Upper Limb

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Anatomy of the upper limb Introduction General considerations Brachial plexus

description

 

Transcript of Upper Limb

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Anatomy of the upper limb

• Introduction

• General considerations

• Brachial plexus

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ANATOMYUPPER LIMB

BRACHIAL PLEXUS

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The spinal nerves from C5 to C8, together with the T1 thoracic spinal nerve, join together to form

the brachial plexus.

The nerve elements combine,

divide and combine again to

mix together the various components that lead into the major nerves of the

shoulder, arm and hand.

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A nerve plexus is an area where nerves branchand rejoin.

The brachial plexus is a group of nerves in the cervical spine from C5 to C8-T1.

This includes the lower half of the cervical nerve roots and the nerve root from the first thoracic vertebra.

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Brachial Plexus

1 Ventral root of C5

2 Ventral root of C6

3 Ventral root of C7

4 Ventral root of C8

5 Ventral root of T1

6 Ulnar

7 Radial

8 Median

9 Musculocutaneous

10 Cords

a Medial

b Posterior

c Lateral

11 Posterior divisions

12 Anterior divisions

a Inferior

b Middle

c Superior

13 Inferior trunk

14 Middle trunk

15 Superior trunk

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Erb’s paralysis

• C5 - C6

• Birth injury

• Arm hangs by the side+Rotate medially

• Forearm pronated + extended

• Flexed wrist + fingers

• deltoid – supraspinatus – infraspinatus –biceps - brachialis

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Klumpke’s paralysis/kloomp’kz/

• C8 – T1

• Intrinsic muscles of the hand + long flexors of the hand ------ paralysis

• Claw hand = extension at MPJ + flexion at IPJ

• Cervical rib can cause paralysis similar to Klumpke’s paralysis with post-fixed T2 contribution

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Winging of the scapula

• Injury to the long thoracic nerve

• Paralysis of serratus anterior muscle

At the surgical neck ---------- injury to the axillary nerve ---- loss of abduction

Humeral fracture

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Arterial blood supplyof the upper limb

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Axillary artery•Continuation of subclavian artery •Runs from lateral border of first rib to lower border of teres major •Pectoralis minor crosses anterior to it and divides it into three parts •First part

• Highest thoracic artery (also called supreme or superior) •Second part

• Lateral thoracic artery • Thoracoacromial artery

•Third part • Subscapular artery • Anterior circumflex humeral artery • Posterior circumflex humeral artery

•Collateral circulation around the scapula •Branches of first part of Subclavian artery anastomose with branches of the third part of axillary artery

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The axillary artery begins at the lateral border of the first rib as a continuation of the subclavian artery.

It changes its name to brachial artery at lower (inferior) border of the teres major muscle.

For purposes of description, it is broken up into three parts by its relation to the pectoralisminor muscle.

The first part is between the lateral border of the first rib and the medial border of the pectoralis minor,

the second part is behind the pectoralis minor and the

third part is between the lateral border of the pectoralis minor and the inferior border of the teres major

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Brachial arteryContinuation of the axillary artery Runs from lower border of teres major to neck of radius Ends by dividing into radial and ulnar arteries

Branches of the brachial arteryProfunda brachi which travels in the radial groove of humerusSuperior ulnar collateral artery o Inferior ulnar collateral artery Nutrient artery to humerusTerminal branches are radial and ulnar arteries

RelationsMedian nerve crosses anterior to it from lateral to medial side at the level of mid arm

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1 superior thoracic a. (supreme thoracic a.) (highest thoracic a.)

2 thoracoacromial a. 3 lateral thoracic a.

4 subscapular a. 5 anterior humeral circumflex a. 6 posterior humeral circumflex a.

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Ulnar artery Gives rise to common interosseous artery Continues as the superficial palmar arch in the hand

Radial arteryContinues as the deep palmar arch in the handMedian artery Vestigial in adult life

Arises from the anterior interosseous branch of common interosseous artery Provides nutrition to Median nerve Chief source of blood supply to the upper limb in foetal life Passes anterior to carpal tunnel

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The diagram also shows that the brachial artery terminates just below the elbow joint as the radial and ulnar arteries, to be covered in the forearm

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1 brachial 2 radial

3 radial recurrent 4 superficial radial 5 deep radial

6 ulnar7 anterior ulnar recurrent 7 posterior ulnar recurrent 8 common interosseous

9 posterior interosseous10 anterior interosseous

11 superficial branch 12 deep branch

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The superficial arterial arch is formed mainly from the ulnar artery and is completed by the superficial branch of the radial. This completion is not always present or may be extremely small.The deep arterial arch is formed mainly by the deep branch of the radial artery andis finished by the deep branch of the ulnar artery.

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Upper limb

Venous drainage

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cephalic v.

Tributaries

lateral side of the dorsal venous arch of the hand; superficial veins of the forearm

Drains Into

axillary vein

Regions Drained

superficial parts of the lateral hand and lateral forearm

Notes

median cubital vein usually shunts some of the blood collected by the cephalic v. to the basilic v. (Latin/Greek, kephale = head)

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The axillary vein lies along the medial side of the artery and is a continuation of the basilic vein.

It begins at the inferior border of the teres major m. and ends at the lateral border of the first rib, where it becomes the subclavian v.

It receives tributaries that parallel the branches of the axillary artery.

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The cephalic v. joins the axillary v. just before it becomes the subclavian.

Penetrating wounds in the larger upper part are serious because air might enter into the venous system.

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The veins that run with their corresponding arteries are frequently multiple (2 or 3 interconnected veins).This interconnected venous network is called the vena commitantes

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Axilla, Pectoral andscapular regions

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medially: serratus anterior and by the ribcage

anteriorly: by the pectoralis major, minor, and subclavius (see also anterior axillary fold)

posteriorly: by the subscapularis above, and teres major and latissimus dorsi below(see also posterior axillary fold)

laterally: by the intertubercular sulcus (coracobrachialis and the short head of the biceps brachii are in the axilla.)

superiorly: by the outer border of first rib, superior border of scapula, and posterior border of clavicle

floor/base: by the skin (visible surface of armpit

Anatomically, the boundaries of the axilla are

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Deep muscles of the chest and front of the arm, with the boundaries of the axilla.

