The upper limb

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The upper limb

• ??????? ?????
• ???

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The muscles of back

• Superficial group
• Trapezius ???
• Latissimus dorsi ???
• Levator scapulae ????
• Rhomboideus???
• Deep group
• Erector spinae ???
• Splenius ??
• Thoracolumbar fascia ????

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The muscles of thorax

• Extrinsic muscles
• Pectoralis major ???
• Pectoralis minor ???
• Serratus anterior ???
• Intrinsic muscles
• Intercostales externi ????
• Intercostales interni ????
• Intercostales intimi ?????

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Major muscles of the trunk

• Trapezius
• Origin superior nuchal line, external occipital
  protuberance, ligamentum nuchae and spinous
  processes of seventh cervical and all thoracic
  vertebrae
• Insertion lateral third of clavicle, acromion,
  and spine of scapulartery
• Acton upper fibers elevate scapula, lower fibers
  depress scapula if scapula is fixed, one side
  acting along, draws head toward the same side,
  and turn face to opposite side both sides
  together, draw head directly backward

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• Latissimus dorsi
• Origin spinous processes of lower six thoracic
  and all lumbar vertebrae, median sacral crest,
  and posterior part of iliac crest.
• Insertion floor of intertubercular groove of
  humerus.
• Action trunk fixed, extends, adducts and
  medially rotates arm arm fixed, elevates trunk.

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• Erector spinae
• Position fills the vertebral groove on each
  side of the spine
• Action extends vertebral column (draw head
  backwar)

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• Pectoralis major
• Origin medial half of clavicle,sternum,1th-6th
  costal cartilages.
• Insertion crest of greater tubercle of humerus.
• Action flexes, adducts and rotates arm medially
  arm fixed, elevates trunk elevates ribs
  1-6,aidding in forced inspiration.

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The Muscles of Upper Limb

• Muscles of shoulder
• Deltoid
• supraspinatus
• Infraspinatus
• Teres minor
• Teres major
• subscapularis

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• Muscles of arm
• Antererior group
• Biceps brachii ????
• Coracobrachialis???
• Brachialis ??
• Posterior group triceps brachii????

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Muscles of forearm

• Superficial layer
• Brachioradialis ???
• Pronator teres ????
• Flexor carpi radialis ?????
• Palmaris longus ???
• Flexor carpi ulnaris ?????

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• Third layer
• Flexor digitorum profundus ????
• Flexor pollicis longus ????
• Fourth layer- pronator quadratus ????
• Action flex radiocarpal joint and fingers,
  pronate forearm

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• Second layer- flexor digitorum
  superficials ????

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• Posterior group (10)
• Superficial layer (5)
• Extensor carpi radialis longus ??????
• Extensor carpi radialis brevis ??????
• Extensor digitorum ???
• Extensor digiti minimi ????
• Extensor carpi ulnaris ?????

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• Deep layer (5)
• Supinator???
• Abductor pollicis longus????
• Extensor pollicis brevis????
• Extensor pollicis longus????
• Extensor indicis ????
• Action extend radiocapral joint and fingers, and
  supinate forearm

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• Muscles of hand
• Lateral group-thenar ?? (4)
• Abductor pollicis brevis????
• Flexor pollicis brevis ????
• Opponens pollicis ????
• Adductor pollicis ???
• Action flex, abduct, adduct and oppose thumb
• Medial group-hypothenar (3)
• Abductor digiti minimi ????
• Flexor digiti minimi brevis?????
• Opponens digiti minimi?????
• Action flex, abduct , and oppose little finger

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• Intermedial group
• Lumbricales ???(4)-flex fingers at MP joints
  extend fingers at IP joints
• Palmar interossei ?????(3)- adduct fingers
  towards middle finger at MP joints
• Dorsal interossei ?????(3)-abduct fingers away
  from middle finger at MP joints

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Major muscles of upper limb

• Deltoid
• Origin lateral third of clavicle, acromion, and
  spine of scapula
• Insertion deltoid tuberosity of humerus
• Action abducts,flexes and medically rotates,
  extends, and laterally rotates arm

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• Teres major
• Origin dorsal surface of inferior angle of
  scapula
• Insertion crest of lesser tubercle of humerus
• Action medially rotates and adducts arm

