LANDMARK |
Anatomic significance |
Clinical significance |
Examination |
Misc |
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Triceps muscle/tendon |
Extends elbow using radial nerve |
May avulse from olecranon; be functionally disrupted with olecranon fracture |
have patient actively extend—but remember to position in such a way that gravity does not help (too much) Test reflex by tapping the triceps tendon with the forearm held loosely at right angles to the rest of the arm |
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Biceps muscle/tendon |
Attaches on radius to flex and supinate; musculocutaneous nerve; |
Misconceptions: More of a supinator than flexor Relatively small contributor to “big guns” of body builder |
“twist the cork out of the bottle” Test reflex by tapping the biceps tendon in the cubital fossa |
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The antecubital fossa. |
Contains (from lateral to medial)
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If ruptured, the biceps tendon ordinarily palpated here may be “absent” Site of venipuncture (median cubital vein, cephalic vein, and basilic vein) Sit e of auscultation for blood pressure (brachial artery) |
Palpation Inspection for ecchymosis |
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Medial epicondyle. |
Site of attachment of:
The ulnar nerve also runs in a groove on the posterior aspect (hence “funny bone”) |
Medial epicondylitis, or “golfer’s elbow”, is an overuse syndrome of the flexor-pronator mass that attaches here Pronator teres and flexor carpi radialis most affected |
Palpation with and without resistance Active forearm pronation and wrist flexion – pain can be suggestive of medial epicondylitis Test stability of ulnar collateral ligament with valgus stress |
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Lateral epicondyle. |
Site of attachment of the radial collateral ligament and common extensor/supinator tendon |
Lateral epicondylitis, or “tennis elbow”, is an overuse syndrome of the extensor, especially extensor carpi radialis brevis |
Palpation with and without resistance Pain with resisted wrist extension with elbow fully extended, resisted extension of long fingers, and maximal flexion of the wrist are suggestive of lateral epicondylitis Test stability of lateral collateral ligament with varus stress |
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Mobile wad of three. |
Also called the mobile wad of Henry, consists of the brachioradialis extensor carpi radialis brevis and extensor carpi radialis longus All are innervated by the radial nerve |
brachioradialis: mostly elbow flexion (but depending on start position may have some pronation/supination) extensor carpi radialis brevis: wrist extension/abduction extensor carpi radialis longus: wrist extension/abduction |
Reflex of brachioradialis muscle can be tested, but not very impressive |
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Flexor pronator mass. |
pronator teres (median nerve) flexor carpi radialis (median nerve) flexor digitorum superficialis (median nerve) palmaris longus (median nerve) flexor carpi ulnaris (ulnar nerve). |
Involved in medial epicondylitis. |
Palpate the medial epicondyle to check for golfers’ elbow Pronator teres: actively pronate the forearm Flexor carpi radialis: actively flex the wrist Flexor digitorum superficialis: actively flex one finger at the PIP while holding the remaining fingers fully extended (to prevent contribution from flexor digitorum profundus) Flexor carpi ulnaris: actively flex the wrist |
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Radial humeral joint and radial head. |
Shallow almost-ball-and-socket type joint between radial head and capitulum of the humerus; this is the joint for pronation and supination
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The annular ligament prevents the radial head from dislocation. Nursemaid’s elbow: subluxation of the radial head caused by sudden pull on extended, pronated forearm
Elbow injections/aspirations: Flex the elbow at 45° and pronate to protect the radial nerve, mark the landmarks of the lateral, or anconeus, triangle: lateral olecranon, lateral epicondyle, and radial head. After sterile preparation of the skin, the needle is inserted perpendicularly at the center of the triangle and aimed toward the medial epicondyle |
Palpate with forearm pronation/supination to assess for arthropathy
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Olecranon with bursa |
Site of insertion of the triceps brachii, part of the flexor carpi ulnaris, and anconeus muscles |
Hume fracture: Fracture of olecranon with anterior displacement of the radial head Olecranon bursitis: inflammation/infection of the olecranon bursa with swelling |
Pinch, to distinguish from deeper stuctures |
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Cubital tunnel. |
Channel through which the ulnar nerve travels over the elbow, bordered by the medial epicondyle of the humerus, the olecranon process of the ulna, and the flexor carpi ulnaris tendon Roof is Osborne’s ligament |
