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AXILLA & UPPER LIMB. Kaan Yücel M.D, Ph.D . 31. March . 2014 Monday. AXILLA ( ARMPIT). 6. Gateway to the upper limb An area of transition between the neck and the arm. . BLOOD COMES ARTERIES BLOOD GOES VEINS MUSCLES,VESSELS, SWEAT GLANDS INNERVATED

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slide1

AXILLA & UPPER LIMB

Kaan Yücel M.D, Ph.D. 31. March. 2014 Monday

slide2

AXILLA

(ARMPIT)

6

  • Gateway to the upper limb
  • An area of transition between the neck and the arm.
slide3

BLOOD COMES

ARTERIES

BLOOD GOES

VEINS

MUSCLES,VESSELS, SWEAT GLANDS INNERVATED

NERVES

slide5

Contents of the axilla

  • Axillary artery and its branches
  • Axillary vein and its tributaries
  • Lymph vessels and lymph nodes
  • Brachial plexus

These structures

are embedded in fat.

slide6

Axillary artery

  • Supplies the walls of the axilla & related regions.
  • Before: Subclavian artery After: Brachial artery
  • From lateral border of 1st rib
  • to
  • Inferior border of teres major
slide7

BRACHIAL PLEXUS

a somatic nerve plexus - upperlimb

formed by intercommunications amongventral rami of

lower 4 cervical nerves ( C 5 - C 8) & T 1

responsible for motor innervation to all of muscles of upper limb

exception trapezius.

slide8

BRACHIAL PLEXUS

  • supplies all of the cutaneous innervation of the upper limb
  • exception
  • area of the axilla (armpit) (intercostobrachialnerve)
  • an area just above thepoint of shoulder (supraclavicular nerves)
  • dorsal scapular area (cutaneous branches of dorsal rami)

communicates with the sympatheticnervoussystem..

slide9

beginsin the neck and extends into the axilla.

  • Almost
  • all branches
  • of the brachial plexus
  • arise in the axilla
  • (after the plexus
  • has crossed the 1st rib).

"Randy Travis Drinks Cold Beer"RootsTrunksDivisionsCords

Branches· Alternatively: "Read The Damn Cadaver Book!"· Alternatively: "Real Texans Drink Coors Beer".

slide10

The parts of the brachial plexus, from medial to lateral, are roots, trunks, divisions, and cords.

All major nerves that innervate the upper limb originate from the brachial plexus, mostly from the cords.

slide11

Long

T

h

o

r

a

c

İ

c

nerve

Dorsal scapular nerve

Suprascapular nerve

The nerve to subclavius muscle

C5

Lateral pectoral nerve

Musculocutaneous nerve

Lateral root of median nerve

Superior trunk

C6

Lateral cord

C7

Middle trunk

Sup. & Inf. Subscapular nerves

Thoracodorsal nerve

Axillary nerve

Radial nerve

Posterior cord

C8

Medial cord

Inferior trunk

T1

Medial pectoral nerve

Medial cutaneous nerve of arm

Medial cutanoues nerve of forearm

Ulnar nerve

Median nerve

Red: Anterior division

Blue: Posterior division

"Randy Travis Drinks Cold Beer"RootsTrunksDivisionsCords

Branches· Alternatively: "Read The Damn Cadaver Book!"· Alternatively: "Real Texans Drink Coors Beer".

slide12

shoulder

Region of upper limb attachment to the trunk

Proximal segment of limb

overlaps parts of the trunk (thorax and back) and lower lateral neck.

includes

Pectoral

Scapular

Deltoid regions of the upper limb

lateral part (greater supraclavicular fossa) of lateral cervical region.

Overlies half of the pectoral girdle.

slide13

The pectoral (shoulder) girdle formed by:

Scapulae and clavicles

completed anteriorly by the manubrium of the sternum (part of the axial skeleton).

slide14

SUPERFICIAL

POSTERIOR AXIOAPPENDICULAR MUSCLES

EXTRINSIC SHOULDER MUSCLES

Trapezius & latissimus dorsi

DEEP

POSTERIOR AXIOAPPENDICULAR MUSCLES

EXTRINSIC SHOULDER MUSCLES

Levatorscapulae& rhomboids

slide15

SCAPULOHUMERAL

(INSTRINSIC SHOULDER) MUSCLES

6 scapulohumeral muscles

Deltoid, teres major, supraspinatus, infraspinatus, subscapularis, and teres minor

pass from scapula to humerus

Act on the glenohumeral joint.

