and abduction. You suspect a pathology of the exor
carpi radialis. The exor carpi radialis is attached distally to which of the following structures:

a) Scaphoid and trapezoid

b) Scaphoid and base of 2nd metacarpal
c) Base of 2nd and 3rd metacarpal
d) Trapezium and base of 1st metacarpal
e) Scaphoid, trapezium and base of 1st metacarpal
Something wrong?

Answer
The exor carpi radialis is attached distally to the base of the 2nd and 3rd metacarpal.

Notes

The anterior forearm is divided into:

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The anterior forearm is divided into:

The super cial compartment consisting of the exor carpi ulnaris, exor carpi radialis, palmaris longus and the
pronator teres
The intermediate compartment consisting of the exor digitorum super cialis
The deep compartment consisting of the exor digitorum profundus, exor pollicis longus and pronator
quadratus

All of the muscles in the anterior forearm are innervated by the median nerve, except for the exor carpi ulnaris and
the medial half of the exor digitorum profundus which are innervated by the ulnar nerve.

Muscle Action Innervation

Flexor carpi ulnaris Flexion and adduction of wrist Ulnar nerve

Flexor carpi radialis Flexion and abduction of wrist Median nerve

Palmaris longus Flexion of wrist Median nerve

Pronator teres Pronation of forearm Median nerve

Flexor digitorum Flexion of MCPJ and PIPJ of all four digits, Median nerve
super cialis exion of wrist

Flexor pollicis longus Flexion of MCPJ and IPJ of thumb Median nerve

Flexor digitorum Flexion of MCPJ and DIPJ of all four digits, Lateral half by median nerve, medial half
profundus exion of wrist by ulnar nerve

Pronator quadratus Pronation of forearm Median nerve

The exor muscles of the anterior forearm all originate from the medial humeral epicondyle. A detailed knowledge of
the distal attachments of the exor tendons is important to allow understanding of the clinical effects of division/injury
at any given level of the nger.

The exor pollicis longus is attached distally to the base of the distal phalanx of the thumb.
The exor digitorum profundus is attached distally to the palmar surface of the distal phalanges of all four
ngers.
The exor digitorum super cialis is attached distally to the palmar surface of the middle phalanges of all four
ngers.
The exor carpi ulnaris is attached distally to the pisiform, hook of hamate and 5th metacarpal.
The exor carpi radialis is attached distally to the base of the 2nd and 3rd metacarpal.
The palmaris longus distally blends with the bres of the exor retinaculum which is continuous with the
palmar aponeurosis.

Flexor tendon Distal attachment

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Flexor tendon Distal attachment

Flexor pollicis longus Base of distal phalanx of thumb

Flexor digitorum profundus Distal phalanges of all four digits

Flexor digitorum super cialis Middle phalanges of all four digits

Flexor carpi ulnaris Pisiform, hook of hamate and 5th metacarpal

Flexor carpi radialis Base of 2nd and 3rd metacarpal

Palmaris longus Palmar aponeurosis

By Henry Vandyke Carter [Public

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By Henry Vandyke Carter [Public
domain], via Wikimedia Commons

By Henry Vandyke Carter [Public domain], via

Wikimedia Commons

A 21 year old female presents to ED following an attempted suicide attempt. She has a deep
laceration to her anterior forearm. Further exploration shows she has divided the exor digitorum
super cialis muscle and has injured the nerve that lies between this and the exor digitorum
profundus muscle. Which of the following movements would most likely be affected as a result of
this injury:

a) Abduction of the ngers

b) Opposition of the thumb
c) Adduction of the thumb
d) Extension of the ngers at the metacarpophalangeal joints
e) Adduction of the wrist
Something wrong?

Answer
The median nerve lies between the exor digitorum super cialis and exor digitorum profundus in the anterior arm.
The median nerve innervates the thenar muscles thus injury will result in weakness of thumb abduction, exion and
opposition. The adductor pollicis is innervated by the ulnar nerve. The wrist adductors are innervated by the ulnar and
radial nerves. The nger extensors are innervated by the radial nerve. Abduction of the ngers is produced by the
interossei, innervated by the ulnar nerve.

Notes
The median nerve is formed from the medial and lateral brachial plexus cords and contains bres from all ve roots (C5
– T1).

Nerve Median nerve

Nerve C5 – T1
roots
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roots

Plexus Medial and lateral cords

cords

Motor All the anterior forearm muscles (except for the exor carpi ulnaris and the medial half of the exor
Supply digitorum profundus), the thenar muscles ( exor pollicis brevis, abductor pollicis brevis, opponens
pollicis) and the lateral two lumbricals

Sensory Lateral aspect of palm and palmar surface and ngertips of lateral three and a half digits
supply

Anatomical course

The median nerve originates in the axilla before passing down the medial side of the arm (initially lateral to the brachial
artery before crossing over to the medial side of the brachial artery). It enters the anterior compartment of the
forearm via the antecubital fossa, travelling between the exor digitorum profundus and exor digitorum super cialis
muscles, before entering the hand via the carpal tunnel and bifurcating into its terminal branches.

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By Henry Vandyke Carter [Public domain], via Wikimedia Commons

Branches

Branches of Origin Supply

Median Nerve

Median nerve Axilla Super cial and intermediate compartment of anterior forearm (pronator teres,
exor carpi radialis, palmaris longus, exor digitorum super cialis, NOT exor
carpi ulnaris)

Anterior Forearm Deep compartment of anterior forearm ( exor pollicis longus, pronator
interosseous quadratus, lateral half of exor digitorum profundus)
nerve

Palmar Forearm Skin over the lateral aspect of the palm

cutaneous
branch

Recurrent Hand Thenar muscles ( exor pollicis brevis, abductor pollicis brevis, opponens pollicis)
branch of
median nerve

Palmar digital Hand Lateral two lumbricals and skin over the palmar surface and ngertips of the
branch lateral three and a half digits

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The median nerve directly innervates the pronator teres, the exor carpi radialis, the palmaris longus and the exor
digitorum super cialis. It gives off no major branches in the arm, but gives rise to the anterior interosseous nerve
(innervating the exor pollicis longus, the pronator quadratus, and the lateral half of the exor digitorum profundus)
and the palmar cutaneous nerve (innervating the lateral aspect of the palm) in the forearm.

In the hand the median nerve bifurcates into the recurrent branch of the median nerve (innervating the thenar
muscles) and the palmar digital branch (innervating the lateral two lumbricals and the skin over the palmar surface and
ngertips of the lateral three and a half digits).

Clinical implications

Lesion Proximal (arm, elbow, proximal forearm) Distal (wrist)

Mechanisms Supracondylar fracture, stab wound to arm or forearm Lacerations just

proximal to exor
retinaculum, carpal
tunnel syndrome

Motor Loss Forearm pronation, wrist exion and abduction, index and middle nger Thumb exion,
exion, thumb exion, abduction and opposition abduction and
opposition, exion of
index and middle
nger MCPJ

Sensory Lateral aspect of palm and palmar surface and ngertips of lateral three Palmar surface and
Loss and a half digits ngertips of lateral
three and a half digits

Signs Forearm rests in supination with wrist in ulnar deviation and thumb Thenar eminence
extended, thenar eminence wasting, hand of Benediction (when asked wasting
to make a st, the patient will be able to ex the little and ring ngers
but not the index and middle ngers)

A proximal median nerve lesion at the elbow may occur due to supracondylar fracture of the humerus or from deep
penetrating wounds to the arm or forearm and may result in:

Pronation of the forearm and exion and abduction of the wrist are lost due to paralysis of the exors and
pronators in the forearm. The forearm thus often rests in supination with ulnar deviation of the wrist (due to
unopposed action of the exor carpi ulnaris).
Flexion, abduction and opposition of the thumb at the MCPJ and IPJ are lost due to paralysis of the thenar
muscles and the exor pollicis longus.
Flexion of the index and middle ngers at the IPJs is lost due to paralysis of the exor digitorum super cialis
and the lateral half of the exor digitorum profundus.
Flexion of the MCPJ of the index and middle ngers is lost due to paralysis of the lateral two lumbrical muscles.
N.B. Flexion of the ring and little ngers at the MCPJ and DIPJ are preserved as these are functions of the
medial half of the exor digitorum profundus and the medial two lumbrical muscles, innervated by the ulnar
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medial half of the exor digitorum profundus and the medial two lumbrical muscles, innervated by the ulnar
nerve (there may be weakness of exion at the PIPJ of these ngers due to paralysis of the exor digitorum
super cialis).
There is loss of sensation over the lateral aspect of the palm, and the skin over the palmar surface and
ngertips of the lateral three and a half digits.

Medial nerve lesion at the wrist often occurs due to lacerations just proximal to the exor retinaculum or to
compression of the median nerve in the carpal tunnel. Only the intrinsic hand muscles are affected. Loss of opposition,
abduction and exion of the MCPJ of the thumb occurs due to paralysis of the thenar muscles. Loss of exion at the
MCPJ of the index and middle nger occurs due to paralysis of the lateral two lumbricals. There is loss of sensation to
the palmar surface and ngertips of the lateral three and a half digits only (the palmar region is spared).

A 27 year old rugby player is brought to the ED complaining of neck pain after a scrum
collapsed. On examination he is tender over C7 and T1. The C8 dermatome is best tested at which
of the following landmarks:

a) Lateral antecubital fossa

b) Medial antecubital fossa
c) Dorsum of middle nger
d) Dorsum of little nger
e) Dorsum of thumb
Something wrong?

Answer
The C8 dermatome is best tested on the dorsal surface of the proximal phalanx of the little nger.

Notes

Dermatome Landmark

C2 Occipital Protuberance

C3 Supraclavicular Fossa

C4 Acromioclavicular Joint

C5 Lateral Antecubital Fossa

C6 Thumb

C7 Middle Finger

C8 Little Finger
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C8 Little Finger

T1 Medial Antecubital Fossa

T2 Apex of Axilla

The C2 dermatome is best tested at least one cm lateral to the occipital protuberance at the base of the skull.
Alternately, it can be located at least 3 cm behind the ear.
The C3 dermatome is best tested in the supraclavicular fossa, at the midclavicular line.
The C4 dermatome is best tested over the acromioclavicular joint.
The C5 dermatome is best tested on the lateral (radial) side of the antecubital fossa just proximal to the elbow.
The C6 dermatome is best tested on the dorsal surface of the proximal phalanx of the thumb.
The C7 dermatome is best tested on the dorsal surface of the proximal phalanx of the middle nger.
The C8 dermatome is best tested on the dorsal surface of the proximal phalanx of the little nger.
The T1 dermatome is best tested on the medial (ulnar) side of the antecubital fossa, just proximal to the medial
epicondyle of the humerus.
The T2 dermatome is best tested at the apex of the axilla.

By Grant, John Charles Boileau (An atlas of anatomy, / by regions 1962) [Public domain], via
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By Grant, John Charles Boileau (An atlas of anatomy, / by regions 1962) [Public domain], via
Wikimedia Commons

A 21 year old presents to ED with an injury to his left arm after falling from a skateboard.
Imaging shows a supracondylar fracture. Which nerve is most likely damaged in this type of injury:

a) Radial nerve
b) Ulnar nerve
c) Median nerve
d) Musculocutaneous nerve
e) Axillary nerve
Something wrong?

Answer

A supracondylar fracture most commonly results in injury to the median nerve. The axillary nerve may be damaged in a
surgical neck of humerus fracture. The radial nerve may be damaged in a midshaft humerus fracture. The ulnar nerve
may be damaged in a medial epicondylar fracture.

Notes
The median nerve is formed from the medial and lateral brachial plexus cords and contains bres from all ve roots (C5
– T1).

Nerve Median nerve

Nerve C5 – T1
roots

Plexus Medial and lateral cords

cords

Motor All the anterior forearm muscles (except for the exor carpi ulnaris and the medial half of the exor
Supply digitorum profundus), the thenar muscles ( exor pollicis brevis, abductor pollicis brevis, opponens
pollicis) and the lateral two lumbricals

Sensory Lateral aspect of palm and palmar surface and ngertips of lateral three and a half digits
supply

Anatomical course

The median nerve originates in the axilla before passing down the medial side of the arm (initially lateral to the brachial
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artery before crossing over to the medial side of the brachial artery). It enters the anterior compartment of the
forearm via the antecubital fossa, travelling between the exor digitorum profundus and exor digitorum super cialis
muscles, before entering the hand via the carpal tunnel and bifurcating into its terminal branches.

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By Henry Vandyke Carter [Public domain], via Wikimedia Commons

Branches

Branches of Origin Supply

Median Nerve

Median nerve Axilla Super cial and intermediate compartment of anterior forearm (pronator teres,
exor carpi radialis, palmaris longus, exor digitorum super cialis, NOT exor
carpi ulnaris)

Anterior Forearm Deep compartment of anterior forearm ( exor pollicis longus, pronator
interosseous quadratus, lateral half of exor digitorum profundus)
nerve

Palmar Forearm Skin over the lateral aspect of the palm

cutaneous
branch

Recurrent Hand Thenar muscles ( exor pollicis brevis, abductor pollicis brevis, opponens pollicis)
branch of
median nerve

Palmar digital Hand Lateral two lumbricals and skin over the palmar surface and ngertips of the
branch lateral three and a half digits

The median nerve directly innervates the pronator teres, the exor carpi radialis, the palmaris longus and the exor
digitorum super cialis. It gives off no major branches in the arm, but gives rise to the anterior interosseous nerve
(innervating the exor pollicis longus, the pronator quadratus, and the lateral half of the exor digitorum profundus)
and the palmar cutaneous nerve (innervating the lateral aspect of the palm) in the forearm.

In the hand the median nerve bifurcates into the recurrent branch of the median nerve (innervating the thenar
muscles) and the palmar digital branch (innervating the lateral two lumbricals and the skin over the palmar surface and
ngertips of the lateral three and a half digits).

Clinical implications

Lesion Proximal (arm, elbow, proximal forearm) Distal (wrist)

Mechanisms Supracondylar fracture, stab wound to arm or forearm Lacerations just

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proximal to exor
retinaculum, carpal
tunnel syndrome

Motor Loss Forearm pronation, wrist exion and abduction, index and middle nger Thumb exion,
exion, thumb exion, abduction and opposition abduction and
opposition, exion of
index and middle
nger MCPJ

Sensory Lateral aspect of palm and palmar surface and ngertips of lateral three Palmar surface and
Loss and a half digits ngertips of lateral
three and a half digits

Signs Forearm rests in supination with wrist in ulnar deviation and thumb Thenar eminence
extended, thenar eminence wasting, hand of Benediction (when asked wasting
to make a st, the patient will be able to ex the little and ring ngers
but not the index and middle ngers)

A proximal median nerve lesion at the elbow may occur due to supracondylar fracture of the humerus or from deep
penetrating wounds to the arm or forearm and may result in:

Pronation of the forearm and exion and abduction of the wrist are lost due to paralysis of the exors and
pronators in the forearm. The forearm thus often rests in supination with ulnar deviation of the wrist (due to
unopposed action of the exor carpi ulnaris).
Flexion, abduction and opposition of the thumb at the MCPJ and IPJ are lost due to paralysis of the thenar
muscles and the exor pollicis longus.
Flexion of the index and middle ngers at the IPJs is lost due to paralysis of the exor digitorum super cialis
and the lateral half of the exor digitorum profundus.
Flexion of the MCPJ of the index and middle ngers is lost due to paralysis of the lateral two lumbrical muscles.
N.B. Flexion of the ring and little ngers at the MCPJ and DIPJ are preserved as these are functions of the
medial half of the exor digitorum profundus and the medial two lumbrical muscles, innervated by the ulnar
nerve (there may be weakness of exion at the PIPJ of these ngers due to paralysis of the exor digitorum
super cialis).
There is loss of sensation over the lateral aspect of the palm, and the skin over the palmar surface and
ngertips of the lateral three and a half digits.

Medial nerve lesion at the wrist often occurs due to lacerations just proximal to the exor retinaculum or to
compression of the median nerve in the carpal tunnel. Only the intrinsic hand muscles are affected. Loss of opposition,
abduction and exion of the MCPJ of the thumb occurs due to paralysis of the thenar muscles. Loss of exion at the
MCPJ of the index and middle nger occurs due to paralysis of the lateral two lumbricals. There is loss of sensation to
the palmar surface and ngertips of the lateral three and a half digits only (the palmar region is spared).

A 34 year old woman sustains a midshaft humerus fracture with nerve damage falling off a
horse. Which of the following movements would most likely be affected by this injury:

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a) Abduction of the arm

b) Pronation of the forearm
c) Extension of the forearm
d) Extension of the wrist
e) Extension of the arm
Something wrong?

Answer
The radial nerve innervates the muscles of the posterior arm and forearm, primarily involved in extension of the
forearm, wrist and ngers (and supination of the forearm). Damage to this nerve in the mid humerus is likely to spare
the triceps brachii muscle, so you would not expect loss of extension of the forearm or arm. The pronators of the
forearm are innervated by the median nerve. Abduction of the arm is primarily produced by the deltoid and
supraspinatus innervated by the axillary nerve and suprascapular nerve respectively.

Notes
The radial nerve is a continuation of the posterior cord, containing bres from C5 – T1.

Nerve Radial nerve

Nerve C5 – T1
roots

Plexus Posterior cord

cords

Motor Triceps brachii, posterior compartment of forearm: super cial muscles (brachioradialis, extensor carpi
Supply radialis longus and brevis, extensor digitorum, extensor digiti minimi, extensor carpi ulnaris) and deep
muscles (supinator, abductor pollicis longus, extensor pollicis longus and brevis, extensor indicis)

Sensory Lower lateral arm, posterior arm, posterior forearm, dorsum of lateral hand and three and a half
supply ngers

Anatomical course

The radial nerve enters the arm by crossing the lower margin of the teres major muscle, where it lies posterior to the
brachial artery. It enters the posterior compartment of the arm, where it descends obliquely passing from medial to
lateral in the radial (spiral) groove of the humerus. After emerging from the spiral groove, the radial nerve pierces the
lateral intermuscular septum and enters the anterior compartment of the arm, descending into the cubital fossa where
it lies between the brachialis and brachioradialis muscles. The radial nerve enters the forearm after passing over the
lateral epicondyle of the humerus. Within the proximal forearm the nerve terminates by bifurcating into the deep
branch and the super cial branch. N.B. Once the deep branch of the radial nerve penetrates between the two heads of
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the supinator muscle to access the posterior compartment of the arm, it becomes known as the posterior interosseous
nerve.

By Henry Vandyke Carter [Public domain], via Wikimedia

Commons

Branches

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Branches of Radial Origin Supply

Nerve

Radial nerve Axilla Triceps brachii, extensor carpi radialis longus, brachioradialis

Posterior Axilla Skin of posterior arm

cutaneous nerve of
the arm

Inferior lateral Arm Skin over lateral aspect of lower arm

cutaneous nerve of
the arm

Posterior Arm Strip of skin down middle of posterior forearm

cutaneous nerve of
the forearm

Deep branch which Forearm Posterior compartment of forearm: super cial muscles (extensor carpi radialis
continues as the brevis, extensor digitorum, extensor digiti minimi, extensor carpi ulnaris) and
posterior deep muscles (supinator, abductor pollicis longus, extensor pollicis longus and
interosseous nerve brevis, extensor indicis)

Super cial branch Forearm Skin of dorsum of the hand and lateral three and a half ngers

In the arm, the radial nerve directly innervates the triceps brachii, the extensor carpi radialis longus and the
brachioradialis. In the forearm, the deep branch, which continues as the posterior interosseous nerve, innervates the
muscles of the posterior compartment of the forearm and the super cial branch supplies the skin of the dorsum of the
hand and lateral three and a half ngers.

The radial nerve also gives rise to several cutaneous branches; the posterior cutaneous nerve of the arm originating in
the axilla, and the inferior lateral cutaneous nerve of the arm and the posterior cutaneous nerve of the forearm
originating in the arm. These cutaneous branches supply skin over the posterior surface of the arm, the lateral aspect
of the arm and the skin down the middle of the posterior forearm respectively.

Clinical implications

Lesion In axilla In spiral groove In forearm In forearm (deep

(super cial branch) branch)

Mechanism Glenohumeral joint Fracture of midshaft Stabbing/laceration Fracture of

dislocation, fracture of of humerus of forearm radial head or
proximal humerus, ‘Saturday posterior
night syndrome’ dislocation
of radius

Motor Loss Loss of extension at elbow, Loss of extension at None Weakness of

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Motor Loss Loss of extension at elbow, Loss of extension at None Weakness of
wrist and ngers wrist and ngers extension at
(triceps brachii wrist and
spared) ngers (extensor
carpi radialis
spared)

Sensory Lower lateral arm, posterior Dorsum of lateral Dorsum of lateral None
Loss arm, posterior forearm, hand and three and a hand and three and
dorsum of lateral hand and half ngers a half ngers
three and a half ngers (cutaneous branches
of arm and forearm
spared)

Signs Wrist drop (unopposed Wrist drop, weak None Wrist drop not
wrist exion), weakness of hand grip typically seen
hand grip ( nger exion is (extensor carpi
weak as the long exor radialis spared)
tendons are not under
tension)

Radial nerve injury at the axilla may occur in glenohumeral joint dislocation, in fractures of the proximal humerus,
through incorrect use of axillary crutches, or due to ‘Saturday Night’ palsy. There is loss of extension of the forearm
due to paralysis of the triceps brachii and loss of extension of the wrist and ngers (predominantly MCPJs, as extension
at the IPJs is primarily a function of the lumbrical and interosseous muscles) and weakness of supination due to
paralysis of the muscles of the posterior compartment of the forearm. All four cutaneous branches of the radial nerve
are affected and there is loss of sensation over the lateral and posterior arm, the posterior forearm and the dorsal
surface of the hand and lateral three and a half digits. There is unopposed wrist exion, giving the appearance of wrist
drop.

The radial nerve in the arm is most susceptible to midshaft fractures of the humerus due to its course in the spiral
groove. Extension of the forearm is not affected as the triceps brachii is spared. There is loss of extension of the wrist
and MCPJs of the ngers and weakness of supination of the forearm. The cutaneous branches of the arm and forearm
have already arisen and sensation loss occurs only on the dorsum of the lateral hand and three and a half digits.

Radial nerve damage in the forearm may present as super cial branch or deep branch damage. The super cial branch is
most commonly damaged by stabbing or laceration to the forearm and results in loss of sensation over the dorsum of
the lateral hand and three and a half digits. The deep branch may be damaged by fracture of the radial head or
posterior dislocation of the radius and results in weakness of extension of the wrist and ngers, but not typically with
wrist drop (as the extensor carpi radialis is spared).

A 16 year old boy is brought to ED having fallen off his skateboard. He is complaining of pain
and weakness in his right upper limb. Imaging shows a fracture of the medial epicondyle. Which of
the following movements would you most expect to be affected in this type of injury:

a) Abduction of the thumb

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b) Extension of the thumb

c) Opposition of the thumb
d) Adduction of the thumb
e) Flexion of the thumb
Something wrong?

Answer
Fracture of the medial epicondyle is most likely to result in damage to the ulnar nerve. The adductor pollicis muscle is
innervated by the ulnar nerve. The thumb extensors are innervated by the radial nerve. The thumb abductors are
innervated by the radial and median nerve. The thumb exors are innervated by the median nerve. The opponens
pollicis is innervated by the median nerve.

Notes

The ulnar nerve is a continuation of the medial cord of the brachial plexus, containing bres from the C8 – T1 nerve
roots.

Nerve Ulnar nerve

Nerve C8 – T1
roots

Plexus Medial cord

cords

Motor All the intrinsic muscles of the hand (except for the thenar muscles and the lateral two lumbricals), the
Supply exor carpi ulnaris and the medial half of the exor digitorum profundus

Sensory Medial half of palm, palmar and dorsal surface of medial one and a half ngers and lateral dorsum of
supply hand

Anatomical course

The ulnar nerve descends down the medial side of the upper arm and passes posterior to the medial epicondyle (where
it is susceptible to damage) before entering the anterior compartment of the forearm by passing between the two
heads of the exor carpi ulnaris. It continues down the medial aspect of the forearm. The ulnar nerve emerges from
beneath the exor carpi ulnaris and becomes super cial just proximal to the wrist where it passes super cial to the
exor retinaculum, together with the ulnar artery, to enter the hand through a groove between the pisiform and the
hook of the hamate where it bifurcates into its terminal branches.

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By Henry Vandyke Carter [Public domain], via Wikimedia Commons

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Branches

Branches of Origin Supply

Ulnar Nerve

Muscular Forearm Flexor carpi ulnaris, medial half of exor digitorum profundus
branch

Palmar Forearm Skin of medial half of palm

cutaneous
branch

Dorsal Forearm Skin of dorsum of medial one and a half ngers and associated dorsal hand area
cutaneous
branch

Deep branch Hand Hypothenar muscles (abductor digiti minimi, exor digiti minimi, opponens digiti
minimi), medial two lumbricals, adductor pollicis and interossei

Super cial Hand Skin of palmar surface of medial one and a half ngers
branch

The ulnar nerve gives off no major branches in the arm, but three branches arise in the forearm:

The muscular branch innervating the exor carpi ulnaris and the medial half of the exor digitorum profundus
The palmar cutaneous branch supplying the skin of the medial half of the palm
The dorsal cutaneous branch supplying the skin of the medial dorsum of the hand and the dorsal surface of the
medial one and a half ngers

The ulnar nerve terminates by bifurcating into:

A deep branch innervating the hypothenar muscles, the medial two lumbricals, the adductor pollicis and the
interossei
A super cial branch supplying the skin of the palmar surface of the medial one and a half ngers

Clinical implications

Lesion Proximal (at elbow) Distal (at wrist)

Mechanism Fracture of medial epicondyle Laceration at wrist

Motor Loss Wrist exion and adduction, nger abduction and adduction, exion Finger abduction and
of ring and little nger, abduction and opposition of little nger, thumb adduction, exion of ring
adduction, extension of IPJs of all digits (less so at index and middle and little nger,
nger due to sparing of lateral two lumbricals) abduction and
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nger due to sparing of lateral two lumbricals) abduction and
opposition of little
nger, thumb adduction,
extension at IPJs

Sensory Medial half of palm, palmar and dorsal surface of medial one and a half Palmar surface of medial
Loss ngers and medial dorsum of hand one and a half ngers

Signs Hand held in abduction (due to unopposed action of exor carpi Claw hand (unopposed
radialis), Froment’s sign (patient is asked to hold a piece of paper extension at MCPJ and
between thumb and at palm as paper is pulled away, patient will ex unopposed exion at
thumb at IPJ to maintain hold – tests adductor pollicis muscle), IPJs of ring and little
hypothenar eminence wasting, N.B. claw hand not typically seen due nger), hypothenar
to paralysis of the exor digitorum profundus eminence wasting,
Froment’s sign

The ulnar nerve is most likely to be injured proximally by a medial epicondyle fracture and results in:

There is weak wrist exion and adduction due to paralysis of the exor carpi ulnaris and the medial half of the
exor digitorum profundus; the hand may be held in abduction (due to unopposed action of the exor carpi
radialis).
There is loss of abduction and adduction of the ngers due to paralysis of the interossei.
There is loss of exion at the MCPJ of the ring and little nger due to paralysis of the medial two lumbricals and
the exor digiti minimi.
There is loss of exion at the DIPJ of the ring and little nger due to paralysis of the medial half of the exor
digitorum profundus (but exion at the PIPJ is likely preserved as this is a function of the exor digitorum
super cialis).
There is weakened extension at the IPJs of the ring and little nger due to paralysis of the interossei and medial
two lumbricals (and to a lesser extent at the IPJs of the index and middle nger).
There is loss of abduction and opposition of the little nger due to paralysis of the hypothenar muscles
(hypothenar wasting may be seen).
There is loss of adduction of the thumb due to paralysis of the adductor pollicis (Froment’s sign).
There is loss of sensation to skin over the medial half of the palm, the palmar and dorsal surface of the medial
one and a half ngers and the medial dorsum of the hand.
There is not typically a claw hand appearance (as may be seen in a lesion at the wrist) due to paralysis of the
exor digitorum profundus.

