Trunk 80 rmteltrlms fteatlas the of mass lateral the from is otidtoai vertebrae thoracic third to first rmteatro uece ntetrans- the on tubercles anterior the from rvrerlMsls(,B) (A, Muscles Prevertebral h hr osxhcria vertebrae cervical sixth to third the hp eas tcnit ftregop of groups three of consists it because shape hw httehmltrlmsl salso is muscle homolateral the that shown ies The fibers. ev upy evcladbaha plexus brachial and cervical supply: Nerve of rotation and flexion lateral in involved have studies spine Electromyographic cervical the forward. bend muscles colli longi verte- cervical the turns and bends muscle ev upy evclpeu C –C4). (C1 plexus cervical supply: Nerve ev upy evclpeu (C1). plexus cervical supply: Nerve usuwr n is and upward runs aii uce edteha forward. head the bend muscles capitis otnaino h necsa muscles. intercostal the of continuation C –C8). (C2 ftesxhcria vertebra cervical sixth the of ( aa ato h ciia bone occipital the of part basal irtbrl fteatlas the of tubercle rior irtbrlso h rnvrepoessof processes transverse the of tubercles rior cln uce A B) (A, Muscles Scalene neirtbrl ntetases process transverse the on tubercle anterior pe hrccadlwrcria vertebrae cervical lower and thoracic upper h evclvrerlcolumn. vertebral cervical the u aii neir ogscpts n lon- and capitis, longus anterior, capitis tus h edsideways. head the atmslsfrqitihlto,a they as inhalation, quiet for muscles tant ofe h head. the flex to rlclm otesd.Tgte,both Together, side. the to column bral nltrlato ftemsl ep otilt to helps muscle the of action Unilateral ato h ciia bone occipital the of part biu fibers oblique ilfibers dial u colli. gus vertebrae es rcse fteffht eodcervical second to vertebrae fifth the of processes verse ia etba.Te r h otimpor- most the are They vertebrae. vical Trunk h rvrerlmslsicueterec- the include muscles prevertebral The The The The hyaiefo h etga iso h cer- the of ribs vestigial the from arise They The 15 ) ogscolli longus ogscapitis longus cln muscles scalene etscptsanterior capitis rectus otebde fteuprcervical upper the of bodies the to ( ( ( 14 16 9 ueirolqefibers oblique superior ) ) .Uiaea otato fthe of contraction Unilateral ). ( n r netdo h ante- the on inserted are and 11 xedfo h oiso the of bodies the from extend ) ( u rmtebde fthe of bodies the from run 7 sruhytinua in triangular roughly is ) ( 4 ) tahdt h basal the to attached ersn h cranial the represent rssfo h ante- the from arises ( ( 6 10 .Tetolongi two The ). .The ). ( 13 ( ( 1 ( 3 .The ). 12 ) .I helps It ). ( ( 2 8 ) extends ) inferior ) othe to ( othe to 5 arise .It ). me- eirtbrlso h rnvreprocesses transverse the of tubercles terior h s necsa space intercostal 1st the ueirpr ftetoa.Terato is action Their thorax. the of part superior clnsmdu.I satce oteapex the the to joins attached is and It medius. vertebra scalenus the from cervical arises seventh which minimus scalenus ev upy evcladbaha plexus brachial and cervical supply: Nerve ev upy rcilpeu C –C7). (C5 plexus brachial supply: Nerve nrae hnteha sbn backward. bent is head the the thus when increased and ribs of pairs two first the lift seventh ev upy rcilpeu C –C8). (C7 plexus brachial supply: Nerve a ec h n i.Teatcmn at attachment The rib. 2nd the reach can ftepleura. the of a is there Occasionally side. one to column ev upy rcilpeu (C8). plexus brachial supply: Nerve a eabsent. be can C –C8). (C4 fte(is)scn osvnhcervical seventh to second (first) the of lcsit. places neirsaeetubercle scalene anterior a vertebrae cal neirtbrlso h transverse the