All the intrinsic muscles but the deltoid and the subscapularis are muscles of the posterior scapular region.

slide16

4 muscles

pass between the scapula and proximal end of humerus:

POSTERIOR SCAPULAR REGION

Supraspinatus

Infraspinatus

Teres minor

Teres major

slide17

+ part of longhead of the triceps brachii,

passesbetween the scapula and the proximal end of the forearm.

slide18

Supraspinatus & Infraspinatus

  • Originate from 2 large fossae, 1 above and 1 below the spine, on the posterior surface of the scapula.
  • Supraspinatus initiates abduction of the arm.
  • Infraspinatuslaterally rotates the humerus.
slide19

Teres minor

  • A cord-like muscle
  • Laterallyrotates the humerus
  • Component of the rotator cuff.
slide20

ROTATOR CUFF MUSCLES

  • 4 intrinsic shoulder muscles
  • Supraspinatus
  • Infraspinatus
  • Teres minor
  • Subscapularis

(SITS muscles)

Form a musculotendinous rotator cuff around the glenohumeral joint.

slide21

ROTATOR CUFF MUSCLES

Functional exception:

All except supraspinatus are rotators of the humerus

Supraspinatus, besides being part of the rotator cuff, initiates and assists the deltoid in the first 15° of abduction of the arm.

slide22

Nerves

The two major nerves of the posterior scapular region: Suprascapular & Axillary nerves

originate from the brachial plexus in the axilla.

slide23

medial & lateral intermuscular septa

Anteriorcompartment – flextheelbowjoint

Posteriorcompartment- extendtheelbowjoint

ARM

Flexion

Extension

Pronation

Supination

slide24

Anterior compartment of the arm coracobrachialis, brachialis, and biceps brachii muscles

innervated predominantly by musculocutaneous nerve.

Posterior compartment

triceps brachii muscle

innervated by radial nerve.

slide25

Brachial artery

  • Deep artery of the arm
  • (L. arteria profunda brachii)
  • Largest branch & most superior origin
  • Accompanies radial nerve along the radial groove
  • Terminates by dividing into middle & radial collateralarteries
slide26

2 main superficial veins of the arm

cephalicand basilic veins.

Cephalicvein – lateralside

intoaxillaryvein

Basilicvein- medialside

Basilicvein+ Brachialveins

Axillaryvein

slide27

4 main nerves pass through the arm:

  • Median
  • Ulnar
  • Musculocutaneous
  • Radial
slide28

1. Whichstructurespassbetweenthearm & forearm?

Most major structures(nerves,veins,arteries)

viacubital fossa,anterior to elbow joint

Exception ulnar nerve

posterior to the medial epicondyle of humerus

slide29

2. How is forearmdivided?

pronation

supination

slide30

3. Movements of theforearmmuscles?

Muscles in theanteriorcompartment

Flexthewrist & digits

Pronatethehand

Muscles in theposteriorcompartment

Extendthewrist & digits

Supinatethehand

slide31

4. Innervation of theforearmmuscles?

Muscles of the anterior compartment

Mainly by median nerve

The one and a half exceptions by ulnar nerve

Muscles of the posterior compartment

All by radial nerve

(directly or by its deep branch)

Watch out,

Median nerve @median plane of the forearm

Ulnar nerve @ medial side

slide32

1. Layers of anteriorcompartmentforearmmuscles?

SuperficialIntermediateDeep

3 muscles

4 muscles

slide33

2. Muscles of thesuperficiallayer?

flexorcarpiradialis

flexorcarpiulnaris

palmarislongus

pronatorteres

twoheads

Ulnarhead

Humeralhead

Medialepicondyle

slide34

2. Muscles of thesuperficiallayer?

flexorcarpiradialis

Medialepicondyle of humerus

Base of metacarpals II & III

2. flexorcarpiulnaris

Humeralhead: Medialepicondyle of humerus

Ulnarhead: Olecranon & Posterior border of ulna

•Pisiform& hamate

•5th metacarpal

3. palmarislongus

Medialepicondyle of humerus

Flexor retinaculum &palmar aponeurosis

4. pronatorteres

Humeralhead: Medialepicondyle& adjacentsupraepicondylarridge

Ulnarhead: Coronoidprocess

Lateral surface of radius

slide35

3. Muscles of theintermediatelayer?

3. ..the muscles of the intermediate and deep layers?