A distal lesion most commonly occurs due to laceration at the wrist. Only intrinsic hand muscles are affected (the exor
carpi ulnaris and medial half of the exor digitorum profundus are spared). A loss of sensation will only affect the
palmar surface of the medial one and a half ngers (the medial palm and the dorsum of the hand are spared). A claw
hand deformity may be seen due to unopposed extension at the MCPJ (by the extensor digitorum) and unopposed
exion at the IPJs (by the FDP and FDS) of the ring and little nger.

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Froment’s sign (right hand). Copyright FRCEM

Success.

Claw hand deformity. By Mcstrother (Own work)

[CC BY 3.0
(http://creativecommons.org/licenses/by/3.0)], via
Wikimedia Commons

A 32 year old woman sustains an injury to the ulnar nerve at the elbow after sustaining a
fracture of the medial epicondyle. Which of the following clinical ndings would you least expect to
see on examination:

a) Weakness of wrist exion

b) Weakness of abduction of the ngers
c) Weakness of adduction of the ngers
d) Weakness of adduction of the thumb
e) Weakness of abduction of the thumb
Something wrong?

Answer
Abduction of the thumb is mediated by the abductor pollicis longus and brevis innervated by the radial nerve and the
median nerve respectively.

Notes
The ulnar nerve is a continuation of the medial cord of the brachial plexus, containing bres from the C8 – T1 nerve
roots.

Nerve Ulnar nerve

Nerve C8 – T1
roots

Plexus Medial cord

cords

Motor All the intrinsic muscles of the hand (except for the thenar muscles and the lateral two lumbricals), the
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Supply exor carpi ulnaris and the medial half of the exor digitorum profundus

Sensory Medial half of palm, palmar and dorsal surface of medial one and a half ngers and lateral dorsum of
supply hand

Anatomical course

The ulnar nerve descends down the medial side of the upper arm and passes posterior to the medial epicondyle (where
it is susceptible to damage) before entering the anterior compartment of the forearm by passing between the two
heads of the exor carpi ulnaris. It continues down the medial aspect of the forearm. The ulnar nerve emerges from
beneath the exor carpi ulnaris and becomes super cial just proximal to the wrist where it passes super cial to the
exor retinaculum, together with the ulnar artery, to enter the hand through a groove between the pisiform and the
hook of the hamate where it bifurcates into its terminal branches.

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By Henry Vandyke Carter [Public domain], via Wikimedia Commons

Branches

Branches of Origin Supply

Ulnar Nerve

Muscular Forearm Flexor carpi ulnaris, medial half of exor digitorum profundus
branch

Palmar Forearm Skin of medial half of palm

cutaneous
branch

Dorsal Forearm Skin of dorsum of medial one and a half ngers and associated dorsal hand area
cutaneous
branch

Deep branch Hand Hypothenar muscles (abductor digiti minimi, exor digiti minimi, opponens digiti
minimi), medial two lumbricals, adductor pollicis and interossei

Super cial Hand Skin of palmar surface of medial one and a half ngers
branch

The ulnar nerve gives off no major branches in the arm, but three branches arise in the forearm:

The muscular branch innervating the exor carpi ulnaris and the medial half of the exor digitorum profundus
The palmar cutaneous branch supplying the skin of the medial half of the palm
The dorsal cutaneous branch supplying the skin of the medial dorsum of the hand and the dorsal surface of the
medial one and a half ngers
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The ulnar nerve terminates by bifurcating into:

A deep branch innervating the hypothenar muscles, the medial two lumbricals, the adductor pollicis and the
interossei
A super cial branch supplying the skin of the palmar surface of the medial one and a half ngers

Clinical implications

Lesion Proximal (at elbow) Distal (at wrist)

Mechanism Fracture of medial epicondyle Laceration at wrist

Motor Loss Wrist exion and adduction, nger abduction and adduction, exion Finger abduction and
of ring and little nger, abduction and opposition of little nger, thumb adduction, exion of ring
adduction, extension of IPJs of all digits (less so at index and middle and little nger,
nger due to sparing of lateral two lumbricals) abduction and
opposition of little
nger, thumb adduction,
extension at IPJs

Sensory Medial half of palm, palmar and dorsal surface of medial one and a half Palmar surface of medial
Loss ngers and medial dorsum of hand one and a half ngers

Signs Hand held in abduction (due to unopposed action of exor carpi Claw hand (unopposed
radialis), Froment’s sign (patient is asked to hold a piece of paper extension at MCPJ and
between thumb and at palm as paper is pulled away, patient will ex unopposed exion at
thumb at IPJ to maintain hold – tests adductor pollicis muscle), IPJs of ring and little
hypothenar eminence wasting, N.B. claw hand not typically seen due nger), hypothenar
to paralysis of the exor digitorum profundus eminence wasting,
Froment’s sign

The ulnar nerve is most likely to be injured proximally by a medial epicondyle fracture and results in:

There is weak wrist exion and adduction due to paralysis of the exor carpi ulnaris and the medial half of the
exor digitorum profundus; the hand may be held in abduction (due to unopposed action of the exor carpi
radialis).
There is loss of abduction and adduction of the ngers due to paralysis of the interossei.
There is loss of exion at the MCPJ of the ring and little nger due to paralysis of the medial two lumbricals and
the exor digiti minimi.
There is loss of exion at the DIPJ of the ring and little nger due to paralysis of the medial half of the exor
digitorum profundus (but exion at the PIPJ is likely preserved as this is a function of the exor digitorum
super cialis).
There is weakened extension at the IPJs of the ring and little nger due to paralysis of the interossei and medial
two lumbricals (and to a lesser extent at the IPJs of the index and middle nger).
There is loss of abduction and opposition of the little nger due to paralysis of the hypothenar muscles
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There is loss of abduction and opposition of the little nger due to paralysis of the hypothenar muscles
(hypothenar wasting may be seen).
There is loss of adduction of the thumb due to paralysis of the adductor pollicis (Froment’s sign).
There is loss of sensation to skin over the medial half of the palm, the palmar and dorsal surface of the medial
one and a half ngers and the medial dorsum of the hand.
There is not typically a claw hand appearance (as may be seen in a lesion at the wrist) due to paralysis of the
exor digitorum profundus.

A distal lesion most commonly occurs due to laceration at the wrist. Only intrinsic hand muscles are affected (the exor
carpi ulnaris and medial half of the exor digitorum profundus are spared). A loss of sensation will only affect the
palmar surface of the medial one and a half ngers (the medial palm and the dorsum of the hand are spared). A claw
hand deformity may be seen due to unopposed extension at the MCPJ (by the extensor digitorum) and unopposed
exion at the IPJs (by the FDP and FDS) of the ring and little nger.

Froment’s sign (right hand). Copyright FRCEM

Success.

Claw hand deformity. By Mcstrother (Own work)

[CC BY 3.0
(http://creativecommons.org/licenses/by/3.0)], via
Wikimedia Commons

A 82 year old woman is brought to the ED by her son. She complains of numbness in her
ngers, her son was concerned this may have been a stroke. On examination you note loss of
sensation to the skin over the palmar surface of the medial one and a half digits. This area is
supplied by which of the following nerves:

a) The super cial branch of the radial nerve

b) The palmar cutaneous branch of the median nerve
c) The palmar cutaneous branch of the ulnar nerve
d) The super cial branch of the ulnar nerve
e) The palmar digital branch of the median nerve
Something wrong?

Answer
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The super cial branch of the ulnar nerve supplies the skin over the palmar surface of the medial one and a half ngers.

Notes

Nerve Origin Skin supplied

Lateral supraclavicular nerve Cervical plexus (C3, Upper half of deltoid muscle
C4)

Superior lateral cutaneous nerve Axillary nerve Lower half of deltoid muscle
of the arm

Inferior lateral cutaneous nerve of Radial nerve Lateral arm below deltoid muscle
the arm

Medial cutaneous nerve of the Brachial plexus (C8, Medial arm

arm T1)

Intercostobrachial nerve Second intercostal Axilla

nerve (T2)

Posterior cutaneous nerve of the Radial nerve Posterior arm

arm

Medial cutaneous nerve of the Brachial plexus (C8, Medial forearm

forearm T1)

Posterior cutaneous nerve of the Radial nerve Posterior forearm

forearm

Lateral cutaneous nerve of the Musculocutaneous Lateral forearm

forearm nerve

Super cial branch of radial nerve Radial nerve Lateral dorsum of hand and lateral three and a
half digits

Palmar cutaneous branch of ulnar Ulnar nerve Medial half of palm

nerve

Dorsal cutaneous branch of ulnar Ulnar nerve Medial dorsum of hand and medial one and a half
nerve ngers

Super cial branch of ulnar nerve Ulnar nerve Palmar surface of medial one and a half digits

Palmar cutaneous branch of Median nerve Lateral half of palm

median nerve
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median nerve

Palmar digital branch of median Median nerve Palmar surface and ngertips of lateral three and
nerve a half digits

Arm:

The lateral supraclavicular nerve, branch of the cervical plexus, supplies the skin over the upper half of the
deltoid muscle.
The superior lateral cutaneous nerve of the arm, branch of the axillary nerve, supplies the skin over the lower
half of the deltoid muscle (regimental badge area).
The inferior lateral cutaneous nerve of the arm, branch of the radial nerve, supplies the skin over the lateral
side of the arm below the deltoid muscle.
The medial cutaneous nerve of the arm, branch of the brachial plexus, supplies skin over the medial arm.
The intercostobrachial nerve, branch of the second intercostal nerve, supplies the skin of the axilla.
The posterior cutaneous nerve of the arm, branch of the radial nerve, supplies the skin over the posterior arm.

Forearm:

The medial cutaneous nerve of the forearm, branch of the brachial plexus, supplies the skin over the medial
aspect of the forearm.
The posterior cutaneous nerve of the forearm, branch of the radial nerve, supplies the skin over the posterior
forearm.
The lateral cutaneous nerve of the forearm, branch of the musculocutaneous nerve, supplies the skin over the
lateral aspect of the forearm.

Hand:

The super cial branch of the radial nerve supplies the skin over the lateral dorsum of the hand and the lateral
three and a half digits.
The palmar cutaneous branch of the ulnar nerve supplies the skin over the medial half of the palm.
The dorsal cutaneous branch of the ulnar nerve supplies the skin over medial dorsum of the hand and the
dorsum of the medial one and a half ngers.
The super cial branch of the ulnar nerve supplies the skin over the palmar surface of the medial one and a half
ngers.
The palmar cutaneous branch of the median nerve supplies the skin over the lateral half of the palm.
The palmar digital branch of the median nerve supplies the skin over the palmar surface and the ngertips of
the lateral three and a half digits.

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Modi ed by FRCEM Success. Original by Henry Vandyke Carter [Public domain], via Wikimedia Commons

You have been asked to review a patient in the Minor Injuries Unit. The 32 year old sustained
a laceration to the forearm during a ght. He has lost sensation over the medial dorsum of the hand
and the dorsum of the medial one and a half digits. This area is supplied by which of the following
nerves:

a) The super cial branch of the radial nerve

b) The deep branch of the radial nerve
c) The dorsal cutaneous branch of the ulnar nerve
d) The super cial branch of the ulnar nerve
e) The digital branch of the median nerve
Something wrong?

Answer
The dorsal cutaneous branch of the ulnar nerve supplies the skin over medial dorsum of the hand and the dorsum of
the medial one and a half ngers.

Notes

Nerve Origin Skin supplied

Lateral supraclavicular nerve Cervical plexus (C3, Upper half of deltoid muscle
C4)
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Superior lateral cutaneous nerve Axillary nerve Lower half of deltoid muscle
of the arm

Inferior lateral cutaneous nerve of Radial nerve Lateral arm below deltoid muscle
the arm

Medial cutaneous nerve of the Brachial plexus (C8, Medial arm

arm T1)

Intercostobrachial nerve Second intercostal Axilla

nerve (T2)

Posterior cutaneous nerve of the Radial nerve Posterior arm

arm

Medial cutaneous nerve of the Brachial plexus (C8, Medial forearm

forearm T1)

Posterior cutaneous nerve of the Radial nerve Posterior forearm

forearm

Lateral cutaneous nerve of the Musculocutaneous Lateral forearm

forearm nerve

Super cial branch of radial nerve Radial nerve Lateral dorsum of hand and lateral three and a
half digits

Palmar cutaneous branch of ulnar Ulnar nerve Medial half of palm

nerve

Dorsal cutaneous branch of ulnar Ulnar nerve Medial dorsum of hand and medial one and a half
nerve ngers

Super cial branch of ulnar nerve Ulnar nerve Palmar surface of medial one and a half digits

Palmar cutaneous branch of Median nerve Lateral half of palm

median nerve

Palmar digital branch of median Median nerve Palmar surface and ngertips of lateral three and
nerve a half digits

Arm:

The lateral supraclavicular nerve, branch of the cervical plexus, supplies the skin over the upper half of the
deltoid muscle.
The superior lateral cutaneous nerve of the arm, branch of the axillary nerve, supplies the skin over the lower
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The superior lateral cutaneous nerve of the arm, branch of the axillary nerve, supplies the skin over the lower
half of the deltoid muscle (regimental badge area).
The inferior lateral cutaneous nerve of the arm, branch of the radial nerve, supplies the skin over the lateral
side of the arm below the deltoid muscle.
The medial cutaneous nerve of the arm, branch of the brachial plexus, supplies skin over the medial arm.
The intercostobrachial nerve, branch of the second intercostal nerve, supplies the skin of the axilla.
The posterior cutaneous nerve of the arm, branch of the radial nerve, supplies the skin over the posterior arm.

Forearm:

The medial cutaneous nerve of the forearm, branch of the brachial plexus, supplies the skin over the medial
aspect of the forearm.
The posterior cutaneous nerve of the forearm, branch of the radial nerve, supplies the skin over the posterior
forearm.
The lateral cutaneous nerve of the forearm, branch of the musculocutaneous nerve, supplies the skin over the
lateral aspect of the forearm.

Hand:

The super cial branch of the radial nerve supplies the skin over the lateral dorsum of the hand and the lateral
three and a half digits.
The palmar cutaneous branch of the ulnar nerve supplies the skin over the medial half of the palm.
The dorsal cutaneous branch of the ulnar nerve supplies the skin over medial dorsum of the hand and the
dorsum of the medial one and a half ngers.
The super cial branch of the ulnar nerve supplies the skin over the palmar surface of the medial one and a half
ngers.
The palmar cutaneous branch of the median nerve supplies the skin over the lateral half of the palm.
The palmar digital branch of the median nerve supplies the skin over the palmar surface and the ngertips of
the lateral three and a half digits.

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Modi ed by FRCEM Success. Original by Henry Vandyke Carter [Public domain], via Wikimedia Commons

A 56 year old illustrator presents to the ED with a 3 day history of right wrist pain. He is
concerned as this is affecting his work. On examination you note crepitations on exion and
extension of the wrist, you suspect an arthritis to be responsible. The wrist joint is formed by
articulations between which of the following bones:

a) Distal radius, distal ulna and scaphoid

b) Distal radius, scaphoid, lunate and triquetrum
c) Distal radius, distal ulna and pisiform
d) Distal radius, triquetrum and trapezoid
e) Distal radius, scaphoid and hamate
Something wrong?

Answer
The wrist joint is a synovial condyloid joint occurring between the distal end of the radius and the articular disc
overlying the distal end of the ulna and the scaphoid, lunate and triquetrum.

Notes

Joint Wrist joint

Type Synovial condyloid joint

Articulations Distal end of the radius and articular disc with scaphoid, lunate and triquetrum

Stabilising Joint capsule, palmar radiocarpal, palmar ulnocarpal and dorsal radiocarpal ligaments, radial and
factors ulnar collateral ligaments of the wrist joint

Movements Flexion and extension, abduction and adduction

The wrist joint is a synovial condyloid joint occurring between the distal end of the radius and the articular disc
overlying the distal end of the ulna and the scaphoid, lunate and triquetrum.
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overlying the distal end of the ulna and the scaphoid, lunate and triquetrum.

The capsule of the wrist joint is reinforced by palmar radiocarpal, palmar ulnocarpal and dorsal radiocarpal ligaments.
The radial and ulnar collateral ligaments of the wrist joint reinforce the medial and lateral sides of the wrist joint.

The wrist joint allows movement around two axes; the hand can be abducted and adducted, and exed and extended at
the wrist joint.

Movement Muscles Involved

Flexion Flexor carpi radialis, exor carpi ulnaris, exor digitorum profundus, exor digitorum super cialis,
palmaris longus

Extension Extensor carpi radialis longus and brevis, extensor carpi ulnaris, extensor digitorum

Abduction Flexor carpi radialis, extensor carpi radialis longus and brevis

Adduction Flexor carpi ulnaris, extensor carpi ulnaris

Modi ed by FRCEM Success. Original by Henry Vandyke Carter [Public domain], via Wikimedia
Commons

A patient presents with weakness of the left forearm and hand. You examine the strength of
the muscles in the anterior forearm. The exor carpi ulnaris tendon is attached distally to which of
the following structures:

a) The lunate and the triquetrum

b) The pisiform, hook of hamate and 5th metacarpal
c) The lunate and the hook of hamate
d) The triquetrum, pisiform and 5th metacarpal
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d) The triquetrum, pisiform and 5th metacarpal
e) The lunate, hook of hamate and 4th metacarpal
Something wrong?

Answer
The exor carpi ulnaris is attached distally to the pisiform, hook of hamate and 5th metacarpal.

Notes

The anterior forearm is divided into:

The super cial compartment consisting of the exor carpi ulnaris, exor carpi radialis, palmaris longus and the
pronator teres
The intermediate compartment consisting of the exor digitorum super cialis
The deep compartment consisting of the exor digitorum profundus, exor pollicis longus and pronator
quadratus

All of the muscles in the anterior forearm are innervated by the median nerve, except for the exor carpi ulnaris and
the medial half of the exor digitorum profundus which are innervated by the ulnar nerve.

Muscle Action Innervation

Flexor carpi ulnaris Flexion and adduction of wrist Ulnar nerve

Flexor carpi radialis Flexion and abduction of wrist Median nerve

Palmaris longus Flexion of wrist Median nerve

Pronator teres Pronation of forearm Median nerve

Flexor digitorum Flexion of MCPJ and PIPJ of all four digits, Median nerve
super cialis exion of wrist

Flexor pollicis longus Flexion of MCPJ and IPJ of thumb Median nerve

Flexor digitorum Flexion of MCPJ and DIPJ of all four digits, Lateral half by median nerve, medial half
profundus exion of wrist by ulnar nerve

Pronator quadratus Pronation of forearm Median nerve

The exor muscles of the anterior forearm all originate from the medial humeral epicondyle. A detailed knowledge of
the distal attachments of the exor tendons is important to allow understanding of the clinical effects of division/injury
at any given level of the nger.

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The exor pollicis longus is attached distally to the base of the distal phalanx of the thumb.
The exor digitorum profundus is attached distally to the palmar surface of the distal phalanges of all four
ngers.
The exor digitorum super cialis is attached distally to the palmar surface of the middle phalanges of all four
ngers.
The exor carpi ulnaris is attached distally to the pisiform, hook of hamate and 5th metacarpal.
The exor carpi radialis is attached distally to the base of the 2nd and 3rd metacarpal.
The palmaris longus distally blends with the bres of the exor retinaculum which is continuous with the
palmar aponeurosis.

Flexor tendon Distal attachment

Flexor pollicis longus Base of distal phalanx of thumb

Flexor digitorum profundus Distal phalanges of all four digits

Flexor digitorum super cialis Middle phalanges of all four digits

Flexor carpi ulnaris Pisiform, hook of hamate and 5th metacarpal

Flexor carpi radialis Base of 2nd and 3rd metacarpal

Palmaris longus Palmar aponeurosis

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By Henry Vandyke Carter [Public

domain], via Wikimedia Commons

By Henry Vandyke Carter [Public domain], via

Wikimedia Commons

A 26 year old woman presents complaining of numbness in her right hand. On examination
she has no sensation to the skin over the lateral half of the palm. This area is supplied by which of
the following nerves:

a) The super cial branch of the radial nerve

b) The palmar cutaneous branch of the median nerve
c) The palmar cutaneous branch of the ulnar nerve
d) The super cial branch of the ulnar nerve
e) The palmar digital branch of the median nerve
Something wrong?

Answer
The palmar cutaneous branch of the median nerve supplies the skin over the lateral half of the palm.

Notes

Nerve Origin Skin supplied

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Nerve Origin Skin supplied

Lateral supraclavicular nerve Cervical plexus (C3, Upper half of deltoid muscle
C4)

Superior lateral cutaneous nerve Axillary nerve Lower half of deltoid muscle
of the arm

Inferior lateral cutaneous nerve of Radial nerve Lateral arm below deltoid muscle
the arm

Medial cutaneous nerve of the Brachial plexus (C8, Medial arm

arm T1)

Intercostobrachial nerve Second intercostal Axilla

nerve (T2)

Posterior cutaneous nerve of the Radial nerve Posterior arm

arm

Medial cutaneous nerve of the Brachial plexus (C8, Medial forearm

forearm T1)

Posterior cutaneous nerve of the Radial nerve Posterior forearm

forearm

Lateral cutaneous nerve of the Musculocutaneous Lateral forearm

forearm nerve

Super cial branch of radial nerve Radial nerve Lateral dorsum of hand and lateral three and a
half digits

Palmar cutaneous branch of ulnar Ulnar nerve Medial half of palm

nerve

Dorsal cutaneous branch of ulnar Ulnar nerve Medial dorsum of hand and medial one and a half
nerve ngers

Super cial branch of ulnar nerve Ulnar nerve Palmar surface of medial one and a half digits

Palmar cutaneous branch of Median nerve Lateral half of palm

median nerve

Palmar digital branch of median Median nerve Palmar surface and ngertips of lateral three and
nerve a half digits

Arm:
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Arm:

The lateral supraclavicular nerve, branch of the cervical plexus, supplies the skin over the upper half of the
deltoid muscle.
The superior lateral cutaneous nerve of the arm, branch of the axillary nerve, supplies the skin over the lower
half of the deltoid muscle (regimental badge area).
The inferior lateral cutaneous nerve of the arm, branch of the radial nerve, supplies the skin over the lateral
side of the arm below the deltoid muscle.
The medial cutaneous nerve of the arm, branch of the brachial plexus, supplies skin over the medial arm.
The intercostobrachial nerve, branch of the second intercostal nerve, supplies the skin of the axilla.
The posterior cutaneous nerve of the arm, branch of the radial nerve, supplies the skin over the posterior arm.

Forearm:

The medial cutaneous nerve of the forearm, branch of the brachial plexus, supplies the skin over the medial
aspect of the forearm.
The posterior cutaneous nerve of the forearm, branch of the radial nerve, supplies the skin over the posterior
forearm.
The lateral cutaneous nerve of the forearm, branch of the musculocutaneous nerve, supplies the skin over the
lateral aspect of the forearm.

Hand:

The super cial branch of the radial nerve supplies the skin over the lateral dorsum of the hand and the lateral
three and a half digits.
The palmar cutaneous branch of the ulnar nerve supplies the skin over the medial half of the palm.
The dorsal cutaneous branch of the ulnar nerve supplies the skin over medial dorsum of the hand and the
dorsum of the medial one and a half ngers.
The super cial branch of the ulnar nerve supplies the skin over the palmar surface of the medial one and a half
ngers.
The palmar cutaneous branch of the median nerve supplies the skin over the lateral half of the palm.
The palmar digital branch of the median nerve supplies the skin over the palmar surface and the ngertips of
the lateral three and a half digits.

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Modi ed by FRCEM Success. Original by Henry Vandyke Carter [Public domain], via Wikimedia Commons

A 58 year old man sustains an injury to the ulnar nerve and complains of sensory loss. Which
of the following areas of skin would you least expect to be affected:

a) Medial half of palm

b) Dorsal surface of medial one and a half digits
c) Palmar surface of medial one and a half digits
d) Dorsal and palmar surface of little nger
e) Medial forearm
Something wrong?

Answer
The ulnar nerve supplies sensation to the medial half of palm, palmar and dorsal surface of medial one and a half ngers
and lateral dorsum of hand.

Notes
The ulnar nerve is a continuation of the medial cord of the brachial plexus, containing bres from the C8 – T1 nerve
roots.

Nerve Ulnar nerve

Nerve C8 – T1
roots

Plexus Medial cord

cords

Motor All the intrinsic muscles of the hand (except for the thenar muscles and the lateral two lumbricals), the
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Supply exor carpi ulnaris and the medial half of the exor digitorum profundus

Sensory Medial half of palm, palmar and dorsal surface of medial one and a half ngers and lateral dorsum of
supply hand

Anatomical course

The ulnar nerve descends down the medial side of the upper arm and passes posterior to the medial epicondyle (where
it is susceptible to damage) before entering the anterior compartment of the forearm by passing between the two
heads of the exor carpi ulnaris. It continues down the medial aspect of the forearm. The ulnar nerve emerges from
beneath the exor carpi ulnaris and becomes super cial just proximal to the wrist where it passes super cial to the
exor retinaculum, together with the ulnar artery, to enter the hand through a groove between the pisiform and the
hook of the hamate where it bifurcates into its terminal branches.

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By Henry Vandyke Carter [Public domain], via Wikimedia Commons

Branches

Branches of Origin Supply

Ulnar Nerve

Muscular Forearm Flexor carpi ulnaris, medial half of exor digitorum profundus
branch

Palmar Forearm Skin of medial half of palm

cutaneous
branch

Dorsal Forearm Skin of dorsum of medial one and a half ngers and associated dorsal hand area
cutaneous
branch

Deep branch Hand Hypothenar muscles (abductor digiti minimi, exor digiti minimi, opponens digiti
minimi), medial two lumbricals, adductor pollicis and interossei

Super cial Hand Skin of palmar surface of medial one and a half ngers
branch

The ulnar nerve gives off no major branches in the arm, but three branches arise in the forearm:

The muscular branch innervating the exor carpi ulnaris and the medial half of the exor digitorum profundus
The palmar cutaneous branch supplying the skin of the medial half of the palm
The dorsal cutaneous branch supplying the skin of the medial dorsum of the hand and the dorsal surface of the
medial one and a half ngers
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The ulnar nerve terminates by bifurcating into:

A deep branch innervating the hypothenar muscles, the medial two lumbricals, the adductor pollicis and the
interossei
A super cial branch supplying the skin of the palmar surface of the medial one and a half ngers

Clinical implications

Lesion Proximal (at elbow) Distal (at wrist)

Mechanism Fracture of medial epicondyle Laceration at wrist

Motor Loss Wrist exion and adduction, nger abduction and adduction, exion Finger abduction and
of ring and little nger, abduction and opposition of little nger, thumb adduction, exion of ring
adduction, extension of IPJs of all digits (less so at index and middle and little nger,
nger due to sparing of lateral two lumbricals) abduction and
opposition of little
nger, thumb adduction,
extension at IPJs

Sensory Medial half of palm, palmar and dorsal surface of medial one and a half Palmar surface of medial
Loss ngers and medial dorsum of hand one and a half ngers

Signs Hand held in abduction (due to unopposed action of exor carpi Claw hand (unopposed
radialis), Froment’s sign (patient is asked to hold a piece of paper extension at MCPJ and
between thumb and at palm as paper is pulled away, patient will ex unopposed exion at
thumb at IPJ to maintain hold – tests adductor pollicis muscle), IPJs of ring and little
hypothenar eminence wasting, N.B. claw hand not typically seen due nger), hypothenar
to paralysis of the exor digitorum profundus eminence wasting,
Froment’s sign

The ulnar nerve is most likely to be injured proximally by a medial epicondyle fracture and results in:

There is weak wrist exion and adduction due to paralysis of the exor carpi ulnaris and the medial half of the
exor digitorum profundus; the hand may be held in abduction (due to unopposed action of the exor carpi
radialis).
There is loss of abduction and adduction of the ngers due to paralysis of the interossei.
There is loss of exion at the MCPJ of the ring and little nger due to paralysis of the medial two lumbricals and
the exor digiti minimi.
There is loss of exion at the DIPJ of the ring and little nger due to paralysis of the medial half of the exor
digitorum profundus (but exion at the PIPJ is likely preserved as this is a function of the exor digitorum
super cialis).
There is weakened extension at the IPJs of the ring and little nger due to paralysis of the interossei and medial
two lumbricals (and to a lesser extent at the IPJs of the index and middle nger).
There is loss of abduction and opposition of the little nger due to paralysis of the hypothenar muscles
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There is loss of abduction and opposition of the little nger due to paralysis of the hypothenar muscles
(hypothenar wasting may be seen).
There is loss of adduction of the thumb due to paralysis of the adductor pollicis (Froment’s sign).
There is loss of sensation to skin over the medial half of the palm, the palmar and dorsal surface of the medial
one and a half ngers and the medial dorsum of the hand.
There is not typically a claw hand appearance (as may be seen in a lesion at the wrist) due to paralysis of the
exor digitorum profundus.