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Lymphatics

Structure Location Afferents from Efferents to Regions drained Notes

axillary nodes axilla cubital nodes;lymphatic vessels from the upper limb, thoracic wall and subscapularregion

efferents vessels form the subclavian trunk, some drainage to inferior deep cervical nodes

upper limb, most of the mammary gland, some of the anterolateral chest wall, posterior thoracic wall and scapular region

axillary nodes number from 20 to 30 and are organized in five groups based on their position within the axilla: 1) pectoral nodes, along the lateral border of the pectoralis major m.; 2) lateral nodes, located along the distal axillary v.; 3) central nodes, centrally located along axillary v.; 4) subscapularnodes, located along the subscapular v. and its tributaries; 5) apical nodes, located at the apex of axilla

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There are some 15 to 20 nodes usually arranged into to five groups. The groups consist of: A pectoral (anterior) L lateral P posterior C central Ap apical

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Muscles of Axilla and the Pectoral region

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Origin medial 1/2 of the clavicle, manubrium & body of sternum, costal cartilages of ribs 2-6, sometimes from the rectus sheath of the upper abdominal w

Pectoralis major

Insertion crest of the greater tubercle of the humerus

Action flexes and adducts the arm, medially rotates the arm

Nerve supply medial and lateral pectoral nerves (C5-T1)

the deep fascia on its anterior surface should not be fused to the fascia of the mammary gland - if it is, this is an important clinical sign indicating breast disease (Latin, pectus = breast bone)

Arterial blood supply pectoral branch of the thoracoacromial trunk

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Pectoralis minororigin ribs 3-5 Insertion coracoid process of the scapulaAction draws the scapula forward, medialward, and downwardNerve supply medial pectoral nerve (C8, T1) arterial supply pectoral branch of the thoracoacromial trunk

Notes; branches of medial pectoral nerve usually pierce pectoralis minor to reach the pectoralis major muscle .

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serratus anteriorOrigin ribs 1-8 or 9Insertion medial border of the scapula on its costal (deep) surfaceAction it draws the scapula forward; the inferior fibers rotate the scapula superiorly

Nerve supply long thoracic nerve (from ventral rami C5-C7) Arterial supply

lateral thoracic a.

a lesion of long thoracic nerve will cause winging of the scapula (i.e., the medial border of the scapula falls away from the posterior chest wall and looks like an angel's wing) (Latin, serratus = to saw)

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Topographical Anatomy of the Thorax

Structure/Space Description/Boundaries Significance

midaxillary line an imaginary vertical line passing through the middle of the axilla

used as a surface landmark for descriptive purposes

midclavicular line an imaginary vertical line passing through the midshaft of the clavicle

used as a surface landmark for descriptive purposes

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deltopectoral triangle

a triangle in the upper chest region that is bounded medially by the clavicle,superiorly by the deltoid m.,

and inferiorly by the pectoralis major m.

the deltopectoral triangle

is pierced by the cephalic vein on its course from the upper limb to join the axillary vein in the axilla

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nipple located superficial to the 4th intercostal space in the male and prepuberal female; areola is dark ring surrounding nipple

location of the left nipple may be used to help locate the apex of heart, which is approximately 8 cm from the midline in the left 5th intercostal space; a surface landmark used to place the stethoscope for auscultation of the bicuspid valve

suprasternal notch the notch located at the superior border of the manubrium of the sternum, between the sternal ends of the clavicles

also known as: jugular notch

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parasternal nodes lateral border of sternum, along the course of the internal thoracic vessels

anterior phrenic nodes, lymphatic vessels from the anterior thoracic wall

larger lymphatic vessels in the root of the neck

medial side of the mammary gland; medial part of the anterior chest wall and muscles

parasternal nodes constitute an important drainage pattern in cases of cancer of the mammary gland; one or two parasternal nodes may be found in the anterior end of intercostal spaces 1-6; also known as: sternal nodes

pectoral nodes along the lateral border of the pectoralis major m. along the course of the lateral thoracic vessels

lymphatic vessels from the mammary gland and anterolateral thoracic wall

central axillary nodes anterolateral thoracic wall and muscles; most of the mammary gland

an important group of nodes to examine during a breast physical exam; also known as: anterior axillary nodes

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SCAPULAR REGION

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Muscles of the Scapular Region

Muscle Origin Insertion Action Innervation Artery Notes

deltoid lateral one-third of the clavicle, acromion, the lower lip of the crest of the spine of the scapula

deltoid tuberosity of the humerus

abducts arm; anterior fibers flex & medially rotate the arm; posterior fibers extend & laterally rotate the arm

axillary nerve (C5,6) from the posterior cord of the brachial plexus

posterior circumflex humeral a.

the deltoid muscle is the principle abductor of the arm but due to poor mechanical advantage it cannot initiate this action; it is assisted by the supraspinatus m.

teres major dorsal surface of the inferior angle of the scapula

crest of the lesser tubercle of the humerus

adducts the arm, medially rotates the arm, assists in arm extension

lower subscapular nerve (C5,6) from the posterior cord of the brachial plexus

circumflex scapular a.

teres major inserts beside the tendon of latissimus dorsi, and assists latissimus in its actions

triceps brachii long head: infraglenoid tubercle of the scapula; lateral head: posterolateral humerus & lateral intermuscular septum; medial head: posteromedial surface of the inferior 1/2 of the humerus

olecranon process of the ulna

extends the forearm; the long head extends and adducts arm

radial nerve deep brachial (profunda brachii) a.

long head of the triceps separates the triangular and quadrangular spaces (teresmajor, teres minor and the humerusare the other boundaries); all three heads of origin insert by a common tendon

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rotator cuff

supraspinatus supraspinatous fossa

greater tubercle of the humerus (highest facet)

abducts the arm (initiates abduction)

suprascapular nerve (C5,6) from the superior trunk of the brachial plexus

suprascapular a.

supraspinatus initiates abduction of the arm, then the deltoid muscle completes the action; a member of the rotator cuff group

infraspinatus infraspinatous fossa

greater tubercle of the humerus (middle facet)

laterally rotates the arm

suprascapular nerve

suprascapular a.

infraspinatus, supraspinatus, teres minor and subscapularis are the rotator cuff muscles

teres minor upper 2/3 of the lateral border of the scapula

greater tubercle of the humerus (lowest facet)

laterally rotates the arm

axillary nerve (C5,6) from the posterior cord of the brachial plexus

circumflex scapular a.