flexor digitorum superficialis

Humeroulnarhead

• Medial epicondyle of humerus

• Adjacent margin of coronoid process

Radialhead

Superior half of anterior border

Shafts of middle phalanges of

medial four digits

slide36

4. Muscles of thedeeplayer?

3. ..the muscles of the intermediate and deep layers?

flexor pollicis longus

flexor digitorum profundus

pronator quadratus

  • Proximal¾ of medial& anteriorsurfaces of ulna
  • Interosseousmembrane
  • Anteriorsurface of radius
  • Adjacentinterosseousmembrane

Distal ¼ of anterior surface of ulna

Distal ¼ of anterior surface of radius

Bases of distal phalanges of 4th &5th digits

Bases of distal phalanges of 2nd &3rd digits

Base of distal phalanx of thumb

slide37

5. Fxns of theanteriorcompartmentmuscles

Flexion of forearm @ theelbowjoint

Pronator teres

Flexionof hand @ thewristjoint

Flexorcarpiradialis et ulnaris- Palmarislongus

Abduction (radialdeviation) of hand @ thewristjoint

Flexorcarpiradialis

Adduction (ulnardeviation) of hand @ thewristjoint

Flexorcarpiulnaris

Pronationof forearm

Pronator teres – Pronatorquadratus

slide38

5. Fxns of theanteriorcompartmentmuscles

Flexordigitorumsuperficialis

  • Flexesproximalinterphalangealjointsof theindex, middle, ring, & littlefingers
  • Flexesmetacarpophalangealjointsof thesamefingersandthewristjoint
  • Flexordigitorumprofundus
  • Flexesdistalphalanges4 & 5 at distalinterphalangealjoints
  • Flexes distal phalanges 2 and 3 at distal interphalangeal joints

Flexorpollicislongus

Flexesphalanges of thumb

slide39

6. Innervation of theanteriorcompartmentmuscles

Allthemusclesbymediannerve

Except1.5 musclesbyulnarnerve

Flexorcarpiulnarisfull

Flexordigitorumprofundusmedialhalf

partassociated w/ring & littlefingers

slide42

9. Mediannerve

principalnerve

no branches in the arm other than small twigs to the brachial artery.

Its major branch in the forearm anterior interosseous nerve

Leaves cubitalfossa by passing between

2 heads of pronator teres

&

humero-ulnar &radial heads of flexor digitorumsuperficialis

slide43

10. Ulnarnerve

Enterstheanteriorcompartmentbypassingposteriorly

around

medialepicondyle of humerus

&

betweenhumeral& ulnarheads of flexorcarpiulnarismuscle

Two small cutaneous branches

palmar branch & dorsal branch

slide44

11. Radialnerve

motor andsensory

functionsin botharm & forearm

but onlysensoryfunctions in thehand

Superficial(sensory)

deep to brachioradialis

Deep(motor)

between two heads of supinator

slide45

12. Lateral & medialcutaneousnerves of forearm

Lateralcutaneousnerve of forearm

Continuationof musculocutaneousnerve

Medialcutaneousnerve of forearm

Branch of medialcord of brachialplexus

Posteriorcutaneousnerve of forearm

Branch of radialnerve

slide46

1. What is the cubital fossa?

An important area of transition between the arm and the forearm.

seen superficially as a depression on the anterior aspect of the elbow.

Deeply, it is a space filled with a variable amount of fat anterior to the most distal part of the humerus and the elbow joint.

slide47

2. What are the boundaries of the cubital fossa?

Superiorly imaginary line connecting medial &lateral epicondyles.

Mediallypronator teres.