A distal lesion most commonly occurs due to laceration at the wrist. Only intrinsic hand muscles are affected (the exor
carpi ulnaris and medial half of the exor digitorum profundus are spared). A loss of sensation will only affect the
palmar surface of the medial one and a half ngers (the medial palm and the dorsum of the hand are spared). A claw
hand deformity may be seen due to unopposed extension at the MCPJ (by the extensor digitorum) and unopposed
exion at the IPJs (by the FDP and FDS) of the ring and little nger.

Froment’s sign (right hand). Copyright FRCEM

Success.

Claw hand deformity. By Mcstrother (Own work)

[CC BY 3.0
(http://creativecommons.org/licenses/by/3.0)], via
Wikimedia Commons

You are demonstrating a vascular examination on a patient to a group of medical students.

Where is the radial artery pulsation best palpated:

a) At the wrist just lateral to the exor carpi radialis tendon

b) At the wrist just medial to the exor carpi radialis tendon
c) At the wrist just medial to the exor carpi ulnaris tendon
d) At the wrist just lateral to the exor carpi ulnaris tendon
e) At the wrist just lateral to the palmaris longus tendon
Something wrong?

Answer

In the distal forearm, the radial artery lies immediately lateral to the large tendon of the exor carpi radialis muscle and
directly anterior to the pronator quadratus and the distal end of the radius; the pulse can be located by using the exor
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directly anterior to the pronator quadratus and the distal end of the radius; the pulse can be located by using the exor
carpi radialis muscle as a landmark.

Notes
The radial artery, branch of the brachial artery, passes along the lateral aspect of the forearm, lying deep to the
brachioradialis muscle proximally, and distally being covered only by skin and fascia, making this an ideal location to
palpate the pulse or to gain arterial access (palpated just lateral to the exor carpi radialis tendon, while compressing
the artery against the radius bone). The radial artery enters the hand by curving around the lateral side of the wrist,
passing over the oor of the anatomical snuffbox and penetrating the dorsolateral aspect of the hand between the
bases of the rst and second metacarpal bones.

The larger ulnar artery, also a branch of the brachial artery, enters the forearm by passing deep to the pronator teres
muscle and passes down the medial side of the forearm between the exor carpi ulnaris and the exor digitorum
profundus muscles. The ulnar artery enters the hand, passing lateral to the pisiform bone and super cial to the exor
retinaculum. The ulnar artery gives rise to the common interosseous artery.

The palmar and dorsal carpal arches are formed from anastomosis between the carpal branches of the radial and ulnar
arteries, and supply the wrist and carpal bones.

Deep veins of the anterior compartment generally accompany the arteries and ultimately drain into brachial veins
associated with the brachial artery in the cubital fossa.

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By Henry Vandyke Carter [Public domain], via Wikimedia Commons

Regarding the distal attachments of the posterior forearm muscle tendons, which of the
following is paired CORRECTLY:

a) Abductor pollicis longus – Base of proximal phalanx of thumb

b) Extensor pollicis brevis – Base of distal phalanx of thumb
c) Extensor carpi radialis longus – Base of 1st metacarpal
d) Extensor carpi ulnaris – Base of 5th metacarpal
e) Extensor digitorum – Bases of 2nd – 4th metacarpals
Something wrong?

Answer

The extensor carpi ulnaris tendon is attached to the base of the 5th metacarpal. The abductor pollicis longus is
attached distally to the lateral side of base of the 1st metacarpal. The extensor digitorum is attached to the base of the
middle and distal phalanges of digits 2 – 5 via extensor hoods. The extensor pollicis brevis is attached to the proximal
phalanx of the thumb. The extensor carpi radialis longus is attached to the base of the 2nd metacarpal.

Notes
The muscles of the posterior forearm are all innervated by the radial nerve.

The posterior forearm is divided into the super cial and deep groups:

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The super cial group is made up of the brachioradialis, the extensor carpi radialis longus and brevis, the
extensor digitorum, the extensor digiti mini, the anconeus and the extensor carpi ulnaris.
The deep group is made up of the supinator, the abductor pollicis longus, the extensor pollicis longus and brevis
and the extensor indicis.

Muscle Action Innervation

Brachioradialis Flexion of elbow Radial nerve

Extensor carpi radialis longus Extension and abduction of wrist Radial nerve

Extensor carpi radialis brevis Extension and abduction of wrist Radial nerve

Extensor digitorum Extension of all four ngers, extension of wrist Radial nerve

Extensor digiti minimi Extension of little nger Radial nerve

Extensor carpi ulnaris Extension and adduction of wrist Radial nerve

Supinator Supination of forearm Radial nerve

Abductor pollicis longus Abduction and extension of thumb Radial nerve

Extensor pollicis longus Extension of thumb (CMCJ, MCPJ, IPJ) Radial nerve

Extensor pollicis brevis Extension of thumb (CMCJ and MCPJ) Radial nerve

Extensor indicis Extension of index nger Radial nerve

A detailed knowledge of the distal attachments of the exor tendons is important to allow understanding of the clinical
effects of division/injury at any given level of the nger.

The abductor pollicis longus is attached distally to the lateral side of base of the 1st metacarpal.
The extensor pollicis brevis is attached to the proximal phalanx of the thumb and the extensor pollicis longus is
attached to the distal phalanx of the thumb.
The extensor carpi radialis longus is attached to the base of the 2nd metacarpal and the extensor carpi radialis
brevis is attached to the bases of the 2nd and 3rd metacarpals.
The extensor digitorum is attached to the base of the middle and distal phalanges of digits 2 – 5 via extensor
hoods.
The extensor carpi ulnaris is attached to the base of the 5th metacarpal.
The extensor digiti minimi is attached to the base of the 5th metacarpal.
The extensor indicis is attached to the extensor hood of the index nger.

Muscle tendon Distal attachment

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Extensor carpi radialis Dorsal surface of base of 2nd metacarpal

longus

Extensor carpi radialis Dorsal surface of base of 2nd and 3rd metacarpal
brevis

Extensor digitorum Dorsal aspects of bases of middle and distal phalanges of all four ngers via
extensor hoods

Extensor carpi ulnaris Tubercle on base of medial 5th metacarpal

Abductor pollicis longus Lateral side of base of 1st metacarpal

Extensor pollicis longus Dorsal surface of base of distal phalanx of thumb

Extensor pollicis brevis Dorsal surface of base of proximal phalanx of thumb

Extensor indicis Extensor hood of index nger

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By Henry Vandyke Carter [Public domain], via

Wikimedia Commons

By Henry Vandyke Carter [Public domain], via

Wikimedia Commons

A 49 year old patient sustains a crush injury to his left hand. You are attempting to assess
which muscle tendons may be affected based on their distal attachment. Regarding the distal
attachments of the anterior forearm muscles, which of the following is paired CORRECTLY:

a) Flexor pollicis longus – base of proximal phalanx of thumb

b) Flexor digitorum profundus – distal phalanges of digits 2 – 5
c) Flexor digitorum super cialis – proximal phalanges of digits 2 – 5
d) Flexor carpi ulnaris – hook of hamate and 4th metacarpal
e) Flexor carpi radialis – base of 1st metacarpal
Something wrong?

Answer
The exor digitorum profundus is attached distally to the palmar surface of the distal phalanges of all four ngers. The
exor pollicis longus is attached distally to the base of the distal phalanx of the thumb. The exor digitorum
super cialis is attached distally to the palmar surface of the middle phalanges of all four ngers. The exor carpi ulnaris
is attached distally to the pisiform, hook of hamate and 5th metacarpal. The exor carpi radialis is attached distally to
the base of the 2nd and 3rd metacarpal.

Notes
The anterior forearm is divided into:

The super cial compartment consisting of the exor carpi ulnaris, exor carpi radialis, palmaris longus and the
pronator teres
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pronator teres
The intermediate compartment consisting of the exor digitorum super cialis
The deep compartment consisting of the exor digitorum profundus, exor pollicis longus and pronator
quadratus

All of the muscles in the anterior forearm are innervated by the median nerve, except for the exor carpi ulnaris and
the medial half of the exor digitorum profundus which are innervated by the ulnar nerve.

Muscle Action Innervation

Flexor carpi ulnaris Flexion and adduction of wrist Ulnar nerve

Flexor carpi radialis Flexion and abduction of wrist Median nerve

Palmaris longus Flexion of wrist Median nerve

Pronator teres Pronation of forearm Median nerve

Flexor digitorum Flexion of MCPJ and PIPJ of all four digits, Median nerve
super cialis exion of wrist

Flexor pollicis longus Flexion of MCPJ and IPJ of thumb Median nerve

Flexor digitorum Flexion of MCPJ and DIPJ of all four digits, Lateral half by median nerve, medial half
profundus exion of wrist by ulnar nerve

Pronator quadratus Pronation of forearm Median nerve

The exor muscles of the anterior forearm all originate from the medial humeral epicondyle. A detailed knowledge of
the distal attachments of the exor tendons is important to allow understanding of the clinical effects of division/injury
at any given level of the nger.

The exor pollicis longus is attached distally to the base of the distal phalanx of the thumb.
The exor digitorum profundus is attached distally to the palmar surface of the distal phalanges of all four
ngers.
The exor digitorum super cialis is attached distally to the palmar surface of the middle phalanges of all four
ngers.
The exor carpi ulnaris is attached distally to the pisiform, hook of hamate and 5th metacarpal.
The exor carpi radialis is attached distally to the base of the 2nd and 3rd metacarpal.
The palmaris longus distally blends with the bres of the exor retinaculum which is continuous with the
palmar aponeurosis.

Flexor tendon Distal attachment

Flexor pollicis longus Base of distal phalanx of thumb

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Flexor digitorum profundus Distal phalanges of all four digits

Flexor digitorum super cialis Middle phalanges of all four digits

Flexor carpi ulnaris Pisiform, hook of hamate and 5th metacarpal

Flexor carpi radialis Base of 2nd and 3rd metacarpal

Palmaris longus Palmar aponeurosis

By Henry Vandyke Carter [Public

domain], via Wikimedia Commons

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By Henry Vandyke Carter [Public domain], via

Wikimedia Commons

A 19 year old male attends ED having sustained a stab wound to his upper limb. On
examination, the patient is unable to ex the distal interphalangeal joints of the ring and little
nger but the proximal interphalangeal joint is intact. Which of the following nerves is most likely
affected, and at which level:

a) Median nerve at elbow

b) Median nerve at wrist
c) Ulnar nerve at elbow
d) Ulnar nerve at wrist
e) Median nerve in proximal forearm
Something wrong?

Answer
Loss of exion at the distal interphalangeal joint of the ring and index nger is likely due to paralysis of the medial half
of the exor digitorum profundus, innervated by the ulnar nerve. Flexion at the proximal interphalangeal joint is
preserved as this is a function of the exor digitorum super cialis, innervated by the median nerve. Ulnar nerve injury
at the wrist would not affect the long exors, so the injury must have been more proximal.

Notes
The ulnar nerve is a continuation of the medial cord of the brachial plexus, containing bres from the C8 – T1 nerve
roots.

Nerve Ulnar nerve

Nerve C8 – T1
roots

Plexus Medial cord

cords

Motor All the intrinsic muscles of the hand (except for the thenar muscles and the lateral two lumbricals), the
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Motor All the intrinsic muscles of the hand (except for the thenar muscles and the lateral two lumbricals), the
Supply exor carpi ulnaris and the medial half of the exor digitorum profundus

Sensory Medial half of palm, palmar and dorsal surface of medial one and a half ngers and lateral dorsum of
supply hand

Anatomical course

The ulnar nerve descends down the medial side of the upper arm and passes posterior to the medial epicondyle (where
it is susceptible to damage) before entering the anterior compartment of the forearm by passing between the two
heads of the exor carpi ulnaris. It continues down the medial aspect of the forearm. The ulnar nerve emerges from
beneath the exor carpi ulnaris and becomes super cial just proximal to the wrist where it passes super cial to the
exor retinaculum, together with the ulnar artery, to enter the hand through a groove between the pisiform and the
hook of the hamate where it bifurcates into its terminal branches.

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By Henry Vandyke Carter [Public domain], via Wikimedia Commons

Branches

Branches of Origin Supply

Ulnar Nerve

Muscular Forearm Flexor carpi ulnaris, medial half of exor digitorum profundus
branch

Palmar Forearm Skin of medial half of palm

cutaneous
branch

Dorsal Forearm Skin of dorsum of medial one and a half ngers and associated dorsal hand area
cutaneous
branch

Deep branch Hand Hypothenar muscles (abductor digiti minimi, exor digiti minimi, opponens digiti
minimi), medial two lumbricals, adductor pollicis and interossei

Super cial Hand Skin of palmar surface of medial one and a half ngers
branch

The ulnar nerve gives off no major branches in the arm, but three branches arise in the forearm:

The muscular branch innervating the exor carpi ulnaris and the medial half of the exor digitorum profundus
The palmar cutaneous branch supplying the skin of the medial half of the palm
The dorsal cutaneous branch supplying the skin of the medial dorsum of the hand and the dorsal surface of the
medial one and a half ngers
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medial one and a half ngers

The ulnar nerve terminates by bifurcating into:

A deep branch innervating the hypothenar muscles, the medial two lumbricals, the adductor pollicis and the
interossei
A super cial branch supplying the skin of the palmar surface of the medial one and a half ngers

Clinical implications

Lesion Proximal (at elbow) Distal (at wrist)

Mechanism Fracture of medial epicondyle Laceration at wrist

Motor Loss Wrist exion and adduction, nger abduction and adduction, exion Finger abduction and
of ring and little nger, abduction and opposition of little nger, thumb adduction, exion of ring
adduction, extension of IPJs of all digits (less so at index and middle and little nger,
nger due to sparing of lateral two lumbricals) abduction and
opposition of little
nger, thumb adduction,
extension at IPJs

Sensory Medial half of palm, palmar and dorsal surface of medial one and a half Palmar surface of medial
Loss ngers and medial dorsum of hand one and a half ngers

Signs Hand held in abduction (due to unopposed action of exor carpi Claw hand (unopposed
radialis), Froment’s sign (patient is asked to hold a piece of paper extension at MCPJ and
between thumb and at palm as paper is pulled away, patient will ex unopposed exion at
thumb at IPJ to maintain hold – tests adductor pollicis muscle), IPJs of ring and little
hypothenar eminence wasting, N.B. claw hand not typically seen due nger), hypothenar
to paralysis of the exor digitorum profundus eminence wasting,
Froment’s sign

The ulnar nerve is most likely to be injured proximally by a medial epicondyle fracture and results in:

There is weak wrist exion and adduction due to paralysis of the exor carpi ulnaris and the medial half of the
exor digitorum profundus; the hand may be held in abduction (due to unopposed action of the exor carpi
radialis).
There is loss of abduction and adduction of the ngers due to paralysis of the interossei.
There is loss of exion at the MCPJ of the ring and little nger due to paralysis of the medial two lumbricals and
the exor digiti minimi.
There is loss of exion at the DIPJ of the ring and little nger due to paralysis of the medial half of the exor
digitorum profundus (but exion at the PIPJ is likely preserved as this is a function of the exor digitorum
super cialis).
There is weakened extension at the IPJs of the ring and little nger due to paralysis of the interossei and medial
two lumbricals (and to a lesser extent at the IPJs of the index and middle nger).
There is loss of abduction and opposition of the little nger due to paralysis of the hypothenar muscles
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There is loss of abduction and opposition of the little nger due to paralysis of the hypothenar muscles
(hypothenar wasting may be seen).
There is loss of adduction of the thumb due to paralysis of the adductor pollicis (Froment’s sign).
There is loss of sensation to skin over the medial half of the palm, the palmar and dorsal surface of the medial
one and a half ngers and the medial dorsum of the hand.
There is not typically a claw hand appearance (as may be seen in a lesion at the wrist) due to paralysis of the
exor digitorum profundus.

A distal lesion most commonly occurs due to laceration at the wrist. Only intrinsic hand muscles are affected (the exor
carpi ulnaris and medial half of the exor digitorum profundus are spared). A loss of sensation will only affect the
palmar surface of the medial one and a half ngers (the medial palm and the dorsum of the hand are spared). A claw
hand deformity may be seen due to unopposed extension at the MCPJ (by the extensor digitorum) and unopposed
exion at the IPJs (by the FDP and FDS) of the ring and little nger.

Froment’s sign (right hand). Copyright FRCEM

Success.

Claw hand deformity. By Mcstrother (Own work)

[CC BY 3.0
(http://creativecommons.org/licenses/by/3.0)], via
Wikimedia Commons

A 87 year old woman is brought in to the ED by her concerned family. They

describe increasing swelling and tenderness of her right wrist. She is now febrile and you suspect
septic arthritis. Which of the following synovial joint type best describes the wrist joint:

a) Synovial plane joint

b) Synovial modi ed hinge joint
c) Synovial saddle joint
d) Synovial condyloid joint
e) Synovial pivot joint
Something wrong?

Answer
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The wrist joint is a synovial condyloid joint occurring between the distal end of the radius and the articular disc
overlying the distal end of the ulna and the scaphoid, lunate and triquetrum.

Notes

Joint Wrist joint

Type Synovial condyloid joint

Articulations Distal end of the radius and articular disc with scaphoid, lunate and triquetrum

Stabilising Joint capsule, palmar radiocarpal, palmar ulnocarpal and dorsal radiocarpal ligaments, radial and
factors ulnar collateral ligaments of the wrist joint

Movements Flexion and extension, abduction and adduction

The wrist joint is a synovial condyloid joint occurring between the distal end of the radius and the articular disc
overlying the distal end of the ulna and the scaphoid, lunate and triquetrum.

The capsule of the wrist joint is reinforced by palmar radiocarpal, palmar ulnocarpal and dorsal radiocarpal ligaments.
The radial and ulnar collateral ligaments of the wrist joint reinforce the medial and lateral sides of the wrist joint.

The wrist joint allows movement around two axes; the hand can be abducted and adducted, and exed and extended at
the wrist joint.

Movement Muscles Involved

Flexion Flexor carpi radialis, exor carpi ulnaris, exor digitorum profundus, exor digitorum super cialis,
palmaris longus

Extension Extensor carpi radialis longus and brevis, extensor carpi ulnaris, extensor digitorum

Abduction Flexor carpi radialis, extensor carpi radialis longus and brevis

Adduction Flexor carpi ulnaris, extensor carpi ulnaris

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Modi ed by FRCEM Success. Original by Henry Vandyke Carter [Public domain], via Wikimedia
Commons

A 18 year patient old presents to ED having cut herself on the distal crease of her wrist. An
image of her hand at rest is shown below. Paralysis to which of the following muscles is most likely
responsible for this deformity:

By Mcstrother (Own work) [CC BY 3.0 (http://creativecommons.org/licenses/by/3.0)], via

Wikimedia Commons

a) Hypothenar muscles
b) Interossei and medial two lumbricals
c) Flexor digitorum profundus
d) Extensor digitorum
e) Extensor digiti minimi
Something wrong?

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Answer
The image shows the claw hand deformity seen in ulnar neuropathy. Loss of innervation to the interossei and medial
two lumbricals leads to loss of extension at the interphalangeal joints of the ring and little nger, with unopposed
exion by the exor digitorum profundus and exor digitorum super cialis. Loss of innervation to the medial two
lumbricals leads to loss of exion at the metacarpophalangeal joints of the ring and little nger, with unopposed
extension by the extensor digitorum, and extensor digiti minimi. This claw hand deformity is typically not seen in a
more proximal ulnar nerve injury where the medial half of the exor digitorum profundus is also paralysed.

Notes

The ulnar nerve is a continuation of the medial cord of the brachial plexus, containing bres from the C8 – T1 nerve
roots.

Nerve Ulnar nerve

Nerve C8 – T1
roots

Plexus Medial cord

cords

Motor All the intrinsic muscles of the hand (except for the thenar muscles and the lateral two lumbricals), the
Supply exor carpi ulnaris and the medial half of the exor digitorum profundus

Sensory Medial half of palm, palmar and dorsal surface of medial one and a half ngers and lateral dorsum of
supply hand

Anatomical course

The ulnar nerve descends down the medial side of the upper arm and passes posterior to the medial epicondyle (where
it is susceptible to damage) before entering the anterior compartment of the forearm by passing between the two
heads of the exor carpi ulnaris. It continues down the medial aspect of the forearm. The ulnar nerve emerges from
beneath the exor carpi ulnaris and becomes super cial just proximal to the wrist where it passes super cial to the
exor retinaculum, together with the ulnar artery, to enter the hand through a groove between the pisiform and the
hook of the hamate where it bifurcates into its terminal branches.

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By Henry Vandyke Carter [Public domain], via Wikimedia Commons

Branches

Branches of Origin Supply

Ulnar Nerve
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Ulnar Nerve

Muscular Forearm Flexor carpi ulnaris, medial half of exor digitorum profundus
branch

Palmar Forearm Skin of medial half of palm

cutaneous
branch

Dorsal Forearm Skin of dorsum of medial one and a half ngers and associated dorsal hand area
cutaneous
branch

Deep branch Hand Hypothenar muscles (abductor digiti minimi, exor digiti minimi, opponens digiti
minimi), medial two lumbricals, adductor pollicis and interossei

Super cial Hand Skin of palmar surface of medial one and a half ngers
branch

The ulnar nerve gives off no major branches in the arm, but three branches arise in the forearm:

The muscular branch innervating the exor carpi ulnaris and the medial half of the exor digitorum profundus
The palmar cutaneous branch supplying the skin of the medial half of the palm
The dorsal cutaneous branch supplying the skin of the medial dorsum of the hand and the dorsal surface of the
medial one and a half ngers

The ulnar nerve terminates by bifurcating into:

A deep branch innervating the hypothenar muscles, the medial two lumbricals, the adductor pollicis and the
interossei
A super cial branch supplying the skin of the palmar surface of the medial one and a half ngers

Clinical implications

Lesion Proximal (at elbow) Distal (at wrist)

Mechanism Fracture of medial epicondyle Laceration at wrist

Motor Loss Wrist exion and adduction, nger abduction and adduction, exion Finger abduction and
of ring and little nger, abduction and opposition of little nger, thumb adduction, exion of ring
adduction, extension of IPJs of all digits (less so at index and middle and little nger,
nger due to sparing of lateral two lumbricals) abduction and
opposition of little
nger, thumb adduction,
extension at IPJs

Sensory Medial half of palm, palmar and dorsal surface of medial one and a half
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Sensory Medial half of palm, palmar and dorsal surface of medial one and a half Palmar surface of medial
Loss ngers and medial dorsum of hand one and a half ngers

Signs Hand held in abduction (due to unopposed action of exor carpi Claw hand (unopposed
radialis), Froment’s sign (patient is asked to hold a piece of paper extension at MCPJ and
between thumb and at palm as paper is pulled away, patient will ex unopposed exion at
thumb at IPJ to maintain hold – tests adductor pollicis muscle), IPJs of ring and little
hypothenar eminence wasting, N.B. claw hand not typically seen due nger), hypothenar
to paralysis of the exor digitorum profundus eminence wasting,
Froment’s sign

The ulnar nerve is most likely to be injured proximally by a medial epicondyle fracture and results in:

There is weak wrist exion and adduction due to paralysis of the exor carpi ulnaris and the medial half of the
exor digitorum profundus; the hand may be held in abduction (due to unopposed action of the exor carpi
radialis).
There is loss of abduction and adduction of the ngers due to paralysis of the interossei.
There is loss of exion at the MCPJ of the ring and little nger due to paralysis of the medial two lumbricals and
the exor digiti minimi.
There is loss of exion at the DIPJ of the ring and little nger due to paralysis of the medial half of the exor
digitorum profundus (but exion at the PIPJ is likely preserved as this is a function of the exor digitorum
super cialis).
There is weakened extension at the IPJs of the ring and little nger due to paralysis of the interossei and medial
two lumbricals (and to a lesser extent at the IPJs of the index and middle nger).
There is loss of abduction and opposition of the little nger due to paralysis of the hypothenar muscles
(hypothenar wasting may be seen).
There is loss of adduction of the thumb due to paralysis of the adductor pollicis (Froment’s sign).
There is loss of sensation to skin over the medial half of the palm, the palmar and dorsal surface of the medial
one and a half ngers and the medial dorsum of the hand.
There is not typically a claw hand appearance (as may be seen in a lesion at the wrist) due to paralysis of the
exor digitorum profundus.

A distal lesion most commonly occurs due to laceration at the wrist. Only intrinsic hand muscles are affected (the exor
carpi ulnaris and medial half of the exor digitorum profundus are spared). A loss of sensation will only affect the
palmar surface of the medial one and a half ngers (the medial palm and the dorsum of the hand are spared). A claw
hand deformity may be seen due to unopposed extension at the MCPJ (by the extensor digitorum) and unopposed
exion at the IPJs (by the FDP and FDS) of the ring and little nger.

Froment’s sign (right hand). Copyright FRCEM

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Froment’s sign (right hand). Copyright FRCEM
Success.

Claw hand deformity. By Mcstrother (Own work)

[CC BY 3.0
(http://creativecommons.org/licenses/by/3.0)], via
Wikimedia Commons

A 29 year old fell heavily while base-jumping and presents to ED with a painful right arm. X-
ray shows a fracture of the medial epicondyle. Which of the following nerves is most likely
damaged in this type of injury:

a) Median nerve
b) Radial nerve
c) Musculocutaneous nerve
d) Ulnar nerve
e) Axillary nerve
Something wrong?

Answer
The ulnar nerve is most susceptible in an fracture of the medial epicondyle.

Notes
The ulnar nerve is a continuation of the medial cord of the brachial plexus, containing bres from the C8 – T1 nerve
roots.