fixes the head of the humerus in the glenoid fossa during abduction & flexion of the arm; a member of the rotator cuff group

subscapularis medial two-thirds of the costal surface of the scapula (subscapular fossa)

lesser tubercle of the humerus

medially rotates the arm; assists extention of the arm

upper and lower subscapular nerves (C5,6)

subscapular a.

subscapularis, supraspinatus, infraspinatus, and teresminor are the rotator cuff muscles

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Nerves of the Scapular Region

Nerve Source Branches Motor Sensory Notes

axillary n. posterior cord of the brachial plexus

superior lateral brachial cutaneous nerve

deltoid, teres minor

skin of the upper lateral arm

axillary n. is endangered by surgical neck fractures

lower subscapular n.

posterior cord of the brachial plexus (C5, C6)

unnamed muscular brs.

subscapularis m., teres major m.

no cutaneous branches

subscapularis and teres major are synergists (medial rotation of the humerus)

middle subscapular n.

posterior cord of the brachial plexus (C7, C8)

unnamed muscular brs.

latissimus dorsi m.

no cutaneous branches

also called the thoracodorsal n.

suprascapular n. superior trunk of the brachial plexus (C5-C6)

no named branches

supraspinatus m., infraspinatus m.

no cutaneous branches

suprascapular n. passes through the scapular notch inferior to the superior transverse scapular ligament

thoracodorsal n. posterior cord of the brachial plexus (C7, C8)

unnamed muscular brs.

latissimus dorsi m.

no cutaneous branches

also called the middle subscapular n.

upper subscapular n.

posterior cord of the brachial plexus (C5, C6)

unnamed muscular brs.

subscapularis m. no cutaneous branches

subscapularis is a strong medial rotator of the humerus

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Arteries of the Scapular Region

Artery Source Branches Supply to Notes

anterior circumflex humeral axillary a., 3rd part unnamed muscular branches deltoid m.; arm muscles near the surgical neck of the humerus

anterior circumflex humeral a. anastomoses with the posterior circumflex humeral a.

posterior circumflex humeral axillary a., 3rd part unnamed muscular branches deltoid; arm muscles near the surgical neck of the humerus

posterior circumflex humeral a. anastomoses with the anterior circumflex humeral a.; it passes through the quadrangular space with the axillary nerve

axillary subclavian a. (axillary a. is the continuation of the subclavian lateral to the 1st rib)

1st part: superior thoracic a.; 2nd part: thoracoacromial a., lateral thoracic a.; 3rd part: anterior humeral circumflex a., posterior humeral circumflex a., subscapular a.

pectoral region, shoulder region and upper limb

pectoralis minor m. crosses anterior to the axillary artery and is used to delineate the 3 parts mentioned at left

circumflex scapular subscapular a. unnamed muscular branches teres major m., teres minor m., infraspinatus m.

circumflex scapular a. anastomoses with the suprascapular a. and the dorsal scapular a. to form the scapular anastomosis

dorsal scapular subclavian a., 3rd part unnamed muscular branches levator scapulae m., rhomboideus major m., rhomboideus minor m.

dorsal scapular a. anastomoses with the suprascapular a. and the subscapular a. to form the scapular anastomosis; dorsal scapular a is a branch of the transverse cervical a. in ~30% of cases

subscapular axillary a., 3rd part circumflex scapular a., thoracodorsal a.

subscapularis m., teres major m., teres minor m., infraspinatus m.

the circumflex scapular branch of the subscapular a.anastomoses with the suprascapular a. and the dorsal scapular a. in the scapular anastomosis

suprascapular thyrocervical trunk muscular supraspinatus & infraspinatus, shoulder joint

anastomoses with the circumflex scapular a. and the dorsal scapular a. to form the scapular anastomosis

thoracodorsal subscapular a. unnamed muscular branches latissimus dorsi m. thoracodorsal a. accompanies the thoracodorsal n.

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Topographic Anatomy of the Scapular Region

Structure/Space Description/Boundaries Significance

quadrangular space the space bounded by the teres minor m. superiorly, the teres major m. inferiorly, the long head of the triceps brachii m. medially and the humerus laterally

the axillary n. and the posterior circumflex humeral a. pass through this space

triangular interval the interval between the teres major m. superiorly, long head of the triceps brachii m. medially and humerus laterally

the radial n. passes through this interval to get from the axilla to the posterior surface of the humerus

triangular space the space bounded by the teres minor m. superiorly, the teres major m. inferiorly and the long head of the triceps brachii m. laterally

the circumflex scapular vessels are located in this space as they pass from the axilla to the dorsum of the scapula

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The scapular and circumflex arteries. (Quadrangular space is visible but not labeled. Posterior humeral circumflex artery is visible entering quadrangular space at center right.)

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Suprascapular and axillary nerves of right side, seen from behind. Quadrangular space is the lateral space, labeled in green at center right. Axillary nerve is visible entering it.

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Pectoral region

The human breast

(Mammary gland )

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consists of 10–20 simple glands.

The presence of more than two nipples is known as polythelia

and the presence of more than two complex mammary glands as polymastia.

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I. Introduction/General Information

A. Embryologically: belong to integument

B. Functionally: part of reproductive system

1. Respond to sexual stimulation

2. Feed babies

C. Modified apocrine sweat glands

- apex of cell becomes part of secretion and breaks off

D. Present in males and females

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II. Anatomy

A. Position and Attachment

1. Lateral aspect of pectoral region

2. Located between ribs 3 and 6/7

3. Extend form sternum to axilla

4. Surrounded by superficial fascia

5. Rest on deep fascia

6. Fixed to skin & underlying fascia by fibrous C.T. bandsa. Cooper’s (Suspensory) Ligamentsb. Ligaments may retract when breast tumors are present

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Breast Anatomy

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Left breast is usually slightly larger

Base is circular, either flattened or concave

Separated from pectoralis major muscle by fascia, retromammary space

B. Structure

1. Outer surface convex, skin covered

2. Nipple:

a. At fourth intercostal space

b. Small conical/cylindrical prominence below center

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Nipple location

4th intercostal space

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c. Surrounded by areola: pigmented ring of skin

d. Thin skinned region lacking hair, sweat glands

e. Contains areolar glands

3. Areola: contains

dark pigment that intensifies with pregnancy

a. Circular and radial smooth muscle fibers

b. Cause nipple erection

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Lobes and Lobules

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5. Excretory (lactiferous) ducts converge toward areola

a. Form ampullae (collection sites of lactiferous sinuses)

b. Ducts become contracted at base of nipple

6. Secretory epitheliuma. Changes with hormonal signals

b. Onset of menstruation

c. Pregnancy (glands begin to enlarge at 2nd month)d. After birth, 1st secretion is colostrom (contain antibodies