Cubital tunnel syndrome: chronic compression of the ulnar nerve, manifests as burning, pain, numbness, and/or tingling in the thumb, index, middle, and radial half of the ring fingers. Patients may also experience wrist pain or weakness in grip strength. |
Assess sensation of ulnar nerve distribution in the hand by lightly touching the volar surface of the ulnar half of the ring finger and the small finger Perform Tinel’s test by tapping on tunnel and assessing for parathesias in the ulnar nerve distribution |
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Radial tunnel. |
Region from the radiohumeral joint past the proximal origin of the supinator |
Radial tunnel syndrome: compression of the radial nerve in the forearm, manifested as burning, pain, numbness, and/or tingling in the thumb, index, middle, and radial half of the ring finger. |
Assess sensation of radial nerve distribution with light touch in the affected digits—may be purely a subjective sense (i.e. by patient history alone) |
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Ulnar shaft. |
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Monteggia fracture: proximal ulna fracture with radial head dislocation (fall on outstretched hand) Nightstick fracture: direct blow can fracture ulnar shaft |
Palpation Assess neurovascular status Pain with passive stretch of digits heralds compartment syndrome |
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Radial shaft. |
Has a bow to it, allowing it to rotate around the ulna |
Galeazzi fracture: distal 1/3 radial shaft fracture with radioulnar dislocation Colles fracture: fall on outstretched hand, fracture of distal radius with apex volar angulation (dorsal displacement) Smith fracture: fracture of distal radius with volar displacement |
Palpation Assess neurovascular status Pain with passive stretch of digits heralds compartment syndrome |
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Ulnar styloid/distal ulna. |
Medial aspect of the distal ulna Site of attachment of ulnar collateral ligament of the wrist |
Fractures of the ulnar styloid can lead to instability of the distal radioulnar joint (DRUJ). |
Palpation, supination, pronation |
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Radial styloid. |
Lateral aspect of distal radius Site of attachment for the brachioradialis tendon and radial collateral ligament of the wrist |
Chauffeur’s fracture: fracture of the radius at the styloid |
Palpation, supination, pronation |
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First compartment extensor tendons. |
Abductor pollicis longus Extensor pollicis brevis Both are at the radial border of anatomic snuffbox Innervated by the posterior interosseous nerve (continuation of radial nerve after passes through supinator) |
DeQuervain’s tenosynovitis: inflammation of the tendon sheath surrounding the abductor pollicis longus/ extensor pollicis brevis |
Finkelstein: Flex thumb into palm, ulnarly deviate the wrist – pain in first compartment suggests DeQuervain’s tenosynovitis |
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Third compartment extensor tendons. |
Extensor pollicis longus, innervated by the posterior interosseous nerve |
Passes around Lister’s tubercle |
Active extension of the thumb |
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Anatomic snuffbox. |
Triangular impression on radial, dorsal aspect of the wrist The scaphoid and trapezium bones form the floor extensor pollicis longus is posterior border extensor pollicis brevis /abductor pollicis longusare the anterior border Styloid process of the radius is proximal border |
Tenderness to palpation in this region may indicate fracture of the scaphoid bone |
Prominent during thumb extension
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Radiocarpal joint. |
Articulation of the distal radius and the scaphoid, lunate, and triquetral bones |
Perilunate dislocation can lead to radiocarpal joint instability |
Flexion, extension, radial/ulnar deviation, pronation, and supination of the wrist |
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Radial pulse. |
Palpated between the tendons of the brachioradialis and flexor carpi radialis at the distal lateral forearm |
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Palpation Allen test: occlude both radial and ulnar arteries manually, pump fist, then release one artery only to examine filling of the palm to assess patency of branches of radial artery |
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Carpal tunnel. |
Covered by the flexor retinaculum (transverse carpal ligament) Medial wall: pisiform and hamate Lateral wall: trapezium and scaphoid Contain the following structures:
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Carpal tunnel syndrome: compression of the median nerve |
Phalen’s test: wrist flexion for about 1 minute elicits same symptoms Tinel’s sign: tapping on volar wrist elicits same symptoms Durkan carpal compression: manual pressure on median nerve at carpal tunnel reproduces symptoms (most sensitive test) |
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Scaphoid tubercle. |
Site of attachment of the transverse carpal ligament |