Nerve Ulnar nerve

Nerve C8 – T1
roots

Plexus Medial cord

cords

Motor All the intrinsic muscles of the hand (except for the thenar muscles and the lateral two lumbricals), the
Supply exor carpi ulnaris and the medial half of the exor digitorum profundus

Sensory Medial half of palm, palmar and dorsal surface of medial one and a half ngers and lateral dorsum of
supply hand

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Anatomical course

The ulnar nerve descends down the medial side of the upper arm and passes posterior to the medial epicondyle (where
it is susceptible to damage) before entering the anterior compartment of the forearm by passing between the two
heads of the exor carpi ulnaris. It continues down the medial aspect of the forearm. The ulnar nerve emerges from
beneath the exor carpi ulnaris and becomes super cial just proximal to the wrist where it passes super cial to the
exor retinaculum, together with the ulnar artery, to enter the hand through a groove between the pisiform and the
hook of the hamate where it bifurcates into its terminal branches.

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By Henry Vandyke Carter [Public domain], via Wikimedia Commons

Branches

Branches of Origin Supply

Ulnar Nerve

Muscular Forearm Flexor carpi ulnaris, medial half of exor digitorum profundus
branch

Palmar Forearm Skin of medial half of palm

cutaneous
branch

Dorsal Forearm Skin of dorsum of medial one and a half ngers and associated dorsal hand area
cutaneous
branch

Deep branch Hand Hypothenar muscles (abductor digiti minimi, exor digiti minimi, opponens digiti
minimi), medial two lumbricals, adductor pollicis and interossei

Super cial Hand Skin of palmar surface of medial one and a half ngers
branch

The ulnar nerve gives off no major branches in the arm, but three branches arise in the forearm:

The muscular branch innervating the exor carpi ulnaris and the medial half of the exor digitorum profundus
The palmar cutaneous branch supplying the skin of the medial half of the palm
The dorsal cutaneous branch supplying the skin of the medial dorsum of the hand and the dorsal surface of the
medial one and a half ngers

The ulnar nerve terminates by bifurcating into:

A deep branch innervating the hypothenar muscles, the medial two lumbricals, the adductor pollicis and the
interossei
A super cial branch supplying the skin of the palmar surface of the medial one and a half ngers
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A super cial branch supplying the skin of the palmar surface of the medial one and a half ngers

Clinical implications

Lesion Proximal (at elbow) Distal (at wrist)

Mechanism Fracture of medial epicondyle Laceration at wrist

Motor Loss Wrist exion and adduction, nger abduction and adduction, exion Finger abduction and
of ring and little nger, abduction and opposition of little nger, thumb adduction, exion of ring
adduction, extension of IPJs of all digits (less so at index and middle and little nger,
nger due to sparing of lateral two lumbricals) abduction and
opposition of little
nger, thumb adduction,
extension at IPJs

Sensory Medial half of palm, palmar and dorsal surface of medial one and a half Palmar surface of medial
Loss ngers and medial dorsum of hand one and a half ngers

Signs Hand held in abduction (due to unopposed action of exor carpi Claw hand (unopposed
radialis), Froment’s sign (patient is asked to hold a piece of paper extension at MCPJ and
between thumb and at palm as paper is pulled away, patient will ex unopposed exion at
thumb at IPJ to maintain hold – tests adductor pollicis muscle), IPJs of ring and little
hypothenar eminence wasting, N.B. claw hand not typically seen due nger), hypothenar
to paralysis of the exor digitorum profundus eminence wasting,
Froment’s sign

The ulnar nerve is most likely to be injured proximally by a medial epicondyle fracture and results in:

There is weak wrist exion and adduction due to paralysis of the exor carpi ulnaris and the medial half of the
exor digitorum profundus; the hand may be held in abduction (due to unopposed action of the exor carpi
radialis).
There is loss of abduction and adduction of the ngers due to paralysis of the interossei.
There is loss of exion at the MCPJ of the ring and little nger due to paralysis of the medial two lumbricals and
the exor digiti minimi.
There is loss of exion at the DIPJ of the ring and little nger due to paralysis of the medial half of the exor
digitorum profundus (but exion at the PIPJ is likely preserved as this is a function of the exor digitorum
super cialis).
There is weakened extension at the IPJs of the ring and little nger due to paralysis of the interossei and medial
two lumbricals (and to a lesser extent at the IPJs of the index and middle nger).
There is loss of abduction and opposition of the little nger due to paralysis of the hypothenar muscles
(hypothenar wasting may be seen).
There is loss of adduction of the thumb due to paralysis of the adductor pollicis (Froment’s sign).
There is loss of sensation to skin over the medial half of the palm, the palmar and dorsal surface of the medial
one and a half ngers and the medial dorsum of the hand.
There is not typically a claw hand appearance (as may be seen in a lesion at the wrist) due to paralysis of the
exor digitorum profundus.
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exor digitorum profundus.

A distal lesion most commonly occurs due to laceration at the wrist. Only intrinsic hand muscles are affected (the exor
carpi ulnaris and medial half of the exor digitorum profundus are spared). A loss of sensation will only affect the
palmar surface of the medial one and a half ngers (the medial palm and the dorsum of the hand are spared). A claw
hand deformity may be seen due to unopposed extension at the MCPJ (by the extensor digitorum) and unopposed
exion at the IPJs (by the FDP and FDS) of the ring and little nger.

Froment’s sign (right hand). Copyright FRCEM

Success.

Claw hand deformity. By Mcstrother (Own work)

[CC BY 3.0
(http://creativecommons.org/licenses/by/3.0)], via
Wikimedia Commons

A 21 year old mechanic presents to ED after sustaining a crush injury to his middle nger
whilst at work. Which of the following muscles is least likely to be affected:

a) Flexor digitorum profundus

b) Palmar interossei
c) Dorsal interossei
d) Lumbrical
e) Extensor digitorum
Something wrong?

Answer
The palmar interossei insert into the extensor hoods of the index, ring and little nger; there is no palmar
interosseus attaching to the middle nger and hence it is least likely to be affected in this injury.

Notes
The interosseous muscles originate from and lie between the metacarpal bones. The dorsal interossei insert into the
extensor hoods and proximal phalanges of the index, middle and ring nger. The palmar interossei insert into the
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extensor hoods of the index, ring and little nger.

The four dorsal interossei act to abduct the index, middle and ring ngers, and the three palmar interossei act to
adduct the index, ring and little ngers. (DAB, PAD). Because the interosseous muscles insert into the extensor hoods,
they also contribute to the complex exion and extension movements of the interphalangeal joints of the digits.

The interosseous muscles are all innervated by the ulnar nerve.

Muscle Action Innervation

Dorsal interossei Abduction of ngers at MCPJ Ulnar nerve

Palmar interossei Adduction of ngers at MCPJ Ulnar nerve

Modi ed by FRCEM Success. Original by By OpenStax [CC BY 4.0

(http://creativecommons.org/licenses/by/4.0)], via Wikimedia Commons

A 32 year old man sustains an injury to the proximal radial nerve after falling from a ladder.
Which of the following muscles would you not expect to be affected:

a) Brachioradialis
b) Supinator
c) Abductor pollicis longus
d) Extensor digiti minimi
e) Pronator quadratus
Something wrong?

Answer
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Answer
The brachioradialis, supinator, abductor pollicis longus and extensor digiti mini are all muscles of the posterior forearm
innervated by the radial nerve. The pronator quadratus is a muscle of the anterior forearm, innervated by the median
nerve.

Notes
The muscles of the posterior forearm are all innervated by the radial nerve.

The posterior forearm is divided into the super cial and deep groups:

The super cial group is made up of the brachioradialis, the extensor carpi radialis longus and brevis, the
extensor digitorum, the extensor digiti mini, the anconeus and the extensor carpi ulnaris.
The deep group is made up of the supinator, the abductor pollicis longus, the extensor pollicis longus and brevis
and the extensor indicis.

Muscle Action Innervation

Brachioradialis Flexion of elbow Radial nerve

Extensor carpi radialis longus Extension and abduction of wrist Radial nerve

Extensor carpi radialis brevis Extension and abduction of wrist Radial nerve

Extensor digitorum Extension of all four ngers, extension of wrist Radial nerve

Extensor digiti minimi Extension of little nger Radial nerve

Extensor carpi ulnaris Extension and adduction of wrist Radial nerve

Supinator Supination of forearm Radial nerve

Abductor pollicis longus Abduction and extension of thumb Radial nerve

Extensor pollicis longus Extension of thumb (CMCJ, MCPJ, IPJ) Radial nerve

Extensor pollicis brevis Extension of thumb (CMCJ and MCPJ) Radial nerve

Extensor indicis Extension of index nger Radial nerve

A detailed knowledge of the distal attachments of the exor tendons is important to allow understanding of the clinical
effects of division/injury at any given level of the nger.

The abductor pollicis longus is attached distally to the lateral side of base of the 1st metacarpal.
The extensor pollicis brevis is attached to the proximal phalanx of the thumb and the extensor pollicis longus is
attached to the distal phalanx of the thumb.
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attached to the distal phalanx of the thumb.
The extensor carpi radialis longus is attached to the base of the 2nd metacarpal and the extensor carpi radialis
brevis is attached to the bases of the 2nd and 3rd metacarpals.
The extensor digitorum is attached to the base of the middle and distal phalanges of digits 2 – 5 via extensor
hoods.
The extensor carpi ulnaris is attached to the base of the 5th metacarpal.
The extensor digiti minimi is attached to the base of the 5th metacarpal.
The extensor indicis is attached to the extensor hood of the index nger.

Muscle tendon Distal attachment

Extensor carpi radialis Dorsal surface of base of 2nd metacarpal

longus

Extensor carpi radialis Dorsal surface of base of 2nd and 3rd metacarpal
brevis

Extensor digitorum Dorsal aspects of bases of middle and distal phalanges of all four ngers via
extensor hoods

Extensor carpi ulnaris Tubercle on base of medial 5th metacarpal

Abductor pollicis longus Lateral side of base of 1st metacarpal

Extensor pollicis longus Dorsal surface of base of distal phalanx of thumb

Extensor pollicis brevis Dorsal surface of base of proximal phalanx of thumb

Extensor indicis Extensor hood of index nger

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By Henry Vandyke Carter [Public domain], via

Wikimedia Commons

By Henry Vandyke Carter [Public domain], via

Wikimedia Commons

A 48 year old man presents to ED having sustained a super cial laceration to his wrist on
broken glass. Which of the following structures passing super cial to the exor retinaculum may be
damaged in this injury:

a) Median and ulnar nerve

b) Median nerve and tendon of the exor digitorum super cialis
c) Ulnar artery and ulnar nerve
d) Ulnar nerve and radial artery
e) Ulnar nerve and tendon of the exor digitorum super cialis
Something wrong?

Answer
The ulnar artery, ulnar nerve, and tendon of the palmaris longus pass into the hand anterior to the exor retinaculum.
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The ulnar artery, ulnar nerve, and tendon of the palmaris longus pass into the hand anterior to the exor retinaculum.
The median nerve and the exor tendons pass into the hand deep to the exor retinaculum, within the carpal tunnel.

Notes
The exor retinaculum (transverse carpal ligament) is a thickened band of brous connective tissue on the volar aspect
of the hand which forms the roof of the carpal tunnel. The exor retinaculum holds the exor tendons in place at the
wrist and prevents them from bowstringing.

It is attached laterally to the scaphoid and trapezium and medially to the pisiform and the hook of the hamate.

The thenar and hypothenar muscles arise from the exor retinaculum.

The ulnar artery, ulnar nerve, and tendon of the palmaris longus pass into the hand anterior to the exor retinaculum,
and therefore do not pass through the carpal tunnel.

The exor carpi radialis tendon passes through the lateral aspect of the exor retinaculum into the hand.

The four tendons of the exor digitorum profundus, the four tendons of the exor digitorum super cialis, the tendon of
the exor pollicis longus and the median nerve pass into the hand posterior to the exor retinaculum, within the carpal
tunnel.

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By Henry Vandyke Carter [Public domain], via Wikimedia Commons

A 54 year old patient presents to ED complaining of weakness in her right hand. She has
recently undergone an endoscopic nerve release for carpal tunnel syndrome but is now
complaining of a severe weakness of her thumb with loss of thumb opposition. Sensation is normal.
Which of the following nerves was likely affected in the surgical procedure.

a) Anterior interosseous nerve

b) Recurrent branch of the median nerve
c) Super cial branch of the ulnar nerve
d) Deep branch of the ulnar nerve
e) Palmar digital branch of the median nerve
Something wrong?

Answer
The recurrent branch of the median nerve has likely been affected, which innervates the thenar muscles, causing
weakness of thumb exion, abduction and opposition, but has no cutaneous innervation.

Notes
The median nerve is formed from the medial and lateral brachial plexus cords and contains bres from all ve roots (C5
– T1).

Nerve Median nerve

Nerve C5 – T1
roots

Plexus Medial and lateral cords

cords

Motor All the anterior forearm muscles (except for the exor carpi ulnaris and the medial half of the exor
Supply digitorum profundus), the thenar muscles ( exor pollicis brevis, abductor pollicis brevis, opponens
pollicis) and the lateral two lumbricals
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pollicis) and the lateral two lumbricals

Sensory Lateral aspect of palm and palmar surface and ngertips of lateral three and a half digits
supply

Anatomical course

The median nerve originates in the axilla before passing down the medial side of the arm (initially lateral to the brachial
artery before crossing over to the medial side of the brachial artery). It enters the anterior compartment of the
forearm via the antecubital fossa, travelling between the exor digitorum profundus and exor digitorum super cialis
muscles, before entering the hand via the carpal tunnel and bifurcating into its terminal branches.

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By Henry Vandyke Carter [Public domain], via Wikimedia Commons

Branches

Branches of Origin Supply

Median Nerve

Median nerve Axilla Super cial and intermediate compartment of anterior forearm (pronator teres,
exor carpi radialis, palmaris longus, exor digitorum super cialis, NOT exor
carpi ulnaris)

Anterior Forearm Deep compartment of anterior forearm ( exor pollicis longus, pronator
interosseous quadratus, lateral half of exor digitorum profundus)
nerve

Palmar Forearm Skin over the lateral aspect of the palm

cutaneous
branch

Recurrent Hand Thenar muscles ( exor pollicis brevis, abductor pollicis brevis, opponens pollicis)
branch of
median nerve

Palmar digital Hand Lateral two lumbricals and skin over the palmar surface and ngertips of the
branch lateral three and a half digits

The median nerve directly innervates the pronator teres, the exor carpi radialis, the palmaris longus and the exor
digitorum super cialis. It gives off no major branches in the arm, but gives rise to the anterior interosseous nerve
(innervating the exor pollicis longus, the pronator quadratus, and the lateral half of the exor digitorum profundus)
and the palmar cutaneous nerve (innervating the lateral aspect of the palm) in the forearm.

In the hand the median nerve bifurcates into the recurrent branch of the median nerve (innervating the thenar
muscles) and the palmar digital branch (innervating the lateral two lumbricals and the skin over the palmar surface and
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muscles) and the palmar digital branch (innervating the lateral two lumbricals and the skin over the palmar surface and
ngertips of the lateral three and a half digits).

Clinical implications

Lesion Proximal (arm, elbow, proximal forearm) Distal (wrist)

Mechanisms Supracondylar fracture, stab wound to arm or forearm Lacerations just

proximal to exor
retinaculum, carpal
tunnel syndrome

Motor Loss Forearm pronation, wrist exion and abduction, index and middle nger Thumb exion,
exion, thumb exion, abduction and opposition abduction and
opposition, exion of
index and middle
nger MCPJ

Sensory Lateral aspect of palm and palmar surface and ngertips of lateral three Palmar surface and
Loss and a half digits ngertips of lateral
three and a half digits

Signs Forearm rests in supination with wrist in ulnar deviation and thumb Thenar eminence
extended, thenar eminence wasting, hand of Benediction (when asked wasting
to make a st, the patient will be able to ex the little and ring ngers
but not the index and middle ngers)

A proximal median nerve lesion at the elbow may occur due to supracondylar fracture of the humerus or from deep
penetrating wounds to the arm or forearm and may result in:

Pronation of the forearm and exion and abduction of the wrist are lost due to paralysis of the exors and
pronators in the forearm. The forearm thus often rests in supination with ulnar deviation of the wrist (due to
unopposed action of the exor carpi ulnaris).
Flexion, abduction and opposition of the thumb at the MCPJ and IPJ are lost due to paralysis of the thenar
muscles and the exor pollicis longus.
Flexion of the index and middle ngers at the IPJs is lost due to paralysis of the exor digitorum super cialis
and the lateral half of the exor digitorum profundus.
Flexion of the MCPJ of the index and middle ngers is lost due to paralysis of the lateral two lumbrical muscles.
N.B. Flexion of the ring and little ngers at the MCPJ and DIPJ are preserved as these are functions of the
medial half of the exor digitorum profundus and the medial two lumbrical muscles, innervated by the ulnar
nerve (there may be weakness of exion at the PIPJ of these ngers due to paralysis of the exor digitorum
super cialis).
There is loss of sensation over the lateral aspect of the palm, and the skin over the palmar surface and
ngertips of the lateral three and a half digits.

Medial nerve lesion at the wrist often occurs due to lacerations just proximal to the exor retinaculum or to
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compression of the median nerve in the carpal tunnel. Only the intrinsic hand muscles are affected. Loss of opposition,
abduction and exion of the MCPJ of the thumb occurs due to paralysis of the thenar muscles. Loss of exion at the
MCPJ of the index and middle nger occurs due to paralysis of the lateral two lumbricals. There is loss of sensation to
the palmar surface and ngertips of the lateral three and a half digits only (the palmar region is spared).

A 29 year old male presents to ED having falling awkwardly during a judo match. On
examination he is unable to ex his index and middle ngers at the metacarpophalangeal or
interphalangeal joints and unable to ex the distal phalanx of his thumb. He has loss of sensation
over the lateral palm and ngers. Which of the following nerves has most likely been injured, and at
what level:

a) Anterior interosseous nerve i the proximal forearm

b) Median nerve in the cubital fossa
c) Ulnar nerve at the elbow
d) Median nerve at the wrist
e) Radial nerve in the midarm
Something wrong?

Answer
The most likely injury is the median nerve at the cubital fossa. The patient has loss of exion at the MCPJ and IPJ of the
index and middle nger caused by paralysis of the lateral two lumbricals and the exor digitorum profundus and exor
digitorum super cialis. Loss of exion of the distal phalanx of the thumb results from paralysis of the exor pollicis
longus. The anterior interosseous nerve, branch of the median nerve, has no cutaneous function. Median nerve injury
at the wrist would spare the forearm exor muscles.

Notes
The median nerve is formed from the medial and lateral brachial plexus cords and contains bres from all ve roots (C5
– T1).

Nerve Median nerve

Nerve C5 – T1
roots

Plexus Medial and lateral cords

cords

Motor All the anterior forearm muscles (except for the exor carpi ulnaris and the medial half of the exor
Supply digitorum profundus), the thenar muscles ( exor pollicis brevis, abductor pollicis brevis, opponens
pollicis) and the lateral two lumbricals

Sensory Lateral aspect of palm and palmar surface and ngertips of lateral three and a half digits
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Sensory Lateral aspect of palm and palmar surface and ngertips of lateral three and a half digits
supply

Anatomical course

The median nerve originates in the axilla before passing down the medial side of the arm (initially lateral to the brachial
artery before crossing over to the medial side of the brachial artery). It enters the anterior compartment of the
forearm via the antecubital fossa, travelling between the exor digitorum profundus and exor digitorum super cialis
muscles, before entering the hand via the carpal tunnel and bifurcating into its terminal branches.

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By Henry Vandyke Carter [Public domain], via Wikimedia Commons

Branches

Branches of Origin Supply

Median Nerve

Median nerve Axilla Super cial and intermediate compartment of anterior forearm (pronator teres,
exor carpi radialis, palmaris longus, exor digitorum super cialis, NOT exor
carpi ulnaris)

Anterior Forearm Deep compartment of anterior forearm ( exor pollicis longus, pronator
interosseous quadratus, lateral half of exor digitorum profundus)
nerve

Palmar Forearm Skin over the lateral aspect of the palm

cutaneous
branch

Recurrent Hand Thenar muscles ( exor pollicis brevis, abductor pollicis brevis, opponens pollicis)
branch of
median nerve

Palmar digital Hand Lateral two lumbricals and skin over the palmar surface and ngertips of the
branch lateral three and a half digits

The median nerve directly innervates the pronator teres, the exor carpi radialis, the palmaris longus and the exor
digitorum super cialis. It gives off no major branches in the arm, but gives rise to the anterior interosseous nerve
(innervating the exor pollicis longus, the pronator quadratus, and the lateral half of the exor digitorum profundus)
and the palmar cutaneous nerve (innervating the lateral aspect of the palm) in the forearm.

In the hand the median nerve bifurcates into the recurrent branch of the median nerve (innervating the thenar
muscles) and the palmar digital branch (innervating the lateral two lumbricals and the skin over the palmar surface and
ngertips of the lateral three and a half digits).

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Clinical implications

Lesion Proximal (arm, elbow, proximal forearm) Distal (wrist)

Mechanisms Supracondylar fracture, stab wound to arm or forearm Lacerations just

proximal to exor
retinaculum, carpal
tunnel syndrome

Motor Loss Forearm pronation, wrist exion and abduction, index and middle nger Thumb exion,
exion, thumb exion, abduction and opposition abduction and
opposition, exion of
index and middle
nger MCPJ

Sensory Lateral aspect of palm and palmar surface and ngertips of lateral three Palmar surface and
Loss and a half digits ngertips of lateral
three and a half digits

Signs Forearm rests in supination with wrist in ulnar deviation and thumb Thenar eminence
extended, thenar eminence wasting, hand of Benediction (when asked wasting
to make a st, the patient will be able to ex the little and ring ngers
but not the index and middle ngers)

A proximal median nerve lesion at the elbow may occur due to supracondylar fracture of the humerus or from deep
penetrating wounds to the arm or forearm and may result in:

Pronation of the forearm and exion and abduction of the wrist are lost due to paralysis of the exors and
pronators in the forearm. The forearm thus often rests in supination with ulnar deviation of the wrist (due to
unopposed action of the exor carpi ulnaris).
Flexion, abduction and opposition of the thumb at the MCPJ and IPJ are lost due to paralysis of the thenar
muscles and the exor pollicis longus.
Flexion of the index and middle ngers at the IPJs is lost due to paralysis of the exor digitorum super cialis
and the lateral half of the exor digitorum profundus.
Flexion of the MCPJ of the index and middle ngers is lost due to paralysis of the lateral two lumbrical muscles.
N.B. Flexion of the ring and little ngers at the MCPJ and DIPJ are preserved as these are functions of the
medial half of the exor digitorum profundus and the medial two lumbrical muscles, innervated by the ulnar
nerve (there may be weakness of exion at the PIPJ of these ngers due to paralysis of the exor digitorum
super cialis).
There is loss of sensation over the lateral aspect of the palm, and the skin over the palmar surface and
ngertips of the lateral three and a half digits.

Medial nerve lesion at the wrist often occurs due to lacerations just proximal to the exor retinaculum or to
compression of the median nerve in the carpal tunnel. Only the intrinsic hand muscles are affected. Loss of opposition,
abduction and exion of the MCPJ of the thumb occurs due to paralysis of the thenar muscles. Loss of exion at the
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MCPJ of the index and middle nger occurs due to paralysis of the lateral two lumbricals. There is loss of sensation to
the palmar surface and ngertips of the lateral three and a half digits only (the palmar region is spared).

A 54 year old woman presents to ED having sustained a laceration to the palm of her hand
while gardening. She is unable to touch the pad of her little nger with her thumb, but sensation is
intact. Which of the following nerves has most likely been injured:

a) Anterior interosseous nerve

b) Recurrent branch of the median nerve
c) Deep branch of the ulnar nerve
d) Super cial branch of the ulnar nerve
e) Deep branch of the radial nerve
Something wrong?

Answer
The recurrent branch of the median nerve innervates the thenar muscles ( exor pollicis brevis, abductor pollicis brevis,
opponens pollicis) and has no sensory function. Damage to this nerve results in weakness of abduction, opposition and
exion of the thumb. The anterior interosseous nerve is a branch of the median nerve and innervates the deep muscles
of the anterior forearm – damage to this nerve would result in weakness of thumb exion but not opposition as
described in this patient.

Notes

The median nerve is formed from the medial and lateral brachial plexus cords and contains bres from all ve roots (C5
– T1).

Nerve Median nerve

Nerve C5 – T1
roots

Plexus Medial and lateral cords

cords

Motor All the anterior forearm muscles (except for the exor carpi ulnaris and the medial half of the exor
Supply digitorum profundus), the thenar muscles ( exor pollicis brevis, abductor pollicis brevis, opponens
pollicis) and the lateral two lumbricals

Sensory Lateral aspect of palm and palmar surface and ngertips of lateral three and a half digits
supply

Anatomical course
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Anatomical course

The median nerve originates in the axilla before passing down the medial side of the arm (initially lateral to the brachial
artery before crossing over to the medial side of the brachial artery). It enters the anterior compartment of the
forearm via the antecubital fossa, travelling between the exor digitorum profundus and exor digitorum super cialis
muscles, before entering the hand via the carpal tunnel and bifurcating into its terminal branches.

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By Henry Vandyke Carter [Public domain], via Wikimedia Commons

Branches

Branches of Origin Supply

Median Nerve

Median nerve Axilla Super cial and intermediate compartment of anterior forearm (pronator teres,
exor carpi radialis, palmaris longus, exor digitorum super cialis, NOT exor
carpi ulnaris)

Anterior Forearm Deep compartment of anterior forearm ( exor pollicis longus, pronator
interosseous quadratus, lateral half of exor digitorum profundus)
nerve

Palmar Forearm Skin over the lateral aspect of the palm

cutaneous
branch

Recurrent Hand Thenar muscles ( exor pollicis brevis, abductor pollicis brevis, opponens pollicis)
branch of
median nerve

Palmar digital Hand Lateral two lumbricals and skin over the palmar surface and ngertips of the
branch lateral three and a half digits

The median nerve directly innervates the pronator teres, the exor carpi radialis, the palmaris longus and the exor
digitorum super cialis. It gives off no major branches in the arm, but gives rise to the anterior interosseous nerve
(innervating the exor pollicis longus, the pronator quadratus, and the lateral half of the exor digitorum profundus)
and the palmar cutaneous nerve (innervating the lateral aspect of the palm) in the forearm.

In the hand the median nerve bifurcates into the recurrent branch of the median nerve (innervating the thenar
muscles) and the palmar digital branch (innervating the lateral two lumbricals and the skin over the palmar surface and
ngertips of the lateral three and a half digits).

Clinical implications

Lesion Proximal (arm, elbow, proximal forearm) Distal (wrist)

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Lesion Proximal (arm, elbow, proximal forearm) Distal (wrist)

Mechanisms Supracondylar fracture, stab wound to arm or forearm Lacerations just

proximal to exor
retinaculum, carpal
tunnel syndrome

Motor Loss Forearm pronation, wrist exion and abduction, index and middle nger Thumb exion,
exion, thumb exion, abduction and opposition abduction and
opposition, exion of
index and middle
nger MCPJ

Sensory Lateral aspect of palm and palmar surface and ngertips of lateral three Palmar surface and
Loss and a half digits ngertips of lateral
three and a half digits

Signs Forearm rests in supination with wrist in ulnar deviation and thumb Thenar eminence
extended, thenar eminence wasting, hand of Benediction (when asked wasting
to make a st, the patient will be able to ex the little and ring ngers
but not the index and middle ngers)

A proximal median nerve lesion at the elbow may occur due to supracondylar fracture of the humerus or from deep
penetrating wounds to the arm or forearm and may result in:

Pronation of the forearm and exion and abduction of the wrist are lost due to paralysis of the exors and
pronators in the forearm. The forearm thus often rests in supination with ulnar deviation of the wrist (due to
unopposed action of the exor carpi ulnaris).
Flexion, abduction and opposition of the thumb at the MCPJ and IPJ are lost due to paralysis of the thenar
muscles and the exor pollicis longus.
Flexion of the index and middle ngers at the IPJs is lost due to paralysis of the exor digitorum super cialis
and the lateral half of the exor digitorum profundus.
Flexion of the MCPJ of the index and middle ngers is lost due to paralysis of the lateral two lumbrical muscles.
N.B. Flexion of the ring and little ngers at the MCPJ and DIPJ are preserved as these are functions of the
medial half of the exor digitorum profundus and the medial two lumbrical muscles, innervated by the ulnar
nerve (there may be weakness of exion at the PIPJ of these ngers due to paralysis of the exor digitorum
super cialis).
There is loss of sensation over the lateral aspect of the palm, and the skin over the palmar surface and
ngertips of the lateral three and a half digits.