of tubercles anterior noteetra necsa ebaeof membrane intercostal external the into bu n-hr fcss taie rmthe tubercle from arises rior It cases. of one-third about h s i slctdbhn h roefor groove artery. the subclavian behind the located is rib 1st the bet a absent, eidtesblva reygroove artery subclavian the behind rcse fteffht eet cervical transverse seventh to the fifth the on of processes tubercles posterior nltrlcnrcintlstecervical the tilts contraction Unilateral rcse fte(hr)fut osxhcervi- sixth to fourth (third) the of processes vertebrae vertebrae al fteper n h s rib 1st the and pleura the of vault The The The A clnsmdu isthe lies medius scalenus ervrino h r a cld h sub- the occlude may arm the of Retroversion .30advl )adtesblva artery. subclavian the and 3) vol. and 360 p. lva reybtenterbadteclavicle. the and rib the between artery clavian neirfrstemda alo the of wall medial the forms anterior hog hc astebaha lxs(see plexus brachial the pass which through nvrerltriangle enovertebral lncltip: Clinical oehrwt h ogscli h scalenus the colli, longus the with Together clnsmnmsmuscle minimus scalenus clnsmedius scalenus clnsanterior scalenus clnsposterior scalenus evclvertebra cervical rnvrecplrlgmn (Hayek) ligament cupular transverse ( ( 21 24 ewe h clnsatro and anterior scalenus the Between ftetases rcs fthe of process transverse the of .I is It ). ) ( ote2d(r)rib (3rd) 2nd the to 18 ) ( 27 ( n sisre nthe on inserted is and netdit h s rib 1st the into inserted 20 e .366). p. see ; ( and ) 17 ( 23 rssfo h pos- the from arises cln opening scalene ( ( 22 a epeetin present be may ) 19 ) ece h fibrous the reaches rssfo the from arises .I hswyit way this In ). ) usfo the from runs ftemsl is muscle the If . ftefrtrib first the of ( 25 ( scal- 26 ante- and .It ). re- ), . 23 25 22 20 24 19 18 2 21 17 26 19 1 4 VII 3 VI V II 15 16 4 8 7 14 6 11 7 27 12 rvrerladSaeeMuscles Scalene and Prevertebral 13 10 5 9 A B and scalene muscles Prevertebral and insertion of musclesand insertion Diagram of origin,course, 81

Trunk 128 Upper Limb: Bones, Ligaments, Joints

Bones of the Metacarpus and Digits The base of the distal phalanx also bears a ridge. At the distal end there is a rough pal- (A–C) mar surface for insertion of the tendon of The five metacarpals of the hand each have the flexor digitorum profundus as well as a a head (1), a shaft (2), and a base (3). On all palmar-facing roughened, spade-shaped of these there are articular facets at one plate (11) at its terminus, the tuberosity of end (base) for articulation with the carpals distal phalanx. and at the other (head) for the phalanges. The palmar surface is slightly concave and Sesamoid bones are regularly found in the the dorsal surface slightly convex. The dor- joints between the metacarpals and the sal surface exhibits a characteristic tri- proximal phalanx of the thumb, one lying angular configuration toward the head. medially and the other laterally. Sesamoid The proximal articular facet of the first bones are also found in variable numbers metacarpal is saddle-shaped; the second in the other fingers. metacarpal has a notched base proximally Upper Limb for articulation with the carpus, and on the Ossification: In both the metacarpals and the medial side with the third metacarpal. On phalanges there is only one epiphysial center of the dorso-radial side of the base of the third ossification in addition to the perichondral di- metacarpal is a styloid process (4) and aphysis (3rd intrauterine month). In the meta- carpals the distal epiphysial centers