Fracture through the tubercle puts the proximal pole of the scaphoid at risk for avascular necrosis |
Palpation at the anatomic snuffbox |
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Ulnar pulse. |
Palpated on the anteromedial wrist |
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Palpation Allen test: occlude both radial and ulnar arteries manually, pump fist, then release one artery only to examine filling of the palm to assess patency of branches of ulnar artery |
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Thenar muscles. |
Abductor pollicis brevisFlexor pollicis brevis Opponens pollicis Innervated by median nerve (except deep head of flexor pollicis brevis; ulnar nerve) |
Wasting can indicate denervation of the median nerve, caused by carpal tunnel syndrome, injuries/disorders to the cervical spine or brachial plexus, or other medial nerve palsy. |
Abductor pollicis brevis: opposition Flexor pollicis brevis: thumb flexion opponens: opposition |
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Hypothenar muscles. |
Abductor, flexor, and opponens digiti minimi Palmaris brevis Innervated by ulnar nerve |
Wasting can indicate denervation of the ulnar nerve, caused by injuries/disorders to the cervical spine or brachial plexus, or other ulnar nerve palsy.. |
Abductor digiti minimi: small finger abduction Flexor digiti minimi: small finger MCP flexion Opponens digiti minimi: flexion/supination of small finger
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Base of the first metacarpal (thumb) |
Site of ligament attachment Insertion of abductor pollicis longus (also on trapezium) and opponens pollicis |
Bennett fracture: base of 1st metacarpal with intraarticular extension Rolando fracture: base of 1st metacarpal with intraarticular extension, Y-shaped |
Inspection, palpation Assess range of motion Radiographs for suspected fracture |
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Base of the metacarpals.
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Site of ligament attachment Base of 2: Insertion of extensor carpi radialis longus/brevis Base of 5: Insertion of extensor carpi ulnaris and opponens digiti minimi |
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Check for rotational deformity by flexing the fingers and examining the directionality of each digit – normal flexed fingers point toward tuberosity of scaphoid |
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Metacarpal heads. |
Form part of the MCP joints
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Site of insertion of flexor and extensor tendons |
Palpation |
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Flexor tendons passing through the palm (pulleys). |
Flexor tendons pass through flexor tendon sheath Pulleys are thickenings of sheath that stabilize the tendons 5 annular (ring) sheaths (A1, A2, A3, A4, A5) 3-4 cruciate pulleys |
A2/4 are most important Tight A1 can cause trigger finger |
Active flexion of the digits |
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Interosseous muscles of the hand. |
Dorsal interossei: four bipennate muscles in the dorsum of the hand that abduct the index, middle, and ring fingers away from midline Palmar interossei: three unipennate muscles between the metacarpals and are attached to the index, ring, and little fingers; these adduct the fingers toward the midline All interosseous muscles are innervated by the deep branch of the ulnar nerve |
The radial artery passes from the back of the hand into the palm between the two heads of the first dorsal interosseous muscle
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Spread the fingers:
Dorsals ABduct (DAB) Palmar ADduct (PAD) |
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Middle phalanx. |
Flexor digitorum superficialis inserts here |
Fractures here can either be dorsal or apex volar angulation |
Check for rotational deformity by flexing the fingers and examining the directionality of each digit – normal flexed fingers point toward tuberosity of scaphoid |
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Distal phalanx. |
Flexor digitorum profundus inserts here Terminal slip of extensor tendon inserts here |
Most common fractured phalanx Associated with nail bed injuries |
Check for rotational deformity by flexing the fingers and examining the directionality of each digit – normal flexed fingers point toward tuberosity of scaphoid |
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Proximal phalanx. |
lumbricals and interossei insert at or near here |
Fractures here usually have apex volar angulation due to proximal fragment in flexion (from interossei) and distal fragment in extension (from central slip) |
Check for rotational deformity by flexing the fingers and examining the directionality of each digit – normal flexed fingers point toward tuberosity of scaphoid |
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Pulp of fingertip |
Contains multiple septa, nerves, and arteries |
Felon: infection of the pulp
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Inspection and palpation |