Medial nerve lesion at the wrist often occurs due to lacerations just proximal to the exor retinaculum or to
compression of the median nerve in the carpal tunnel. Only the intrinsic hand muscles are affected. Loss of opposition,
abduction and exion of the MCPJ of the thumb occurs due to paralysis of the thenar muscles. Loss of exion at the
MCPJ of the index and middle nger occurs due to paralysis of the lateral two lumbricals. There is loss of sensation to
the palmar surface and ngertips of the lateral three and a half digits only (the palmar region is spared).

A 31 year old lady slipped on a wet bathroom

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A 31 year old lady slipped on a wet bathroom oor and fell onto her outstretched hand. She is
tender over the anatomical snuffbox and imaging shows a fracture of the scaphoid bone. Which of
the following structures is most likely to be damaged in this type of injury:

a) Brachial profunda artery

b) Ulnar artery
c) Radial artery
d) Princeps pollicis artery
e) Deep palmar arterial arch
Something wrong?

Answer

The radial artery passes over the oor of the anatomical snuffbox, just superior to the scaphoid bone and hence it is the
most likely to be injured in this type of injury. Once in the hand the radial artery divides into the princeps pollicis artery
and the deep palmar arterial arch.

Notes
The anatomical snuffbox is the triangular depression formed on the posterolateral side of the dorsal wrist and 1st
metacarpal by the extensor tendons passing into the thumb.

Anatomical Structure
Boundaries

Medial border Tendon of extensor pollicis longus

Lateral border Tendons of the abductor pollicis longus and extensor pollicis brevis

Proximal border Radial styloid process

Distal border 1st metacarpal

Floor Scaphoid and trapezium bones

Roof Skin

Contents Radial artery, terminal portion of the super cial branch of the radial nerve, cephalic
vein

It is bounded laterally by the tendons of the abductor pollicis longus and the extensor pollicis brevis and medially by
the tendon of the extensor pollicis longus.

The oor of the anatomical snuffbox is formed by the scaphoid and trapezium carpal bones. The radial styloid process
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The oor of the anatomical snuffbox is formed by the scaphoid and trapezium carpal bones. The radial styloid process
can be palpated proximally and the 1st metacarpal can be palpated distally.

The radial artery crosses the oor of the anatomical snuffbox. Subcutaneously terminal parts of the super cial branch
of the radial nerve and the origin of the cephalic vein pass over the anatomical snuffbox.

The anatomical snuffbox is important clinically as the scaphoid is palpable within the snuffbox; localised pain and
tenderness of the anatomical snuffbox is most likely due to a scaphoid fracture.

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By Grant, John Charles Boileau (An atlas of anatomy, / by regions 1962) [Public domain], via
Wikimedia Commons

A 29 year old woman is brought to the ED after concerns were raised for her welfare by a
neighbour. She has a deep laceration to the anterior aspect of the right wrist. You are concerned
about an injury to the underlying structures including the exor retinaculum. The exor
retinaculum is attached medially to which of the following structures:

a) Triquetrum and pisiform

b) Lunate and triquetrum
c) Lunate and hook of the hamate
d) Pisiform and hook of the hamate
e) Ulna, lunate and triquetrum
Something wrong?

Answer
The exor retinaculum is attached medially to the pisiform and the hook of the hamate.

Notes
The exor retinaculum (transverse carpal ligament) is a thickened band of brous connective tissue on the volar aspect
of the hand which forms the roof of the carpal tunnel. The exor retinaculum holds the exor tendons in place at the
wrist and prevents them from bowstringing.

It is attached laterally to the scaphoid and trapezium and medially to the pisiform and the hook of the hamate.

The thenar and hypothenar muscles arise from the exor retinaculum.

The ulnar artery, ulnar nerve, and tendon of the palmaris longus pass into the hand anterior to the exor retinaculum,
and therefore do not pass through the carpal tunnel.

The exor carpi radialis tendon passes through the lateral aspect of the exor retinaculum into the hand.

The four tendons of the exor digitorum profundus, the four tendons of the exor digitorum super cialis, the tendon of
the exor pollicis longus and the median nerve pass into the hand posterior to the exor retinaculum, within the carpal
tunnel.
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tunnel.

By Henry Vandyke Carter [Public domain], via Wikimedia Commons

A 32 year old farm worker has presented to the ED with an infected laceration on a nger. You
are concerned about the possible spread of infection into the midpalmar space. Infections in the
digital synovial sheath of which ngers are most likely to spread to the midpalmar space:

a) Thumb and index ngers

b) Lateral three ngers
c) Medial two ngers
d) Thumb and little nger
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e) Index and middle nger

Something wrong?

Notes
Infections may occur in the digital synovial sheath for example after a puncture wound of a nger.

Infection in the middle three ngers is usually contained as they have separate synovial sheaths.

The synovial sheath of the little nger is usually continuous with the common exor sheath and thus infection may
spread to this sheath and from here to the midpalmar space.

Infections in the thumb may spread to the midpalmar space via the continuous synovial sheath of the exor pollicis
longus.

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By Henry Vandyke Carter [Public domain], via Wikimedia Commons

A patient sustains a fracture of the midshaft of the humerus with resultant damage to the
radial nerve. He has wrist drop and is unable to extend his ngers. He is still able to supinate his
forearm. Supination of the forearm is still possible through the action of which of the following
muscles:

a) Supinator
b) Coracobrachialis
c) Biceps brachii
d) Brachialis
e) Supraspinatus
Something wrong?

Answer
Supination of the forearm is primarily produced by the supinator (radial nerve) and the biceps brachii
(musculocutaneous nerve). Radial nerve damage will result in paralysis of the supinator muscle, but the biceps brachii
muscle function is preserved.

Notes
The anterior compartment of the arm consists of three muscles.

Muscle Actions Innervation

Coracobrachialis Flexion of arm Musculocutaneous nerve (C5 – C7)

Biceps brachii Flexion and supination of Musculocutaneous nerve (C5, C6)

forearm, exion of arm

Brachialis Flexion of forearm Musculocutaneous nerve (C5, C6); small contribution by

radial nerve (C7) to lateral muscle

The coracobrachialis (green) is innervated by the musculocutaneous nerve (C5 – C7). It acts to ex the arm at the
glenohumeral joint.

The biceps brachii (red) is innervated by the musculocutaneous nerve (C5 – C6). The biceps is primarily a powerful
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exor and supinator of the forearm at the elbow joint. It also assists with exion of the arm at the shoulder joint (with
the coracobrachialis muscle). The biceps re ex tap predominantly tests spinal cord segment C6.

The brachialis (blue) is innervated primarily by the musculocutaneous nerve (C5, C6) with a small contribution from the
radial nerve (C7). The brachialis exes the forearm at the elbow joint.

Modi ed by FRCEM Success. Original by Henry Vandyke Carter [Public domain], via Wikimedia
Commons

A 32 year old farmer sustained a puncture wound to the base of the thumb. The wound
became infected and the infection spread to the midpalmar space. The tendon(s) of which muscle
will most likely be affected:

a) Flexor digitorum profundus

b) Flexor pollicis brevis
c) Flexor pollicis longus
d) Flexor digitorum super cialis
e) Flexor carpi radialis
Something wrong?

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Answer
Tenosynovitis in the thumb may spread through the synovial sheath of the exor pollicis longus tendon, also known as
the radial bursa.

Notes
Tenosynovitis can be due to an infection of the synovial sheaths of the digits. Infections may occur in the digital
synovial sheath for example after a puncture wound to a nger.

Infection in the middle three ngers is usually contained as they have separate synovial sheaths.

The synovial sheath of the little nger is usually continuous with the common exor sheath (the ulnar bursa) and thus
infection may spread to this sheath and from here to the midpalmar space.

Infections in the thumb may spread to the midpalmar space via the continuous synovial sheath of the exor pollicis
longus, also known as the radial bursa.

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By Henry Vandyke Carter [Public domain], via Wikimedia Commons

A 34 year old patient presents to ED having sustained an injury to her right hand whilst
playing cricket. She is unable to fully straighten her right middle  nger as the distal
phalanx remains exed. A picture of her hand is shown below. Which of the following structures
within the digit was most likely injured:

By Howcheng (Own work) [CC BY-SA 3.0

(http://creativecommons.org/licenses/by-sa/3.0),
via Wikimedia Commons

a) Super cial branch of radial nerve

b) Insertion of central slip of extensor digitorum tendon
c) Insertion of terminal extensor digitorum tendon
d) Insertion of exor digitorum profundus tendon
e) Palmar digital branch of median nerve
Something wrong?

Answer
Damage to the insertion of the terminal extensor digitorum tendon would result in loss of extension at the distal
interphalangeal joint causing a xed exion deformity, called the Mallet deformity.

Notes
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Notes
The tendons of the extensor digitorum (and extensor pollicis longus) pass onto the dorsal aspect of the digits and
expand over the proximal phalanges to form complex extensor hoods. The central slip inserts into the base of the
middle phalanx, and distally the tendon inserts into the distal phalanx of each digit.

Division of the central slip of the extensor tendon will result in the Boutonniere deformity, with loss of extension of the
proximal interphalangeal joint and loss of exion of the distal interphalangeal joint. The middle phalanx is held in
forced exion, with hyperextension of the distal phalanx.

Division of the terminal extensor tendon will result in the Mallet deformity, with loss of extension at the distal
interphalangeal joint; the distal phalanx is held in forced exion due to unopposed action of the exor digitorum
profundus muscle.

Structure Terminal extensor tendon Central slip of extensor tendon

Attachment Distal phalanx Middle phalanx

Movements Loss of extension at distal Loss of extension at proximal interphalangeal joint and
affected in interphalangeal joint exion at distal interphalangeal joint
injury

Deformity in Mallet deformity: Distal Boutonniere deformity: Middle phalanx held in xed
injury phalanx held in xed exion exion with hyperextension of distal phalanx

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Modi ed by FRCEM Success. Original by Henry Vandyke Carter [Public domain], via Wikimedia
Commons

A 45 year old woman sustains an injury to the median nerve at the elbow after falling
awkwardly. Which of the following clinical features are you least likely to see on examination:

a) Weakness of pronation
b) Weakness of wrist exion
c) Loss of exion of the medial four digits.
d) Loss of sensation to skin over the lateral palm and lateral three and a half digits
e) Hand of Benediction appearance when the patient is asked to make a st
Something wrong?

Answer
Flexion of the index and middle ngers at the IPJs is lost due to paralysis of the exor digitorum super cialis and the
lateral half of the exor digitorum profundus. Flexion of the MCPJs of the index and middle ngers are lost due to
paralysis of the lateral two lumbrical muscles. Flexion of the ring and little ngers are preserved as these are supported
by the medial half of the exor digitorum profundus and the medial two lumbrical muscles, innervated by the ulnar
nerve.

Notes
The median nerve is formed from the medial and lateral brachial plexus cords and contains bres from all ve roots (C5
– T1).

Nerve Median nerve

Nerve C5 – T1
roots

Plexus Medial and lateral cords

cords

Motor All the anterior forearm muscles (except for the exor carpi ulnaris and the medial half of the exor
Supply digitorum profundus), the thenar muscles ( exor pollicis brevis, abductor pollicis brevis, opponens
pollicis) and the lateral two lumbricals

Sensory Lateral aspect of palm and palmar surface and ngertips of lateral three and a half digits
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Sensory Lateral aspect of palm and palmar surface and ngertips of lateral three and a half digits
supply

Anatomical course

The median nerve originates in the axilla before passing down the medial side of the arm (initially lateral to the brachial
artery before crossing over to the medial side of the brachial artery). It enters the anterior compartment of the
forearm via the antecubital fossa, travelling between the exor digitorum profundus and exor digitorum super cialis
muscles, before entering the hand via the carpal tunnel and bifurcating into its terminal branches.

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By Henry Vandyke Carter [Public domain], via Wikimedia Commons

Branches

Branches of Origin Supply

Median Nerve

Median nerve Axilla Super cial and intermediate compartment of anterior forearm (pronator teres,
exor carpi radialis, palmaris longus, exor digitorum super cialis, NOT exor
carpi ulnaris)

Anterior Forearm Deep compartment of anterior forearm ( exor pollicis longus, pronator
interosseous quadratus, lateral half of exor digitorum profundus)
nerve

Palmar Forearm Skin over the lateral aspect of the palm

cutaneous
branch

Recurrent Hand Thenar muscles ( exor pollicis brevis, abductor pollicis brevis, opponens pollicis)
branch of
median nerve

Palmar digital Hand Lateral two lumbricals and skin over the palmar surface and ngertips of the
branch lateral three and a half digits

The median nerve directly innervates the pronator teres, the exor carpi radialis, the palmaris longus and the exor
digitorum super cialis. It gives off no major branches in the arm, but gives rise to the anterior interosseous nerve
(innervating the exor pollicis longus, the pronator quadratus, and the lateral half of the exor digitorum profundus)
and the palmar cutaneous nerve (innervating the lateral aspect of the palm) in the forearm.

In the hand the median nerve bifurcates into the recurrent branch of the median nerve (innervating the thenar
muscles) and the palmar digital branch (innervating the lateral two lumbricals and the skin over the palmar surface and
ngertips of the lateral three and a half digits).

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Clinical implications

Lesion Proximal (arm, elbow, proximal forearm) Distal (wrist)

Mechanisms Supracondylar fracture, stab wound to arm or forearm Lacerations just

proximal to exor
retinaculum, carpal
tunnel syndrome

Motor Loss Forearm pronation, wrist exion and abduction, index and middle nger Thumb exion,
exion, thumb exion, abduction and opposition abduction and
opposition, exion of
index and middle
nger MCPJ

Sensory Lateral aspect of palm and palmar surface and ngertips of lateral three Palmar surface and
Loss and a half digits ngertips of lateral
three and a half digits

Signs Forearm rests in supination with wrist in ulnar deviation and thumb Thenar eminence
extended, thenar eminence wasting, hand of Benediction (when asked wasting
to make a st, the patient will be able to ex the little and ring ngers
but not the index and middle ngers)

A proximal median nerve lesion at the elbow may occur due to supracondylar fracture of the humerus or from deep
penetrating wounds to the arm or forearm and may result in:

Pronation of the forearm and exion and abduction of the wrist are lost due to paralysis of the exors and
pronators in the forearm. The forearm thus often rests in supination with ulnar deviation of the wrist (due to
unopposed action of the exor carpi ulnaris).
Flexion, abduction and opposition of the thumb at the MCPJ and IPJ are lost due to paralysis of the thenar
muscles and the exor pollicis longus.
Flexion of the index and middle ngers at the IPJs is lost due to paralysis of the exor digitorum super cialis
and the lateral half of the exor digitorum profundus.
Flexion of the MCPJ of the index and middle ngers is lost due to paralysis of the lateral two lumbrical muscles.
N.B. Flexion of the ring and little ngers at the MCPJ and DIPJ are preserved as these are functions of the
medial half of the exor digitorum profundus and the medial two lumbrical muscles, innervated by the ulnar
nerve (there may be weakness of exion at the PIPJ of these ngers due to paralysis of the exor digitorum
super cialis).
There is loss of sensation over the lateral aspect of the palm, and the skin over the palmar surface and
ngertips of the lateral three and a half digits.

Medial nerve lesion at the wrist often occurs due to lacerations just proximal to the exor retinaculum or to
compression of the median nerve in the carpal tunnel. Only the intrinsic hand muscles are affected. Loss of opposition,
abduction and exion of the MCPJ of the thumb occurs due to paralysis of the thenar muscles. Loss of exion at the
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MCPJ of the index and middle nger occurs due to paralysis of the lateral two lumbricals. There is loss of sensation to
the palmar surface and ngertips of the lateral three and a half digits only (the palmar region is spared).

A 20 year old woman presents to ED with a painful swollen digit. Three days ago she attended
with a dog bite that had penetrated the common exor synovial sheath of the forearm. Which of
the following digits is the most likely to be involved with spread of infection from this location:

a) Thumb
b) Index nger
c) Middle nger
d) Ring nger
e) Little nger
Something wrong?

Answer
The synovial sheath of the little nger is usually continuous with the common exor sheath of the forearm, unlike the
middle three ngers which have separated synovial sheaths. The synovial sheath of the thumb is continuous with the
synovial sheath of the exor pollicis longus.

Notes
Tenosynovitis can be due to an infection of the synovial sheaths of the digits. Infections may occur in the digital
synovial sheath for example after a puncture wound to a nger.

Infection in the middle three ngers is usually contained as they have separate synovial sheaths.

The synovial sheath of the little nger is usually continuous with the common exor sheath (the ulnar bursa) and thus
infection may spread to this sheath and from here to the midpalmar space.

Infections in the thumb may spread to the midpalmar space via the continuous synovial sheath of the exor pollicis
longus, also known as the radial bursa.

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By Henry Vandyke Carter [Public domain], via Wikimedia Commons

A 24 year old butcher has sustained a deep laceration to the distal crease of the wrist where
he has cut through the ulnar nerve. Which of the following clinical ndings would you most expect
to see on examination:

a) Loss of sensation to the dorsum of the medial hand

b) Weakness of exion at the proximal interphalangeal joints of all four ngers
c) Loss of opposition of the thumb
d) Weakness of extension at the interphalangeal joints of all four ngers
e) Weakness of extension of the thumb
Something wrong?

Answer
The ulnar nerve innervates the interossei and the medial two lumbricals, which are important muscles in extension of
the ngers at the interphalangeal joints. Flexion at the proximal interphalangeal joints is produced primarily by the
exor digitorum super cialis, innervated by the median nerve. Sensation to the dorsum of the medial hand is
innervated by the dorsal cutaneous branch of the ulnar nerve which arises in the forearm, proximal to the site of
laceration. Extension of the the thumb is primarily a function of the radial nerve, and opposition of the thumb, the
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median nerve.

Notes
The ulnar nerve is a continuation of the medial cord of the brachial plexus, containing bres from the C8 – T1 nerve
roots.

Nerve Ulnar nerve

Nerve C8 – T1
roots

Plexus Medial cord

cords

Motor All the intrinsic muscles of the hand (except for the thenar muscles and the lateral two lumbricals), the
Supply exor carpi ulnaris and the medial half of the exor digitorum profundus

Sensory Medial half of palm, palmar and dorsal surface of medial one and a half ngers and lateral dorsum of
supply hand

Anatomical course

The ulnar nerve descends down the medial side of the upper arm and passes posterior to the medial epicondyle (where
it is susceptible to damage) before entering the anterior compartment of the forearm by passing between the two
heads of the exor carpi ulnaris. It continues down the medial aspect of the forearm. The ulnar nerve emerges from
beneath the exor carpi ulnaris and becomes super cial just proximal to the wrist where it passes super cial to the
exor retinaculum, together with the ulnar artery, to enter the hand through a groove between the pisiform and the
hook of the hamate where it bifurcates into its terminal branches.

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By Henry Vandyke Carter [Public domain], via Wikimedia Commons

Branches

Branches of Origin Supply

Ulnar Nerve

Muscular Forearm Flexor carpi ulnaris, medial half of exor digitorum profundus
branch

Palmar Forearm Skin of medial half of palm

cutaneous
branch

Dorsal Forearm Skin of dorsum of medial one and a half ngers and associated dorsal hand area
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Dorsal Forearm Skin of dorsum of medial one and a half ngers and associated dorsal hand area
cutaneous
branch

Deep branch Hand Hypothenar muscles (abductor digiti minimi, exor digiti minimi, opponens digiti
minimi), medial two lumbricals, adductor pollicis and interossei

Super cial Hand Skin of palmar surface of medial one and a half ngers
branch

The ulnar nerve gives off no major branches in the arm, but three branches arise in the forearm:

The muscular branch innervating the exor carpi ulnaris and the medial half of the exor digitorum profundus
The palmar cutaneous branch supplying the skin of the medial half of the palm
The dorsal cutaneous branch supplying the skin of the medial dorsum of the hand and the dorsal surface of the
medial one and a half ngers

The ulnar nerve terminates by bifurcating into:

A deep branch innervating the hypothenar muscles, the medial two lumbricals, the adductor pollicis and the
interossei
A super cial branch supplying the skin of the palmar surface of the medial one and a half ngers

Clinical implications

Lesion Proximal (at elbow) Distal (at wrist)

Mechanism Fracture of medial epicondyle Laceration at wrist

Motor Loss Wrist exion and adduction, nger abduction and adduction, exion Finger abduction and
of ring and little nger, abduction and opposition of little nger, thumb adduction, exion of ring
adduction, extension of IPJs of all digits (less so at index and middle and little nger,
nger due to sparing of lateral two lumbricals) abduction and
opposition of little
nger, thumb adduction,
extension at IPJs

Sensory Medial half of palm, palmar and dorsal surface of medial one and a half Palmar surface of medial
Loss ngers and medial dorsum of hand one and a half ngers

Signs Hand held in abduction (due to unopposed action of exor carpi Claw hand (unopposed
radialis), Froment’s sign (patient is asked to hold a piece of paper extension at MCPJ and
between thumb and at palm as paper is pulled away, patient will ex unopposed exion at
thumb at IPJ to maintain hold – tests adductor pollicis muscle), IPJs of ring and little
hypothenar eminence wasting, N.B. claw hand not typically seen due nger), hypothenar
to paralysis of the exor digitorum profundus eminence wasting,
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Froment’s sign

The ulnar nerve is most likely to be injured proximally by a medial epicondyle fracture and results in:

There is weak wrist exion and adduction due to paralysis of the exor carpi ulnaris and the medial half of the
exor digitorum profundus; the hand may be held in abduction (due to unopposed action of the exor carpi
radialis).
There is loss of abduction and adduction of the ngers due to paralysis of the interossei.
There is loss of exion at the MCPJ of the ring and little nger due to paralysis of the medial two lumbricals and
the exor digiti minimi.
There is loss of exion at the DIPJ of the ring and little nger due to paralysis of the medial half of the exor
digitorum profundus (but exion at the PIPJ is likely preserved as this is a function of the exor digitorum
super cialis).
There is weakened extension at the IPJs of the ring and little nger due to paralysis of the interossei and medial
two lumbricals (and to a lesser extent at the IPJs of the index and middle nger).
There is loss of abduction and opposition of the little nger due to paralysis of the hypothenar muscles
(hypothenar wasting may be seen).
There is loss of adduction of the thumb due to paralysis of the adductor pollicis (Froment’s sign).
There is loss of sensation to skin over the medial half of the palm, the palmar and dorsal surface of the medial
one and a half ngers and the medial dorsum of the hand.
There is not typically a claw hand appearance (as may be seen in a lesion at the wrist) due to paralysis of the
exor digitorum profundus.

A distal lesion most commonly occurs due to laceration at the wrist. Only intrinsic hand muscles are affected (the exor
carpi ulnaris and medial half of the exor digitorum profundus are spared). A loss of sensation will only affect the
palmar surface of the medial one and a half ngers (the medial palm and the dorsum of the hand are spared). A claw
hand deformity may be seen due to unopposed extension at the MCPJ (by the extensor digitorum) and unopposed
exion at the IPJs (by the FDP and FDS) of the ring and little nger.

Froment’s sign (right hand). Copyright FRCEM

Success.

Claw hand deformity. By Mcstrother (Own work)

[CC BY 3.0
(http://creativecommons.org/licenses/by/3.0)], via
Wikimedia Commons

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A 21 year old man presents to the ED after sustaining a penetrating knife injury to the hand.
You suspect injury to the structure attached to the proximal lumbrical muscles. The lumbrical
muscles originate from which of the following structures:

a) The exor retinaculum

b) The tendon of the palmaris longus
c) The palmar aponeurosis
d) The tendons of the exor digitorum super cialis
e) The tendons of the exor digitorum profundus
Something wrong?

Answer
The lumbrical muscles originate from the tendons of the exor digitorum profundus muscle.

Notes
The lumbrical muscles originate from the tendons of the exor digitorum profundus in the palm and insert into the
extensor hoods of the medial four ngers.

The lumbrical muscles act to ex these ngers at the metacarpophalangeal joints (MCPJs) and extend them at the
interphalangeal joints (IPJs).

The medial two lumbricals are innervated by the ulnar nerve and the lateral two lumbricals are innervated by the
median nerve.

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Modi ed by FRCEM Success. Original by CFCF (Own work) [CC BY-SA 4.0
(http://creativecommons.org/licenses/by-sa/4.0)], via Wikimedia Commons

A 23 year old man presents to the ED after cutting his forearm. On examination there is a
deep laceration with an arterial spurt. You suspect an ulnar artery injury. Regarding the ulnar
artery, which of the following statements is INCORRECT:

a) The ulnar artery passes down the forearm between the exor carpi ulnaris and the exor pollicis longus muscle.
b) The ulnar artery enters the hand passing lateral to the pisiform bone.
c) The ulnar artery passes anterior to the exor retinaculum.
d) The ulnar artery gives rise to the common interosseous artery.
e) The ulnar artery is a branch of the brachial artery.
Something wrong?

Answer
The larger ulnar artery, also a branch of the brachial artery, enters the forearm by passing deep to the pronator teres
muscle and passes down the medial side of the forearm between the exor carpi ulnaris and the exor digitorum
profundus muscles. The ulnar artery enters the hand, passing lateral to the pisiform bone and super cial to the exor
retinaculum. The ulnar artery gives rise to the common interosseous artery.

Notes
The radial artery, branch of the brachial artery, passes along the lateral aspect of the forearm, lying deep to the
brachioradialis muscle proximally, and distally being covered only by skin and fascia, making this an ideal location to
palpate the pulse or to gain arterial access (palpated just lateral to the exor carpi radialis tendon, while compressing
the artery against the radius bone). The radial artery enters the hand by curving around the lateral side of the wrist,
passing over the oor of the anatomical snuffbox and penetrating the dorsolateral aspect of the hand between the
bases of the rst and second metacarpal bones.

The larger ulnar artery, also a branch of the brachial artery, enters the forearm by passing deep to the pronator teres
muscle and passes down the medial side of the forearm between the exor carpi ulnaris and the exor digitorum
profundus muscles. The ulnar artery enters the hand, passing lateral to the pisiform bone and super cial to the exor
retinaculum. The ulnar artery gives rise to the common interosseous artery.

The palmar and dorsal carpal arches are formed from anastomosis between the carpal branches of the radial and ulnar
arteries, and supply the wrist and carpal bones.

Deep veins of the anterior compartment generally accompany the arteries and ultimately drain into brachial veins
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Deep veins of the anterior compartment generally accompany the arteries and ultimately drain into brachial veins
associated with the brachial artery in the cubital fossa.