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7. “Tail of Spence” = axillary tail a. prolongation of upper, outer quadrant in axillary direction

b. Passes under axillary fascia

c. May be mistaken for axillary lymph nodes

8. Fatty Tissue: surrounds surface, fills spaces between lobes

a. Determines form & size of breast

b. No fatty deposit under nipple & areola

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“Tail of Spence”

Axillary Tail

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Breast: Fatty Tissue

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Vessels & nerves

1. Arteries: derived from thoracic branches of three pairs of arteries

a. Axillary arteries

continuous with subclavian a.

gives rise to external mammary ( = lateral thoracic) artery

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b. Internal mammary (thoracic) arteries

1) first descending branch of subclavian artery

2) supply intercostal spaces & breast

3) used for coronary bypass surgery

c. Intercostal arteries:

1) numerous branches from internal & external mammary arteries

2) supply intercostal spaces & breast

Veins: a. form a ring around the base of the nipple (“circulus

venosus”)

b. Large veins pass from circulus venosus to circumference

Of mammary gland, then toc. External mammary v to axillary v or d. Internal mammary v to subclavian v

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Subclavian a.

Axillary a.

External mammary (thoracic) a.

Internal mammary (thoracic) a.

Arterial Supply to the Breast

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Veins draining the Breast

Subclavian vein

External mammary vein

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Innervation: derived from:a. anterior & lateral cutaneous nerves of thorax b. spinal segments T3 – T6

Lymphatics: clinically significant!a. Glandular lymphatics drain into

anterior axillary (pectoral) nodes

central axillary nodes

apical nodes

deep cervical nodes subclavicular (subclavian) nodesb. Medial quadrants drain into parasternal nodes

c. Superficial regions of skin, areola, nipples: -form large channels & drain into pectoral nodes

d. NOTE: axillary nodes also drain lymph from arm

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Subclavian nodes

Axillary nodes

Lateral pectoral

nodes

Parasternal nodes

Lymph Nodes of the Breast

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Lymph Nodes and Lymph Drainage

Axillary Nodes

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Routes of Metastasis

• From medial lymphatics to parasternal nodes

– Then to mediastinal nodes

• Across the sternum in lymphatics to

opposite side via cross-mammary pathways

– Then to contralateral breast

• From subdiaphragmatic lymphatics to nodes in abdomen

– Then to liver, ovaries, peritoneum

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Subdiaphragmatic Lymph Channels

Channels to Contralateral Breast

Axillary Lymph Channels

Major Routes of Metastasis

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The veins describe anastomotic circle around the base of the papilla, called by Haller the circulus venosus.From this, large branches transmit the blood to the circumference of the gland, and end in the axillary and internal mammary veins.

The arteries supplying the mammæ are derived from the thoracic branches of the axillary,

the intercostals,and the internal mammary.

The arteries supplying the mammæ are derived from the thoracic branches of the axillary,

the intercostals,and the internal mammary.

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Muscles of the upper limb

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ORIGINCoracoid process of scapula with biceps brachii

INSERTIONUpper half medial border of humerus

ACTIONFlexes and weakly adducts arm

NERVEMusculocutaneous nerve (C5, 6, 7) (from lateral cord)

CORACOBRACHIALIS

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Latin musculus biceps brachii

Gray's subject #124 443

Origin short head: coracoid process of the scapula. long head: supraglenoid tubercle

Insertion radial tuberosity and bicipittal aponeurosis into deep fascia on medial part of forearm

Artery brachial artery

Nerve Musculocutaneous nerve (C5–C7)

Actions flexes elbow and supinates forearm

Antagonist Triceps brachii muscle

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Muscle Origin Insertion Artery Nerve Action Antagonist

coracobrachialis coracoid process of scapula

medial humerus brachial artery musculocutaneous nerve

adducts humerus

biceps brachii short head: coracoid process of the scapula. long head: supraglenoid tubercle

radial tuberosity brachial artery Musculocutaneous nerve (Lateral cord: C5, C6, C7)

flexes elbow and supinatesforearm

Triceps brachii muscle

brachialis anterior surface of the humerus, particularly the distal half of this bone

coronoid process and the tuberosity of the ulna

radial recurrent artery

musculocutaneous nerve

flexion at elbow joint

Anterior compartment

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POSTERIOR COMPARTMENT

• TRICEPS MUSCLE

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Schematic drawing with measurements indicating the relationship of the radial nerve to osseous landmarks.

Note the course of the radial nerve along the posterior humerus and its relationship to the distal deltoid tuberosity and lateral epicondyle

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MUSCLES THAT ACT ON ANTERIOR FOREARM:•BICEPS BRACHII•BRACHIALIS•BRACHIORADIALIS•PRONATOR TERESMUSCLES THAT ACT ON POSTERIOR FOREARM:•TRICEPS BRACHII - LONG HEAD•TRICEPS BRACHII - MEDIAL HEAD•TRICEPS BRACHII - LATERAL HEAD•ANCONEUS

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Muscle Origin Insertion Artery Nerve ActionAntagonist

triceps brachii

long head:scapulalateral head:posterior humerusmedial head:posterior humerus

olecranonprocess of ulna

Profundabrachii

radial nerve

extendsforearm, caput longum adductsshoulder

Biceps brachii muscle

anconeus

Lateral epicondyle of the humerus

lateral surface of the olecranonprocess and the superior part of the posterior ulna

Profundabrachii, recurrent interosseousartery

radial nerve(C7, C8, and T1)

partly blended in with the triceps, which it assists in extension of the forearm. Stabilises the elbow and abducts the ulna during pronation.

Posterior compartment

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Cubital FossaThe cubital fossa is the region of the upper limb in front of the elbow joint.

It is a triangular area with the following boundaries:

laterally, brachioradialis muscle medially, pronator teres muscle superiorly, an imaginary line from the

medial and lateral epicondyles.

