Regional Anatomy of the Upper Limb 1

Wu Genghua

Medical College Yangzhou University Anterior surface of the •Incisions: Upper Limb

 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. Superficial veins and nerves Mamma Structures

 Contains skin, mammary glands and adipose tissue  Consists of 15 to 20 Lobes of mammary gland that radiate outward from the nipple  lactiferous duct  lactiferous sinuse  Suspensory ligaments of breast (cooper’s ligaments): connective tissue septa that extend from the skin to the deep fascia

Pectoral Region

Superficial structures

 Superficial n.

 Supraclavicular n.

 Anterior cutaneous branches of intercostal n.

 lateral cutaneous branches of intercostal 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

Pectoral Region

Deep structures clavipectoral fascia

 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.

Axillary region 腋区 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 Boundaries of the axillary fossa

 The posterior wall

 latissimus dorsi

 teres major

 subscapularis and scapula  Trilateral and quadrilateral space

 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.

Boundaries of the axillary fossa

 The medial wall Biceps brachii (long head)

 serratus anterior Biceps brachii (short head)  Upper four ribs Coracobrachialis  Intercostal muscles

 The lateral wall

 Coracobrachialis

 Biceps brachii

 Intertubercular groove

Contents of axillary fossa

 Brachial plexus and branches  Axillary a. and principal branches  Axillary v. and tributaries  Axillary lymph nodes  Loose connective tissue

Branches of axillary artery

 First part gives off

 thoracoacromial a.  Second part gives off

 lateral thoracic a.  Third part gives off

 subscapular a.  Throcodorsal a.  Circumflex scapular a.

 Anterior humeral circumflex a.

 Posterior humeral circumflex a. 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

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

Main branches of infraclavicular part 1. Lateral cord  Musculocutaneous n.  Lateral root of median n. 2. Medial cord  Medial root of median n.  Ulnar n.  Medial brachial cutaneous n.  Medial antebrachial cutaneous n. 3. Posterior cord  Radial n.  Axillary n.  Thoracodorsal n. companies with the throcodorsal a., supplies latissimus dorsi

Axillary lymph nodes

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

Central ln.

Pectoral ln.

Lateral ln.

Subscapular ln. Breast cancer 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

 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  Coracobrachialis  Brachialis  Blood supply:  brachial artery  Nerve supply to the muscles:  musculocutaneous nerve  Structures passing through the compartment:  musculocutaneous nerve  median nerve  ulnar nerve  brachial artery  medial antebrachial cutaneous nerve Cubital fossa

Boundaries  Base－line drawn through epicondyles of humerus  Laterally－brachioradialis  Medially － pronator teres  Roof－skin, superficial facia, deep fascia and aponeurosis of biceps  Floor－brachialis, supinator and capsule of elbow joint Contents of the cubital fossa

 Medial to 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.

 Lateral antebrachial cutaneous n. 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

 Pronator teres

 Flexor carpi radialis

 Palmaris longus

 Flexor carpi ulnaris

Muscles of anterior osseofascial sheath of the forearm Second layer  Flexor digitorum superficialis

Third layer  Flexor digitorum profundus  Flexor pollicis longus

Fourth layer  Pronator quadratus

Action: flex radiocarpal joint and fingers, pronate forearm

Radial artery

 Begins: in the cubital fossa at the neck of the radius.  Course: passes downward and laterally  Branches

 Radial recurrent a.

 Superfical palmar branch

 Principal artery of thumb

Ulnar artery

 Begins in the cubital fossa at the neck of the radius.  Course: passes downward and medially  Branches

 Ulnar recurrent a.

 Common interosseous artery  Anterior interossous a.  Posterior interosseous a.

 Deep palmar branch Superficial palmar arch

 Formed by ulnar artery and superficial palmar branch of radial artery  The curve of arch lies across the palm, 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

 Formed by radial artery and deep palmar 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 n.

Course:  Passes between the two heads of the pronator teres.  It continues downward behind the flexor digitorum superficialis.  At the wrist, it enters the palm by passing behind the flexor retinaculum. Distribution:  Flexor of forearm except brachioradialis, flexor carpi ulnaris and ulnar half of flexor digitorum profundus

Ulnar nerve

 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

 Course

 Runs down on the lateral side of the radial artery.

 In the distal part of the forearm, it leaves the artery and passes backward, reaches the posterior surface of the wrist and hand.  Distribution: brachioradialis

★Carpal tunnel Palmar carpal ligament Flexor retinaculum

 Composition: Formed by flexor retinaculum and carpal groove  Structures passing through the carpal tunnel

 Median n.

 The tendons of flexor digitorum superficialis and flexor digitorum profundus enclosed by common flexor synovial sheath

 The tendon of flexor pollicis longus enclosed by synovial sheath for flexor pollicis longus Deep fascia of the wrist

 Ulnar carpal canal

 Formed by the distal part of palmar carpal ligament and flexor reticulum

 Transmit the ulnar a., v. and n.  Radial carpal canal

 The radial end of flexor reticulum is attached to the tubercles of scaphoid and trapezium

 Transmit tendon of flexor carpi radialis Carpal tunnel

Synovial sheath for flexor pollicis longus

Common flexor synovial sheath

Fingers

 Vessels

 Proper palmar digital a.

 Nerves：

 Proper palmar digital n.

 Have a rest You must identify follow structures！

Pectoral region and Axilla

 Muscles  Nerves  Pectoralis major  Long thoracic n.  Pectoralis minor  Lateral cord  Serratus anterior  musculocutaneous n.  Arteries and veins  lateral root of median n.  Axillary artery  Medial cord  thoracoacromial a.  Medial root of median n.  lateral thoracic a.  Ulnar n.  subscapular a.  Posterior cord  Throcodorsal a.  Radial n.  Circumflex scapular a.  Axillary n.

 Posterior humeral circumflex a.  Thoracodorsal n.  Axillary vein

You must identify follow structures！

 Superficial vv.  Forearm  Cephalic v.  Brachioradialis  Basilic v.  Pronator teres  Median cubital v.  Flexor carpi radialis  Arm  Palmaris longus  Biceps brachii  Flexor carpi ulnaris  Coracobrachilis  Flexor digitorum superficialis  Bracialis  Flexor digitorum profundus  Musculocutaneous n.  Flexor pollicis longus  Median n.  Pronator quadratus  Ulnar n.  Ulnar n.  Brachial a.  Radial n.  Profunda brachii a.  Median n.  Ulnar a.  Radial a.