develop in radially an articular facet for the second the 2nd year of life, except for the 1st metacarpal, metacarpal. Proximally, for junction with in whose proximal end the center appears in the the carpus, there is one articular facet, and 2nd– 3rd year. In the phalanges epiphysial ossifi- on the ulnar side there are two articular cation centers occur only proximally. facets for articulation with the fourth meta- carpal. The fourth metacarpal has two artic- Clinical tip: Pseudoepiphyses may develop in the ular facets radially but only one on its ulnar metacarpal bones. In radiographs they may be side for articulation with the fifth metacar- distinguished from true epiphyses, as they are pal. attached to the diaphysis by a piece of bone. The 1st metacarpal bone may have a pseudo- epiphysis at its distal end, but all other meta- The bones of the digits: Each digit (i.e., the carpal bones have them at the proximal end: index, middle, ring and little finger) con- they must be distinguished from fractures. sists of more than one bone, namely, a Pseudoepiphyses are found more commonly in proximal (5), a medial (6), and a distal phalanx certain diseases. (7). The sole exception is the thumb, which has only two phalanges. Each proximal phalanx has a flattened pal- mar surface, dorsally and transversally it is convex and has roughened sharpened borders for the attachment of the fibrous tendon sheaths of the flexor muscles. It has a shaft (8), a distal phalangeal head (also called a “trochlea”) (9), and a proximal base (10). The base has a transverse oval socket, an articular facet for the metacarpals. The base of the middle phalanx has two con- vex facets separated by a smooth ridge to conform to the shape of the head of the proximal phalanx. A B 3rd i.u.m. 3rd i.u.m. 3rd 2nd–3rd metacarpals anddigits view ofDorsal right on their opposing surfaces facetsArticular of metacarpals years C bones and phalangeal metacarpal bones Ossification of 3rd i.u.m. 3rd 2nd year 2nd 4 11 8 10 1 7 6 2 5 3 9 oe fteMtcru n Digits and Metacarpus the of Bones 129 Upper Limb Lower Limb 272 rmteln lna ligament plantar long the from oe Limb: Lower uce fteSl fteFoot the of Sole the of Muscles h lna ednu haho peroneus of sheath tendinous plantar the h aeo h it metatarsal fifth the of base the h ogpatrligament plantar long the nrni uce fteLtl o (A–C) Toe Little the of Muscles Intrinsic continued (A–C) Toe, Great the of Muscles strong longus ev upy aea lna ev (S1– nerve plantar lateral supply: Nerve the support to and metatarsal fifth the flex ev upy epbac ftelateral the of branch deep supply: Nerve phalanx. proximal the flex ev upy aea lna ev (S1– nerve plantar lateral supply; Nerve ogpatrlgmn ( the ligament plantar metatarsal, long fourth the include may S2). absent. often quite is It arch. plantar lna ev (S1–S2). nerve plantar S2). lna acnouodllgmn,the ligament, calcaneocuboidal plantar nybcmsvsbeatrtefeo digi- flexor the after visible becomes only ( gus. h uceat seilya a as especially acts muscle The toe. great eaaslligament metatarsal dut h ra o n a hnplantar then may and toe great the adducts metatarsals metatarsal csa lna lxro h itetoe. little the of flexor plantar a as acts with merges aslrlgmnso h metatarso- the of ligaments capsular cuboid n rmtebsso h eodadthird and second the of bases the from and noteltrlssmi bone sesamoid lateral the into ednu hah( sheath tendinous ou ogsadtefeo digitorum flexor the and longus torum esro h lna rhs nadto it addition In arches. plantar the of tensor rvs( brevis phalanx lna ednu haho