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venous layer1 cephalic vein 2 basilic vein 3 median cubital vein

artery-nerve layer1 brachial artery 2 median nerve

bony floor1 humerus2 radius 3 ulna

aponeurotic layer1 bicipital aponeurosis 2 biceps tendon

muscular floor1 supinator2 brachialis3 biceps tendon

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flexor carpi radialisorigincommon flexor tendon from the medial epicondyle of the humerusinsertionbase of the second and third metacarpalsactionflexes the wrist, abducts the handNerve supplymedian nerve

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flexor carpi ulnaris

Origincommon flexor tendon & (ulnar head) from medial border of olecranon & upper 2/3 of the posterior border of the ulnainsertionpisiform, hook of hamate, and base of 5thmetacarpalactionFlex the wrist, adducts handNerve supplyulnar nerve

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flexor digitorum profundusoriginposterior border of the ulna, proximal two-thirds of medial border of ulna, interosseousmembrane insertionbase of the distal phalanx of digits 2-5actionflexes the metacarpophalangeal, proximal interphalangeal and distal interphalangeal jointsNerve supplymedian nerve via anterior interosseous branch (radial one-half); ulnar nerve (ulnar one-half)

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flexor digitorum superficialisoriginhumeroulnar head: common flexor tendon; radial head: middle 1/3 of radius insertionshafts of the middle phalanges of digits 2-5 actionflexes the metacarpophalangealand proximal interphalangeal jointsNerve supplymedian nerve

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flexor pollicis longus

originanterior surface of radius and interosseousmembraneinsertionbase of the distal phalanx of the thumbactionflexes the metacarpophalangeal and interphalangeal joints of the thumb Nerve supplymedian nerve via anterior interosseousbranch

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pronator quadratus

originmedial side of the anterior surface of the distal one-fourth of the ulna insertionanterior surface of the distal one-fourth of the radius actionpronates the forearm Nerve supplymedian nerve via anterior interosseousbranch

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palmaris longus

originmedial epicondyle of humerusinsertiondistal half of flexor retinaculum and palmaris aponeurosisactionflexes hand (at wrist) and tightens palmar aponeurosisNerve supplymedian n. (C7 and C8) ulnar a.

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pronator teresorigincommon flexor tendon and (deep or ulnar head) from medial side of coronoid process of the ulna inserionmidpoint of the lateral side of the shaft of the radius Actio pronates the forearmNerve supplymedian nerve

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supinatororiginlateral epicondyle of the humerus, supinator crest & fossa of the ulna, radial collateral ligament, annular ligamentinsertionlateral side of proximal one-third of the radiusactionsupinates the forearm Nerve supplydeep radial nerve

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Muscle Origin Insertion Artery Nerve Action Antagonist

pronator teres

humeral head: medial epicondyle of humerus(common flexor tendon)ulnar head: coronoid process of the ulna

radius ulnar artery and radial artery

median nerve

pronation of forearm, flexeselbow

Supinator muscle

palmaris longus

medial epicondyle of humerus(common flexor tendon)

palmar aponeurosis

ulnar artery

median nerve

wrist flexor Extensor carpiradialisbrevis, Extensor carpiradialislongus, Extensor carpiulnaris

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flexor carpi radialis

medial epicondyle of humerus(common flexor tendon)

Bases of second and third metacarpal bones

ulnar artery Median nerve

Flexion and abduction at wrist

Extensor carpi radialis brevis muscle, Extensor carpi radialis longus muscle

flexor carpi ulnaris

medial epicondyle of the humerus(common flexor tendon)

pisiform ulnar artery muscular branches of ulnar nerve

flexion of wrist

Extensor carpi ulnaris muscle

flexor digitorum superficialis

medial epicondyle of the humerus(common flexor tendon), as well as parts of the radiusand ulna.

phalanges ulnar artery median nerve flexor of fingers(primarily at proximal interphalangeal joints)

Extensor digitorummuscle

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Muscle Origin Insertion Artery Nerve Action Antagonist

pronator quadratus

medial, anterior surface of the ulna

lateral, anterior surface of the radius

anterior interosseous artery

median nerve(anterior interosseous nerve)

pronates the forearm Supinator muscle

flexor digitorum profundus

ulna distal phalanges anterior interosseous artery

median(anterior interosseous), muscular branches of ulnar

flex hand, interphalangeal joints

Extensor digitorum muscle

flexor pollicis longus

The middle 2/4 of the volar [disambiguation

needed] surface of the radius and the adjacent interosseus membrane. (Also occasionally a small origin slightly on the medial epicondyle of the ulna.)

The base of the distal phalanx of the thumb

Anterior interosseous artery

Anterior interosseous nerve(branch of median nerve) (C8, T1)

Flexion of the thumb Extensorpollicislongusmuscle, Extensorpollicisbrevismuscle

Deep

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The muscles are largely involved with flexion and pronation.

The superficial muscles have their origin on the common flexor tendon.

The Ulna nerve and artery are also contained within this compartment@@@@@@@@@@@@@@@@

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Forearm posterior compartment

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abductor pollicis longusorigin middle one-third of the posterior surface of the radius, interosseousmembrane, mid-portion of posterolateral ulna

Insertion radial side of the base of the first metacarpal

Action abducts the thumb at carpometacarpal joint

Nerve supply radial nerve, deep branch

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Brachioradialis

origin upper two-thirds of the lateral supracondylar ridge of the humerus

Insertion lateral side of the base of the styloidprocess of the radius

Action flexes the elbow, assists in pronation & supination

Nerve supply radial nerve

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The Brachioradialis, flexor of the forearm, is

unusual in that it is located in the

posterior compartment, but it is actually in the anterior portion of the forearm.