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• Biceps brachii
• Origin long head, supraglenoid tubercle short
  head, coracoid process
• Insertion radical tuberosity
• Action supinator of forearm, flexor of elbow
  joint, weak flexor of should joint
• Pronator teres
• Origin medical epicondyle of humerus and deep
  fascia of forearm
• Insertion middle of lateral surface of radius
• Action pronation of forearm and flexion of elbow

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• Triceps brachii
• Origin long head, infraglenoid tubercle lateral
  head, above groove for radical n., medical head,
  below groove for radical n.
• Insertion olecranon of ulna
• Action extends elbow joint), long head can
  extend and adduct shoulder joint

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• Supinator
• Origin lateral epicondyle of humerus and upper
  part of lateral border of ulna
• Insertion upper third of anterior surface of
  radius
• Action supination of forearm

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Arteries of upper limb

• Axillary artery
• Continuation of subclavian artery at lateral
  border of first rib
• Becomes brachial artery at lower border of teres
  major
• Divided into three parts by overlying pectoralis
  minor
• First portion, above muscle-gives rise to
  thoracoacromial a. ?????
• Second portion, behind muscle-gives rise to
  lateral thoracic a. ?????
• Third portion, below muscle-gives rise to
  subscapular a. ?????, anterior and posterior
  humeral circumflex a. ??????? the former then
  divides into throcodorsal a. ???? and circumflex
  scapular a. ?????

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• Brachial artery
• Continuation of axillary artery
• Divides into radial and ulnar arteries at level
  of neck of radius
• Branches
• Deep brachial a. ????-accompanies with radial
  nerve
• Superior ulnar collaeral a. ??????-accompanies
  with ulnar nerve
• Inferior ulnar collateral a.??????

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• Radial artery and branches
• Radial recurrent a. ?????
• Superfical palmar branch ???
• Principal artery of thumb ?????
• Ulnar artery and branches
• Ulnar recurrent a. ?????
• Common interosseous artery ?????
• Anterior interossous a. ?????
• Posterior interosseous a. ?????
• Deep palmar branch ???

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• Superficial palmar arch ???
• Formed by ulnar artery and superficial palmar
  branch of radial artery
• 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

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• Deep palmar arch ???
• Formed by radial artery and deep palmar branch of
  ulnar artery
• Curve of arch lies across upper part of palmar at
  level with proximal border of extended thumb
• Gives rise to three palmar metacarpal arteries

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Veins of the upper limb

• Deep veins accompany the arteries of the same
  region and bear similar names
• Superficial veins
• Cephalic vein ???
• Arises from the lateral side of the dorsal venous
  rete of hand
• Ascends on radial side of the forearm to the
  elbow and then in the lateral side of biceps
  brachii furrow, continues up the arm in the
  deltopectoral groove and then to the
  infraclavicular fossa, where it pierces
  clavipectoral fascia to drain into axillary vein

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• Basilic vein ????
• Arises from the medial side of the dorsal venous
  rete of hand
• Ascends on the ulnar side of forearm to the elbow
  and then in the medial bicepital brachii furrow
  to middle of the arm where it pierces the deep
  fascia and joins the brachial vein or axillary
  vein
• Median cubital vein ?????
• 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

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The lymphatic drainage of upper limb

• Lymphatic vessels
• Superficial-follow the superficial veins, drain
  into supratrochlear and axillary lymph nodes
• Deep-accompany main vessels, end in axillary
  lymph nodes
• lymph nodes
• Cubital lymph node lies above medial epicondyle
  of humerus
• Axillary lymph node-arranged in five groups

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• Axillary lymph nodes????-arranged in five groups
• Lateral lymph nodes ?????- lie around the
  distal end of axillary vein , receiving drainage
  from the arm, forearm, and hand
• Pectoral lymph nodes ?????-lie along lateral
  thoracic vessels, receive afferents from anterior
  thoracic wall including central and lateral
  portion of mamma
• Subscapular lymph node ??????-along subscapular
  vessels, receive lymph from nape and scapular
  region
• Efferents above three groups pass to central
  lymph node

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• Central lymph node?????-lie in fat of axillary
  fossa, receive drainage from all the above nodes,
  efferents pass to apical lymph node
• Apical lymph node ????
• Lie in the apex of the axilla, along the proximal
  end of axillary vessels
• Receive drainage chiefly from central lymph node
  , upper portion of mamma
• Efferents form subclavian trunk, the right
  subclavian trunk joints the right lymphatic duct
  left usually drains directly into thoracic duct

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Brachial plexus ??

