Surface Landmarks of the Upper Limb: Bones, Vessels and Muscles

Table of Contents

Surface Landmarks of the Upper Limb

Surface anatomy turns deep three-dimensional structures into visible or palpable reference points. In the upper limb, accurate landmarking supports range-of-motion measurement, posture and scapular analysis, muscle testing, pulse checks, swelling measurement, splint fabrication and clear documentation. Use the patient’s position, side and consent every time.

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Landmarks are guides, not diagnoses

Palpable structures vary with body habitus, age, posture, muscle tension, injury and anatomical variation. A surface point may represent more than one deeper structure. Use gentle palpation, compare sides, combine findings with movement and sensation, and refer uncertain or high-risk findings for medical assessment or imaging.

Learning outcomes

Locate and describe the principal bony landmarks of the shoulder, arm, forearm and hand.
Palpate the major superficial vessels and identify safe pulse points.
Identify muscles and tendons by position and resisted contraction.
Use landmarks to position a goniometer, measure swelling and describe symptoms.
Apply consent, privacy, infection-prevention and neurovascular safety principles.

1. Surface-marking method

Explain what you will inspect, touch or measure and why; obtain consent and provide a chaperone for sensitive examinations when appropriate.
Expose only the area required and maintain dignity with draping.
Position the patient and record it; a landmark changes when the limb moves.
Inspect colour, swelling, scars, muscle bulk, deformity and asymmetry before palpation.
Use finger pads and gentle pressure; locate bone first, then follow soft-tissue structures.
Ask the patient to move or contract lightly to confirm a muscle/tendon.
Compare sides, measure consistently and avoid marking infected or broken skin.
Document side, position, landmark, distance/angle, symptom response and method.

2. Shoulder-girdle bony landmarks

Landmark	How to locate	Clinical/measurement use
Clavicle	Trace the S-shaped ridge from sternum to acromion.	Alignment, fracture screening, shoulder-girdle posture and SC/AC joint reference.
Sternoclavicular joint	Medial clavicle meets manubrium at the upper sternum.	Clavicular elevation/depression and anterior shoulder pain.
Acromion	Follow the scapular spine laterally to its broad tip.	Shoulder width, glenohumeral axis approximation and deltoid attachment.
Coracoid process	Palpable deep to the anterior deltoid, inferior/medial to the clavicle; palpate gently.	Pectoralis minor, coracobrachialis and biceps short-head reference; avoid aggressive pressure.
Spine of scapula	Posterior ridge running medially from acromion.	Scapular position, posture and muscle attachment.
Medial border/inferior angle	Medial border lies beside thoracic spine; inferior angle moves with arm elevation.	Scapular winging, upward rotation and dyskinesis assessment.
Glenoid region	Deep lateral scapular surface; not directly palpable like acromion.	Use acromion and humeral head as safer surface references.

3. Arm and elbow landmarks

Landmark	Location	Use
Humeral shaft	Firm contour between deltoid and elbow, more palpable medially/laterally than anteriorly.	Alignment, swelling and fracture precautions.
Deltoid tuberosity	Lateral humeral shaft below deltoid bulk; not always directly prominent.	Deltoid insertion and muscle contour.
Medial epicondyle	Prominent medial distal humerus.	Common flexor origin and ulnar nerve lies posteriorly; avoid sustained pressure.
Lateral epicondyle	Prominent lateral distal humerus.	Common extensor origin and elbow-axis reference.
Olecranon	Posterior point of elbow, especially in flexion.	Triceps insertion, elbow range and pressure protection.
Radial head	Just distal to lateral epicondyle; rotate forearm to feel it move.	Elbow joint, pronation/supination and radial-head injury assessment.
Cubital fossa	Triangular anterior elbow region between brachioradialis and pronator teres.	Brachial pulse, venepuncture anatomy and biceps tendon; avoid deep pressure.

4. Forearm, wrist and hand landmarks

Landmark	Location/technique	Clinical use
Radial shaft/styloid	Thumb-side forearm and distal lateral wrist.	Radial pulse, goniometer alignment and wrist deviation.
Ulnar shaft/styloid	Little-finger side; styloid is prominent distally.	Ulnar-sided wrist pain, DRUJ and wrist-axis references.
Lister’s tubercle	Dorsal distal radius.	Extensor pollicis longus pulley and wrist orientation.
Pisiform	Small pea-shaped bone at ulnar-volar wrist.	FCU insertion and Guyon-canal orientation.
Scaphoid/anatomical snuffbox	Depression on radial wrist when thumb is extended; tenderness requires caution.	Scaphoid injury screening and radial artery relationship.
Metacarpal heads	Knuckles on the dorsum of the hand.	MCP alignment, swelling and grip posture.
Phalangeal joints	PIP and DIP creases of digits; thumb has one IP joint.	Hand range, tendon glide and deformity documentation.
Thenar/hypothenar eminences	Muscle masses at thumb/little-finger sides of palm.	Intrinsic muscle bulk and median/ulnar nerve screening.