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extensor carpi radialis longus

Origin lower one-third of the lateral supracondylar ridge of the humerus

Insertion dorsum of the second metacarpal bone (base)

Action extends the wrist; abducts the hand

Nerve supply radial nerve

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extensor carpi radialis brevisorigincommon extensor tendon (lateral epicondyle of humerus)insertiondorsum of the third metacarpal bone (base)

Action extends the wrist; abducts the hand

Nerve supply deep radial nerve

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extensor carpi ulnarisorigin common extensor tendon & the middle one-half of the posterior border of the ulna insertionmedial side of the base of the 5th metacarpal actionextends the wrist; adducts the hand Nerve supply deep radial nerve

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extensor digiti minimiorigincommon extensor tendon (lateral epicondyle of the humerus) insertionjoins the extensor digitorum tendon to the 5th digit and inserts into the extensor expansion actionextends the metacarpophalangeal, proximal interphalangeal and distal interphalangealjoints of the 5th digit

Nerve supply deep radial nerve

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extensor digitorumorigincommon extensor tendon (lateral epicondyle of the humerus) insertionextensor expansion of digits 2-5actionextends the metacarpophalangeal, proximal interphalangeal and distal interphalangeal joints of the 2nd-5th digits; extends wrist deepNerve supply radial nerve

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extensor indicisorigininterosseous membrane and the posterolateral surface of the distal ulnaInsertionits tendon joins the tendon of the extensor digitorum to the second digit; both tendons insert into the extensor expansionactionextends the index finger at the metacarpophalangeal, proximal interphalangeal and distal interphalangealjointsNerve supply deep radial nerve

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extensor pollicis brevis

origininterosseous membrane and the posterior surface of the distal radius insertionbase of the proximal phalanx of the thumb actionextends the thumb at the metacarpophalangeal joint Nerve supplydeep radial

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extensor pollicis longusOrigininterosseous membrane and middle

part of the posterolateral surface of the ulna insertionbase of the distal phalanx of the thumb actionextends the thumb at the interphalangeal joint Nerve supplydeep radial nerve

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Nerves of the upper limbs

Radial nerve

Median nerve

Ulnar nerve

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RADIAL NERVE

The radial nerve originates as a terminal branch of the posterior cord of the brachial plexus.

It goes through the arm, first in the posterior compartment of the arm,

and later in the anterior compartment of the arm,

and continues in the posterior compartment of the forearm.

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In armFrom the brachial plexus, it travels posteriorly through what is often called the triangular interval (US) or the triangular space of the axilla (UK).

The radial nerve enters the arm behind the axillary artery/brachial artery, and it then travels posteriorly on the medial side of the arm.

After giving off branches to the long and medial heads of the triceps brachii, it enters a groove on the humerus, the radial sulcus.

Along with the deep brachial artery, the radial nerve winds around in the groove (between the medial and lateral heads of the triceps) towards the forearm, running laterally on the posterior aspect of the humerus.

While in the groove, it gives off a branch to the lateral head of the triceps brachii.The radial nerve emerges from the groove on the lateral aspect of the humerus.At this point, it pierces the lateral intermuscular septum and enters the anterior compartment of the arm.

It continues its journey inferiorly between the brachialis and brachioradialis muscles.When the radial nerve reaches the distal part of the humerus, it passes anterior to the lateral epicondyle and continues in the forearm

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Branches/InnervationsThe following are branches/innervations of the radial nerve (including the superficial branch of the radial nerve and the deep branch of the radial nerve/posterior interosseous nerve).

Cutaneous

Cutaneous innervation is provided by the following nerves:

Posterior cutaneous nerve of arm (originates in axilla)

Inferior lateral cutaneous nerve of arm (originates in arm)

Posterior cutaneous nerve of forearm (originates in arm)

The superficial branch of the radial nerve provides sensory innervation to much of the back of the hand, including the web of skin between the thumb and index finger

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In forearmIn the forearm, it branches into a superficial branch (primarily sensory) and a deep branch (primarily motor).

The superficial branch of the radial nerve descends in the forearm under the brachioradialis.It eventually pierces the deep fascia near the back of the wrist.

The deep branch of the radial nerve pierces the supinator muscle, after which it is known as the posterior interosseous nerve.

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MotorMuscular branches of the radial nerve:Triceps brachiiAnconeusBrachioradialisExtensor carpi radialis longus

Deep branch of the radial nerve:Extensor carpi radialis brevisSupinator

Posterior interosseous nerve (a continuation of the deep branch after the supinator):Extensor digitorumExtensor digiti minimiExtensor carpi ulnarisAbductor pollicis longusExtensor pollicis brevisExtensor pollicis longusExtensor indicis

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The Median nerveis derived from the lateral and medial cords of the Brachial plexus.

Disk herniations in the Cervical spine (at the level of C5-C8 and T1) can cause numbness and/or decreased grip-strength in the hand

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the median nerve courses with brachial artery on medial side of arm between biceps brachii and brachialis.

At first lateral to the artery, it then crosses anteriorly to run medial to the artery in the distal arm and into the cubitalfossa.

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The unbranched portion of the median nerve innervates muscles of superficial and intermediate groups of the anterior

compartment exceptflexor carpi ulnaris

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The median nerve does give off two branches as it courses through the forearm:

The anterior interosseous branch courses with the anterior interosseous artery and innervates all the muscles of the anterior compartment of the forearm except the flexor carpi ulnaris and the medial (ulnar) half of flexor digitorum profundus. Its ends with its innervation of pronator quadratus.

The palmar cutaneous branch of the median nerve arises at the distal part of the forearm. It supplies sensory innervation to the lateral aspect of the skin of the palm (but not the digits).

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DistributionArmThe median nerve has no voluntary motor or cutaneous function in the (upper) arm. It gives vascular branches to the wall of the brachial artery. These vascular branches carry sympathetic fibers.ForearmIt innervates all of the flexors in the forearm except flexor carpi ulnaris and that part of flexor digitorum profundus that supplies the medial two digits. The latter two muscles are supplied by the ulnar nerve (specifically the Muscular branches of ulnar nerve).The main portion of the median nerve supplies the following muscles:Superficial group:Pronator teres Flexor carpi radialis Palmaris longusIntermediate group:Flexor digitorum superficialis muscleThe anterior interosseus branch of the median nerve supplies the following muscles:Deep group:Flexor digitorum profundus (only the lateral half) Flexor pollicis longusPronator quadratus

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MEDIAN NERVEBranches in the handThe median nerve enters the hand through the carpal tunnel, deep to the flexor retinaculum along with the tendons of flexor digitorum superficialis, flexor digitorum profundus, and flexor pollicis longus.From there it sends off several branches:1. Recurrent branch to muscles of the thenar compartment (the recurrent branch is also called "the million dollar nerve")[1]

2. Digital cutaneous branches to common palmar digital branch and proper palmar digital branch of the median nerve which supply the:

a) lateral (radial) three and a half digits on the palmar side b) index, middle and ring finger on dorsum of the hand

The median nerve supplies motor innervation to the first and second lumbricalmuscles.