eoeslon- peroneus of sheath tendinous plantar hlneljit ftetidffhdigits third–fifth the of joints phalangeal u.The gus. The The The 10 ) dutrhallucis adductor tetnst h aeo h proximal the of base the to extends It lxrdgt minimi digiti flexor poesdgt minimi digiti opponens n lofo h eptransverse deep the from also and ( ( biu head oblique 4 2 13 ( rnvrehead transverse and ) aebe eoe ( removed been have ) 17 ). ( 14 ) ( h butrdgt iii It minimi. digiti abductor the 6 ti netdit h fifth the into inserted is It fteffhdigit fifth the of .Isfntosaet plantar to are functions Its ). uce,Fsis n pca Features Special and Fascias, Muscles, .Ohrsrae forigin of surfaces Other ). aea cuneiform lateral 8 . fteprnu lon- peroneus the of ) ohheads Both ( 3 ( 7 ) 1 ( ,adteplantar the and ), 9 has ) ( ) rssfo the from arises 7 ( 15 rssfo the from arises ), ) n rmthe from and ( w heads two and r inserted are 7 rssfrom arises ( ( ) 12 11 ( ( 16 n from and 5 A ) ) ) usually ), .The ). fthe of bones, arises from .It rmtelwrsraeo h calcaneus the of surface lower the from h rxmlphalanx proximal the h ueoiyo h it metatarsal fifth the of tuberosity the aea rcs ftetbrcalcanei tuber the of process lateral itete ntemi tatal om the foot. forms the actually the of it margin of main lateral the muscles In the toe. of little longest and largest ev upy aea lna ev (S1– nerve plantar lateral supply: Nerve also acts it extent, small a to and, digit fifth arch the supports it muscles other the Like 2). S ftefo.I diini lna lxsthe flexes plantar it addition In foot. the of sa abductor. an as n h lna pnuoi n xed to extends and aponeurosis plantar the and The 23 udau plantae Quadratus butrdgt minimi digiti abductor ( 22 ) taie rmthe from arises It fteffhdigit. fifth the of ( 18 sthe is ) ( ( ( 20 19 21 ), ), ) 15 12 A after removal of flexors muscles inregionof 5thdigit, hallucisAdductor muscle and 18 8 9 7 23 23 3 1 22 18 15 17 21 19 B 16 survey sole of foot; Muscles of 10 13 12 14 20 6 4 nrni uce fteFoot the of Muscles Intrinsic 6 5 18 9 3 C 11 of muscles course, andinsertion Diagram of origin, 2 273

Lower Limb Peripheral Pathways 372 eihrlNre n Vessels: and Nerves Peripheral hrccartery thoracic aismsdorsi latissimus otmda fali the is all of medial Most omdfo h rcilvis trn cen- runs It veins. brachial the from formed the is there the laterally with humerus and medially, lies ev ( nerve u hog h xla h onaisof boundaries The axilla. the through run udaglrsae(e .34 oadthe toward 374) p. (see space quadrangular odgvsofthe off gives posterior cord The branches. various into divide u copne ytepoud brachii profunda the by accompanied cus u o h ailnre The nerve. radial the for cus os ( dorsi icmlxhmrlatr n en( vein and artery humeral circumflex ( ( sefgr) rdrcl rmteaxillary the from directly or figure), (see and rey( artery nl sep 7)b the by 370) p. (see angle brachii rey nte rnho h axillary the of branch the artery, Another artery. deltoid artery eirt h xlayatr,adthere and artery, axillary the to pos- and terior lateral medial, region axillary the rly eevn agrnme fsmall of number larger a receiving trally, h en ie f the off gives vein, the hrccwl ihthe with wall thoracic h xlaaethe are axilla the hrc-coilatr n1%o cases of 10% in artery thoraco-acromial h xlayatr r the are artery axillary the the the h xlaynre( nerve axillary the branch. otro icmlxhmrlarteries humeral circumflex posterior rfnabahiartery brachii profunda etrlsminor pectoralis en.I sjie ntedloetrltri- deltopectoral the in joined is It veins. h he od ftebaha lxslein lie plexus brachial