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Anatomy For Upper limbs http://www.muhadharaty.com/anatomy-upper I http://goo.gl/rjRf4F I LOKA © Content Topics: Page: The axilla 3 The breast 11 The arm 16 The forearm 24 The hand 29 Joints 32 Arteries 36 Make it easy! 38 Part1: The Axilla 1- Is a pyramidal space between the upper part of the arm & the lateral thoracic wall 2- It has : 4 walls (anterior , posterior , medial , lateral) Apex Base The apex 1- Is pointed upward in the direction of the root of the neck (to receive the brachial plexus) 2- It communicates with the superior aperture (inlet thorax) of thorax (to receive the axillary artery –(continuity of subclavian artery)-) 3- Apex is known as "Cervico-axillary canal" 4- It allows the passage of the "Neuro-vascular bundle"( brachial plexus & Axillary artery) to the upper limb 5- It has bony boundaries : The clavicle anteriorly. Outer border of the first rib medially Upper part of the scapula posteriorl The base 1- Is formed by skin & superficial fascia of the axilla 2- Its bounded by ( anterior axillary fold anteriorly, posterior axillary fold posteriorly , the chest wall medially ) Note : The lateral border of Pectoralis major M forms the anterior fold of the axilla. The posterior fold forms by latissimus dorsi & teres major Ms 3- it is concave when the limb is beside the trunk 4- it becomes flat & straight on raising and abducting the limb due to suspensory ligament of the axilla. The anterior wall 1- is formed by : The clavicle 3 muscles ( Pectoralis major & minor Ms in addition to the subclavius M) The Clavi-pectoral fascia muscle Origin (arises from) insertion Nerve supply (innervate) Main actions Pectoralis major 1- clavicular head : anterior surface of medial half of clavicle 2- sternocostal head : anterior surface of sternum , superior six costal cartilages 3- abdominal head Outer lip of the intertubercul ar groove(crest of Greater tubercle ) Medial and lateral pectoral nerves Adducts and medially rotates humerus at shoulder joint Pectoralis minor From 3rd to 5th ribs near their costal cartilages Superior surface of coracoid process of scapula Medial Produces the pectoral nerve depression of the scapula subclavius From costal cartilage of the first rib Subclavius groove on inferior surface of clavicle Nerve to subclavius Anchors and depresses clavicle at steronclavicular joint. The clavipectoral fascia: 12345- Is part of the deep fascia attached to the clavicle it encloses the subclavius M then descends down ward deep to Pectoralis major & enclosing Pectoralis minor M ends as suspensory ligament of the axilla Function : it protects the contents of the axilla by filling in the interval between the clavicle and the Pectoralis minor M. 6- It is pierced by the following structures: Lateral pectoral nerve.(as it passes to the Pectoralis major M.) Cephalic vein Pectoral branch of thoracoacromial artery. Some lymphatic vessels The posterior wall Is formed by 3 muscles, these are subscapularis, teres major & latissimus dorsi Ms. muscle Origin (arises from) insertion Nerve supply (innervated) subscapularis Subscapular fossa of scapula Lesser tuberosity of humerus Teres major Posterior surface of lateral border of scapula near the inferior angle Medial lip of Lower intertubercular subscapular groove (crest nerve of lesser tubercle) Latissimus dorsi A- Spines of T7_T12 Into the floor vertebrae. of intertubercular B- Thoracolumbar (Bicipital) fascia. groove C- Iliac crest of the Hip bone. Main actions Upper and 1- Medially lower rotates subscapular shoulder joint nerve (from and adducts it posterior cord) 2- Helps to hold humeral head in glenoid cavity Adducts and medially rotates shoulder joint The middle Adducts shoulder subscapular joint (thoracodorsal) Elevates body nerve toward arms during climbing D- Inferior angle of scapula The medial wall Is formed by: The upper 4-5 ribs And their intercostal spaces And the upper part of serratus anterior muscle covering them muscle Origin insertion serratus External anterior (outer) surfaces of lateral parts of 1st to 8th-9th ribs Nerve supply Anterior Long surface of thoracic medial border nerve of scapula Main actions When it contract it pulls the scapula forward around the rib cage / when its upper or lower fibers contract separately they help to produce downward or upward rotation of the scapula The lateral wall Is formed by the intertubercular ( Bicipital ) groove containing the coracobrachialis M & short head of Biceps The Contents of the Axilla The axillary vessels The Brachial plexus The axillary lymph nodes 1-The axillary vessels: 1- The axillary artery, starts as the continuity of the subclavian artery at the outer border of the first rib& ends at the lower border of teres major M( the lower limit of the axilla),where it continue as the Brachial artery. 