5. Superficial vessels and pulse points

5.1 Arterial landmarks

Brachial pulse: medial arm and cubital fossa, just medial to the biceps tendon; use gentle pressure and never compress both arms simultaneously.
Radial pulse: anterior wrist on the thumb side, lateral to flexor carpi radialis tendon.
Ulnar pulse: anterior wrist on the little-finger side, deeper and often less distinct.
Palmar perfusion: inspect colour, warmth, capillary refill and symmetry; specialist tests are required for detailed arterial patency.

5.2 Venous landmarks

Vein	Surface course	Safety
Cephalic	Lateral forearm/arm, then deltopectoral groove.	Common access route; anatomy varies and nearby nerves must be respected.
Basilic	Medial forearm/arm, becoming deep near the mid-arm.	Close to neurovascular structures after piercing fascia.
Median cubital	Oblique connection across cubital fossa.	Common venepuncture site; do not use physiotherapy palpation as venepuncture.
Dorsal venous network	Visible on dorsum of hand, especially with dependency or warmth.	Observe swelling and skin changes without excessive pressure.

6. Palpating muscles and tendons

A muscle becomes easier to identify when the patient performs a low-load action against gravity or light resistance. Explain the movement, stabilise the joint and palpate the muscle belly or tendon while watching for substitution.

Structure	Position/test movement	Surface clue
Deltoid	Abduct arm in the scapular plane against light resistance.	Large cap over shoulder; middle fibres fill the lateral contour.
Biceps	Flex elbow with forearm supinated.	Anterior arm belly and distal tendon in cubital fossa.
Triceps	Extend elbow against resistance.	Posterior arm bulk and olecranon tendon.
Brachioradialis	Flex elbow with forearm midway between pronation/supination.	Prominent lateral forearm muscle toward radial styloid.
Flexor carpi radialis	Flex and radially deviate wrist.	Tendon at volar radial wrist.
Flexor carpi ulnaris	Flex and ulnarly deviate wrist.	Tendon toward pisiform.
Extensor digitorum	Extend MCP joints against gentle resistance.	Dorsal forearm tendons become visible toward knuckles.
First dorsal interosseous	Abduct index finger against resistance.	Muscle belly in first web space.

7. Landmarks for measurement

Goniometry: use acromion/epicondyles/styloids or agreed joint axes; document the patient position and whether the movement is active or passive.
Scapular distance: measure from fixed thoracic references only with a consistent arm position; scapulae move with elevation.
Oedema: use circumferential points measured from a fixed landmark, identical tape tension and the same time of day when possible.
Muscle length: identify the relevant joints and stabilise proximal segments so compensations do not disguise restriction.
Hand function: document grip position, finger joint angles, thumb opposition and object size during tasks.

Clinical scenario: wrist swelling after injury

Inspect colour, temperature, deformity and skin integrity; palpate only gently after checking fracture precautions; compare radial/ulnar pulses and sensation; measure circumference at marked points; record pain and movement limitation. Severe pain, deformity, neurovascular change or disproportionate swelling requires urgent review rather than repeated measurement.

8. Neurovascular safety during palpation

Do not compress the medial epicondyle region for a prolonged time because the ulnar nerve is superficial.
Protect the radial artery in the snuffbox and the brachial artery in the cubital fossa.
Check distal pulse, colour, warmth, capillary refill, sensation and active movement after injury or immobilisation.
Do not mark broken, infected, irradiated or fragile skin with ordinary marker.
Stop for severe pain, paraesthesia, dizziness, sudden colour change or a new neurological deficit.

9. Examination points and revision questions

High-yield points

Acromion, coracoid, scapular spine and inferior angle are key shoulder landmarks.
Medial/lateral epicondyles, olecranon, radial head and cubital fossa orient the elbow.
Radial and ulnar styloids, pisiform, snuffbox and metacarpal heads guide wrist/hand assessment.
Brachial, radial and ulnar pulses must be interpreted with colour, temperature, sensation and movement.
Muscle palpation is confirmed by a controlled contraction, not by location alone.

Describe how to locate the acromion, coracoid, scapular spine and inferior angle.
Explain the relationship of the ulnar nerve to the medial epicondyle.
Locate the brachial, radial and ulnar pulses safely.
Describe how to identify the cephalic, basilic and median cubital veins.
Explain how to palpate deltoid, biceps, triceps and first dorsal interosseous.
List six safety precautions for upper-limb surface examination.

References for further study

Educational note: Palpation and neurovascular assessment are supervised practical skills. Follow local consent, privacy, infection-prevention and referral policies.