regional anatomy of the upper limb

SDU. SDU. LIZHENHUALIZHENHUA

Regional Anatomy of the Upper Limb

山东大学医学院解剖教研室李振华


Parts and regions of upper limb

Shoulder region － junction of arm and trunk

Arm － between should and elbow Elbow － bend of arm, joint between

arm and forearm Forearm － between elbow and hand Hand


Surface anatomy of upper limb

Shoulder region: Acromion Spine of scapula Coracoid process Greater tubercle Anterior and posterior axillary folds

Arm

Medial and lateral biceps brachii furrow

Deltoid tuberosity Elbow

Medial and lateral epicondyles Head of radius Olecranon Tendon of biceps brachii

Wrist and hand Styloid process Head of ulna Dorsal tubercle Proximal wrist crease Middle wrist crease Distal wrist crease Tendon of palmaris Tendon of flexor carpi ulnaris Tendon of carpi ulnaris Radial longitudinal crease Proximal palmar crease Distal palmar crease


In extension, the medial and lateral epicondyles and the top of the olecranon process are in a straight line; in flexion, the bony point form the boundaries of an equilateral triangle.

The acromion, the greater tubercle and coracoid process form the boundaries of an equilateral triangle.


1650 ～ 1700

Carring angle 提携角

The carrying angle, which opens laterally, is seen when the elbow joint is extended and lies between the arm and forearm. The angel is 1700 in males and 1670 in females. The angle disappears when the elbow joint is flexed.


The Pectoral Region and the Axilla


Mamma 乳房Position Lie in superficial fascia over

the pectorals major and pectoral fascia

Extend from 3rd to 7th ribs vertically, and from parasternal line to midaxillary line transversally


Mamma 乳房Structures Contains skin, mammary glan

ds and adipose tissue Consists of 15 to 20 Lobes o

f mammary gland 乳腺小叶 that radiate outward from the nipple

lactiferous duct 输乳管 lactiferous sinuse 输乳管窦 Suspensory ligaments of br

east 乳房悬韧带 (cooper’s ligaments): connective tissue septa that extend from the skin to the deep fascia


Pectoral Region

Superficial structures Superficial nn.

Supraclavicular n. 锁骨上神经 Anterior cutaneous branches of inter

costal n. 肋间神经前皮支 lateral cutaneous branches of interco

stal n. 肋间神经外侧皮支


Superficial veins of the upper limb

Cephalic vein 头静脉 Arises from the lateral side of the dorsal ve

nous rete on the back of hand Winds around the lateral border of the fore

arm; it then ascends into the cubital fossa and up the front of the arm on the lateral side of the biceps.

It continues up in the deltopectoral groove and then to the infraclavicular fossa, where it pierces clavipectoral fascia to drain into axillary vein.



Basilic vein 贵要静脉 Arises from the medial side of the dorsal v

enous rete of hand Winds around the medial border of the for

earm Then ascends into the cubital fossa and u

p the front of the arm on the medial side of the biceps to middle of the arm where it pierces the deep fascia and joins the brachial vein or axillary vein



Median cubital vein 肘正中静脉 Links cephalic vein and basilic vein in

the cubital fossa It is a frequent site for venipuncture to

remove a sample of blood or add fluid to the blood


Pectoral Region

Deep structures Deep fascia

Superficial layer Deep layer—clavipectoral fascia

锁胸筋膜 The deep fascia which extends be

tween subclavius, coracoid process and pectoralis minor muscles The structures pass through th

e clavipectoral fascia Cephalic v. Thoracoacromial a. Lateral pectoral n.


Muscles connecting the upper limb to the thoracic wall

Pectoralis major 胸大肌 Subclevius 锁骨下肌

Pectoralis minor 胸小肌

Serratus anterior 前锯肌


Muscles connecting the upper limb to the thoracic wall

Posterior group Trapezius Levator scapulae Rhomboid minor Rhomboid major Latissimus dorsi


Muscles connecting the scapula to the humerus

Deltoid Supraspinatus Infraspinatus Teres minor Teres major Subscapularis


Myotendionous cuff (rotator cuff) 肌腱袖

The name given to the tendons of the subscapularis, the supraspinatus, the infraspinatus, and the teres minor muscles, which are fused to the underlying capsule of the shoulder joint.

The cuff is important in stabilizing the shoulder joint.


Axillary region 腋区


The Axillary fossa 腋窝

A pyramid-shaped space between the upper part of the arm and the side of the chest

through which major neurovascular structures pass between the thorax and upper extremity

Axillary fossa has an apex, a base and four walls


Boundaries of the axillary fossa

Apex is bounded by Middle 1/3 of clavicle Lateral border of first rib Upper border of the scapula

Base is formed by the skin stretching between the anterior and posterior walls



Anterior wall Formed by pectoralis major, pectoralis

minor and subclavius muscles Clavipectoral fascia 锁胸筋膜

The deep fascia which extends between subclavius, coracoid process and pectoralis minor muscles

The structures pass through the clavipectoral fascia Cephalic v. Thoracoacromial a. Lateral pectoral n.



