Topographic Anatomy Superior Limbs [PDF]

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Surface Anatomy of Upper Limb

Biceps + Triceps brachii Olecrenon Process Medial Epicondyle Cubital Fossa – Anterior surface elbow – Contents • Median Cubital Vein • Brachial Artery • Median Nerve

– Boundaries • Medial= Pronator teres • Lateral= Brachioradialis • Superior= Line between epicondyles Frolich, Human Anatomy,UpprLimb

Surface Anatomy of Upper Limb

• Carpal Tunnel – Carpals concave anteriorly – Carpal ligament covers it – Contains: long tendons, Median nerve – Inflammation of tendons = compression of Median nerve

• Anatomical Snuffbox – Lateral = E.pollicis brevis – Medial = E. pollicis longus – Floor = scaphoid, styloid of radius – Contains Radial Artery (pulse) Frolich, Human Anatomy,UpprLimb

Regional anatomy of upper limb

Parts and regions • 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

Anatomical snuff box • When the thumb is abducted and extended, a triangular hollow appears between the tendon of the extensor pollicis longs medially and the tendons of the extensor pollicis brevis and abductor pollicis longus laterally. • The floor of the snuff box is the scaphoid and trapezium bones and crossed by the radial a..

Carring angle

1650 ～ 1700

Mamma 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

Structures － contains skin, mammary glands and adipose tissue • Each brest has about 15 ～ 20 lobes of mammary gland • Each lobe radiates out from the nipple and has a lactiferous duct which opens separately on the summit of the nipple and possesses a dilated lactiferous sinuses just prior to its termination

• Suspensory ligaments of breast (cooper’s

ligaments ) － strands of connective tissue runs between skin and deep fascia and serve to support the mammary glands

Axillary fossa 腋窝 • The axillary fossa is a pyramid-shaped space through which major neurovascular structures pass between the thorax and upper extremity

Boundaries • The apex is a triangular space limited by the first rib, the scapula, and the middle third of clavicle. • The base － skin and fascia of the axillary fossa

• The anterior wall – Pectoralis major, pectoralis minor and subclavius muscles – Clavipectoral fascia • The deep faxcia which extends between subclavius, coracoid process and pectoralis minor muscles • The structures pass through the clavipectoral faxcia – Cephalic v. – Thoracoacromial a. – Lateral pectoral n.

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The posterior wall － teres major, latissimus dorsi, subscapularis and scapula Trilateral and quadrilateral foramina •

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Between the subscapularis and teres major, there is a long triangular space whose lateral side is surgical neck of humerus. The long head of triceps brachii subdivides this space into a medial trilateral foramen and a lateral quadrilateral foramen. The posterior humeral circumflex a. and axillary n. pass through the quadrilateral foramen. The circumflex scapular a. passes through the triangular space to reach the dorsum of the scapula.

• The broad medial wall － serratus anterior ， intercostal muscles and upper four ribs

• The narrow lateral wall － coracobrachialis, biceps brachii and intertubercular groove

Contents Brachial plexus, axillary a. and principal branches, axillary v. and tributaries, axillary lymph nodes and loose connective tissue

Formation:

Brachial plexus

• Five roots: formed by anterior rami of C5-C8 and T1 spinal nerves, roots C5 ～ C7give rise to long thoracic n. • Three trunks – The upper trunk is formed by the joining of root C4,C5,C6. – The middle trunk is the continuation of root C7. – The lower trunk is formed by the joining of root C8 and T1.

• Six divisions: above clavicle, trunks form anterior and posterior divisions • Three cords: below clavicle, divisions form three cords that surround the second portion of axillary a.

Position: passes through the scalene fissure to posterosuperior of subclavian artery, then enters the axilla to form lateral, medial and posterior cords

Main branches • Lateral cord – Musculocutaneous n. – Lateral root to median n.

• Medial cord – – – –

Medial root to median n. Ulnar n. Medial brachial cutaneous n. Medial antebrachial cutaneous n.