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HandIn the hand, the median nerve supplies motor innervation to the 1st and 2nd lumbricalmuscles.

It also supplies the muscles of the thenareminence by a recurrent thenar branch.

The rest of the intrinsic muscles of the hand are supplied by the ulnar nerve.

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The muscles of the hand supplied by the median nerve can be

remembered using the mnemonic, "LOAF" for

Lumbricals 1 & 2,

Opponens pollicis,

Abductor pollicis brevis

and Flexor pollicis brevis.

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The median nerve innervates the skin of the palmar side of the thumb, the index and middle finger,

half the ring finger, and the nail bed of these fingers

The Opponens pollicis muscle is innervated exclusively by the Median nerve

. The inability to firmly hold an object between the index finger and thumb is a classic sign of Median nerve pathology.

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The lateral part of the palm is supplied by the palmarcutaneous branch of the median nerve, which leaves the nerve proximal to the wrist creases.

This palmar cutaneous branch travels in a separate fascial groove adjacent to the flexor carpi radialis and then superficial to the flexor retinaculum.

It is therefore spared in carpal tunnel syndrome.

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ULNAR NERVE

ArmThe ulnar nerve comes from the medial cord of the brachial plexus, and descends on the posteromedial aspect of the humerus. It goes behind the medial epicondyle, through the cubital tunnel, at the elbow

ForearmIt enters the anterior (flexor) compartment of the forearm through the two heads of flexor carpi ulnaris and runs alongside the ulna. There it supplies one and a half muscles (flexor carpi ulnaris & medial half of flexor digitorum profundus).It soon joins with the ulnar artery, and the two travel inferiorly together, deep to the flexor carpi ulnaris muscle.

In the forearm it gives off the following branches:[2]

Muscular branches of ulnar nervePalmar branch of ulnar nerveDorsal branch of ulnar nerve

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Hand

After it travels down the ulna, the ulnar nerve enters the palm of

the hand.

The ulnar nerve and artery pass superficial to the

flexor retinaculum, via the ulnar canal

The course of the ulnar nerve through the wrist contrasts with

that of the median nerve, which travels deep to the flexor retinaculum of the hand and therefore through the carpal tunnel

In the handUlnar nerve gives

Superficial branch of ulnar nerveDeep branch of ulnar nerve

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HAND ANATOMYAND

THE WRIST

Page 178: Upper Limb

Carpal bones1. scaphoid2. lunate3. triquetrum4. pisiform5. trapezium 6. trapezoid 7. capitate8. hamate hook of hamate

Metacarpal bones9. I 10. II 11. III 12. IV 13. V

Phalanges proximal 14 middle 15 distal 16

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•flexor retinaculum (FR) •1 scaphoid•2 trapezium •3 pisiform•4 hamate

median nerve tendons of flexor digitorum superficialistendons of flexor digitorum profundustendon of flexor pollicis longustendon of flexor carpi radialis

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Muscles of the Hand From Superficial to Deep

The intrinsic muscles of the hand can be arranged into three groups

according to either to a region or to depth.

Regional groups of muscles are the thenar and hypothenar group.

The thenar muscles are three in number and act on the thumb.

The hypothenar group are three in number and act on the little finger.

The ramainder muscles can be arranged from superficial to deep as

shown in the diagrams below.

Once the palmar aponeurosis is removed, the first layer is made up of

the tendons of the flexor digitorum superficialis. This and the other

layers are shown below.

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Flexor digitorumsuperficialis

Palmar aponeurosis Lumbricals

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Palmar interossei

Dorsal interossei

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The superficial arterial arch is formed mainly from the ulnar artery and is completed by the superficial branch of the radial. This completion is not always present or may be extremely small.The deep arterial arch is formed mainly by the deep branch of the radial artery andis finished by the deep branch of the ulnar artery.

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The dorsal venous plexus of the hand and the ensuing cephalic (1) and basilic (2) veins drain the superficial aspects of the hand.

The cephalic vein ends up in the axillary vein just before it becomes the subclavian and the basilic vein joins the brachial vein to become the axillary vein.

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posterior antebrachial cutaneous skin of dorsum of wrist

radial nerveskin of dorsum of thumb and

2 1/2 digits as far as the distal interphalangeal joint

ulnar nerveulnar 1 1/2 digits and

adjacent part of dorsum of hand

Dorsum of Hand

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ulnar nerve

sensory to skin of ulnar 1 1/2 digits

motor to muscles of hypothenar eminence

motor to ulnar two lumbricalsmotor to 7 interossei

motor to adductor pollicismuscle

median nerve

sensory to skin of palmaraspect of thumb and 2 1/2

digits including the skin on the dorsal

aspect of the distal phalanges

motor to muscles of thenareminence

motor to radial two lumbricalmuscles

palm of hand

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abductor digiti minimi (hypothenar muscle)

pisiformproximal phalanx of little

fingerulnar abducts little finger

flexor digiti minimi (hypothenar muscle)

flexor retinaculumhook of hamate

proximal phalanx of little finger

ulnar flexes little finger

opponens digiti minimi (hypothenar muscle)

flexor retinaculumhook of hamate

5th metacarpal ulnaropposes little finger to

other digits

palmar interosseus Imedial side of 2nd

metacarpalmedial base of index finger ulnar

adducts index finger towards middle finger

interosseous IIlateral side of 4th

metacarpallateral base of ring finger ulnar

adducts ring finger towards middle finger

interosseous IIIlateral side of 5th

metacarpalmedial base of little finger ulnar

adducts little finger towards middle finger

dorsal interosseous Iadjacent sides of

metacarpal boneslateral aspect of extensor expansion of ring finger

ulnarabducts ring finger away

from middle finger

dorsal interosseous IIadjacent sides of

metacarpal bonesmedial aspect of extensor expansion of middle finger

ulnarabducts the middle finger

away from its long axis

dorsal interosseous IIIadjacent sides of

metacarpal boneslateral aspect of extensor

expansion of middle fingerulnar

abducts the middle finger away from its long axis

dorsal interosseous IVadjacent sides of

metacarpal boneslateral aspect of extensor expansion of index finger

ulnarabducts the index finger away from the middle

finger

lumbricals I & IItendons of flexor

digitorum superficialislateral aspect of extensor

expansionmedian

flex the metacarpophalangeal joint extend the interphalangeal

joints

lumbricals III & IVtendons of flexor

digitorum superficialislateral aspect of extensor

expansionulnar

flex the metacarpophalangeal joint extend the interphalangeal

joints

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deep nerves of palm of hand

superficial nervesof palm of hand

dorsum of the hand

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The anatomical snuffbox,

or radial fossa, (in Latin Foveola radialis),

is a triangular deepening on the radial, dorsal aspect of the hand –at the level of the carpal bones,

specifically, the scaphoid and trapezium bones forming the floor.