By Henry Vandyke Carter [Public domain], via Wikimedia Commons

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A patient sustains an injury to the anterior forearm after falling from a bicycle. Which of the
following muscles would you least expect to be affected in this injury:

a) Palmaris longus
b) Brachioradialis
c) Pronator quadratus
d) Pronator teres
e) Flexor digitorum profundus
Something wrong?

Answer
The brachioradialis is a muscle of the posterior compartment of the forearm. It acts to ex the forearm at the elbow.

Notes
The anterior forearm is divided into:

The super cial compartment consisting of the exor carpi ulnaris, exor carpi radialis, palmaris longus and the
pronator teres
The intermediate compartment consisting of the exor digitorum super cialis
The deep compartment consisting of the exor digitorum profundus, exor pollicis longus and pronator
quadratus

All of the muscles in the anterior forearm are innervated by the median nerve, except for the exor carpi ulnaris and
the medial half of the exor digitorum profundus which are innervated by the ulnar nerve.

Muscle Action Innervation

Flexor carpi ulnaris Flexion and adduction of wrist Ulnar nerve

Flexor carpi radialis Flexion and abduction of wrist Median nerve

Palmaris longus Flexion of wrist Median nerve

Pronator teres Pronation of forearm Median nerve

Flexor digitorum Flexion of MCPJ and PIPJ of all four digits, Median nerve
super cialis exion of wrist

Flexor pollicis longus Flexion of MCPJ and IPJ of thumb Median nerve

Flexor digitorum Flexion of MCPJ and DIPJ of all four digits, Lateral half by median nerve, medial half
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Flexor digitorum Flexion of MCPJ and DIPJ of all four digits, Lateral half by median nerve, medial half
profundus exion of wrist by ulnar nerve

Pronator quadratus Pronation of forearm Median nerve

The exor muscles of the anterior forearm all originate from the medial humeral epicondyle. A detailed knowledge of
the distal attachments of the exor tendons is important to allow understanding of the clinical effects of division/injury
at any given level of the nger.

The exor pollicis longus is attached distally to the base of the distal phalanx of the thumb.
The exor digitorum profundus is attached distally to the palmar surface of the distal phalanges of all four
ngers.
The exor digitorum super cialis is attached distally to the palmar surface of the middle phalanges of all four
ngers.
The exor carpi ulnaris is attached distally to the pisiform, hook of hamate and 5th metacarpal.
The exor carpi radialis is attached distally to the base of the 2nd and 3rd metacarpal.
The palmaris longus distally blends with the bres of the exor retinaculum which is continuous with the
palmar aponeurosis.

Flexor tendon Distal attachment

Flexor pollicis longus Base of distal phalanx of thumb

Flexor digitorum profundus Distal phalanges of all four digits

Flexor digitorum super cialis Middle phalanges of all four digits

Flexor carpi ulnaris Pisiform, hook of hamate and 5th metacarpal

Flexor carpi radialis Base of 2nd and 3rd metacarpal

Palmaris longus Palmar aponeurosis

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By Henry Vandyke Carter [Public

domain], via Wikimedia Commons

By Henry Vandyke Carter [Public domain], via

Wikimedia Commons

A 54 year old lady presents to ED having injured her left arm. She is complaining of weak hand
grip of her left hand. The patient is unable to hold onto a piece of paper between her thumb and her
index nger without exing the distal joint of her thumb. Weakness of which of the following
muscles causes this sign to appear:

a) Flexor pollicis brevis

b) Flexor pollicis longus
c) Adductor pollicis
d) Lumbricals
e) Opponens pollicis
Abductor pollicis brevis

Something wrong?

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Answer
This is a positive Froment’s sign, which is seen in ulnar neuropathy, caused by weakness of the adductor pollicis muscle.

Notes

The ulnar nerve is a continuation of the medial cord of the brachial plexus, containing bres from the C8 – T1 nerve
roots.

Nerve Ulnar nerve

Nerve C8 – T1
roots

Plexus Medial cord

cords

Motor All the intrinsic muscles of the hand (except for the thenar muscles and the lateral two lumbricals), the
Supply exor carpi ulnaris and the medial half of the exor digitorum profundus

Sensory Medial half of palm, palmar and dorsal surface of medial one and a half ngers and lateral dorsum of
supply hand

Anatomical course

The ulnar nerve descends down the medial side of the upper arm and passes posterior to the medial epicondyle (where
it is susceptible to damage) before entering the anterior compartment of the forearm by passing between the two
heads of the exor carpi ulnaris. It continues down the medial aspect of the forearm. The ulnar nerve emerges from
beneath the exor carpi ulnaris and becomes super cial just proximal to the wrist where it passes super cial to the
exor retinaculum, together with the ulnar artery, to enter the hand through a groove between the pisiform and the
hook of the hamate where it bifurcates into its terminal branches.

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By Henry Vandyke Carter [Public domain], via Wikimedia Commons

Branches

Branches of Origin Supply

Ulnar Nerve

Muscular Forearm Flexor carpi ulnaris, medial half of exor digitorum profundus
branch

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Palmar Forearm Skin of medial half of palm

cutaneous
branch

Dorsal Forearm Skin of dorsum of medial one and a half ngers and associated dorsal hand area
cutaneous
branch

Deep branch Hand Hypothenar muscles (abductor digiti minimi, exor digiti minimi, opponens digiti
minimi), medial two lumbricals, adductor pollicis and interossei

Super cial Hand Skin of palmar surface of medial one and a half ngers
branch

The ulnar nerve gives off no major branches in the arm, but three branches arise in the forearm:

The muscular branch innervating the exor carpi ulnaris and the medial half of the exor digitorum profundus
The palmar cutaneous branch supplying the skin of the medial half of the palm
The dorsal cutaneous branch supplying the skin of the medial dorsum of the hand and the dorsal surface of the
medial one and a half ngers

The ulnar nerve terminates by bifurcating into:

A deep branch innervating the hypothenar muscles, the medial two lumbricals, the adductor pollicis and the
interossei
A super cial branch supplying the skin of the palmar surface of the medial one and a half ngers

Clinical implications

Lesion Proximal (at elbow) Distal (at wrist)

Mechanism Fracture of medial epicondyle Laceration at wrist

Motor Loss Wrist exion and adduction, nger abduction and adduction, exion Finger abduction and
of ring and little nger, abduction and opposition of little nger, thumb adduction, exion of ring
adduction, extension of IPJs of all digits (less so at index and middle and little nger,
nger due to sparing of lateral two lumbricals) abduction and
opposition of little
nger, thumb adduction,
extension at IPJs

Sensory Medial half of palm, palmar and dorsal surface of medial one and a half Palmar surface of medial
Loss ngers and medial dorsum of hand one and a half ngers

Signs Hand held in abduction (due to unopposed action of exor carpi Claw hand (unopposed
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radialis), Froment’s sign (patient is asked to hold a piece of paper extension at MCPJ and
between thumb and at palm as paper is pulled away, patient will ex unopposed exion at
thumb at IPJ to maintain hold – tests adductor pollicis muscle), IPJs of ring and little
hypothenar eminence wasting, N.B. claw hand not typically seen due nger), hypothenar
to paralysis of the exor digitorum profundus eminence wasting,
Froment’s sign

The ulnar nerve is most likely to be injured proximally by a medial epicondyle fracture and results in:

There is weak wrist exion and adduction due to paralysis of the exor carpi ulnaris and the medial half of the
exor digitorum profundus; the hand may be held in abduction (due to unopposed action of the exor carpi
radialis).
There is loss of abduction and adduction of the ngers due to paralysis of the interossei.
There is loss of exion at the MCPJ of the ring and little nger due to paralysis of the medial two lumbricals and
the exor digiti minimi.
There is loss of exion at the DIPJ of the ring and little nger due to paralysis of the medial half of the exor
digitorum profundus (but exion at the PIPJ is likely preserved as this is a function of the exor digitorum
super cialis).
There is weakened extension at the IPJs of the ring and little nger due to paralysis of the interossei and medial
two lumbricals (and to a lesser extent at the IPJs of the index and middle nger).
There is loss of abduction and opposition of the little nger due to paralysis of the hypothenar muscles
(hypothenar wasting may be seen).
There is loss of adduction of the thumb due to paralysis of the adductor pollicis (Froment’s sign).
There is loss of sensation to skin over the medial half of the palm, the palmar and dorsal surface of the medial
one and a half ngers and the medial dorsum of the hand.
There is not typically a claw hand appearance (as may be seen in a lesion at the wrist) due to paralysis of the
exor digitorum profundus.

A distal lesion most commonly occurs due to laceration at the wrist. Only intrinsic hand muscles are affected (the exor
carpi ulnaris and medial half of the exor digitorum profundus are spared). A loss of sensation will only affect the
palmar surface of the medial one and a half ngers (the medial palm and the dorsum of the hand are spared). A claw
hand deformity may be seen due to unopposed extension at the MCPJ (by the extensor digitorum) and unopposed
exion at the IPJs (by the FDP and FDS) of the ring and little nger.

Froment’s sign (right hand). Copyright FRCEM

Success.

Claw hand deformity. By Mcstrother (Own work)

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Claw hand deformity. By Mcstrother (Own work)
[CC BY 3.0
(http://creativecommons.org/licenses/by/3.0)], via
Wikimedia Commons

A 78 year old woman suffers a destructive injury to the anatomical snuff box region after
falling on an outstretched hand. Which of the following carpal bones would you not expect to be
affected in this injury:

a) Scaphoid bone
b) Trapezium bone
c) Radial styloid process
d) Trapezoid bone
e) 1st metacarpal
Something wrong?

Answer
The trapezoid bone is not palpated in the anatomical snuffbox. The oor of the anatomical snuffbox is formed by the
scaphoid and trapezium carpal bones. The radial styloid process can be palpated proximally and the 1st metacarpal can
be palpated distally.

Notes
The anatomical snuffbox is the triangular depression formed on the posterolateral side of the dorsal wrist and 1st
metacarpal by the extensor tendons passing into the thumb.

Anatomical Structure
Boundaries

Medial border Tendon of extensor pollicis longus

Lateral border Tendons of the abductor pollicis longus and extensor pollicis brevis

Proximal border Radial styloid process

Distal border 1st metacarpal

Floor Scaphoid and trapezium bones

Roof Skin

Contents Radial artery, terminal portion of the super cial branch of the radial nerve, cephalic
vein
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vein

It is bounded laterally by the tendons of the abductor pollicis longus and the extensor pollicis brevis and medially by
the tendon of the extensor pollicis longus.

The oor of the anatomical snuffbox is formed by the scaphoid and trapezium carpal bones. The radial styloid process
can be palpated proximally and the 1st metacarpal can be palpated distally.

The radial artery crosses the oor of the anatomical snuffbox. Subcutaneously terminal parts of the super cial branch
of the radial nerve and the origin of the cephalic vein pass over the anatomical snuffbox.

The anatomical snuffbox is important clinically as the scaphoid is palpable within the snuffbox; localised pain and
tenderness of the anatomical snuffbox is most likely due to a scaphoid fracture.

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By Grant, John Charles Boileau (An atlas of anatomy, / by regions 1962) [Public domain], via
Wikimedia Commons

A patient presents to ED having fallen on her left arm at a roller disco party. She has fractured
the medial epicondyle of the humerus and damaged the nerve most commonly associated with this
type of injury. Which of the following would you most expect to be affected:

a) Flexion of the proximal interphalangeal joint of the ring ringer

b) Flexion of the distal interphalangeal joint of the index nger
c) Abduction of the index nger
d) Abduction of the thumb
e) Sensation over the middle nger
Something wrong?

Answer
The ulnar nerve is the most commonly injured nerve in a medial epicondyle fracture. Abduction of the index nger is
produced by the dorsal interossei innervated by the ulnar nerve. Flexion of the proximal interphalangeal joint of the
ring nger is produced by the exor digitorum super cialis innervated by the median nerve. Flexion of the distal
interphalangeal joint of the index nger is produced by the lateral half of the exor digitorum profundus innervated by
the median nerve. Abduction of the thumb is produced by the abductor pollicis longus and brevis innervated by the
median nerve. Sensation over the medial nger is supplied by the median nerve.

Notes

The ulnar nerve is a continuation of the medial cord of the brachial plexus, containing bres from the C8 – T1 nerve
roots.

Nerve Ulnar nerve

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Nerve C8 – T1
roots

Plexus Medial cord

cords

Motor All the intrinsic muscles of the hand (except for the thenar muscles and the lateral two lumbricals), the
Supply exor carpi ulnaris and the medial half of the exor digitorum profundus

Sensory Medial half of palm, palmar and dorsal surface of medial one and a half ngers and lateral dorsum of
supply hand

Anatomical course

The ulnar nerve descends down the medial side of the upper arm and passes posterior to the medial epicondyle (where
it is susceptible to damage) before entering the anterior compartment of the forearm by passing between the two
heads of the exor carpi ulnaris. It continues down the medial aspect of the forearm. The ulnar nerve emerges from
beneath the exor carpi ulnaris and becomes super cial just proximal to the wrist where it passes super cial to the
exor retinaculum, together with the ulnar artery, to enter the hand through a groove between the pisiform and the
hook of the hamate where it bifurcates into its terminal branches.

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By Henry Vandyke Carter [Public domain], via Wikimedia Commons

Branches

Branches of Origin Supply

Ulnar Nerve

Muscular Forearm Flexor carpi ulnaris, medial half of exor digitorum profundus
branch

Palmar Forearm Skin of medial half of palm

cutaneous
branch

Dorsal Forearm Skin of dorsum of medial one and a half ngers and associated dorsal hand area
cutaneous
branch

Deep branch Hand Hypothenar muscles (abductor digiti minimi, exor digiti minimi, opponens digiti
minimi), medial two lumbricals, adductor pollicis and interossei

Super cial Hand Skin of palmar surface of medial one and a half ngers
branch

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The ulnar nerve gives off no major branches in the arm, but three branches arise in the forearm:

The muscular branch innervating the exor carpi ulnaris and the medial half of the exor digitorum profundus
The palmar cutaneous branch supplying the skin of the medial half of the palm
The dorsal cutaneous branch supplying the skin of the medial dorsum of the hand and the dorsal surface of the
medial one and a half ngers

The ulnar nerve terminates by bifurcating into:

A deep branch innervating the hypothenar muscles, the medial two lumbricals, the adductor pollicis and the
interossei
A super cial branch supplying the skin of the palmar surface of the medial one and a half ngers

Clinical implications

Lesion Proximal (at elbow) Distal (at wrist)

Mechanism Fracture of medial epicondyle Laceration at wrist

Motor Loss Wrist exion and adduction, nger abduction and adduction, exion Finger abduction and
of ring and little nger, abduction and opposition of little nger, thumb adduction, exion of ring
adduction, extension of IPJs of all digits (less so at index and middle and little nger,
nger due to sparing of lateral two lumbricals) abduction and
opposition of little
nger, thumb adduction,
extension at IPJs

Sensory Medial half of palm, palmar and dorsal surface of medial one and a half Palmar surface of medial
Loss ngers and medial dorsum of hand one and a half ngers

Signs Hand held in abduction (due to unopposed action of exor carpi Claw hand (unopposed
radialis), Froment’s sign (patient is asked to hold a piece of paper extension at MCPJ and
between thumb and at palm as paper is pulled away, patient will ex unopposed exion at
thumb at IPJ to maintain hold – tests adductor pollicis muscle), IPJs of ring and little
hypothenar eminence wasting, N.B. claw hand not typically seen due nger), hypothenar
to paralysis of the exor digitorum profundus eminence wasting,
Froment’s sign

The ulnar nerve is most likely to be injured proximally by a medial epicondyle fracture and results in:

There is weak wrist exion and adduction due to paralysis of the exor carpi ulnaris and the medial half of the
exor digitorum profundus; the hand may be held in abduction (due to unopposed action of the exor carpi
radialis).
There is loss of abduction and adduction of the ngers due to paralysis of the interossei.
There is loss of exion at the MCPJ of the ring and little nger due to paralysis of the medial two lumbricals and
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There is loss of exion at the MCPJ of the ring and little nger due to paralysis of the medial two lumbricals and
the exor digiti minimi.
There is loss of exion at the DIPJ of the ring and little nger due to paralysis of the medial half of the exor
digitorum profundus (but exion at the PIPJ is likely preserved as this is a function of the exor digitorum
super cialis).
There is weakened extension at the IPJs of the ring and little nger due to paralysis of the interossei and medial
two lumbricals (and to a lesser extent at the IPJs of the index and middle nger).
There is loss of abduction and opposition of the little nger due to paralysis of the hypothenar muscles
(hypothenar wasting may be seen).
There is loss of adduction of the thumb due to paralysis of the adductor pollicis (Froment’s sign).
There is loss of sensation to skin over the medial half of the palm, the palmar and dorsal surface of the medial
one and a half ngers and the medial dorsum of the hand.
There is not typically a claw hand appearance (as may be seen in a lesion at the wrist) due to paralysis of the
exor digitorum profundus.

A distal lesion most commonly occurs due to laceration at the wrist. Only intrinsic hand muscles are affected (the exor
carpi ulnaris and medial half of the exor digitorum profundus are spared). A loss of sensation will only affect the
palmar surface of the medial one and a half ngers (the medial palm and the dorsum of the hand are spared). A claw
hand deformity may be seen due to unopposed extension at the MCPJ (by the extensor digitorum) and unopposed
exion at the IPJs (by the FDP and FDS) of the ring and little nger.

Froment’s sign (right hand). Copyright FRCEM

Success.

Claw hand deformity. By Mcstrother (Own work)

[CC BY 3.0
(http://creativecommons.org/licenses/by/3.0)], via
Wikimedia Commons

A 34 year old tree surgeon suffers a crush injury to the entire little nger. Which of the
following muscles would you least expect to be affected in this injury:

a) Lumbrical
b) Palmar interosseous muscle
c) Dorsal interosseous muscle
d) Flexor digitorum profundus
e) Flexor digitorum super cialis

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Something wrong?

Answer
The dorsal interossei insert into the extensor hoods and proximal phalanges of the index, middle and ring nger, but
not the little nger, which has its own abductor digiti minimi muscle, part of the hypothenar eminence.

Notes
The interosseous muscles originate from and lie between the metacarpal bones. The dorsal interossei insert into the
extensor hoods and proximal phalanges of the index, middle and ring nger. The palmar interossei insert into the
extensor hoods of the index, ring and little nger.

The four dorsal interossei act to abduct the index, middle and ring ngers, and the three palmar interossei act to
adduct the index, ring and little ngers. (DAB, PAD). Because the interosseous muscles insert into the extensor hoods,
they also contribute to the complex exion and extension movements of the interphalangeal joints of the digits.

The interosseous muscles are all innervated by the ulnar nerve.

Muscle Action Innervation

Dorsal interossei Abduction of ngers at MCPJ Ulnar nerve

Palmar interossei Adduction of ngers at MCPJ Ulnar nerve

Modi ed by FRCEM Success. Original by By OpenStax [CC BY 4.0

(http://creativecommons.org/licenses/by/4.0)], via Wikimedia Commons

You have been asked to review a 45 year old gardener who has sustained a laceration to the
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You have been asked to review a 45 year old gardener who has sustained a laceration to the
dorsal surface of their wrist. You are concerned about the possibility of injury to underlying
structures. The extensor retinaculum is attached to which of the following structures:

a) The scaphoid laterally and the pisiform and triquetrum medially

b) The radius laterally and the ulna medially
c) The radius laterally and the pisiform and triquetrum medially
d) The scaphoid laterally and the ulna medially
e) The radius laterally and the lunate and triquetrum medially
Something wrong?

Answer
The extensor retinaculum is attached laterally to the anterolateral radius above the styloid process and medially to the
pisiform and triquetrum bones.

Notes
The extensor retinaculum (dorsal carpal ligament) lies obliquely across the extensor surface of the wrist joint, and
holds the extensor tendons in place during movement of the wrist.

It is attached laterally to the anterolateral radius above the styloid process and medially to the pisiform and triquetrum
bones. It does NOT attach to the ulna.

The extensor tendons pass through the extensor tunnel, deep to the extensor retinaculum, in six compartments lined
by synovial sheaths:

The tendons of the extensor digitorum and extensor indicis share a synovial sheath on the posterior surface of
the wrist
The tendons of the extensor carpi ulnaris and extensor digiti minimi have separate sheaths on the medial side
of the wrist
The tendons of the abductor pollicis longus and extensor pollicis brevis, the extensor carpi radialis longus and
extensor carpi radialis brevis and the extensor pollicis longus have three separate sheaths on the lateral side of
the wrist

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By Henry Vandyke Carter [Public domain], via Wikimedia Commons

A patient presents to ED complaining of weakness in her left arm. She tells you she sustained
a fracture to this arm about 2 months ago, but is unable to give you more detail. Examination
reveals loss of wrist extension and weakness of grasp. Extension at the elbow joint is normal, and
there is no loss of sensation. Which of the following nerves is most likely affected:

a) Posterior interosseous nerve

b) Super cial branch of the radial nerve
c) Recurrent branch of the median nerve
d) Ulnar nerve
e) Anterior interosseous nerve
Something wrong?

Answer
The posterior interosseous nerve is the continuation of the deep branch of the radial nerve which innervates the
muscles of the posterior compartment of the forearm. Damage to this nerve may occur due to fracture of the radial
head or posterior dislocation of radius and results in weakness of wrist extension and nger extension (resulting in
weak nger exion and grip strength as the long exor tendons are not under tension). The super cial branch of the
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weak nger exion and grip strength as the long exor tendons are not under tension). The super cial branch of the
radial nerve supplies skin over the dorsum of the lateral hand and lateral three and a half ngers and thus is not
affected in this case. The anterior interosseous nerve is a branch of the median nerve supplying muscles in the
anterior forearm and the recurrent branch innervates the thenar muscles.

Notes
The radial nerve is a continuation of the posterior cord, containing bres from C5 – T1.

Nerve Radial nerve

Nerve C5 – T1
roots

Plexus Posterior cord

cords

Motor Triceps brachii, posterior compartment of forearm: super cial muscles (brachioradialis, extensor carpi
Supply radialis longus and brevis, extensor digitorum, extensor digiti minimi, extensor carpi ulnaris) and deep
muscles (supinator, abductor pollicis longus, extensor pollicis longus and brevis, extensor indicis)

Sensory Lower lateral arm, posterior arm, posterior forearm, dorsum of lateral hand and three and a half
supply ngers

Anatomical course

The radial nerve enters the arm by crossing the lower margin of the teres major muscle, where it lies posterior to the
brachial artery. It enters the posterior compartment of the arm, where it descends obliquely passing from medial to
lateral in the radial (spiral) groove of the humerus. After emerging from the spiral groove, the radial nerve pierces the
lateral intermuscular septum and enters the anterior compartment of the arm, descending into the cubital fossa where
it lies between the brachialis and brachioradialis muscles. The radial nerve enters the forearm after passing over the
lateral epicondyle of the humerus. Within the proximal forearm the nerve terminates by bifurcating into the deep
branch and the super cial branch. N.B. Once the deep branch of the radial nerve penetrates between the two heads of
the supinator muscle to access the posterior compartment of the arm, it becomes known as the posterior interosseous
nerve.

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By Henry Vandyke Carter [Public domain], via Wikimedia

Commons

Branches

Branches of Radial Origin Supply

Nerve

Radial nerve Axilla Triceps brachii, extensor carpi radialis longus, brachioradialis

Posterior Axilla Skin of posterior arm

cutaneous nerve of
the arm

Inferior lateral Arm Skin over lateral aspect of lower arm

cutaneous nerve of
the arm

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Posterior Arm Strip of skin down middle of posterior forearm

cutaneous nerve of
the forearm

Deep branch which Forearm Posterior compartment of forearm: super cial muscles (extensor carpi radialis
continues as the brevis, extensor digitorum, extensor digiti minimi, extensor carpi ulnaris) and
posterior deep muscles (supinator, abductor pollicis longus, extensor pollicis longus and
interosseous nerve brevis, extensor indicis)

Super cial branch Forearm Skin of dorsum of the hand and lateral three and a half ngers

In the arm, the radial nerve directly innervates the triceps brachii, the extensor carpi radialis longus and the
brachioradialis. In the forearm, the deep branch, which continues as the posterior interosseous nerve, innervates the
muscles of the posterior compartment of the forearm and the super cial branch supplies the skin of the dorsum of the
hand and lateral three and a half ngers.

The radial nerve also gives rise to several cutaneous branches; the posterior cutaneous nerve of the arm originating in
the axilla, and the inferior lateral cutaneous nerve of the arm and the posterior cutaneous nerve of the forearm
originating in the arm. These cutaneous branches supply skin over the posterior surface of the arm, the lateral aspect
of the arm and the skin down the middle of the posterior forearm respectively.

Clinical implications

Lesion In axilla In spiral groove In forearm In forearm (deep

(super cial branch) branch)

Mechanism Glenohumeral joint Fracture of midshaft Stabbing/laceration Fracture of

dislocation, fracture of of humerus of forearm radial head or
proximal humerus, ‘Saturday posterior
night syndrome’ dislocation
of radius

Motor Loss Loss of extension at elbow, Loss of extension at None Weakness of

wrist and ngers wrist and ngers extension at
(triceps brachii wrist and
spared) ngers (extensor
carpi radialis
spared)

Sensory Lower lateral arm, posterior Dorsum of lateral Dorsum of lateral None
Loss arm, posterior forearm, hand and three and a hand and three and
dorsum of lateral hand and half ngers a half ngers
three and a half ngers (cutaneous branches
of arm and forearm
spared)

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Signs Wrist drop (unopposed Wrist drop, weak None Wrist drop not
wrist exion), weakness of hand grip typically seen
hand grip ( nger exion is (extensor carpi
weak as the long exor radialis spared)
tendons are not under
tension)

Radial nerve injury at the axilla may occur in glenohumeral joint dislocation, in fractures of the proximal humerus,
through incorrect use of axillary crutches, or due to ‘Saturday Night’ palsy. There is loss of extension of the forearm
due to paralysis of the triceps brachii and loss of extension of the wrist and ngers (predominantly MCPJs, as extension
at the IPJs is primarily a function of the lumbrical and interosseous muscles) and weakness of supination due to
paralysis of the muscles of the posterior compartment of the forearm. All four cutaneous branches of the radial nerve
are affected and there is loss of sensation over the lateral and posterior arm, the posterior forearm and the dorsal
surface of the hand and lateral three and a half digits. There is unopposed wrist exion, giving the appearance of wrist
drop.

The radial nerve in the arm is most susceptible to midshaft fractures of the humerus due to its course in the spiral
groove. Extension of the forearm is not affected as the triceps brachii is spared. There is loss of extension of the wrist
and MCPJs of the ngers and weakness of supination of the forearm. The cutaneous branches of the arm and forearm
have already arisen and sensation loss occurs only on the dorsum of the lateral hand and three and a half digits.

Radial nerve damage in the forearm may present as super cial branch or deep branch damage. The super cial branch is
most commonly damaged by stabbing or laceration to the forearm and results in loss of sensation over the dorsum of
the lateral hand and three and a half digits. The deep branch may be damaged by fracture of the radial head or
posterior dislocation of the radius and results in weakness of extension of the wrist and ngers, but not typically with
wrist drop (as the extensor carpi radialis is spared).

You are performing a neurological examination on a patient who complains of weakness of

the left arm. You note muscle wasting in the posterior forearm. The muscles of the posterior
compartment of the forearm are all innervated by which of the following nerves:

a) Axillary nerve
b) Musculocutaneous nerve
c) Radial nerve
d) Median nerve
e) Ulnar nerve
Something wrong?

Answer
The muscles of the posterior forearm are all innervated by the radial nerve.

Notes
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The muscles of the posterior forearm are all innervated by the radial nerve.