• Formation
• Five roots formed by anterior rami of C5-C8 and
  T1 spinal nerves, roots C5C7give rise to long
  thoracic n.????
• Three trunks
• The upper trunk is formed by the joining of root
  C4,C5,C6.
• The middle trunk is the continuation of root C7.
• The lower trunk is formed by the joining of root
  C8 and T1.
• Six divisions above clavicle, trunks form
  anterior and posterior divisions
• Three cords below clavicle, divisions form three
  cords that surround the second portion of
  axillary a.

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• Position
• passes through the scalene fissure to
  posterosuperior of subclavian artery, then
  enters the axilla to form lateral, medial and
  posterior cords
• Main branches
• Lateral cord
• Musculocutaneous n. ????
• Lateral root to median n. ???????
• Medial cord
• Medial root to median n. ???????
• Ulnar n. ???
• Medial brachial cutaneous n.??????
• Medial antebrachial cutaneous n.
  ???????

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• Posterior cord
• radial n. ???
• axillary n. ???
• thoracodorsal n. ????

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• Musculocutaneous ????
• Distribution Biceps brachii, brachalis and
  coracobrachialis BBC nerve skin on anterior
  aspect of forearm

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• Median ????
• Distribution Flexor of forearm except
  brachioradialis, flexor carpi ulnaris and ulnar
  half of flexor digitorum profundus, thenar except
  adductor pollicis, first two lumbricals skin of
  thenar, central part of palm, palmar aspect of
  radial three and one-half fingers, including
  middle and distal fingers on dorsum
• Injury Apehand ??
• produces sign of benediction, in which the index
  and middle fingers cannot be flexed and the thumb
  cannot be opposed

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• Ulnar nerve
• Distribution Flexor carpi ulnaris, ulnar half of
  flexor digitorum profundus, hypothenar muscles,
  interossei, 3rd and 4th lumbricals and adductor
  pollicis skin of hypothenar, palmar surface of
  ulnar one and one-half fingers, ulnar half of
  dorsum of hand, posterior aspect of ulnar two and
  one-half fingers
• Injury clawhand

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• Radial ???
• Distribution Extensor muscles of arm and
  forearm, brachioradialis skin on back of arm,
  forearm, and radial side of dorsum of hand and
  radial two and one-half fingers
• Injury Wristdrop

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• Axillary ???
• Distribution Deltoid and teres minor
  muscle skin over deltoid and upper posterior
  aspect of arm
• Injury result in deltoid andteres minor
  paralysis (loss of shoulser abdution and weel
  external rotation) with loss of sensation over
  the deltoid

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Regional anatomy of upper limb

• ??????? ?????
• ???

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Parts and regions

• 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

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Surface anatomy

• 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
• Forearm-between elbow and hand
• Hand-styloid process, dorsal tubercle

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• Anatomical snuff box ???
• When the thumb is abducted and extended, a
  triangular hollow appears between the tendon of
  the extensor pollicis longs medially and the
  tendons of the extensor pollicis brevis and
  abductor pollicis longus laterally.
• The floor of the snuff box is the scaphoid and
  trapezium bones and crossed by the radial a..

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Carring angle ???
16501700
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Mamma ??

• 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

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• Structures-contains skin, mammary glands and
  adipose tissue
• Each brest has about 1520 lobes of mammary gland
• Each lobe radiates out from the nipple and has a
  lactiferous duct??? which opens separately on the
  summit of the nipple and possesses a dilated
  lactiferous sinuses???? just prior to its
  termination

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• Suspensory ligaments of breast?????(coopers
  ligaments )-strands of connective tissue runs
  between skin and deep fascia and serve to support
  the mammary glands

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Axillary fossa ??