The name originates from the use of this surface for placing and then sniffing powdered tobacco, or “snuff.”

Anatomical snuff box

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Anatomical snuff box

The boundaries

The medial border of the snuffbox is the tendon of the extensor pollicis longus.

The lateral border tendons, of the extensor pollicis brevis and the abductor pollicislongus.

The proximal border is formed by the styloid process of the radius

The distal border is formed by the approximate apex of the schematic snuffbox isosceles triangle.

The floor of the snuffbox varies depending on the position of the wrist, but both the trapezium and primarily the scaphoid can be palpated.

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Deep to the tendons which form the borders of the anatomical snuff box liesthe radial artery,

which passes through the anatomical snuffbox on its course from the normal radial pulse detecting area,to the proximal space in between the first and second metacarpals to contributeto the superficial and deep palmar arches.

The cephalic vein arises within the anatomical snuffbox,

while the dorsal cutaneous branch of the radial nerve can be palpated by stroking along the extensor pollicis longus with the dorsal aspect of a fingernail

Page 207: Upper Limb
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Ligaments Of The Upper LimbThe acromio-clavicular ligament joins the acromion process to the clavicle.The coraco-clavicular ligament joins the coracoid process to the clavicle.The coraco-acromial ligament joins the coracoid process to the acromion process.

The ligaments of the shoulder-joint are :1. Capsular. 3. Gleno-humeral.2. Coraco-humeral. 4. Glenoid

The ligaments of the elbow are in the form of a capsule which surrounds the joint on all sides. They are the(1) External lateral, (3) Anterior,(2) Internal lateral, (4) Posterior.

The ligaments of the wrist are the(1) Anterior, (3) Internal lateral,(2) Posterior, (4) External lateral.

Synovial Membrane.—The pisiform, and the upper metacarpal joint of the thumb, have each a separate synovial membrane. The other carpal and metacarpal joints have a single synovial membrane.

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Zone I consists of the profundus tendon only and is bounded proximally by the insertion of the superficialis tendons and distally by the insertion of the FDP tendon into the distal phalanx. Zone II is often referred to as "Bunnell's no man's land," . Proximal to zone II, the flexor digitorum superficialis (FDS) tendons lie superficial to the flexor digitorum profundus (FDP) tendons.

Within zone II and at the level of the proximal third of the proximal phalanx,

the FDS tendons split into 2 slips, collectively known as Camper chiasma. These slips then divide around the FDP tendon and reunite on the dorsal

aspect of the FDP, inserting into the distal end of the middle phalanx

The 5 flexor tendon zones in the hand are

Zone III extends from the distal edge of the carpal ligament to the proximal edge of the A1 pulley, Within zone III, the lumbrical muscles originate from the FDP tendons. The distal palmar crease superficially marks the termination of zone III and the beginning of zone II.

Zone IV includes the carpal tunnel and its contents (ie, the 9 digital flexors and the median nerve).

Zone V extends from the origin of the flexor tendons at their respective muscle bellies to the proximal edge of the carpal tunnel.

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Retinacular portion of the flexor tendon sheath (pulley system).

Membranous portion of the flexor tendon sheath

Flexor tendons with attached vincula.

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The forearm can be divided anatomically into anterior and posterior compartments. The anterior compartment contains the flexor-pronator group of muscles, most of which arise from a common flexor attachment on the medial epicondyle of the humerus.The 8 muscles of the anterior compartment may be divided further into 3 distinct functional groups, as follows: (1) muscles that rotate the radius on the ulna, (2) (2) muscles that flex the wrist, and (3) (3) muscles that flex the digits. The muscles that flex the digits include the flexor digitorum profundus (FDP),

flexor digitorum superficialis (FDS), and the flexor pollicis longus (FPL).

Flexor Muscles of the Digits

Page 219: Upper Limb

The digital flexor sheath is a closed synovial system consisting of both membranous and retinacular portions.The membranous portion comprises visceral and parietal layers that invest the flexor digitorum profundus (FDP) and flexor digitorum superficialis (FDS) tendons in the distal aspect of the hand.

The retinacular component consists of tissue condensations arranged in cruciform, annular, and transverse patterns that overlie the membranous, or synovial, lining.

The digital flexor sheath has been proposed to have a 3-fold function, as follows: (1) it facilitates smooth gliding of the tendons; (2) the retinacular component acts as a fulcrum, adding a mechanical advantage

to flexion;(3) it is a contained system, or bursa, with synovial fluid bathing the tendons and

aiding in their nutrition.

Digital Flexor Sheath

Page 220: Upper Limb

The membranous portion of the sheath appears macroscopically as a number of cul-de-sacs, or plicae, that interdigitate between both the tendons and the retinacular tissue condensations.

The first cul-de-sac is located approximately 10-14 mm proximal to the distal metacarpal head and represents the point of transition between the parietal and visceral layers of synovium.

This outpouching occurs for each separate tendon, in effect forming 2 separate plicae. (Note that this is true only for the middle 3 rays of the hand.

In most instances, both the first- and fifth-digit synovial layers begin much more proximally at the level of the wrist, and are referred to as the radial and ulnar bursa, respectively.)

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Distally, the parietal layer of synovium forms plicae between each of the retinacularelements of the pulley system.

The synovium ends distally, forming a final single cul-de-sac prior to the insertion of the FDP tendon on the distal phalanx.

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Zone 1 (distal interphalangeal [DIP] joint) Zone 2 (middle phalanx) Zone 3 (proximal interphalangeal [PIP] joint) Zone 4 (proximal phalanx) Zone 5 (metacarpophalangeal [MCP] joint) Zone 6 (dorsum of hand) Zone 7 (wrist) Zone 8 (dorsal forearm)

Extensor TendonZones of hand.

The dorsum of the hand, wrist, and forearm are divided into 8 anatomic zones