the of cords three The The h esl n evst h pe limb upper the to nerves and vessels The ttetniosisrino h latissimus the of insertion tendinous the At xlayRgo (A) Region Axillary cplrarteries scapular 22 12 ,and ), evs copne yteposterior the by Accompanied nerves. ) rcilartery brachial xlayartery axillary aea cords lateral thoracodorsal ( 3 22 ( 20 10 ( ,teailr reycniusas continues artery axillary the ), 5 23 n the and ) usi h eilbcptlsul- bicipital medial the in runs ) ,wt its with ), ihwihi usit h sul- the into runs it which with ) usaua artery subscapular and ) deltoid ( ( 16 ( ( h radial The minor. teres etrlsmajor pectoralis 25 coracobrachialis ( hr edo h biceps the of head short 13 axillary 2 21 ( 9 ( .Tels rnhsof branches last The ). neiryadthe and anteriorly ) pectoral 3 ( 19 omte(fe du- (often the form ) ,wihle aea to lateral lies which ), rnhs A branches. rssfo the from arises ) 15 otrol.The posteriorly. ) asstruhthe through passes ) ertsanterior serratus n ie f the off gives and ) and ) ehlcvein cephalic ( thoraco-acromial anterior xlayvein axillary 20 ( 21 ( sisfirst its as ) ( 11 14 and ) medial ), ,gvsoff gives ), circumflex acromial pe Limb Upper ( ( 17 ( 1 lateral 6 ( radial and ) 18 and ) ). ( 18 ( 24 ). ( ( 8 7 4 ). ), ) ) ) ,fo hc the which from roots ), lateral nevtsi.The and it. anterior serratus innervates the of surface lateral iso the on lies evs13ji h eilcutaneous medial the join intercostal 1–3 of Branches nerves groove. this reach aea oto h einnre(eedu- (here nerve median the of root lateral ato h rcilpeu,dsed nthe on descends plexus, brachial the of part lctd,the plicated), eiland (medial bifurcation median plicated) nrcaiua part Infraclavicular – ntewl ftetoa,the thorax, the of wall the On f the off ilcr,the cord, dial ( ( eilbaha uaeu nerve cutaneous brachial medial nerve nercilctnosnerve cutaneous antebrachial rey h einnre copne by accompanied nerve, median The artery. Rosadspalvclrpr,sep 360) p. see part, supraclavicular and (Roots h rcilatr,te nestemedial the enters then artery, brachial the rcilnreas nerve brachial iiia roe te rnhso h me- the of branches Other groove. bicipital rcilplexus Brachial hc ire h coracobrachialis. the pierces which aeteltsiu os ( dorsi latissimus the vate h aea od ieof pr rmthe from apart off, give cords lateral The 30 26 in fteC n 1nreros tpresents It roots. nerve T1 and C8 the of sions osso h la ufc ftehn and hand the of surface ulnar forearm. sensory the by on accompanied losses flexors, digital long scue yle- by caused is paralysis ) (Dejerine-Klumpke lncltip: Clinical ihprlsso h hr admslsand muscles hand short the of paralysis with ). axillary the to superficial continues ) otro cord Posterior – cord Medial – cord Lateral – ( 32 ailnerve Radial nerve – Axillary – nerve cutaneous antebrachial Medial nerve cutaneous brachial – Medial nerve – Ulnar nerve median of root – Medial – nerve median of root Lateral nerve – Musculocutaneous – hrcdra nerve thoracodorsal ,aiigfo h supraclavicular the from arising ), subscapularis uclctnosnerve musculocutaneous oe rcilpeu paralysis plexus brachial Lower la nerve ulnar necsorcilnerves intercostobrachial usaua nerve subscapular ( 33 3 ( ). 27 n a give may and ) ( 35 einnerve median ,the ), ( ogthoracic long 28 oinner- to ) n the and ) ( 29 medial also ) ( ( 31 34 ), ) 26 34 31 22 20 23 8 1 12 21 18 14 1 17 16 5 524 25 19 6 8 9 28 27 A 011 10 laterally, vein axillary pulledmedially) Region of axilla (median pulled nerve 1 7 930 29 13 3 33 535 15 4 xlayRegion Axillary 32 2 4 373 Peripheral Pathways