The posterior wall latissimus dorsi teres major subscapularis and scapula

Trilateral and quadrilateral foramina 三边孔和四边孔 The posterior humeral circumflex a. an

d axillary n. pass through the quadrilateral foramen.

The circumflex scapular a. passes through the triangular space to reach the dorsum of the scapula.



The medial wall serratus anterior Upper four ribs Intercostal muscles

The lateral wall Coracobrachialis Biceps brachii Intertubercular groove

Biceps brachii (long head)

Biceps brachii (short head)

Coracobrachialis


Contents of axillary fossa

Brachial plexus and branches Axillary a. and principal branch

es Axillary v. and tributaries Axillary lymph nodes Loose connective tissue


Axillary artery 腋动脉

Begins at the at lateral border of first

rib as a continuation of subclavian ar

tery At the lower border of teres major it

becomes the brachial artery. Divided into three parts by overlying

pectoralis minor


Branches of axillary artery First part gives off

thoracoacromial a. 胸肩峰动脉 Second part gives off

lateral thoracic a. 胸外侧动脉 Third part gives off

subscapular a. 肩胛下动脉 Throcodorsal a. 胸背动脉 Circumflex scapular a. 旋肩胛动脉

Anterior humeral circumflex a. 旋肱前动脉 Posterior humeral circumflex a. 旋肱后动脉


Axillary vein 腋静脉

Formed at the lower border of the teres major by the union the brachial vein and the basilic vein

Runs upward on the medial side of the axillary artery

Ends at the lateral border of the first rib by becoming the subclavian vein


Brachial plexus 臂丛Formation Five roots: formed by anterior ra

mi of C5-C8 and T1 spinal nerves

Three trunks (upper, middle and lower)

Six divisions Three cords

Lateral cord Medial cord Posterior cord

C5

C6

C7

C8T1


Brachial plexus 臂丛Position: Passes through the scalene fissu

re to posterosuperior of subclavian artery

Then enters the axilla to form lateral, medial and posterior cords

Supraclavicular part Long thoracic n. 胸长神经 compa

nies with the lateral thoracic a., supplies serratus anterior


Paralysis of the serratus anterior

When the serratus anterior paralyzed because of injury to the long thoracic nerve, the medial border of the scapula moves laterally and posteriorly away from the thoracic wall, giving the scapula the appearance of a wing.

Winged scapula 翼状肩


Main branches of infraclavicular part

1. Lateral cord Musculocutaneous n. 肌皮神经 Lateral root of median n. 正中神经外侧根

2. Medial cord Medial root of median n. 正中神经内侧根 Ulnar n. 尺神经 Medial brachial cutaneous n. 臂内侧皮神经 Medial antebrachial cutaneous n.

前臂内侧皮神经

3. Posterior cord Radial n. 桡神经 Axillary n. 腋神经 Thoracodorsal n. 胸背神经 companies with the throcodorsal a., supplies l

atissimus dorsi


Main branches of infraclavicular part

Axillary n. 腋神经

Radial n. 桡神经

Thoracodorsal n.胸背神经


Axillary 腋神经 Origin: Arises from the posterior cord

of the brachial plexus in the axilla. Course: Passes backward and enters t

he quadrangular space with the posterior circumflex humeral artery.

Distribution: Deltoid and teres minor muscle; shoulder joint; skin over deltoid and upper posterior aspect of arm

Injury: result in deltoid and teres minor paralysis (loss of shoulder abdcution and weak external rotation) with loss of sensation over the deltoid


Axillary lymph nodes

Axillary lymph nodes vary in s

ize from a pin-head to a large

bean. They are arranged in fi

ve groups.



Pectoral lymph nodes 胸肌淋巴结

Lying along the lower border of pectoralis minor behind the pectoralis major

Receive lymph vessels from the lateral quadrants of the breast and superficial vessels from the anterolateral abdominal wall above the level of the umbilicus



Lateral lymph nodes 外侧淋巴结

Along medial side distal part axillary vein

Receives lymph from upper limb



Subscapular lymph node 肩胛下淋巴结

Lying along subscapular vessels, in front of the subscapularis

Receive superficial lymph vessels from the back, down as far as the level of the iliac crests

Efferents above three groups pass to central lymph node



Central lymph node 中央淋巴结

Lying in the center of the axilla in the axillary fat

Receive lymph from the above three nodes

Efferents pass to apical lymph node



Apical lymph node 尖淋巴结

Lying at the apex of the axilla at the lateral border of the fist rib

Receive lymph the efferent lymph vessels from all the other axillary nodes

The efferents of the apical nodes form the subclavian trunk



Lateral ln.

