Regional Anatomy of the Upper Limb

1. Regional Anatomy of the Upper Limb 山东大学医学院 解剖教研室 李振华

2. 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

3. 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 Surface anatomy of upper limb

4. 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.

5. Carring angle 提携角 1650～1700 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.

6. The Pectoral Region and the Axilla

7. 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

8. Mamma 乳房 Structures • Contains skin, mammary glands and adipose tissue • Consists of 15 to 20 Lobes of mammary gland乳腺小叶thatradiate outward from the nipple • lactiferous duct 输乳管 • lactiferous sinuse 输乳管窦 • Suspensory ligaments of breast 乳房悬韧带(cooper’s ligaments): connective tissue septa that extend from the skin to the deep fascia

9. Pectoral Region Superficial structures • Superficial nn. • Supraclavicular n. 锁骨上神经 • Anterior cutaneous branches of intercostal n. 肋间神经前皮支 • lateral cutaneous branches of intercostal n. 肋间神经外侧皮支

10. Superficialveins of the upper limb Cephalic vein头静脉 • Arises from the lateral side of the dorsal venous rete on the back of hand • Winds around the lateral border of the forearm; 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.

11. Superficialveins of the upper limb Basilic vein贵要静脉 • Arises from the medial side of the dorsal venous rete of hand • Winds around the medial border of the forearm • Then ascends into the cubital fossa and up 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

12. Superficialveins of the upper limb 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

13. Pectoral Region Deep structures • Deep fascia • Superficial layer • Deep layer—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.

14. 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

15. Muscles connecting the upper limb to the thoracic wall Posterior group • Trapezius • Levator scapulae • Rhomboid minor • Rhomboid major • Latissimus dorsi

16. Muscles connecting the scapula to the humerus • Deltoid • Supraspinatus • Infraspinatus • Teres minor • Teres major • Subscapularis

17. 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.

18. Axillary region 腋区

19. 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

20. 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 isformed bythe skin stretching between the anterior and posterior walls

21. Boundaries of the axillary fossa • 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.

22. Boundaries of the axillary fossa • 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. and axillary n. pass through the quadrilateral foramen. • The circumflex scapular a. passes through the triangular space to reach the dorsum of the scapula.

23. Boundaries of the axillary fossa • 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

24. Contents of axillary fossa • Brachial plexus and branches • Axillary a. and principal branches • Axillary v. and tributaries • Axillary lymph nodes • Loose connective tissue

25. Axillary artery腋动脉 • Begins at the at lateral border of first rib as a continuation of subclavian artery • At the lower border of teres major it becomes the brachial artery. • Divided into three parts by overlying pectoralis minor

26. 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

27. 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

28. Brachial plexus 臂丛 C5 C6 Formation • Five roots: formed by anterior rami of C5-C8 and T1 spinal nerves • Three trunks (upper, middle and lower) • Six divisions • Three cords • Lateral cord • Medial cord • Posterior cord C7 C8 T1

29. Brachial plexus 臂丛 Position: • Passes through the scalene fissure 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companies with the lateral thoracic a., supplies serratus anterior

30. 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

31. 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 latissimus dorsi

32. Main branches of infraclavicular part Axillary n. 腋神经 Radial n. 桡神经 Thoracodorsal n. 胸背神经

33. Axillary 腋神经 • Origin: Arises from the posterior cord of the brachial plexus in the axilla. • Course: Passes backward and enters the 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

34. Axillary lymph nodes Axillary lymph nodes vary in size from a pin-head to a large bean. They are arranged in five groups.

35. Axillary lymph nodes 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

36. Axillary lymph nodes Lateral lymph nodes外侧淋巴结 • Along medial side distal part axillary vein • Receives lymph from upper limb

37. Axillary lymph nodes 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

38. Axillary lymph nodes 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

39. Axillary lymph nodes 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

40. Axillary lymph nodes Efferents form subclavian trunk, the right subclavian trunk joints the right lymphatic duct; left usually drains directly into thoracic duct Apical ln. Subclavian trunk Central ln. Pectoral ln. Lateral ln. Subscapular ln.

41. Breast cancer

42. pulmonary metastasis

43. 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

44. The anterior brachial region臂前区

45. 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 .

46. 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

47. Muscles of anterior osseofascial sheath of the arm • Biceps brachii 肱二头肌 • Coracobrachialis 喙肱肌 • Brachialis 肱肌

48. Brachial artery 肱动脉 • Beginsat the lower border of the teres major as a continuation of axillary artery • Terminatesopposite 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.

49. 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.

50. 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.