2- The axillary artery is closely related to the cords of the brachial plexus and their branches and it is enclosed with them in a connective tissue sheath , called the "Axillary sheath" 3- is crossed by the Pectoralis minor M ,which divides it into 3 parts : The first part The second part The third part 1- Between outer border of first rib & the upper border of Pectoralis minor M 2- it gives a single branch known as highest thoracic or superior thoracic A ( is small and runs along the upper border of Pectoralis minor) 3- Relations : Anteriorly : Pectoralis major and the covering fascia and skin . the cephalic vein crosses the artery. Posteriorly : long thoracic nerve (nerve to serratus ant.) Laterally : three cords of the brachial plexus Medially : axillary vein. 1- lies behind Pectoralis minor M 2- is related to the 3 cords of the brachial plexus laterally to lateral cord medially to medial cord posteriorly to the posterior cord while anteriorly it is related to 1- extends from lower border of Pectoralis minor to lower border of teres major muscle where it continues as the Brachial artery 2- it is related to the derivatives of the 3 cords of the brachial plexus 3- Relations : it gives 3 branches It gives 2 branches thoracoacromia l (it gives 4 branches) 2 of them to bones (acromial & clavicular) other 2 to muscles (Deltoid & pectoral branches). subscapularis lateral thoracic descends to the side of the chest wall to accompany the long thoracic nerve within the substance of serratus anterior muscle. Pectoralis minor M 3- Relations : Anteriorly : Pectoralis minor , Pectoralis major , and the covering fascia and skin Posteriorly : posterior cord of brachial plexus , subscapularis muscle , and shoulder joint Laterally : lateral cord of brachial plexus Medially : medial cord of the brachial plexus and the axillary v thoracodorsal branch anterior & posterior circumflex humeral arteries around the surgical neck of the humerus circumflex scapular branch Anteriorly : Pectoralis major for a short distance , lower down the artery is crossed by medial root of median nerve. Posteriorly : subscapularis , latissimus dorsi and teres major . the axillary and radial nerve also lie behind the artery Laterally : coracobrachialis , biceps , and the humerus . the lateral root of median nerve and musculocutaneous nerve also lie on the lateral side Medially : ulnar nerve , axillary vein , and medial cutaneous nerve of the arm Note : 1- Thoracoacromial artery : pierces the clavipectoral fascia and immediately divides into terminal branches 2- Lateral thoracic artery : runs along the lower border of Pectoralis minor 3- Subscapular artery : runs along the lower border of subscapularis muscle 4- Anterior and posterior circumflex humeral arteries: run around the front and the back of the surgical neck of the humerus. 5- Axillary vein : it is formed in the region of the lower border of teres major muscle by the union of the venae comitantes of the brachial artery and basilic vein it runs upward on the medial side of the axillary artery and ends at the lateral border of the first rib becoming the subclavian vein 2-The Brachial plexus: 1- It is formed by : the ventral rami of lower 4 cervical nerves & the ventral ramus of the first thoracic nerve. 2- The first stage is roots arrangement to form trunks (C5& 6th form the upper trunk, C 7 alone forms the middle trunk while C 8 & T 1 form the lower ( inferior ) trunk .The second stage is the splitting of each trunk to form anterior & posterior divisions. The third stage is the formation of the 3 cords by the Re-union of these divisions .The posterior divisions of the 3 trunks unite to form the posterior cord ,the anterior division of the upper & middle trunks unite to form the lateral cord, while the anterior division of inferior trunk Forms the medial cord of the brachial plexus. 3- The last stage is the derivatives of each cord as follows: The posterior cord gives off: (ULTRA) The lateral cord gives the following derivatives:(2ML) The medial cord gives: (4MU) 1- Upper subscapular. 2- Middle subscapular (Thoracodorsal). 3- Lower subscapular 4- Axillary nerve. 5- Radial nerve. 1- Lateral pectoral nerve. 2- Musculocutaneous nerve. 3- Lateral root to median nerve. 12345- Medial pectoral nerve. Medial cutaneous of Arm. Medial cutaneous of forearm. Ulnar nerve. Medial root to median nerve. 