Pectoral ln.

Subscapular ln.

Central ln.

Apical ln.

Efferents form subclavian trunk, the right subclavian trunk joints the right lymphatic duct; left usually drains directly into thoracic duct

Subclavian trunk


Breast cancer


pulmonary metastasis


Axillary sheath 腋鞘

Extension of deep cervical fascia of the neck, forming a tubular sheath that surrounds axillary a. and v., and brachial plexus


The anterior brachial region 臂前区


Deep fascia

Encloses the arm sends septa between the various groups of muscles to allow them to slide on each other and to give an increased area of origin for their fibers.

The lateral and medial intermuscular septa divide the distal part of the arm into anterior and posterior osseofascial compartments .


Contents of anterior osseofascial compartment of the arm

Muscles: biceps brachii 肱二头肌 Coracobrachialis 喙肱肌 Brachialis 肱肌

Blood supply: brachial artery 肱动脉

Nerve supply to the muscles: musculocutaneous nerve 肌皮神经

Structures passing through the compartment:

musculocutaneous nerve 肌皮神经 median nerve 正中神经 ulnar nerve 尺神经 brachial artery 肱动脉 medial antebrachial cutaneous nerve 前臂内侧皮神经


Muscles of anterior osseofascial sheath of the arm

Biceps brachii 肱二头肌 Coracobrachialis 喙肱肌

Brachialis 肱肌


Brachial artery 肱动脉 Begins at the lower border of the teres m

ajor as a continuation of axillary artery Terminates opposite the neck of radius

by dividing into radial and ulnar arteries Branches

Deep brachial a. 肱深动脉 follows the radial nerve into the spinal groove of the humerus

Superior ulnar collaeral a. 尺侧上副动脉 follows the ulnar nerve

Inferior ulnar collateral a. 尺侧下副动脉 takes part in the anastomosis around the elbow joint.


Musculocutaneous nerve 肌皮神经

Distribution: Biceps brachii Brachalis Coracobrachialis

At the lateral margin of biceps tendon it pierces the deep fascia just above the elbow. It runs down the lateral aspect of the forearm as the lateral antebrachial cutaneous n. which supply skin on anterior aspect of forearm.


Median nerve 正中神经

Origin: arises from the medial and lateral cord of the brachial plexus.

Course: Descends on the lateral side of

brachial artery. Halfway down the arm, it

crosses the brachial artery to reach its medial side.


Ulnar nerve 尺神经

Origin: arises from the medial cord of the brachial plexus.

Course: Descends on the medial side of brachial ar

tery. At the middle of the arm, it pierces the me

dial intermuscular septum and passes down behind the medial epicondyle of the humerus.


Cubital fossa 肘窝Boundaries Base － line drawn through epicondyle

s of humerus Laterally － brachioradialis Medially － pronator teres Roof － skin, superficial facia, deep fa

scia and aponeurosis of biceps Floor － brachialis, supinator and caps

ule of elbow joint


Contents of the cubital fossa

Medial to biceps brachii tendon Brachial a. 肱动脉－ divides into radial and

ulnar a., usually at apex of fossa Median n. 正中神经

Lateral to the biceps brachii tendon Radial n. 桡神经 Lateral antebrachial cutaneous n.

前臂外侧皮神经


Contents of anterior osseofascial sheath of the forearm

Muscle (9) Blood supply to the muscles:

ulnar and radial arteries. Nerve supply to the muscles:

median nerve and ulnar nerve


Muscles of anterior osseofascial sheath of the forearm

Superficial layer Brachioradialis 肱桡肌 Pronator teres 旋前圆肌 Flexor carpi radialis 桡侧腕屈肌 Palmaris longus 掌长肌 Flexor carpi ulnaris 尺侧腕屈肌


Muscles of anterior osseofascial sheath of the forearm

Second layer Flexor digitorum superficialis 指浅屈

肌

Third layer Flexor digitorum profundus 指深屈肌 Flexor pollicis longus 拇长屈肌

Fourth layer Pronator quadratus 旋前方肌

Action: flex radiocarpal joint and fingers, pronate forearm


Radial artery 桡动脉

Begins: in the cubital fossa at the neck of the radius.

Course: passes downward and laterally Branches

Radial recurrent a. 桡侧返动脉 Superfical palmar branch 掌浅支 Principal artery of thumb 拇主要动脉


Ulnar artery 尺动脉 Begins in the cubital fossa at the

neck of the radius. Course: passes downward and m

edially Branches

Ulnar recurrent a. 尺侧返动脉 Common interosseous artery

骨间总动脉 Anterior interossous a.