• The axillary fossa is a pyramid-shaped space
  through which major neurovascular structures pass
  between the thorax and upper extremity

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• Boundaries
• The apex is a triangular space limited by the
  first rib, the scapula, and the middle third of
  clavicle.
• The base-skin and fascia of the axillary fossa

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• The anterior wall
• Pectoralis major, pectoralis minor and subclavius
  muscles
• Clavipectoral fascia ????
• The deep faxcia which extends between subclavius,
  coracoid process and pectoralis minor muscles
• The structures pass through the clavipectoral
  faxcia
• Cephalic v.
• Thoracoacromial a.
• Lateral pectoral n.

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• The posterior wall-teres major, latissimus dorsi,
  subscapularis and scapula
• Trilateral and quadrilateral foramina
  ???????
• Between the subscapularis and teres major, there
  is a long triangular space whose lateral side is
  surgical neck of humerus. The long head of
  triceps brachii subdivides this space into a
  medial trilateral foramen and a lateral
  quadrilateral foramen.
• 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.

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• The broad medial wall-serratus anterior,intercosta
  l muscles and upper four ribs
• The narrow lateral wall-coracobrachialis, biceps
  brachii and intertubercular groove
• Contents
• Brachial plexus, axillary a. and principal
  branches, axillary v. and tributaries, axillary
  lymph nodes and loose connective tissue

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Brachial plexus ??

• Formation
• Five roots formed by anterior rami of C5-C8 and
  T1 spinal nerves, roots C5C7give rise to long
  thoracic n.????
• Three trunks
• The upper trunk is formed by the joining of root
  C4,C5,C6.
• The middle trunk is the continuation of root C7.
• The lower trunk is formed by the joining of root
  C8 and T1.
• Six divisions above clavicle, trunks form
  anterior and posterior divisions
• Three cords below clavicle, divisions form three
  cords that surround the second portion of
  axillary a.

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• Position
• passes through the scalene fissure to
  posterosuperior of subclavian artery, then
  enters the axilla to form lateral, medial and
  posterior cords
• Main branches
• Lateral cord
• Musculocutaneous n. ????
• Lateral root to median n. ???????
• Medial cord
• Medial root to median n. ???????
• Ulnar n. ???
• Medial brachial cutaneous n.??????
• Medial antebrachial cutaneous n.
  ???????

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• Posterior cord
• radial n. ???
• axillary n. ???
• thoracodorsal n. ????

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• Axillary sheath ??-extension of deep cervical
  fascia of the neck, forming a tubular sheath that
  surrounds axillary a. and v., and brachial plexus

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• Axillary artery
• Continuation of subclavian artery at lateral
  border of first rib
• Becomes brachial artery at lower border of teres
  major
• Divided into three parts by overlying pectoralis
  minor
• First portion, above muscle-gives rise to
  thoracoacromial a. ?????
• Second portion, behind muscle-gives rise to
  lateral thoracic a. ?????
• Third portion, below muscle-gives rise to
  subscapular a. ?????, anterior and posterior
  humeral circumflex a. ??????? the former then
  divides into throcodorsal a.???? and circumflex
  scapular a. ?????

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• Axillary lymph node-arranged in five groups
• Lateral lymph nodes-lie around the distal end of
  axillary artery vein , receive afferent vessels
  from upper limb.
• Pectoral lymph nodes-lie along lateral thoracic
  vessels, receive afferents from anterior thoracic
  wall including central and lateral portion of
  mamma
• Subscapular lymph node-along subscapular vessels,
  receive lymph from nape and scapular region
• Efferents above three groups pass to central
  lymph node
• Central lymph node-lie in fat of axillary fossa,
  receive lymph from all the above nodes, efferents
  pass to apical lymph node
• Apical lymph node-lie in the apex of the axilla,
  along the proximal end of axillary vessels,
  receive afferents chiefly from central lymph node
  , upper portion of mamma efferents form
  subclavian trunk, the right subclavian trunk
  joints the right lymphatic duct left usually
  drains directly into thoracic duct

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Cubiral fossa ??

• Boundaries
• Base-line drawn through epicondyles of humerus
• Apex-brachioradialis laterally and pronator teres
  medially
• Roof-skin, superficial faxcia, deep faxcia and
  aponeurosis of biceps
• Floor-brachialis, supinator and capsule of elbow
  joint

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• Contents-from lateral to medial
• 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.
  and lateral antebrachial cutaneous n.

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Carpal tunnel ??