4- In addition to these derivatives ,the upper trunk gives 2 branches suprascapular & nerve to subclavius muscle while the roots gives dorsal scapular & long thoracic nerve (C5-7) (Roots branch : 1- dorsal scapular 2- Long thoracic // Upper trunk branches : 1-Subclavian n. 2- Suprascapular n) 5- At the end of the brachial plexus the four main nerves of the arm emerge (musculocutaneous , median , ulnar, radial) 3-The axillary lymph nodes: Which are arranges in the following groups: 1- Anterior ( pectoral ) group Under anterior border of Pectoralis major M. Receives lymph vessels from : lateral quadrants of the breast Superficial vessels from the anterolateral abdominal wall above the level of the umbilicus 2- Posterior ( subscapular ) group Along the course of subscapular vessels. Receives superficial lymph vessels from the back , down as far as the level of the iliac crests 3- Lateral (humeral) group Along the course of the axillary V near Bicipital groove. Receives most of the lymph vessels of the upper limb (except those superficial vessels draining the lateral side) 4- Central group Within the loose areolar tissue of the base of the axilla. Receives lymph from the above three groups 5- Medial group Along the course of lateral thoracic vein. 6- Apical group in the apex of the axilla It receives lymphatic from the above groups & takes them (direct them) to the deep cervical nodes in the root of the neck. Part2: The Breast 1- Is rudimentary in male & well developed in the female specially in lactating woman 2- It is a modified sweat gland 3- Located : - under the superficial fascia covering the pectoral region - and lying on the deep fascia covering Pectoralis major & part of the serratus anterior Ms. 4- It extends from the side of the sternum medially to the anterior axillary fold laterally 5- ( part of it extends into the axilla as axillary tail of the breast) 6- while supero-inferiorly it extends from the level of 2nd rib to the 6th rib. 7- The gland consists of 15-20 lobes extending from the periphery of the gland to the area near the nipple Each lobe has its own duct( lactiferous duct) which opens externally in to the nipple( has about 15-20 openings) The nipple is a small conical projecting part surrounded by a lighter area ( Areola) o The breast is supplied by: 1- Pectoral branch of thoracoacromial artery. 2- Mammary branches from the lateral thoracic artery. 3- Perforating branches from the internal thoracic artery (i.e internal mammary A ). 4- Branches from intercostal arteries for the spaces 3rd-5th. Rotator Cuff Muscles: - are 4 in number surrounding the capsule of the shoulder joint to support &share in stabilizing the shoulder joint - One of these Ms. inserts into the lesser tuberosity ( Subscapularis ) - the other 3 are inserted into the greater tuberosity (Supraspinatus ,Infraspinatus & teres minor muscles) muscle Origin (arises from) insertion subscapularis Subscapular Lesser fossa of scapula tuberosity of humerus Nerve supply (innervated) Main actions Upper and lower subscapular nerve (from posterior cord) 1- Medially rotates shoulder joint and adducts it 2- Helps to hold humeral head in glenoid cavity Supraspinatous Supraspinous superior facet of Suprascapular fossa of scapula greater nerve tuberosity Abduct the humerus (shoulder joint) Infraspinatous Infraspinous Middle facet of fossa of scapula greater tuberosity Suprascapular nerve Teres minor Superior part of lateral border of scapula Axillary nerve 1- Laterally rotates shoulder joint 2- Helps to hold humeral head in glenoid cavity of scapula Inferior facet of greater tuberosity The muscles responsible for Abduction movement of the arm at shoulder joint are: 1- From 0 – 18 degree by Supraspinatous muscle. 2- 18—90 degree by Deltoid muscle(innervated by the Axillary nerve ). 3- Beyond 90 degree & above the head is by Trapezius & Serratus anterior muscles. The muscles attaching the limb to the back muscle Origin (arises from) insertion Nerve supply (innervated) Main actions Trapezius 1- From medial third of the superior nuchal line. 2- From ligamentum nuchae. 3- From the spine of C 7 vertebra 4- From spines of T1 –T 12 vertebrae transverse processes of upper 4 cervical vertebrae. - into the front of lateral third of the clavicle - acromion process - upper lip of the spine of the scapula. the spinal root of accessory nerve(11th cranial nerve)which is motor ,while proprioception sensations from C4 & C5 nerves. Elevates, retracts, and rotate the scapula. In the area around the superior angle of scapula dorsal scapular nerve from the ventral ramus of C5. Abduct the humerus (shoulder joint) spines of C 7 & T 1 vertebrae dorsal aspect of Dorsal scapular vertebral border nerve. of scapula at the base of the spine. Levator scapulae Rhomboid minor Depresses scapula. Superior rotation of scapula. 1- Retract scapula and rotate it to depress glenoid Rhomboid major spines of T 2 – T 5 vertebrae into dorsal dorsal scapular aspect of nerve vertebral border below the base of the spine till inferior angle of scapula 2- Fix scapula to thoracic wall Latissimus dorsi A- Spines of T 7 __T 12 vertebrae. Into the floor of intertubercular (Bicipital) groove Adducts shoulder joint B- Thoracolumbar fascia. C- Iliac crest of the Hip bone. The middle subscapular (thoracodorsal) nerve Elevates body toward arms during climbing D- Inferior angle of scapula Note : Leveator scapulae , Rhomboid major and minor : 1- are known collectively as Elevators of the scapula( one of them is levaetor scapulae) 2- all the 3 has a common nerve supply( dorsal scapular nerve) 3- all the 3 has a common action ( all of them work