The posterior forearm is divided into the super cial and deep groups:

The super cial group is made up of the brachioradialis, the extensor carpi radialis longus and brevis, the
extensor digitorum, the extensor digiti mini, the anconeus and the extensor carpi ulnaris.
The deep group is made up of the supinator, the abductor pollicis longus, the extensor pollicis longus and brevis
and the extensor indicis.

Muscle Action Innervation

Brachioradialis Flexion of elbow Radial nerve

Extensor carpi radialis longus Extension and abduction of wrist Radial nerve

Extensor carpi radialis brevis Extension and abduction of wrist Radial nerve

Extensor digitorum Extension of all four ngers, extension of wrist Radial nerve

Extensor digiti minimi Extension of little nger Radial nerve

Extensor carpi ulnaris Extension and adduction of wrist Radial nerve

Supinator Supination of forearm Radial nerve

Abductor pollicis longus Abduction and extension of thumb Radial nerve

Extensor pollicis longus Extension of thumb (CMCJ, MCPJ, IPJ) Radial nerve

Extensor pollicis brevis Extension of thumb (CMCJ and MCPJ) Radial nerve

Extensor indicis Extension of index nger Radial nerve

A detailed knowledge of the distal attachments of the exor tendons is important to allow understanding of the clinical
effects of division/injury at any given level of the nger.

The abductor pollicis longus is attached distally to the lateral side of base of the 1st metacarpal.
The extensor pollicis brevis is attached to the proximal phalanx of the thumb and the extensor pollicis longus is
attached to the distal phalanx of the thumb.
The extensor carpi radialis longus is attached to the base of the 2nd metacarpal and the extensor carpi radialis
brevis is attached to the bases of the 2nd and 3rd metacarpals.
The extensor digitorum is attached to the base of the middle and distal phalanges of digits 2 – 5 via extensor
hoods.
The extensor carpi ulnaris is attached to the base of the 5th metacarpal.
The extensor digiti minimi is attached to the base of the 5th metacarpal.
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The extensor digiti minimi is attached to the base of the 5th metacarpal.
The extensor indicis is attached to the extensor hood of the index nger.

Muscle tendon Distal attachment

Extensor carpi radialis Dorsal surface of base of 2nd metacarpal

longus

Extensor carpi radialis Dorsal surface of base of 2nd and 3rd metacarpal
brevis

Extensor digitorum Dorsal aspects of bases of middle and distal phalanges of all four ngers via
extensor hoods

Extensor carpi ulnaris Tubercle on base of medial 5th metacarpal

Abductor pollicis longus Lateral side of base of 1st metacarpal

Extensor pollicis longus Dorsal surface of base of distal phalanx of thumb

Extensor pollicis brevis Dorsal surface of base of proximal phalanx of thumb

Extensor indicis Extensor hood of index nger

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By Henry Vandyke Carter [Public domain], via

Wikimedia Commons

By Henry Vandyke Carter [Public domain], via

Wikimedia Commons

A 54 year old man presents to the ED after tripping on a kerb. He tells you he fell onto his
outstretched right hand. He complains of pain in his right wrist and on examination you note
anatomical snuffbox tenderness. Which of the following structures passes through the anatomical
snuffbox:

a) Median nerve
b) Ulnar nerve
c) Radial artery
d) Basilic vein
e) Palmaris longus tendon
Something wrong?

Answer

The radial artery crosses the oor of the anatomical snuffbox lying deep to the extensor tendons of the thumb and
adjacent to the scaphoid and trapezium bones. The other structures listed do not pass through the anatomical
snuffbox.

Notes
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The anatomical snuffbox is the triangular depression formed on the posterolateral side of the dorsal wrist and 1st
metacarpal by the extensor tendons passing into the thumb.

Anatomical Structure
Boundaries

Medial border Tendon of extensor pollicis longus

Lateral border Tendons of the abductor pollicis longus and extensor pollicis brevis

Proximal border Radial styloid process

Distal border 1st metacarpal

Floor Scaphoid and trapezium bones

Roof Skin

Contents Radial artery, terminal portion of the super cial branch of the radial nerve, cephalic
vein

It is bounded laterally by the tendons of the abductor pollicis longus and the extensor pollicis brevis and medially by
the tendon of the extensor pollicis longus.

The oor of the anatomical snuffbox is formed by the scaphoid and trapezium carpal bones. The radial styloid process
can be palpated proximally and the 1st metacarpal can be palpated distally.

The radial artery crosses the oor of the anatomical snuffbox. Subcutaneously terminal parts of the super cial branch
of the radial nerve and the origin of the cephalic vein pass over the anatomical snuffbox.

The anatomical snuffbox is important clinically as the scaphoid is palpable within the snuffbox; localised pain and
tenderness of the anatomical snuffbox is most likely due to a scaphoid fracture.

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By Grant, John Charles Boileau (An atlas of anatomy, / by regions 1962) [Public domain], via
Wikimedia Commons

An 18 year old lady has sustained a posterior dislocation of the radius with damage to the
deep branch of the radial nerve after falling awkwardly during her routine at a gymnastic
competition. Which of the following clinical features would you most expect on examination:

a) Inability to abduct the digits at the MCP joint

b) Inability to adduct the digits at the MCP joint
c) Inability to extend the digits at the MCP joint
d) Inability to extend the digits at the MCP, DIP and PIP joints
e) Inability to extend the digits and at the PIP and DIP joints
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Something wrong?

Answer
The deep branch of the radial nerve innervates the muscles of the posterior forearm. Paralysis of the extensor
digitorum, extensor digiti minimi and extensor indicis will result in loss of extension at the MCP joints. Extension at the
DIP and PIP joints of the digits is largely performed by the lumbricals and the interossei (and to a much lesser extent
assisted by the long extensors). Abduction and adduction at the MCP joints is produced by the interossei. The
interossei and medial two lumbricals are innervated by the ulnar nerve and the lateral two lumbricals by the median
nerve.

Notes
The radial nerve is a continuation of the posterior cord, containing bres from C5 – T1.

Nerve Radial nerve

Nerve C5 – T1
roots

Plexus Posterior cord

cords

Motor Triceps brachii, posterior compartment of forearm: super cial muscles (brachioradialis, extensor carpi
Supply radialis longus and brevis, extensor digitorum, extensor digiti minimi, extensor carpi ulnaris) and deep
muscles (supinator, abductor pollicis longus, extensor pollicis longus and brevis, extensor indicis)

Sensory Lower lateral arm, posterior arm, posterior forearm, dorsum of lateral hand and three and a half
supply ngers

Anatomical course

The radial nerve enters the arm by crossing the lower margin of the teres major muscle, where it lies posterior to the
brachial artery. It enters the posterior compartment of the arm, where it descends obliquely passing from medial to
lateral in the radial (spiral) groove of the humerus. After emerging from the spiral groove, the radial nerve pierces the
lateral intermuscular septum and enters the anterior compartment of the arm, descending into the cubital fossa where
it lies between the brachialis and brachioradialis muscles. The radial nerve enters the forearm after passing over the
lateral epicondyle of the humerus. Within the proximal forearm the nerve terminates by bifurcating into the deep
branch and the super cial branch. N.B. Once the deep branch of the radial nerve penetrates between the two heads of
the supinator muscle to access the posterior compartment of the arm, it becomes known as the posterior interosseous
nerve.

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By Henry Vandyke Carter [Public domain], via Wikimedia

Commons

Branches

Branches of Radial Origin Supply

Nerve

Radial nerve Axilla Triceps brachii, extensor carpi radialis longus, brachioradialis

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Posterior Axilla Skin of posterior arm

cutaneous nerve of
the arm

Inferior lateral Arm Skin over lateral aspect of lower arm

cutaneous nerve of
the arm

Posterior Arm Strip of skin down middle of posterior forearm

cutaneous nerve of
the forearm

Deep branch which Forearm Posterior compartment of forearm: super cial muscles (extensor carpi radialis
continues as the brevis, extensor digitorum, extensor digiti minimi, extensor carpi ulnaris) and
posterior deep muscles (supinator, abductor pollicis longus, extensor pollicis longus and
interosseous nerve brevis, extensor indicis)

Super cial branch Forearm Skin of dorsum of the hand and lateral three and a half ngers

In the arm, the radial nerve directly innervates the triceps brachii, the extensor carpi radialis longus and the
brachioradialis. In the forearm, the deep branch, which continues as the posterior interosseous nerve, innervates the
muscles of the posterior compartment of the forearm and the super cial branch supplies the skin of the dorsum of the
hand and lateral three and a half ngers.

The radial nerve also gives rise to several cutaneous branches; the posterior cutaneous nerve of the arm originating in
the axilla, and the inferior lateral cutaneous nerve of the arm and the posterior cutaneous nerve of the forearm
originating in the arm. These cutaneous branches supply skin over the posterior surface of the arm, the lateral aspect
of the arm and the skin down the middle of the posterior forearm respectively.

Clinical implications

Lesion In axilla In spiral groove In forearm In forearm (deep

(super cial branch) branch)

Mechanism Glenohumeral joint Fracture of midshaft Stabbing/laceration Fracture of

dislocation, fracture of of humerus of forearm radial head or
proximal humerus, ‘Saturday posterior
night syndrome’ dislocation
of radius

Motor Loss Loss of extension at elbow, Loss of extension at None Weakness of

wrist and ngers wrist and ngers extension at
(triceps brachii wrist and
spared) ngers (extensor
carpi radialis
spared)
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spared)

Sensory Lower lateral arm, posterior Dorsum of lateral Dorsum of lateral None
Loss arm, posterior forearm, hand and three and a hand and three and
dorsum of lateral hand and half ngers a half ngers
three and a half ngers (cutaneous branches
of arm and forearm
spared)

Signs Wrist drop (unopposed Wrist drop, weak None Wrist drop not
wrist exion), weakness of hand grip typically seen
hand grip ( nger exion is (extensor carpi
weak as the long exor radialis spared)
tendons are not under
tension)

Radial nerve injury at the axilla may occur in glenohumeral joint dislocation, in fractures of the proximal humerus,
through incorrect use of axillary crutches, or due to ‘Saturday Night’ palsy. There is loss of extension of the forearm
due to paralysis of the triceps brachii and loss of extension of the wrist and ngers (predominantly MCPJs, as extension
at the IPJs is primarily a function of the lumbrical and interosseous muscles) and weakness of supination due to
paralysis of the muscles of the posterior compartment of the forearm. All four cutaneous branches of the radial nerve
are affected and there is loss of sensation over the lateral and posterior arm, the posterior forearm and the dorsal
surface of the hand and lateral three and a half digits. There is unopposed wrist exion, giving the appearance of wrist
drop.

The radial nerve in the arm is most susceptible to midshaft fractures of the humerus due to its course in the spiral
groove. Extension of the forearm is not affected as the triceps brachii is spared. There is loss of extension of the wrist
and MCPJs of the ngers and weakness of supination of the forearm. The cutaneous branches of the arm and forearm
have already arisen and sensation loss occurs only on the dorsum of the lateral hand and three and a half digits.

Radial nerve damage in the forearm may present as super cial branch or deep branch damage. The super cial branch is
most commonly damaged by stabbing or laceration to the forearm and results in loss of sensation over the dorsum of
the lateral hand and three and a half digits. The deep branch may be damaged by fracture of the radial head or
posterior dislocation of the radius and results in weakness of extension of the wrist and ngers, but not typically with
wrist drop (as the extensor carpi radialis is spared).

You have been asked to review a 32 year old pastry chef. She sustained a laceration to her left
thenar eminence whilst working. Which of the following muscles is part of the thenar eminence:

a) Extensor pollicis brevis

b) Extensor pollicis longus
c) Adductor pollicis
d) Abductor pollicis longus
e) Abductor pollicis brevis
Something wrong?

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Answer
The thenar eminence consists of the opponens pollicis, the abductor pollicis brevis and the exor pollicis brevis. The
adductor pollicis is an intrinsic hand muscle, but not part of the thenar eminence. The extensor pollicis longus and
brevis, and the abductor pollicis longus are found in the posterior forearm.

Notes

The thenar eminence consists of the opponens pollicis, the abductor pollicis brevis and the exor pollicis brevis. The
thenar muscles are all innervated by the median nerve.

Muscle Action Innervation

Opponens pollicis (blue) Medially rotates thumb Median nerve

Abductor pollicis brevis (green) Abducts thumb at MCPJ Median nerve

Flexor pollicis brevis (red) Flexes thumb at MCPJ Median nerve

Modi ed by FRCEM Success. Original by By OpenStax [CC BY 4.0

(http://creativecommons.org/licenses/by/4.0)], via Wikimedia Commons

A 32 year old man presents to ED with a deep laceration to the proximal part of the forearm.
On further assessment, when the patient is asked to make a st, he is unable to ex the
metacarpophalangeal joints or interphalangeal joints of the index and middle nger or the thumb.
For the most part the ring and little ngers are intact, although you note some weakness at the
proximal interphalangeal joint. There is loss of sensation over the lateral palm and the palmar
surface of the lateral three and a half ngers. Which of the following nerve(s) has most likely been
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surface of the lateral three and a half ngers. Which of the following nerve(s) has most likely been
affected:

a) Median nerve
b) Ulnar nerve
c) Median and ulnar nerve
d) Radial nerve
e) Median and radial nerve
Something wrong?

Answer
In a median nerve injury affecting the extrinsic and intrinsic muscles of the hand there is:

Weakness of exion of the distal interphalangeal joints of the index and middle nger due to paralysis of the
lateral half of the exor digitorum profundus (the medial two digits are controlled by the medial half
innervated by the ulnar nerve)
Weakness of exion of the metacarpophalangeal joints of the index and middle nger due to paralysis of the
lateral two lumbricals (the medial two digits are controlled by the medial two lumbricals innervated by the
ulnar nerve)
Weakness of exion of the proximal interphalangeal joints of all four ngers may be seen due to paralysis of
the exor digitorum super cialis
Weakness of thumb exion, abduction and opposition due to paralysis of the exor pollicis longus and the
thenar muscles
Loss of sensation to the lateral palm and the lateral three and a half ngers

If the ulnar nerve was affected as well, all four digits would be affected.

Notes

The median nerve is formed from the medial and lateral brachial plexus cords and contains bres from all ve roots (C5
– T1).

Nerve Median nerve

Nerve C5 – T1
roots

Plexus Medial and lateral cords

cords

Motor All the anterior forearm muscles (except for the exor carpi ulnaris and the medial half of the exor
Supply digitorum profundus), the thenar muscles ( exor pollicis brevis, abductor pollicis brevis, opponens
pollicis) and the lateral two lumbricals
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Sensory Lateral aspect of palm and palmar surface and ngertips of lateral three and a half digits
supply

Anatomical course

The median nerve originates in the axilla before passing down the medial side of the arm (initially lateral to the brachial
artery before crossing over to the medial side of the brachial artery). It enters the anterior compartment of the
forearm via the antecubital fossa, travelling between the exor digitorum profundus and exor digitorum super cialis
muscles, before entering the hand via the carpal tunnel and bifurcating into its terminal branches.

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By Henry Vandyke Carter [Public domain], via Wikimedia Commons

Branches

Branches of Origin Supply

Median Nerve

Median nerve Axilla Super cial and intermediate compartment of anterior forearm (pronator teres,
exor carpi radialis, palmaris longus, exor digitorum super cialis, NOT exor
carpi ulnaris)

Anterior Forearm Deep compartment of anterior forearm ( exor pollicis longus, pronator
interosseous quadratus, lateral half of exor digitorum profundus)
nerve

Palmar Forearm Skin over the lateral aspect of the palm

cutaneous
branch

Recurrent Hand Thenar muscles ( exor pollicis brevis, abductor pollicis brevis, opponens pollicis)
branch of
median nerve

Palmar digital Hand Lateral two lumbricals and skin over the palmar surface and ngertips of the
branch lateral three and a half digits

The median nerve directly innervates the pronator teres, the exor carpi radialis, the palmaris longus and the exor
digitorum super cialis. It gives off no major branches in the arm, but gives rise to the anterior interosseous nerve
(innervating the exor pollicis longus, the pronator quadratus, and the lateral half of the exor digitorum profundus)
and the palmar cutaneous nerve (innervating the lateral aspect of the palm) in the forearm.

In the hand the median nerve bifurcates into the recurrent branch of the median nerve (innervating the thenar
muscles) and the palmar digital branch (innervating the lateral two lumbricals and the skin over the palmar surface and
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ngertips of the lateral three and a half digits).

Clinical implications

Lesion Proximal (arm, elbow, proximal forearm) Distal (wrist)

Mechanisms Supracondylar fracture, stab wound to arm or forearm Lacerations just

proximal to exor
retinaculum, carpal
tunnel syndrome

Motor Loss Forearm pronation, wrist exion and abduction, index and middle nger Thumb exion,
exion, thumb exion, abduction and opposition abduction and
opposition, exion of
index and middle
nger MCPJ

Sensory Lateral aspect of palm and palmar surface and ngertips of lateral three Palmar surface and
Loss and a half digits ngertips of lateral
three and a half digits

Signs Forearm rests in supination with wrist in ulnar deviation and thumb Thenar eminence
extended, thenar eminence wasting, hand of Benediction (when asked wasting
to make a st, the patient will be able to ex the little and ring ngers
but not the index and middle ngers)

A proximal median nerve lesion at the elbow may occur due to supracondylar fracture of the humerus or from deep
penetrating wounds to the arm or forearm and may result in:

Pronation of the forearm and exion and abduction of the wrist are lost due to paralysis of the exors and
pronators in the forearm. The forearm thus often rests in supination with ulnar deviation of the wrist (due to
unopposed action of the exor carpi ulnaris).
Flexion, abduction and opposition of the thumb at the MCPJ and IPJ are lost due to paralysis of the thenar
muscles and the exor pollicis longus.
Flexion of the index and middle ngers at the IPJs is lost due to paralysis of the exor digitorum super cialis
and the lateral half of the exor digitorum profundus.
Flexion of the MCPJ of the index and middle ngers is lost due to paralysis of the lateral two lumbrical muscles.
N.B. Flexion of the ring and little ngers at the MCPJ and DIPJ are preserved as these are functions of the
medial half of the exor digitorum profundus and the medial two lumbrical muscles, innervated by the ulnar
nerve (there may be weakness of exion at the PIPJ of these ngers due to paralysis of the exor digitorum
super cialis).
There is loss of sensation over the lateral aspect of the palm, and the skin over the palmar surface and
ngertips of the lateral three and a half digits.

Medial nerve lesion at the wrist often occurs due to lacerations just proximal to the exor retinaculum or to
compression of the median nerve in the carpal tunnel. Only the intrinsic hand muscles are affected. Loss of opposition,
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compression of the median nerve in the carpal tunnel. Only the intrinsic hand muscles are affected. Loss of opposition,
abduction and exion of the MCPJ of the thumb occurs due to paralysis of the thenar muscles. Loss of exion at the
MCPJ of the index and middle nger occurs due to paralysis of the lateral two lumbricals. There is loss of sensation to
the palmar surface and ngertips of the lateral three and a half digits only (the palmar region is spared).

A 69 year old lady presents to ED having tripped on a curb and fallen on her left arm. Imaging
shows a midshaft fracture of the humerus. Which of the following structures was most likely
injured:

a) Axillary nerve and axillary artery

b) Radial nerve and deep brachial artery
c) Axillary nerve and posterior humeral circum ex artery
d) Long thoracic nerve and lateral thoracic artery
e) Ulnar nerve and cephalic vein
Something wrong?

Answer

A midshaft humeral fracture may injure the radial nerve and brachial artery where they lie together in the spiral groove
of the humerus.

Notes
The radial nerve is a continuation of the posterior cord, containing bres from C5 – T1.

Nerve Radial nerve

Nerve C5 – T1
roots

Plexus Posterior cord

cords

Motor Triceps brachii, posterior compartment of forearm: super cial muscles (brachioradialis, extensor carpi
Supply radialis longus and brevis, extensor digitorum, extensor digiti minimi, extensor carpi ulnaris) and deep
muscles (supinator, abductor pollicis longus, extensor pollicis longus and brevis, extensor indicis)

Sensory Lower lateral arm, posterior arm, posterior forearm, dorsum of lateral hand and three and a half
supply ngers

Anatomical course

The radial nerve enters the arm by crossing the lower margin of the teres major muscle, where it lies posterior to the
brachial artery. It enters the posterior compartment of the arm, where it descends obliquely passing from medial to
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brachial artery. It enters the posterior compartment of the arm, where it descends obliquely passing from medial to
lateral in the radial (spiral) groove of the humerus. After emerging from the spiral groove, the radial nerve pierces the
lateral intermuscular septum and enters the anterior compartment of the arm, descending into the cubital fossa where
it lies between the brachialis and brachioradialis muscles. The radial nerve enters the forearm after passing over the
lateral epicondyle of the humerus. Within the proximal forearm the nerve terminates by bifurcating into the deep
branch and the super cial branch. N.B. Once the deep branch of the radial nerve penetrates between the two heads of
the supinator muscle to access the posterior compartment of the arm, it becomes known as the posterior interosseous
nerve.

By Henry Vandyke Carter [Public domain], via Wikimedia

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By Henry Vandyke Carter [Public domain], via Wikimedia
Commons

Branches

Branches of Radial Origin Supply

Nerve

Radial nerve Axilla Triceps brachii, extensor carpi radialis longus, brachioradialis

Posterior Axilla Skin of posterior arm

cutaneous nerve of
the arm

Inferior lateral Arm Skin over lateral aspect of lower arm

cutaneous nerve of
the arm

Posterior Arm Strip of skin down middle of posterior forearm

cutaneous nerve of
the forearm

Deep branch which Forearm Posterior compartment of forearm: super cial muscles (extensor carpi radialis
continues as the brevis, extensor digitorum, extensor digiti minimi, extensor carpi ulnaris) and
posterior deep muscles (supinator, abductor pollicis longus, extensor pollicis longus and
interosseous nerve brevis, extensor indicis)

Super cial branch Forearm Skin of dorsum of the hand and lateral three and a half ngers

In the arm, the radial nerve directly innervates the triceps brachii, the extensor carpi radialis longus and the
brachioradialis. In the forearm, the deep branch, which continues as the posterior interosseous nerve, innervates the
muscles of the posterior compartment of the forearm and the super cial branch supplies the skin of the dorsum of the
hand and lateral three and a half ngers.

The radial nerve also gives rise to several cutaneous branches; the posterior cutaneous nerve of the arm originating in
the axilla, and the inferior lateral cutaneous nerve of the arm and the posterior cutaneous nerve of the forearm
originating in the arm. These cutaneous branches supply skin over the posterior surface of the arm, the lateral aspect
of the arm and the skin down the middle of the posterior forearm respectively.

Clinical implications

Lesion In axilla In spiral groove In forearm In forearm (deep

(super cial branch) branch)

Mechanism Glenohumeral joint Fracture of midshaft Stabbing/laceration Fracture of

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dislocation, fracture of of humerus of forearm radial head or

proximal humerus, ‘Saturday posterior
night syndrome’ dislocation
of radius

Motor Loss Loss of extension at elbow, Loss of extension at None Weakness of

wrist and ngers wrist and ngers extension at
(triceps brachii wrist and
spared) ngers (extensor
carpi radialis
spared)

Sensory Lower lateral arm, posterior Dorsum of lateral Dorsum of lateral None
Loss arm, posterior forearm, hand and three and a hand and three and
dorsum of lateral hand and half ngers a half ngers
three and a half ngers (cutaneous branches
of arm and forearm
spared)

Signs Wrist drop (unopposed Wrist drop, weak None Wrist drop not
wrist exion), weakness of hand grip typically seen
hand grip ( nger exion is (extensor carpi
weak as the long exor radialis spared)
tendons are not under
tension)

Radial nerve injury at the axilla may occur in glenohumeral joint dislocation, in fractures of the proximal humerus,
through incorrect use of axillary crutches, or due to ‘Saturday Night’ palsy. There is loss of extension of the forearm
due to paralysis of the triceps brachii and loss of extension of the wrist and ngers (predominantly MCPJs, as extension
at the IPJs is primarily a function of the lumbrical and interosseous muscles) and weakness of supination due to
paralysis of the muscles of the posterior compartment of the forearm. All four cutaneous branches of the radial nerve
are affected and there is loss of sensation over the lateral and posterior arm, the posterior forearm and the dorsal
surface of the hand and lateral three and a half digits. There is unopposed wrist exion, giving the appearance of wrist
drop.

The radial nerve in the arm is most susceptible to midshaft fractures of the humerus due to its course in the spiral
groove. Extension of the forearm is not affected as the triceps brachii is spared. There is loss of extension of the wrist
and MCPJs of the ngers and weakness of supination of the forearm. The cutaneous branches of the arm and forearm
have already arisen and sensation loss occurs only on the dorsum of the lateral hand and three and a half digits.

Radial nerve damage in the forearm may present as super cial branch or deep branch damage. The super cial branch is
most commonly damaged by stabbing or laceration to the forearm and results in loss of sensation over the dorsum of
the lateral hand and three and a half digits. The deep branch may be damaged by fracture of the radial head or
posterior dislocation of the radius and results in weakness of extension of the wrist and ngers, but not typically with
wrist drop (as the extensor carpi radialis is spared).

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A 29 year old woman is brought to the ED after concerns were raised for her welfare by a
neighbour. She has a deep laceration to the anterior aspect of the right wrist. You are concerned
about an injury to the underlying structures including the exor retinaculum. The exor
retinaculum is attached laterally to which of the following structures:

a) Scaphoid and radius

b) Scaphoid and trapezium
c) Scaphoid and trapezoid
d) Trapezium and trapezoid
e) Radius and scaphoid
Something wrong?

Answer
The exor retinaculum is attached laterally to the scaphoid and trapezium.

Notes
The exor retinaculum (transverse carpal ligament) is a thickened band of brous connective tissue on the volar aspect
of the hand which forms the roof of the carpal tunnel. The exor retinaculum holds the exor tendons in place at the
wrist and prevents them from bowstringing.

It is attached laterally to the scaphoid and trapezium and medially to the pisiform and the hook of the hamate.

The thenar and hypothenar muscles arise from the exor retinaculum.

The ulnar artery, ulnar nerve, and tendon of the palmaris longus pass into the hand anterior to the exor retinaculum,
and therefore do not pass through the carpal tunnel.

The exor carpi radialis tendon passes through the lateral aspect of the exor retinaculum into the hand.

The four tendons of the exor digitorum profundus, the four tendons of the exor digitorum super cialis, the tendon of
the exor pollicis longus and the median nerve pass into the hand posterior to the exor retinaculum, within the carpal
tunnel.

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By Henry Vandyke Carter [Public domain], via Wikimedia Commons

A 57 year old woman presents to the ED complaining of pain in her wrist associated with
tingling in her hand. You suspect carpal tunnel syndrome. Which of the following structures does
NOT pass through the carpal tunnel into the hand:

a) Tendons of the exor digitorum super cialis

b) Tendons of the exor digitorum profundus
c) Tendon of the exor pollicis longus
d) Ulnar artery
e) Median nerve
Something wrong?

Answer
The tendons of the exor pollicis longus, exor digitorum super cialis and exor digitorum profundus pass through the
carpal tunnel together with the median nerve. The ulnar nerve and ulnar artery pass into the hand anterior to the
exor retinaculum and carpal tunnel.