• Flexor retinaculum
• Thickening of deep fascia in the hand
• Attached laterally to scaphoid and trapeziun and
  medially to pisiform and hamate
• Form an osseofibrous tunnel (carpal tunnel) with
  carpal groove-transmits median n., flexor
  digitorum supericialis, flexor digitorum
  profundus, and flexor pollicus longus from
  forearm into hand

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Skin incisions
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Superficial fascia
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• Clavipectoral fascia ????
• The deep faxcia which extends between subclavius,
  coracoid process and pectoralis minor muscles
• The structures pass through the clavipectoral
  faxcia
• Cephalic v.
• Thoracoacromial a.
• Lateral pectoral n.

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Musculocutaneous n.
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Muscolocutaneous n.
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Posterior region of upper limb

• ??????? ?????
• ???

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Skin incisions
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Cutaneous n. and superificial v.
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Hand

• ??????? ?????
• ???

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Palm of hand ??

• Flexor retinaculum ?????
• Thickening of deep fascia in the hand
• Attached laterally to scaphoid and trapeziun and
  medially to pisiform and hamate
• Carpal tunnel ??
• Formed by flexor retinaculum and carpal groove
• Transmits
• Median n.
• Flexor digitorum superficialis and flexor
  digitorum profundus enclosed by common flexor
  sheath
• Flexor pollicus longus enclosed by tendinous
  sheath of flexor pollicus longus

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Deep palmar fascia ?????

• Superficial layer
• Thenar fascia ????
• Hypothenar fascia ?????
• Palmar aponeurosis ??? thick triangular
  membrane
• Deep layer-palmar interosseous fascia
  ??????

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Osseofascial compartments of palm
??????

• Lateral compartment ???
• Medial compartment ???
• Intermediate compartment ???

Laeral intermuscular septum
Medial intermuscular septum
91

• Intermediate compartment ???
• Formed by palmar aponeurosis, Laeral and medial
  intermuscular septum, palmar interosseous fascia
• Contents superficial palmar arch, a., v.,n.,
  tendons of flexor digitorum superficialis and
  profundus, lumbricales, common flexor sheath

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Fascia spaces ????

• Thenar space ????
• Midpalmar space????

Midplmar septum ???
Thenar space
Midpalmar space
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Dorsum of hand ??

• Extensor retinaculum ?????
• Thickening of deep faxcia of forearm a wrist
• Attached laterally to radius and medially to
  styloid process of ulna and triquetrum
• Forms six fibrous compartments for extensor
  tendons passing from forearm into hand

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• ? tendons of abductor pollicis longus and
  extensor pollicis brevis and their synovial
  sheaths
• ? tendons of extensor carpi radialis longus and
  brevis and their synovial sheaths
• ? tendon of pollicis longus and its synovial
  sheath
• ? tendons of extensor digitorum, extensor indicis
  and their synovial sheaths
• ? tendon of extensor digiti minimi and its
  synovial sheaths
• ? tendon of extensor carpi ulnaris and its
  synovial sheaths

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• Fascia of the dorsal hand
• The superficial fascia
• Deep fascia-the dorsal fascia of hand
• Superficial layer (dorsal aponeurosis) ????
• Deep layer (dorsal interosseous fascia)
  ??????

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• Two spaces
• The dorsal subcutaneous space ??????
• The dorsal subaponeurotic space ???????

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Nerves of hand

• Median n.-thenar except adductor pollicis, first
  two lumbricals skin of thenar, central part of
  palm, palmar aspect of radial three and one-half
  fingers, including middle and distal fingers on
  dorsum
• Ulnar n.-hypothenar muscles, interossei, 3rd and
  4th lumbricals and adductor pollicis skin of
  hypothenar, palmar surface of ulnar one and
  one-half fingers

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• Radial n.-skin of radial side of dorsum of hand
  and radial two and one-half fingers

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Fingers ??

• Pulp space ???? On the palmar
  side of the tips of the fingers and thumb. They
  contain fatty tissue that is divided into
  numerous compartments by fibrous septa that pass
  between the distal phalanx and the skin. The pulp
  space is limited proximally by the firm adherence
  of skin and the distal flexion crease to the
  underlying tissue this prevents pulp infection
  from spreading proximally along the finger.

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• vessels
• ?2?????????2?????,???????????
• Nerves
• ??????????