in elevating the scapula) Deltoid muscle: muscle Origin (arises from) Deltoid the same areas of the insertion of the trapezius M - the inferior aspect of the crest of spines of scapula - acromion process - lateral third of the clavicle insertion The M fibers from the 3 sites of origin converted into a single tendon of insertion & being inserted into the Deltoid tuberosity( on the lateral aspect of the middle part of the humerus). Nerve supply Axillary nerve Main actions 1- flexion of arm at shoulder joint(anterior fibers) 2- extension of the arm (posterior fibers) 3- abduction of the arm at shoulder ( middle fibers) 4- in fact it is considered as powerfull & main abductor M of the arm( from 18-90 degree) Note : if the Axillary nerve is injured or compressed by local haematoma due to fracture at the surgical neck of the humerus ,abduction becomes impossible because of loss of innervation of the deltoid M Part3: The Arm - The arm is surrounded by deep fascia ( brachial fascia ) - This fascia sends 2 septae attaching to medial & lateral compartments (muscles) compartments (muscles) anterior ( B.B.C muscles) posterior compartment which are flexors at the Elbow joint) is an Extensor compartment at the Elbow joint mainly Triceps M & lower down a small M (Anconeus M ). these Ms are Biceps brachi,Brachialis & Coracobrachialis. A. The anterior compartment contains the followings: 1- Muscles : The 3 Ms. ( B.B.C .) 2- blood : The Brachial Artery. 3- Nerve : Three nerves ( the Musculocutaneous ,Median & Ulnar nerves) 4- The stracture passing through : 1- musclucotanous nerve 2- median nerve 3- ulnar nerve 4- brachial artery 5- basilic vein 6- radial nerve (lower compartment) Origin insertion Biceps brachii - long head: from supraglenoid tubercle of the scapula, - short head: from coracoid process of scapula in common origin with the Coracobrachialis muscle the 2 head leads to a common belly of the muscle before going to insert ( by a single tendon) into the radial tubercle of the radius bone Brachialis anterior surface of the lower part of the shaft of the humerus its insertion into the front(anterior surface) of Coronoid process of the Ulna bone Coracobrachialis Coracoid process of the Scapula in common with the short head of Biceps on the medial aspect of upper part of the shaft of the humerus. Nerve supply Musculocutaneous N ( from lateral cord). muscle Main actions Biceps is a powerful supinator of the forearm in addition to flexion at the Elbow joint. It is a flexor at Elbow joint along with the Biceps M. Assists in flexion and adduction of shoulder joint. Notes: 1- The three B.B.C muscles are supplied by musculocutaneous nerve ( from lateral cord ).It is motor to the 3 Ms. & sensory to the skin on the lateral side of the F.A (How?) , where after supplying motor to the 3 Ms. of anterior compartment of Arm ,it will continue as lateral cutaneous nerve to the forearm. 2- The Musculocutaneous nerve motor component is only to the 3 Ms. of the anterior compartment , while both the Median & Ulnar are not supplying any structure in the Arm ,these 2 nerves just passing through the anterior compartment to reach their areas of destination( supply) in the F.A & the Palm of the Hand. Bicipital Aponeurosis As the tendon of Biceps passes through the front of Elbow (Cubital fossa) in its way to its insertion site it sends a flat ribbon like Aponeurosis medially & superficially to cover the terminal part of the brachial A+ the Median nerve known as Bicipital Aponeurosis. The Sensory Nerve supply of the Arm: 1- Medial cutaneous nerve of Arm from the Medial cord of the Brachial Plexus. 2- Upper lateral cutaneous of Arm from the Axillary nerve. 3- Lower lateral cutaneous nerve of Arm from the Radial nerve while running in the spiral ( Radial ) groove on the back of the shaft of the Humerus. 4- Posterior cutaneous nerve of Arm from Radial nerve as it descends through the Axilla. runs in the anterior compartment The Ulnar nerve then it passes through the 2 heads of origin of flexor carpi ulnaris M of the F.A. The Median nerve then both the terminal part of the Brachial A + the Median nerve are sheltered by Bicipital aponeurosis within the Cubital fossa then inters the medial intermuscular septa (leave the arm ) to reach the F.A by passing behind the medial Epicondyle of the humerus( by passing the cubital fossa) is formed on the anterolateral aspect of the beginning of the brachial A then it becomes on the lateral side of the upper third of the Brachial A then crossing obliquely in front of the middle third of the A ( from lateral to medial ) to becomes on the medial side of the lower third of the Brachial A B. The posterior compartment It contains: 1234- mainly the Triceps M the Radial nerve Profunda Brachi A and just inferiorly near the back of the Elbow joint, there is a small superficially placed slightly triangular muscle known as "Anconeus" Origin (arises from) insertion Triceps brachii - The long