Laterallybrachioradialis.

slide48

3. Whatarethe contents of the cubital fossa?

1) Terminal part of the brachial artery,radial and ulnar arteries

2) Biceps brachii tendon

3) Median nerve

4) Radial nerve

5) (Deep) accompanying veins of the arteries

slide49

1. Which muscles are in the superficial layer?

Lateral epicondyle of humerus

Lateral epicondyle of humerus

Brachioradialis

Extensor carpi radialis longus

Proximal part of supraepicondylar ridge of humerus

Distal part of supraepicondylar ridge of humerus

Extensor carpi radialis brevis

Lateral epicondyle of humerus

common extensor origin

Lateral epicondyle of humerus

common extensor origin

Lateral epicondyle of humerus

Extensor carpi ulnaris

Extensor expansion (hood) of the 5th digit

Extensor digitorum

Olecranon and proximal posterior surface of ulna

Extensor digiti minimi

dorsal aspects of the bases of the middle and distal phalanges of the medial four digits

Anconeus

Lateral surface of distal end of radius proximal to styloid process

Common originlateralepicondyle of the humerus

Except for the brachioradialis and anconeus, extend as tendons into the hand.

Base of 3rd metacarpal

Base of 5th metacarpal

Base of 2nd metacarpal

Base of 2nd metacarpal

Base of the 5th metacarpal

Base of 3rdmetacarpals

slide50

Posterior surface of distal 1/3 of ulna and interosseous membrane

Posterior surface of proximal halves of ulna, radius, and interosseous membrane

2. Which muscles are in the deep layer?

Superficial (humeroulnar) head

•lateral epicondyle of humerus

•radial collateral and anular ligaments

Deep (ulnar) head

Supinator crest of the ulna

Supinator

Abductor pollicis longus

Extensor pollicis longus

Extensor pollicis brevis

Base of 1st metacarpal

Extensor indicis

Posterior surface of middle third of ulna and interosseous membrane

Dorsal surface of base of distal phalanx of thumb

Lateral surface of radius superior to the anterior oblique line

Extensor expansion (hood) of 2nd digit

Posterior surface of distal third of radius and interosseous membrane

Dorsal surface of base of proximal phalanx of the thumb

Except for the supinator muscle, all these deep layer muscles originate from the posterior surfaces of the radius, ulna, and interosseous membrane and pass into the thumb and fingers.

slide51

What is palmar aponeurosis?

A triangular condensation of deep fascia that covers the palm and is anchored to the skin in distal regions.

Continuous with the palmaris longus tendon, when present; otherwise, anchored to the flexor retinaculum.

slide52

functionsthe intrinsic muscles of the hand?

Palmarinterossei

adduct the thumb, index, ring, and little fingers with respect to a long axis through the middle finger

Dorsalinterossei

major abductors of the index, middle, and ring fingers, at the metacarpophalangeal joints

slide53

functionsthe intrinsic muscles of the hand?

Lumbricals

flexing metacarpophalangealjoints

extending interphalangeal joints

medial two deep branch of the ulnar nerve

lateral two median nerve

slide54

functionsthe intrinsic muscles of the hand?

Palmarisbrevis

deepens cup of the palm by pulling on skin over the hypothenar eminence

forming a distinct ridge.

This may improve grip.

slide55

How are the intrinsic muscles innervated?

All of the intrinsic muscles of the hand

by deep branch of the ulnar nerve

Except

three thenar & two lateral lumbrical muscles

by median nerve

slide56

arteries of the hand?

Superficial palmar arch

Deep palmar arch

palmar digital artery

common palmar digital arteries

princepspollicisartery

radialisindicisartery

•three palmar metacarpal arteries

•three perforating branches

slide57

Before penetrating the back of the hand, the radial artery gives rise to two vessels:

dorsal carpal branch passes medially as the dorsal carpal arch, across the wrist

dorsal metacarpal arteries

dorsaldigitalarteries

first dorsal metacarpal artery

supplies adjacent sides of the index finger and thumb.

slide58

veins of the hand?

Cephalic veinoriginates from

lateral side of dorsal venous network.

Basilic vein originates from

medial side of dorsal venous network.

slide59

sensory innervation of the hand?

Ulnar nerve medial side of the palm,medial half of the dorsum of the hand, 5th finger, medialhalf of the 4th finger,anterior surfaces of medial ½ digits

Mediannervepalmar surfaces of the lateral 3 ½ digits and cutaneous regions over the dorsal aspects of the distal phalanges (nail beds) of the same digits

Radialnervedorsolateral aspect of the palm, dorsal aspects of the lateral three,one-half digits distally to approximately the terminal interphalangealjoints

slide60

carpal tunnel?

base of the carpal arch formed

medially by

pisiform & hook of hamate

laterally by

tubercles of scaphoid & trapezium

SLTP

TTCH