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Brachial Plexus and Branches  Axillary A

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Brachial Plexus and Branches  Axillary A 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. .
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