head: from The muscle fibers of the 3 heads of origin converge inferiorly into a single tendon which is inserted into the top of the Olecranon process of the Ulna bone Anconeus Lateral epicondyle of humerus infraglenoid tubercle of the scapula - The lateral head: from posterior aspect of the shaft of the Humerus above the spiral groove - the Medial head: from the back of the humerus below the spiral groove & slightly from the medial side of the Humerus Lateral surface of Olecranon and superior part of posterior surface of ulna Nerve supply Main actions it is a powerful Extensor muscle at the Elbow joint. Radial Nerve muscle assists triceps in extending elbow joint, stabilizes elbow joint , adducts ulna during pronation Notes: 1- The spiral groove separates the lateral head from the medial head of the Triceps. 2- The Triceps is supplied by many branches from the Radial nerve at different levels. There are 2 main Triangular spaces a superior horizontal one - between: 1- teres minor ( above ) 2- teres major ( below ) 3- the Surgical neck of the Humerus laterally. - This space is divided by the long head of Triceps into: a smaller triangular space medially - between 1- teres minor 2- teres major 3- long head of Triceps - transmits the Circumflex scapular branch of the Subscapular artery) a lateral Quadriangular space bounded by : 1- teres minor above 2- teres major below 3- long head of Triceps mediall 4- the Surgical neck of the Humerus laterally - transmits the Axillart nerve & posterior circumflex humeral A. The inferior vertical Triangular space - between: 1- teres major ( above ) 2- long head of Triceps (medially ) 3- the side of the Humerus. It transmits the Radial nerve & Profunda Brachi A (a branch from the Brachial A ). The Intermuscular Spaces Note : - The Axillary nerve as it passes through the Quadriangular space ,it divides into: anterior division : supplies the major part of the Deltoid M, posterior division :supplies teres minor ,the remaining part of the Deltoid and then continues as upper lateral cutaneous nerve of the Arm ( supplies the skin on the upper lateral part of Deltoid) The Cubital Fossa - Is a triangular depressed space in front of the Elbow joint - It is bounded by : the Pronator teres medially Brachioradialis laterally - its base is formed by an imaginary line joining the 2 epicondyles of the humerus - its apex is formed as brachioradialis M crosses over the pronator teres - The floor is formed by the insertion of Brachialis M & the supinator M below it - its roof is formed by the skin & fascia - The contents includes 2 groups as follows: A-The superficial contents are B-Deep group of structures includes 1-Median Cubital vein joining the Cephalic & Basilic veins. 1-The termination of the Brachial A & its bifurcation into Radial and Ulnar As. 2-Lateral cutaneous nerve of the F.A 2-The Median nerve just medial to the terminal laterally. part of the Brachial A. 3-Medial cutaneous nerve of F.A medially. 4-Bicepital Aponeurosis . 3-Tendon of Biceps Brachii in its way to reach its insertion site. 4-Radial nerve laterally emerging in the groove 5-Some superficial lymphatic vessels between Brachialis & Brachioradialis. & lymph nodes THE BRACHIAL ARTERY - Is the direct continuity of the Axillary artery at the lower border of Teres major M - it runs in the anterior compartment of the Arm & ends opposite the Neck of the Radius bone ( in the Cubital fossa ) by dividing into Ulnar & Radial As - It gives the following branches: 1- Profunda brachi ( Deep brachial , deep artery of arm) which goes to the Radial( spiral ) groove on the back of the shaft of the humerus accompanies by the Radial nerve ( after the Axilla) The A divides into 3 smaller branches while running in the spiral groove ascending branch to reach surgical neck of humerus & share in the anastomosis there with both anterior & posterior circumflex humeral A from 3rd part of Axillary A the second one is middle collateral descends on the back of the Arm to reach the back of Elbow joint the 3rd branch is the Radial collateral (considered the continuity of the profunda brachi A.This branch accompanies the Radial nerve into the front of lateral epicondyle. 2- Superior ulnar collateral A which accompanies the Ulnar nerve into the medial intermuscular septum. 3- Nutrient branch to the Humerus bone . 