• Posterior cord – radial n. – axillary n. – thoracodorsal n.

• Axillary sheath － extension of deep cervical fascia of the neck, forming a tubular sheath that surrounds axillary a. and v., and brachial plexus

Axillary artery •

Continuation of subclavian artery at lateral border of first rib Becomes brachial artery at lower border of teres major Divided into three parts by overlying pectoralis minor

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First portion, above muscle － gives rise to thoracoacromial a. Second portion, behind muscle － gives rise to lateral thoracic a. Third portion, below muscle － gives rise to subscapular a. anterior and posterior humeral circumflex a.; the former then divides into throcodorsal a. and circumflex scapular a.

Axillary lymph node － arranged in five groups • Lateral lymph nodes － lie around the distal end of axillary artery vein , receive afferent vessels from upper limb. • Pectoral lymph nodes － lie along lateral thoracic vessels, receive afferents from anterior thoracic wall including central and lateral portion of mamma • Subscapular lymph node － along subscapular vessels, receive lymph from nape and scapular region • Efferents above three groups pass to central lymph node • Central lymph node － lie in fat of axillary fossa, receive lymph from all the above nodes, efferents pass to apical lymph node • Apical lymph node － lie in the apex of the axilla, along the proximal end of axillary vessels, receive afferents chiefly from central lymph node , upper portion of mamma; efferents form subclavian trunk, the right subclavian trunk joints the right lymphatic duct; left usually drains directly into thoracic duct

Boundaries

Cubiral fossa

• Base － line drawn through epicondyles of humerus • Apex － brachioradialis laterally and pronator teres medially • Roof － skin, superficial faxcia, deep faxcia and aponeurosis of biceps • Floor － brachialis, supinator and capsule of elbow joint

Contents － from lateral to medial • Biceps brachii tendon • Brachial a. － divides into radial and ulnar a.,usually at apex of fossa • Median n. Lateral to the biceps brachii tendon － radial n. and lateral antebrachial cutaneous n.

Carpal tunnel Flexor retinaculum • Thickening of deep fascia in the hand • Attached laterally to scaphoid and trapeziun and medially to pisiform and hamate • Form an osseofibrous tunnel (carpal tunnel) with carpal groove － transmits median n., flexor digitorum supericialis, flexor digitorum profundus, and flexor pollicus longus from forearm into hand

eninous sheath of flexor pollicis longus

Common flexor sheath

Clavipectoral fascia • The deep faxcia which extends between subclavius, coracoid process and pectoralis minor muscles • The structures pass through the clavipectoral faxcia – Cephalic v. – Thoracoacromial a. – Lateral pectoral n.

Axillary a. Thoracoacromial a. Lateral pectoral n. Musculocutaneous n. Medial antebrachial cutaneous n. Median n.

Ulnar n. Medial brachial cutaneous n.

Intercostobrachial n. Thoracodorsal n. & a. Long thoracic n. & lateral thoracic a.

Posterior humeral circumflex a. & axillary n. Circumflex scapular a. Radial n.

Musculocutaneou s n. Median n.

Medial brachial cutaneous n. Deep brachial a. Ulnar n. Superior ulnar coleteral a. Medial antebrachial cutaneous n.

Musculocutaneous n. Median n. Axillary a. Brachial a.

Medial antebrachial Medial brachialn. cutaneous cutaneous Deep brachial n. a. Superior ulnar coleteral a. & Ulnar n.

Inferior ulnar coleteral a.

Lateral anterachial cutaneous n. & cephelic v.

Medial interracial cutaneous n. & basiic v.

Median cubital v.

Ulnar n. Brachial a. Radial a. Radial recurrent a. n. Radial

Median n. Ulnar a. Ulnar recurrent a. Ulnar n.

Muscolocutaneous n. Brachial a. Radial n. Radial recurrent a. Radial a.

Ulnar recurrent a. Common interosseous a.