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Notes

Anatomical Structure
Boundaries

Roof Flexor retinaculum

Carpal arch Pisiform and hook of the hamate medially, tubercles of the scaphoid and trapezium laterally

Contents Four tendons of exor digitorum profundus, four tendons of exor digitorum super cialis,
tendon of exor pollicis longus, median nerve

The carpal tunnel is formed by a deep carpal arch and a super cial exor retinaculum. The base of the carpal tunnel is
formed medially by the pisiform and the hook of the hamate and laterally by the tubercles of the scaphoid and
trapezium. The exor retinaculum is a thickened band of brous connective tissue on the volar aspect of the hand,
which bridges the gap between these carpal bones and forms the roof of the carpal tunnel.

The following structures pass through the carpal tunnel:

the four tendons of the exor digitorum profundus (FDP)

the four tendons of the exor digitorum super cialis (FDS)
the tendon of the exor pollicis longus (FPL)
the median nerve.

Free movement of the tendons in the carpal tunnel is facilitated by synovial sheaths, which surround the tendons. All of
the tendons of the FDP and FDS are contained within a single synovial sheath with a separate sheath enclosing the
tendon of the FPL. The median nerve lies anterior to the tendons in the carpal tunnel.

Carpal tunnel syndrome is caused by compression of the median nerve within the carpal tunnel.

Modi ed by FRCEM Success. Original by Henry Vandyke Carter [Public domain], via Wikimedia
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Modi ed by FRCEM Success. Original by Henry Vandyke Carter [Public domain], via Wikimedia
Commons

A 28 year old man presents to ED with a stab wound to the rst dorsal compartment of the
wrist of his left hand. Which of the following tendons may be affected in this injury:

a) Extensor carpi radialis longus and brevis

b) Extensor pollicis brevis and abductor pollicis longus
c) Extensor pollicis longus and extensor pollicis brevis
d) Abductor pollicis longus and brevis
e) Extensor pollicis longus
Something wrong?

Answer

Extensor tendons in the dorsal compartments of the wrist (from lateral to medial):

1. Extensor pollicis brevis and abductor pollicis longus

2. Extensor carpi radialis longus and brevis
3. Extensor pollicis longus
4. Extensor digitorum and extensor indicis
5. Extensor digiti minimi
6. Extensor carpi ulnaris

By Anatomyczar (Own work) [CC BY-SA 4.0 (http://creativecommons.org/licenses/by-sa/4.0)], via Wikimedia

Commons

Notes
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Notes
The extensor retinaculum (dorsal carpal ligament) lies obliquely across the extensor surface of the wrist joint, and
holds the extensor tendons in place during movement of the wrist.

It is attached laterally to the anterolateral radius above the styloid process and medially to the pisiform and triquetrum
bones. It does NOT attach to the ulna.

The extensor tendons pass through the extensor tunnel, deep to the extensor retinaculum, in six compartments lined
by synovial sheaths:

The tendons of the extensor digitorum and extensor indicis share a synovial sheath on the posterior surface of
the wrist
The tendons of the extensor carpi ulnaris and extensor digiti minimi have separate sheaths on the medial side
of the wrist
The tendons of the abductor pollicis longus and extensor pollicis brevis, the extensor carpi radialis longus and
extensor carpi radialis brevis and the extensor pollicis longus have three separate sheaths on the lateral side of
the wrist

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By Henry Vandyke Carter [Public domain], via Wikimedia Commons

A 32 year old woman presents to ED following an injury to her right elbow. She is complaining
of weak grip in her right hand. You ask her to hold onto a piece of paper with both hands as you pull
it away from her. The result of the test is shown below. Which of the following nerves is most likely
damaged:

Image by FRCEM Success.

a) Axillary nerve
b) Median nerve
c) Musculocutaneous nerve
d) Radial nerve
e) Ulnar nerve
Something wrong?

Answer
The image demonstrates Froment’s sign, caused by damage to the ulnar nerve. Loss of adduction of the thumb due to
paralysis of the adductor pollicis results in the patient having to ex the distal phalanx in order to hold onto the piece of
paper.

Notes
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The ulnar nerve is a continuation of the medial cord of the brachial plexus, containing bres from the C8 – T1 nerve
roots.

Nerve Ulnar nerve

Nerve C8 – T1
roots

Plexus Medial cord

cords

Motor All the intrinsic muscles of the hand (except for the thenar muscles and the lateral two lumbricals), the
Supply exor carpi ulnaris and the medial half of the exor digitorum profundus

Sensory Medial half of palm, palmar and dorsal surface of medial one and a half ngers and lateral dorsum of
supply hand

Anatomical course

The ulnar nerve descends down the medial side of the upper arm and passes posterior to the medial epicondyle (where
it is susceptible to damage) before entering the anterior compartment of the forearm by passing between the two
heads of the exor carpi ulnaris. It continues down the medial aspect of the forearm. The ulnar nerve emerges from
beneath the exor carpi ulnaris and becomes super cial just proximal to the wrist where it passes super cial to the
exor retinaculum, together with the ulnar artery, to enter the hand through a groove between the pisiform and the
hook of the hamate where it bifurcates into its terminal branches.

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By Henry Vandyke Carter [Public domain], via Wikimedia Commons

Branches

Branches of Origin Supply

Ulnar Nerve

Muscular Forearm Flexor carpi ulnaris, medial half of exor digitorum profundus
branch

Palmar Forearm Skin of medial half of palm

cutaneous
branch

Dorsal Forearm Skin of dorsum of medial one and a half ngers and associated dorsal hand area
cutaneous
branch

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Deep branch Hand Hypothenar muscles (abductor digiti minimi, exor digiti minimi, opponens digiti
minimi), medial two lumbricals, adductor pollicis and interossei

Super cial Hand Skin of palmar surface of medial one and a half ngers
branch

The ulnar nerve gives off no major branches in the arm, but three branches arise in the forearm:

The muscular branch innervating the exor carpi ulnaris and the medial half of the exor digitorum profundus
The palmar cutaneous branch supplying the skin of the medial half of the palm
The dorsal cutaneous branch supplying the skin of the medial dorsum of the hand and the dorsal surface of the
medial one and a half ngers

The ulnar nerve terminates by bifurcating into:

A deep branch innervating the hypothenar muscles, the medial two lumbricals, the adductor pollicis and the
interossei
A super cial branch supplying the skin of the palmar surface of the medial one and a half ngers

Clinical implications

Lesion Proximal (at elbow) Distal (at wrist)

Mechanism Fracture of medial epicondyle Laceration at wrist

Motor Loss Wrist exion and adduction, nger abduction and adduction, exion Finger abduction and
of ring and little nger, abduction and opposition of little nger, thumb adduction, exion of ring
adduction, extension of IPJs of all digits (less so at index and middle and little nger,
nger due to sparing of lateral two lumbricals) abduction and
opposition of little
nger, thumb adduction,
extension at IPJs

Sensory Medial half of palm, palmar and dorsal surface of medial one and a half Palmar surface of medial
Loss ngers and medial dorsum of hand one and a half ngers

Signs Hand held in abduction (due to unopposed action of exor carpi Claw hand (unopposed
radialis), Froment’s sign (patient is asked to hold a piece of paper extension at MCPJ and
between thumb and at palm as paper is pulled away, patient will ex unopposed exion at
thumb at IPJ to maintain hold – tests adductor pollicis muscle), IPJs of ring and little
hypothenar eminence wasting, N.B. claw hand not typically seen due nger), hypothenar
to paralysis of the exor digitorum profundus eminence wasting,
Froment’s sign

The ulnar nerve is most likely to be injured proximally by a medial epicondyle fracture and results in:
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There is weak wrist exion and adduction due to paralysis of the exor carpi ulnaris and the medial half of the
exor digitorum profundus; the hand may be held in abduction (due to unopposed action of the exor carpi
radialis).
There is loss of abduction and adduction of the ngers due to paralysis of the interossei.
There is loss of exion at the MCPJ of the ring and little nger due to paralysis of the medial two lumbricals and
the exor digiti minimi.
There is loss of exion at the DIPJ of the ring and little nger due to paralysis of the medial half of the exor
digitorum profundus (but exion at the PIPJ is likely preserved as this is a function of the exor digitorum
super cialis).
There is weakened extension at the IPJs of the ring and little nger due to paralysis of the interossei and medial
two lumbricals (and to a lesser extent at the IPJs of the index and middle nger).
There is loss of abduction and opposition of the little nger due to paralysis of the hypothenar muscles
(hypothenar wasting may be seen).
There is loss of adduction of the thumb due to paralysis of the adductor pollicis (Froment’s sign).
There is loss of sensation to skin over the medial half of the palm, the palmar and dorsal surface of the medial
one and a half ngers and the medial dorsum of the hand.
There is not typically a claw hand appearance (as may be seen in a lesion at the wrist) due to paralysis of the
exor digitorum profundus.

A distal lesion most commonly occurs due to laceration at the wrist. Only intrinsic hand muscles are affected (the exor
carpi ulnaris and medial half of the exor digitorum profundus are spared). A loss of sensation will only affect the
palmar surface of the medial one and a half ngers (the medial palm and the dorsum of the hand are spared). A claw
hand deformity may be seen due to unopposed extension at the MCPJ (by the extensor digitorum) and unopposed
exion at the IPJs (by the FDP and FDS) of the ring and little nger.

Froment’s sign (right hand). Copyright FRCEM

Success.

Claw hand deformity. By Mcstrother (Own work)

[CC BY 3.0
(http://creativecommons.org/licenses/by/3.0)], via
Wikimedia Commons

You have been asked to give a tutorial to a group of nurses regarding venous cannulation. As
part of the session you cover the basic anatomy of the venous system of the arm. Regarding the
super cial veins of the upper limb, which of the following statement is CORRECT:
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a) The cephalic vein arises from the ventral venous network.

b) The cephalic vein ascends along the medial forearm and arm.
c) The basilic vein arises from the medial aspect of the dorsal venous network.
d) The basilic vein ascends along the posterior forearm and arm.
e) The cephalic and basilic vein drain into the median cubital vein in the upper arm.
Something wrong?

Answer
The basilic vein arises from the medial aspect of the dorsal venous network, ascends along the medial aspect of the
forearm and arm and becomes the axillary vein.

Notes
The cephalic, basilic and median cubital veins are the main super cial veins of the upper limb.

The cephalic vein arises from the lateral aspect of the dorsal venous network, ascends along the anterolateral border
of the forearm and arm and drains into the axillary vein.

The basilic vein arises from the medial aspect of the dorsal venous network, ascends along the medial aspect of the
forearm and arm and becomes the axillary vein.

The two super cial veins communicate via the median cubital vein which passes obliquely across the anterior elbow in
the antecubital fossa. The median cubital vein is a common site of venepuncture.

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By Henry Vandyke Carter [Public domain],

via Wikimedia Commons

You are examining the arm of a 34 year old man who has injured his radial nerve. You test the
muscles supplied by the radial nerve. The brachioradialis muscle primarily assists with which of the
following movements:

a) Flexion of the forearm

b) Flexion of the arm
c) Flexion of the hand
d) Supination of the forearm
e) Pronation of the forearm
Something wrong?

Answer
The brachioradialis muscle is an accessory exor of the forearm at the elbow (together with the biceps brachii and the
brachialis). It is located in the posterior compartment of the forearm.

Notes
The muscles of the posterior forearm are all innervated by the radial nerve.

The posterior forearm is divided into the super cial and deep groups:

The super cial group is made up of the brachioradialis, the extensor carpi radialis longus and brevis, the
extensor digitorum, the extensor digiti mini, the anconeus and the extensor carpi ulnaris.
The deep group is made up of the supinator, the abductor pollicis longus, the extensor pollicis longus and brevis
and the extensor indicis.
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Muscle Action Innervation

Brachioradialis Flexion of elbow Radial nerve

Extensor carpi radialis longus Extension and abduction of wrist Radial nerve

Extensor carpi radialis brevis Extension and abduction of wrist Radial nerve

Extensor digitorum Extension of all four ngers, extension of wrist Radial nerve

Extensor digiti minimi Extension of little nger Radial nerve

Extensor carpi ulnaris Extension and adduction of wrist Radial nerve

Supinator Supination of forearm Radial nerve

Abductor pollicis longus Abduction and extension of thumb Radial nerve

Extensor pollicis longus Extension of thumb (CMCJ, MCPJ, IPJ) Radial nerve

Extensor pollicis brevis Extension of thumb (CMCJ and MCPJ) Radial nerve

Extensor indicis Extension of index nger Radial nerve

A detailed knowledge of the distal attachments of the exor tendons is important to allow understanding of the clinical
effects of division/injury at any given level of the nger.

The abductor pollicis longus is attached distally to the lateral side of base of the 1st metacarpal.
The extensor pollicis brevis is attached to the proximal phalanx of the thumb and the extensor pollicis longus is
attached to the distal phalanx of the thumb.
The extensor carpi radialis longus is attached to the base of the 2nd metacarpal and the extensor carpi radialis
brevis is attached to the bases of the 2nd and 3rd metacarpals.
The extensor digitorum is attached to the base of the middle and distal phalanges of digits 2 – 5 via extensor
hoods.
The extensor carpi ulnaris is attached to the base of the 5th metacarpal.
The extensor digiti minimi is attached to the base of the 5th metacarpal.
The extensor indicis is attached to the extensor hood of the index nger.

Muscle tendon Distal attachment

Extensor carpi radialis Dorsal surface of base of 2nd metacarpal

longus

Extensor carpi radialis Dorsal surface of base of 2nd and 3rd metacarpal
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brevis

Extensor digitorum Dorsal aspects of bases of middle and distal phalanges of all four ngers via
extensor hoods

Extensor carpi ulnaris Tubercle on base of medial 5th metacarpal

Abductor pollicis longus Lateral side of base of 1st metacarpal

Extensor pollicis longus Dorsal surface of base of distal phalanx of thumb

Extensor pollicis brevis Dorsal surface of base of proximal phalanx of thumb

Extensor indicis Extensor hood of index nger

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By Henry Vandyke Carter [Public domain], via

Wikimedia Commons

By Henry Vandyke Carter [Public domain], via

Wikimedia Commons

A 71 year old lady attends ED complaining of pain in her arm following a fall. Imaging
demonstrates a midshaft humerus fracture. An injury of the radial nerve in the spiral groove would
typically demonstrate which of the following physical signs:

a) Weakness of forearm extension

b) Weakness of thumb abduction and extension
c) Weakness of thumb opposition
d) Weakness of forearm pronation
e) Weakness of abduction and adduction of the ngers
Something wrong?

Answer
The radial nerve innervates the abductor pollicis longus and the extensor pollicis longus and brevis. Injury would
therefore result in loss of extension and abduction of the thumb. The radial nerve does also innervate the triceps
brachii, but injury at the mid humerus level usually spares this muscle and thus you would not expect weakness of
forearm extension.

Notes
The radial nerve is a continuation of the posterior cord, containing bres from C5 – T1.

Nerve Radial nerve

Nerve C5 – T1
roots

Plexus Posterior cord

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cords

Motor Triceps brachii, posterior compartment of forearm: super cial muscles (brachioradialis, extensor carpi
Supply radialis longus and brevis, extensor digitorum, extensor digiti minimi, extensor carpi ulnaris) and deep
muscles (supinator, abductor pollicis longus, extensor pollicis longus and brevis, extensor indicis)

Sensory Lower lateral arm, posterior arm, posterior forearm, dorsum of lateral hand and three and a half
supply ngers

Anatomical course

The radial nerve enters the arm by crossing the lower margin of the teres major muscle, where it lies posterior to the
brachial artery. It enters the posterior compartment of the arm, where it descends obliquely passing from medial to
lateral in the radial (spiral) groove of the humerus. After emerging from the spiral groove, the radial nerve pierces the
lateral intermuscular septum and enters the anterior compartment of the arm, descending into the cubital fossa where
it lies between the brachialis and brachioradialis muscles. The radial nerve enters the forearm after passing over the
lateral epicondyle of the humerus. Within the proximal forearm the nerve terminates by bifurcating into the deep
branch and the super cial branch. N.B. Once the deep branch of the radial nerve penetrates between the two heads of
the supinator muscle to access the posterior compartment of the arm, it becomes known as the posterior interosseous
nerve.

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By Henry Vandyke Carter [Public domain], via Wikimedia

Commons

Branches

Branches of Radial Origin Supply

Nerve

Radial nerve Axilla Triceps brachii, extensor carpi radialis longus, brachioradialis

Posterior Axilla Skin of posterior arm

cutaneous nerve of
the arm

Inferior lateral Arm Skin over lateral aspect of lower arm

cutaneous nerve of
the arm

Posterior Arm Strip of skin down middle of posterior forearm

cutaneous nerve of
the forearm

Deep branch which Forearm Posterior compartment of forearm: super cial muscles (extensor carpi radialis
continues as the brevis, extensor digitorum, extensor digiti minimi, extensor carpi ulnaris) and
posterior deep muscles (supinator, abductor pollicis longus, extensor pollicis longus and
interosseous nerve brevis, extensor indicis)

Super cial branch Forearm Skin of dorsum of the hand and lateral three and a half ngers

In the arm, the radial nerve directly innervates the triceps brachii, the extensor carpi radialis longus and the
brachioradialis. In the forearm, the deep branch, which continues as the posterior interosseous nerve, innervates the
muscles of the posterior compartment of the forearm and the super cial branch supplies the skin of the dorsum of the
hand and lateral three and a half ngers.
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hand and lateral three and a half ngers.

The radial nerve also gives rise to several cutaneous branches; the posterior cutaneous nerve of the arm originating in
the axilla, and the inferior lateral cutaneous nerve of the arm and the posterior cutaneous nerve of the forearm
originating in the arm. These cutaneous branches supply skin over the posterior surface of the arm, the lateral aspect
of the arm and the skin down the middle of the posterior forearm respectively.

Clinical implications

Lesion In axilla In spiral groove In forearm In forearm (deep

(super cial branch) branch)

Mechanism Glenohumeral joint Fracture of midshaft Stabbing/laceration Fracture of

dislocation, fracture of of humerus of forearm radial head or
proximal humerus, ‘Saturday posterior
night syndrome’ dislocation
of radius

Motor Loss Loss of extension at elbow, Loss of extension at None Weakness of

wrist and ngers wrist and ngers extension at
(triceps brachii wrist and
spared) ngers (extensor
carpi radialis
spared)

Sensory Lower lateral arm, posterior Dorsum of lateral Dorsum of lateral None
Loss arm, posterior forearm, hand and three and a hand and three and
dorsum of lateral hand and half ngers a half ngers
three and a half ngers (cutaneous branches
of arm and forearm
spared)

Signs Wrist drop (unopposed Wrist drop, weak None Wrist drop not
wrist exion), weakness of hand grip typically seen
hand grip ( nger exion is (extensor carpi
weak as the long exor radialis spared)
tendons are not under
tension)

Radial nerve injury at the axilla may occur in glenohumeral joint dislocation, in fractures of the proximal humerus,
through incorrect use of axillary crutches, or due to ‘Saturday Night’ palsy. There is loss of extension of the forearm
due to paralysis of the triceps brachii and loss of extension of the wrist and ngers (predominantly MCPJs, as extension
at the IPJs is primarily a function of the lumbrical and interosseous muscles) and weakness of supination due to
paralysis of the muscles of the posterior compartment of the forearm. All four cutaneous branches of the radial nerve
are affected and there is loss of sensation over the lateral and posterior arm, the posterior forearm and the dorsal
surface of the hand and lateral three and a half digits. There is unopposed wrist exion, giving the appearance of wrist
drop.
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drop.

The radial nerve in the arm is most susceptible to midshaft fractures of the humerus due to its course in the spiral
groove. Extension of the forearm is not affected as the triceps brachii is spared. There is loss of extension of the wrist
and MCPJs of the ngers and weakness of supination of the forearm. The cutaneous branches of the arm and forearm
have already arisen and sensation loss occurs only on the dorsum of the lateral hand and three and a half digits.

Radial nerve damage in the forearm may present as super cial branch or deep branch damage. The super cial branch is
most commonly damaged by stabbing or laceration to the forearm and results in loss of sensation over the dorsum of
the lateral hand and three and a half digits. The deep branch may be damaged by fracture of the radial head or
posterior dislocation of the radius and results in weakness of extension of the wrist and ngers, but not typically with
wrist drop (as the extensor carpi radialis is spared).

A 23 year old woman sustains a laceration injury to her posterior forearm. Which of the
following muscles would you least expect to be affected in this injury:

a) Abductor pollicis longus

b) Supinator
c) Brachioradialis
d) Brachialis
e) Extensor digiti minimi
Something wrong?

Answer
The brachialis is found in the anterior arm.

Notes
The muscles of the posterior forearm are all innervated by the radial nerve.

The posterior forearm is divided into the super cial and deep groups:

The super cial group is made up of the brachioradialis, the extensor carpi radialis longus and brevis, the
extensor digitorum, the extensor digiti mini, the anconeus and the extensor carpi ulnaris.
The deep group is made up of the supinator, the abductor pollicis longus, the extensor pollicis longus and brevis
and the extensor indicis.

Muscle Action Innervation

Brachioradialis Flexion of elbow Radial nerve

Extensor carpi radialis longus Extension and abduction of wrist Radial nerve

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Extensor carpi radialis brevis Extension and abduction of wrist Radial nerve

Extensor digitorum Extension of all four ngers, extension of wrist Radial nerve

Extensor digiti minimi Extension of little nger Radial nerve

Extensor carpi ulnaris Extension and adduction of wrist Radial nerve

Supinator Supination of forearm Radial nerve

Abductor pollicis longus Abduction and extension of thumb Radial nerve

Extensor pollicis longus Extension of thumb (CMCJ, MCPJ, IPJ) Radial nerve

Extensor pollicis brevis Extension of thumb (CMCJ and MCPJ) Radial nerve

Extensor indicis Extension of index nger Radial nerve

A detailed knowledge of the distal attachments of the exor tendons is important to allow understanding of the clinical
effects of division/injury at any given level of the nger.

The abductor pollicis longus is attached distally to the lateral side of base of the 1st metacarpal.
The extensor pollicis brevis is attached to the proximal phalanx of the thumb and the extensor pollicis longus is
attached to the distal phalanx of the thumb.
The extensor carpi radialis longus is attached to the base of the 2nd metacarpal and the extensor carpi radialis
brevis is attached to the bases of the 2nd and 3rd metacarpals.
The extensor digitorum is attached to the base of the middle and distal phalanges of digits 2 – 5 via extensor
hoods.
The extensor carpi ulnaris is attached to the base of the 5th metacarpal.
The extensor digiti minimi is attached to the base of the 5th metacarpal.
The extensor indicis is attached to the extensor hood of the index nger.

Muscle tendon Distal attachment

Extensor carpi radialis Dorsal surface of base of 2nd metacarpal

longus

Extensor carpi radialis Dorsal surface of base of 2nd and 3rd metacarpal
brevis

Extensor digitorum Dorsal aspects of bases of middle and distal phalanges of all four ngers via
extensor hoods

Extensor carpi ulnaris Tubercle on base of medial 5th metacarpal

Abductor pollicis longus

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Abductor pollicis longus Lateral side of base of 1st metacarpal

Extensor pollicis longus Dorsal surface of base of distal phalanx of thumb

Extensor pollicis brevis Dorsal surface of base of proximal phalanx of thumb

Extensor indicis Extensor hood of index nger

By Henry Vandyke Carter [Public domain], via

Wikimedia Commons
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Wikimedia Commons

By Henry Vandyke Carter [Public domain], via

Wikimedia Commons

You have been asked to teach a group of medical students about hand injuries. You cover
some anatomical principles including blood supply to the hand. Regarding the palmar arches, which
of the following statements is CORRECT:

a) The super cial palmar arch lies just deep to the long exor tendons of the digits.
b) Blood supply to the hand is poor, and laceration will usually result in only mild bleeding.
c) The deep palmar arch is formed primarily from the ulnar artery.
d) The deep palmar arch lies super cial to the palmar aponeurosis.
e) The deep palmar arch usually lies proximal to the super cial palmar arch.
Something wrong?

Answer
The deep palmar arch usually lies proximal to the super cial palmar arch.

Notes

There are two palmar arches which supply the hand.

The ulnar artery forms the super cial palmar arch which communicates laterally with a palmar branch of the radial
artery. The super cial palmar arch lies super cial to the long exor tendons of the digits and just deep to the palmar
aponeurosis. It is located across the centre of the palm, about level with the distal border of the extended thumb.

The radial artery forms the deep palmar arch which communicates medially with the deep palmar branch of the ulnar
artery. The deep palmar arch lies between the metacarpal bones and the long exor tendons of the digits. It is located
approximately 1 cm proximal to the super cial palmar arch.

Laceration to the palmar arches results in profuse bleeding.

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By Rhcastilhos (Gray1237.png) [Public domain], via Wikimedia Commons

A 21 year old patient sustains a laceration which transects the exor retinaculum. Regarding
the exor retinaculum, which of the following statements is INCORRECT:

a) The exor retinaculum forms the roof of the carpal tunnel.

b) The thenar and hypothenar muscles arise from the exor retinaculum.
c) The ulnar artery passes into the hand anterior to the exor retinaculum.
d)
The tendons of the exor pollicis longus, exor digitorum profundus and exor digitorum super cialis pass into the
hand posterior to the exor retinaculum.
e) The ulnar nerve and the median nerve pass into the hand posterior to the exor retinaculum.
Something wrong?

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Answer
The median nerve passes into the hand posterior to the exor retinaculum, within the carpal tunnel, but the ulnar
nerve passes into the hand anterior to the exor retinaculum.

Notes

The exor retinaculum (transverse carpal ligament) is a thickened band of brous connective tissue on the volar aspect
of the hand which forms the roof of the carpal tunnel. The exor retinaculum holds the exor tendons in place at the
wrist and prevents them from bowstringing.

It is attached laterally to the scaphoid and trapezium and medially to the pisiform and the hook of the hamate.

The thenar and hypothenar muscles arise from the exor retinaculum.

The ulnar artery, ulnar nerve, and tendon of the palmaris longus pass into the hand anterior to the exor retinaculum,
and therefore do not pass through the carpal tunnel.

The exor carpi radialis tendon passes through the lateral aspect of the exor retinaculum into the hand.

The four tendons of the exor digitorum profundus, the four tendons of the exor digitorum super cialis, the tendon of
the exor pollicis longus and the median nerve pass into the hand posterior to the exor retinaculum, within the carpal
tunnel.

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By Henry Vandyke Carter [Public domain], via Wikimedia Commons

A 27 year old woman sustains an injury to the proximal median nerve after cutting herself
whilst separating frozen chicken breasts using a knife. Which of the following muscles would you
not expect to be affected:

a) Opponens pollicis
b) Abductor pollicis brevis
c) Flexor pollicis brevis
d) Adductor pollicis
e) Flexor pollicis longus
Something wrong?

Answer
The thenar muscles (opponens pollicis, abductor pollicis brevis and exor pollicis brevis) are all innervated by the
median nerve. The exor pollicis longus in the anterior forearm is also innervated by the median nerve. The adductor
pollicis, an intrinsic hand muscle, is innervated by the ulnar nerve. The muscles of the hand supplied by the median
nerve can be remembered using the mnemonic, “LOAF” for Lumbricals 1 & 2, Opponens pollicis, Abductor pollicis
brevis and Flexor pollicis brevis.

Notes
The thenar eminence consists of the opponens pollicis, the abductor pollicis brevis and the exor pollicis brevis. The
thenar muscles are all innervated by the median nerve.

Muscle Action Innervation

Opponens pollicis (blue) Medially rotates thumb Median nerve

Abductor pollicis brevis (green) Abducts thumb at MCPJ Median nerve

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Flexor pollicis brevis (red) Flexes thumb at MCPJ Median nerve

Modi ed by FRCEM Success. Original by By OpenStax [CC BY 4.0

(http://creativecommons.org/licenses/by/4.0)], via Wikimedia Commons

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