4- Muscular branches to supply B.B.C muscles of anterior compartment of Arm. 5- Inferior ulnar collateral which arises just above the Cubital fossa& goes to the medial intermuscular septum to join the Ulnar N. THE RADIAL NERVE In the Axilla Is the direct continuity of the posterior cord after giving off its branches. it gives branches to : - 2 muscular ( many branches to medial & lateral heads of triceps + Nerve to Anconeus M) - long head - other 2 branches as sensory these are : - medial head of Triceps M - posterior cutaneous nerve of Arm. then it divides within the Cubital fossa into: - Superficial (sensory) - deep branch (motor). The deep branch will pierce supinator & becomes posterior interosseous N. THE MEDIAN NERVE In the spiral groove it gives 4 branches : 1-lower lateral cutaneous of Arm 2- posterior cutaneous of F.A. then it leaves the septum to appear in the Cubital fossa between Brachialis & Brachioradialis Ms ( gives branches to both ) Is formed by a contribution from both lateral & medial cords of the Brachial plexus then descends within the anterior compartment of the Armin direct relation with the Brachial A Then the Radial N leaves the spiral groove & enters the lateral intermuscular septum with the Radial collateral A It reaches the Cubital fossa just medial to the terminal part of the Brachial A& becomes sheltered with the A by the Bicepital aponeurosis - It supplies 4 Ms of the superficial group of the flexor Ms of the F.A directly 1- Pronater teres 2- Flexor carpi radialis Finally it leaves the F.A by passing deep to Flexor Retinaculum to reach the Palm of the Hand. 3-Palmaris longus 4-Flexor digitorum superficialis) - it supplies two & a half Ms of the deep Flexor group indirectly (via the anterior interosseous branch of the Median N ) 1-to the lateral half of Flexor digitorum profundus 2-Flexor pollicis longus 3- Pronater quadratus Ms then the N leaves the Cubital fossa by passing between the 2 heads of the Pronater teres M Part4: The Forearm The Flexor Compartment of Forearm - Is the anteromedial compartment of the F.A - It includes 8 Ms. ( 5 of them are superficial & 3 deep) The superficial are : - Pronater teres - Flexor carpi radialis - Palmaris longus - Flexor digitorum superficialis - Flexor carpi Ulnaris The other 3 deep Ms are : - Flexor digitorum profundus - Flexor pollicis longus - Pronater quadratus Ms muscle Origin (arises from) insertion Nerve supply Pronater teres humeral head : arises from medial epicondyle& medial supracondylar line into the lateral surface - Four of them of the middle part of the are shaft of the Radius innervated bone. directly by ulnar head: from medial side of Coronoid process of the ulna. Flexor carpi radialis medial epicondyle of humerus into the base of the 2nd metacarpal bone. Palmaris longus medial epicondyle palmer aponeurosis. Flexor carpi ulnaris humeral head : from medial epicondyle into the Pisiform bone (one of the carpal bones). ulnar head: from medial side of olecranon process of ulna bone median N ,two & half indirectly (via the anterior interosseous branch of the median N ). - Flexor carpi ulnaris & The M gives 4 tendons medial half to the medial 4 fingers( each tendon inserts into of Flexor the sides of the middle digitorum phalange of the profundus corresponding finger). are supplied by the ulnar The M gives 4 tendons nerve. to the 4 medial fingers ( Flexor digitorm superficialis ,humeral head from medial epicondyle, ulnar collateral ligament & medial margin of coronoid process of ulna bone. While the radial head arises from oblique line on the anterior surface of the radius bone Flexor digitorum profundus from the upper 3/4(three fourth)of anterior, medial &posterior surfaces of the ulna bone and from anterior surface of interosseous membrane. Flexor pollicis longus takes origin from middle 2/4 of anterior surface of Radius bone &interosseous membrane into the base of distal phalanx of the thumb Pronater quadratus oblique line on the lower 1/4 of anterior surface of ulna bone into the lower 1/4 of anterior surface of the radius bone inserts into the base of the distal phalanges). THE FLEXOR RETINACULUM - It is the thickened part of the deep fascia of the F.A - located anteriorly at the junction between the F.A & palm of the hand in front of some carpal bones - It is attached to : pisiform & hook of hamate medially scaphoid & trapezium laterally - this fibrous retinaculum bridges over some carpal bones forming a fibro—osseous tunnel known as the "carpal tunnel" - the carpal tunnel through which pass the following structures: 1- Four tendons of Flexor digitorum superficialis. 2- Four tendons of Flexor digitorum profundus. 3- Tendon of Flexor pollicis longus . 4- The Median nerve.Thus the median N is liable for compression in certain circumstances leading to what is called Carpal Tunnel Syndrome. - The following structures cross superficial to Flexor Retinaculum: 1-Tendon of palmaris longus M. 2-The Ulnar Nerve. 3-The Ulnar Artery. 