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Nail and associated structures. |
Nail: cornified epithelium Nail/germinal matrix: under eponychium Nail bed/sterile matrix: under the nail Paronychia: radial and ulnar nail folds Eponychia: proximal nail fold |
Nail grows 1 mm per week and germinal matrix must be intact/repaired for normal nail growth Paronychia/eponychia are common sites of infection |
Inspection and palpation |
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Volar plate |
Fibrocartilaginous structure on palmar aspect of MCP and IP joints |
Reinforce the joint capsules Limit hyperextension Injuries often referred to as “jammed” fingers Hyperextension of the PIP can lead to volar plate avulsion injuries |
Palpation Assess range of motion of the MCP joint X-rays can rule out volar plate avulsion injuries |
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Flexor carpi radialis |
Wrist flexor/abductor (radial deviation) Originates on medial epicondyle of humerus and inserts on the base of the second/third metacarpal Innervated by median nerve |
Radial artery is immediately lateral to the FCR |
Active flexion and radial deviation of the wrist |
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Palmaris longus |
Small muscle between flexor carpi radialis and flexor carpi ulnaris Originates at medial epicondyle and inserts at flexor retinaculum/palmar aponeurosis Flexes wrist Innervated by median nerve |
Absent in about 1/7 of population Tendon used in Tommy John’s surgery for reconstruction of the ulnar collateral ligament of the elbow and other tendon grafts |
Have patient pinch the thumb to pinky with wrist flexion |
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Lunate |
Crescent (moon) shaped
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Kienbock’s disease: avascular necrosis of the lunate Perilunate dislocation: lunate stays in place while carpus dislocates, 25% missed on presentation |
Palpation Assess range of motion of wrist |
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Lister’s tubercle |
On dorsum of the radius Pulley for the extendor pollicis longus tendon (wraps around the ulna side and turns 45 degrees)
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“Lighthouse” of the wrist |
Palpation |
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Sensory distribution of radial nerve |
Sensation of the lateral arm, posterior forearm, radial half of dorsum of hand and dorsal aspect of radial 3 ½ digits |
Lesions cause numbness and tingling of affected dermatome |
Assess light touch, pinprick, two-point discrimination in dermatomal distribution |
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Sensory distribution of median nerve |
Sensation of the palmar aspect of lateral 3 ½ digits including nail beds |
Lesions cause numbness and tingling of affected dermatome Involved in carpal tunnel syndrome |
Assess light touch, pinprick, two-point discrimination in dermatomal distribution |
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Sensory distribution of ulnar nerve |
Sensation of the ulnar half of the palm and dorsum of the hand, medial 1 ½ digits on both palmar and dorsal aspects of hand |
Lesions cause numbness and tingling of affected dermatome Cubital tunnel syndrome is a compressive neuropathy of the ulnar nerve |
Assess light touch, pinprick, two-point discrimination in dermatomal distribution |
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Ulnar collateral ligament of thumb |
Runs along the ulnar aspect of the MCP of the thumb It is the on the radial side of the wrist Composed of: Proper collateral ligament (resists valgus load with thumb in flexion) Accessory collateral ligament (resists valgus load with thumb in extension) |
Skier’s thumb: acute injury of the ligament Gamekeeper’s thumb: chronic injury of the ligament, leading to a tear or sometimes avulsion from its insertion at the proximal phalanx of the thumb Stener lesion: avulsed ligament +/- bony attachment displaced above adductor aponeurosis |
Palpation Valgus stress in both flexion and extension – stress joint with radial deviation at neutral (accessory ulnar collateral ligament) and 30° (proper ulnar collateral ligament) of flexion |
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Pisiform |
Sesamoid bone found in the wrist Contained within the flexor carpi ulnaris tendon |
Forms the ulnar border of the carpal tunnel
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Palpation Not involved in motion of the wrist |
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Hook of hamate |
Found on the proximal, ulnar side of the hamate Forms the ulnar border of the carpal tunnel Forms the radial border for Guyon’s canal (passage for ulnar nerve and artery) Site of attachment for ligaments from the pisiform, the transverse carpal ligament, and tendon of the flexor carpi ulnaris |
Fractures of hook of the hamate can present with ulnar neuropathy/laceration of ulnar artery |
Palpation Assess integrity of ulnar nerve: sensory distribution, motor of intrinsic hand muscles, grip strength |
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