Median n. Ulnar a., v. & n.

Palmar aponeurosis

Superficial palmar a. Ulnar a. recurrent n.

Posterior region of upper limb 山东大学医 学院 解剖 教研室 李振 华

Skin incisions

Cutaneous n. and superificial v.

Trapezium Deltoid Triangle of ausculation Latissimus dorsi Thoracolumbar fascia

Levator scapular Rhomboideus

Suprascapular n.& a. Supraspinatus Teres minor Infraspinatus

Teres major

Axillary n. Posterio humeral Deep brachial a. circumflex Radial n.

Radial n.

Deep brachial a.

Posterior interosseousa. Posterior interosseous n.

Hand

Palm of hand Flexor retinaculum • Thickening of deep fascia in the hand • Attached laterally to scaphoid and trapeziun and medially to pisiform and hamate

Carpal tunnel • •

Formed by flexor retinaculum and carpal groove Transmits – Median n. – Flexor digitorum superficialis and flexor digitorum profundus enclosed by common flexor sheath – Flexor pollicus longus enclosed by tendinous sheath of flexor pollicus longus

endinous sheath of flexor pollicis longus

Common flexor sheath

Deep palmar fascia Superficial layer • Thenar fascia • Hypothenar fascia • Palmar aponeurosis thick triangular membrane

Deep layer － palmar interosseous fascia

Osseofascial compartments of palm • Lateral compartment • Medial compartment • Intermediate compartment

Medial intermuscular Palmar septum aponeurosis Hypothenar fascia

Laeral intermuscular septum Thenar fascia

Adductor pollicis Palmar interosseous fascia

Intermediate compartment • Formed by palmar aponeurosis, Laeral and medial intermuscular septum, palmar interosseous fascia • Contents: superficial palmar arch, a., v.,n., tendons of flexor digitorum superficialis and profundus, lumbricales, common flexor sheath

Fascia spaces • Thenar space • Midpalmar space

Midplmar septum

Thenar space Midpalmar space

Dorsum of hand Extensor retinaculum Thickening of deep faxcia of forearm a wrist • Attached laterally to radius and medially to styloid process of ulna and triquetrum • Forms six fibrous compartments for extensor tendons passing from forearm into hand:

• ① tendons of abductor pollicis longus and extensor pollicis brevis and their synovial sheaths; • ② tendons of extensor carpi radialis longus and brevis and their synovial sheaths; • ③ tendon of pollicis longus and its synovial sheath; • ④ tendons of extensor digitorum, extensor indicis and their synovial sheaths; • ⑤ tendon of extensor digiti minimi and its synovial sheaths; • ⑥ tendon of extensor carpi ulnaris and its synovial sheaths

Fascia of the dorsal hand • The superficial fascia • Deep fascia － the dorsal fascia of hand – Superficial layer (dorsal aponeurosis) – Deep layer (dorsal interosseous fascia)

Two spaces • The dorsal subcutaneous space • The dorsal subaponeurotic space

Superficial fascia Dorsal aponeurosis Dorsal interosseous fascia

Dorsal subaponeurotic space Dorsal subcutaneous space

Nerves of hand

• Median n. － thenar except adductor pollicis, first two lumbricals; skin of thenar, central part of palm, palmar aspect of radial three and one-half fingers, including middle and distal fingers on dorsum • Ulnar n. － hypothenar muscles, interossei, 3rd and 4th lumbricals and adductor pollicis; skin of hypothenar, palmar surface of ulnar one and one-half fingers

• Radial n. － skin of radial side of dorsum of hand and radial two and one-half fingers

• Pulp space

Fingers

– On the palmar side of the tips of the fingers and thumb. They contain fatty tissue that is divided into numerous compartments by fibrous septa that pass between the distal phalanx and the skin. The pulp space is limited proximally by the firm adherence of skin and the distal flexion crease to the underlying tissue; this prevents pulp infection from spreading proximally along the finger.

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vessels : Nerves ：