4-Palmer cutaneous branch of the Median nerve. it doesn’t supply any structure in the arm The Ulnar Nerve Is one of the branches of the medial cord of the Brachial plexus It leaves the Arm by passing behind the medial epicondyle of the humerus to reach the F.A just above the middle part of the Arm it pierces the medial intermuscular septum of the Arm (accompanied by both superior & inferior Ulnar collateral As ). Just before it leaves the F.A it gives palmer cutaneous branch which passes superficial to the Flexor retinaculum to reach the Palm of the hand. It passes between the 2 heads of Flexor carpi ulnaris to reach F.A. In the F.A it descends under cover the Flexor carpi ulnaris M accompanied by the Ulnar A. then at the lower part of the F.A it gives dorsal ulnar cutaneous branch which goes to the back of the hand to supply sensations It supplies : 1- Flexor carpi ulnaris 2- medial half of Flexor digitorum profundus M 5-Palmer cutaneous branch of the Ulnar nerve Posterior compartment of Forearm It includes 7 superficial & 5 deep Ms : The superficial are : - Brachioradialis - Extensor carpi radialis longus - Extensor carpi radialis brevis - Extensor digitorum - Extensor digiti minimi - Extensor carpi ulnaris - Anconeus The deep Ms are : - Abductor pollicis longus - Extensor pollicis brevis - Extensor pollicis longus - Extensor indices - Supinator muscle Origin (arises from) insertion 1- Brachioradialis - upper two thirds of lateral into the lateral side of Radius bone. supracondylar ridge - lateral intermuscular septum 2- Extensor carpi - lower third of lateral suracondylar radialis longus ridge into the base of 2nd metacarpal bone - lateral intermuscular septum 3- Extensor carpi radialis brevis - lateral epicondyle - radial collateral ligament into the base of the 3rd metacarpal bone 4- Extensor digitorum lateral epicondyle .It gives 4 tendons to the medial four fingers on the back& insert via extensor expansion to middle & distal phalanges. 5- Extensor digiti minimi lateral epicondyle too Its tendon join the tendon of extensor digitorum for the little finger 6- Extensor carpi ulnaris - lateral epicondyle - posterior border of Ulna bone the medial side of the base of 5th metacarpal bone. 7- Anconeus lateral epicondyle - into the lateral side of Olecranon process - upper one fourth of posterior surface of Ulna bone. 8- Abductor pollicis longus - posterior surface of Ulna - Radius below the Anconeus into the base of 1st metacarpal bone 9- Extensor pollicis brevis - posterior surface of Radius- from interosseous membrane To the base of the proximal phalanx of the Thumb. 10- Extensor pollicis longus - posterior surface of Ulna - interosseous membrane to the base of the distal phalanx of the Thumb 11- Extensor indices - from posterior surface of Ulna - interosseous membrane Its tendon goes with the tendon from extensor digitorum for the index finger & joins its extensor expansion 12- Supinator from many sites as: It wraps round the upper third of Radius to get insertion to the posterior surface ,lateral & anterior surfaces of the upper third of Radius bone - lateral epicondyle - Radial collateral ligament - annular ligament of superior Radioulnar joint - from Supinator crest of Ulna bone. Note: the following for innervations: 1-Brachioradialis & Extensor carpi radialis longus from Radial nerve before its division. 2-The Supinator by deep branch of Radial N as it pierces its substance. 3-Anconeus by the nerve to Anconeus given off by Radial N as it runs in Spiral groove. 4-All the rest of the Extensor Ms are supplied by the posterior interosseous N which is the direct continuity of the deep branch of Radial N as it leaves the substance of Supinator M to run on the posterior surface of the interosseous membrane. THE SNUFF BOX 1- Is seen at the base of the Thumb posteriorly 2- it is bounded : laterally ( or anteriorly )by the tendons of Abductor pollicis longus & that of Extensor pollicis brevis medially ( or posteriorly) by the tendon of Extensor pollicis longus 3- Its roof is formed by the skin & fascia being crossed superficially by the terminal branches of superficial branch of Radial N & the beginning of Cephalic vein 4- where as its floor is formed by Scaphoid bone + Styloid process of the Radius bone lying on them the Radial artery ( feel pulsation here). EXTENSOR RETINACULUM 1- Exactly like the Flexor Retinaculum on the back of the Wrist region at the junction between back of F.A & Dorsal aspect of the Hand 2- It is attached to : the lower end of anterior border of Radius ( laterally ) to the Pisiform + Triquetral bones with the Styloid process of Ulna ( medially ) 3- Deep to it the extensor tendons pass via 6 compartments. Part5: The Hand The palm of the hand consists of 4 compartment: Thennar compartment (3muscles) Hypothennar compartment abductor ,flexor and opponence pollicis brevis supplies by recurrent branch of median nerve. has (3ms) Central compartment contains: abductor and flexor digiti minimi and opponence digiti minimi supplies by the deep branch of ulnar nerve. palmer aponeurosis superficial palmer arch cutaneous branches of median nerve 8 tendons belong to flexor dugitorum superficialis and profundus four lumbrical muscles associated with the 4 tendons of flexor digitorum profundus Adductor -interosseous compartment has four palmer and 4 dorsal interossei muscles adductor pollicis muscle deep palmer arch deep branch of ulnar nerve and metacarpal bones Sensory nerve supply of hand are: A- Palm by 1- superficial branch of ulnar