骨间前动脉 Posterior interosseous a.

骨间后动脉 Deep palmar branch 掌深支


Superficial palmar arch 掌浅弓 Formed by ulnar artery and superfici

al palmar branch of radial artery The curve of arch lies across the pal

m, level with the distal border of fully extended thumb

Gives rise to three common palmar digital arteries each then divides into two proper palmar digital arteries


Deep palmar arch 掌深弓 Formed by radial artery and deep pa

lmar branch of ulnar artery The curve of arch lies across upper

part of palmar at level with proximal border of extended thumb

Gives rise to three palmar metacarpal arteries


Median 正中神经

Course: Passes between the two heads of the pronat

or teres. It continues downward behind the flexor digit

orum superficialis. At the wrist, it enters the palm by passing be

hind the flexor retinaculum.Distribution: Flexor of forearm except brachioradialis, flex

or carpi ulnaris and ulnar half of flexor digitorum profundus


Ulnar nerve 尺神经 Course

Passes from behind the medial epicondyle of the humerus, and enters the front of the forearm by passing between the two heads of the flexor capi ulnaris.

In the distal two-third of the forearm, the ulnar artery lies on the lateral side of the ulnar nerve.

Enters the palm of the hand b passing in front of the flexor retinaculum and lateral to the pisiform bone.

Distribution: flexor carpi ulnaris and ulnar half of flexor digitorum profundus


Superficial branch of the radial nerve桡神经浅支

Course Runs down on the lateral side of th

e radial artery. In the distal part of the forearm, it le

aves the artery and passes backward, reaches the posterior surface of the wrist and hand.

Distribution: brachioradialis


Skin incisions

Make the skin incisions indicated in figure and reflect the skin flaps.

Be careful not to cut too deep. As you remove the skin, look for the cephalic v., basilic v. and median cubital v.


Cut and reflect the pectoralis major

Clean the pectoralis major m.. Indentify the deltopectoral groove and the cephalic vein, which drains blood into the axillary v.

The pectoralis major m. forms the anterior axillary fold.

Cut and partlly reflect the pectoralis majorm. Close to its attachment to the clavicle. Look for the lateral pectoral n. on its underside.


Detach the pectoralis minor

Identify and clean the thoracoacromial artery medial to the pectoralis minor.

Next, detach the pectoralis minor from the costal cartilages of ribs 3, 4, and 5, and reflect it toward the should.


Axillary a.

Thoracoacromial a.

Musculocutaneous n.

Median n.

Medial antebrachial cutaneous n.

Ulnar n.

Medial brachial cutaneous n.

Intercostobrachial n.Thoracodorsal n. & a.

Long thoracic n. & lateral thoracic a.

Lateral pectoral n.


Posterior humeral circumflex a. & axillary n.

Radial n.

Circumflex scapular a.


Musculocutaneous n.

Median n.Medial brachial cutaneous n.

Ulnar n.


Superior ulnar coleteral a.

Brachial a.


Musculocutaneous n.

Median n.

Axillary a.

Brachial a.


Medial brachial cutaneous n.

Deep brachial a.

Superior ulnar coleteral a.& Ulnar n.

Inferior ulnar coleteral a.


Muscolocutaneous n.

Brachial a.

Radial n.

Radial recurrent a.

Radial a.

Median n.

Ulnar recurrent a.

Common interosseous a.

Ulnar a., v. & n.


Radial recurrent a.

Radial a.

Radial n.

Median n.

Ulnar n.

Ulnar a.

Ulnar recurrent a.

Ulnar n.

Brachial a.


Palmar aponeurosis


Superficial palmar a.

recurrent n.

Ulnar a.


You must identify follow structures ！

Pectoral region and Axilla Muscles

Pectoralis major Pectoralis minor Serratus anterior

Arteries and veins Axillary artery thoracoacromial a. lateral thoracic a. subscapular a. Throcodorsal a. Circumflex scapular a. Posterior humeral circumflex a. Axillary vein

Nerves Long thoracic n. Lateral cord musculocutaneous n. lateral root of median n. Medial cord Medial root of median n. Ulnar n. Posterior cord Radial n. Axillary n. Thoracodorsal n.


You must identify follow structures ！ Superficial vv.

Cephalic v. Basilic v. Median cubital v.

Arm Biceps brachii Coracobrachilis Bracialis Musculocutaneous n. Median n. Ulnar n. Brachial a. Profunda brachii a.

Forearm Brachioradialis Pronator teres Flexor carpi radialis Palmaris longus Flexor carpi ulnaris Flexor digitorum superficialis Flexor digitorum profundus Flexor pollicis longus Pronator quadratus Ulnar n. Radial n. Median n. Ulnar a. Radial a.

regional anatomy of the upper limb

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