to medial one and half fingers 2- median nerve to supply lateral 3 and half finger 3- palmer cutaneous branches of median and ulnar nerve B- Dorsum of hand by 1- superficial branch of radial nerve 2- dorsal ulnar cutaneous branch Blood supply of palm of hand A- Deep palmer arch - which is formed mainly by deep palmer branch of radial artery - and to lesses extent by superficial palmer branch of ulnar artery Motor innervation of hand by A- Recurrent branch of median nerve to : 1- thennar muscles 2- the first 2 lumbrical also by median nerve. B- Deep branch of ulnar supplies : 1- adductor pollicis 2- 4palmer and 4 dorsal interossei 3- 3rd and 4th lumbrical muscles 4- the hypothennar muscles - B- Superficial palmer arch mainly by superficial palmer branch of ulnar artery and to lesser extent by superficial palmer bdanch of radial artery In addition to princeps pollicis Nd radialis indices from the radial artery The palmer interossei : are unipennate each one arises from the metacarpal bone of the same finger and they act in adduction of the fingers toward the middle finger. The dorsal interossei : are bipennate each one arises from contigous sides of adjacent metacarpal bone and acts in abduction of fingers or fanning out of fingers - The interossei are inserted into the extensor expansion on the back of the corresponding finger and all interossei are supplied by deep branch of ulnar nerve... Note : - The extensor digitorum muscle has 4 tendons one for each finger running on the back of the finger on reaching proximal phalanx - the tendon expand on each side of the proximal phalanx to meet together and inserts into the distal phalanx - while the central part of the tendon inserts into the middle phalanx of corresponding finger. Each extensor expansion receives the insertion of 3 small muscles these are one lumbrical, one dorsal and one palmer interossei Spaces in the hand are: 1- The pulp space on the palmer aspect of the finger 2- The thenner space at the base of the thumb. 3- Mid-palmar space just medial to thenner space. 4- Ulnar bursa surround the tendons of flexor digitorum superficialis and profundus and follows deep to flexor retinaculum and follows the flexor tendon to little finger. 5- Radial bursa follow the flexor tendons of flexor pollicis longus and that to index finger. - These spaces play a role in transmition of infection in the hand and with the forearm just proximal to flexor retinaculum The venous drainage of hand starts as dorsal venous arch which drains the fingers .From lateral side of the arch the cephalic vein starts and from ulnar side the basilic vein starts Part6: Joints THE SHOULDER JOINT - It is a synovial joint of ball & socket variety between the shallow glenoid cavity of Scapula & hemispheroidal head of Humerus ( both articular surfaces are covered by hyaline cartilage) - The concavity of Glenoid fossa is deepened by a fibro-cartilagenous rim known as Glenoid labrum. - The thin & lax capsule allows freedom of movements at the joint ,it is re-inforced by the tendons of the Rotator cuff Ms. - The capsule is lined by from inside by synovial membrane which forms a cavity (synovial cavity). - The ligaments of the joint are: 1- Glenohumeral ligaments which are 3 in number, superior ,middle & inferior (known as intrinsic ligaments). 2- Coraco-humeral ligament( Extrinsic ligament ).It is a thick band from the root of coracoid process to the upper part of the front of greater tuberosity. 3- Transverse humeral ligament ( Extrinsic ) ,it stretches between the lips of Bicepital groove of the humerus converting it into a canal for the passage of the tendon of long head of biceps. 4- Coraco-acromial ligament( accessory),its apex attached to the acromion & its base attaches to the lateral border of the Coracoid process. 5- There are 4 bursae related to the joint ,these are the subscapular, infraspinatous, Subacromial & subcoracoid bursae. - The joint receives articular ( sensory ) nerve supply from the Axillary & Suprascapular nerves. - It receives blood supply from anterior & posterior circumflex humeral ,and also from circumflex scapular & Suprascapular arteries. - The movements are as follows: 1- Flexion is performed by anterior fibers of Deltoid, clavicular head of Pectoralis major, Biceps & Coracobrachialis muscles. 2- Extension by posterior fibers of Deltoid& teres major muscles. 3- Abduction by Supraspinatous up to 18 degree, then by the lateral fibers of Deltoid from 18—90 degree. Beyond 80 degree occurs at the shoulder girdle due to rotation of scapula by Trapezius & Serratus anterior muscles. 4- Adduction by Pectoralis major & Latissimus dorsi muscles. 5- Medial rotation by Pectoralis major, anterior fibers of Deltoid& Subscapularis . 6- Lateral rotation by posterior fibers of Deltoid, Infraspinatous & Teres minor Ms. 7- Circumduction is a combination of all the above movements. Applied Anatomy: 1- Due to instability of the joint & laxity of the capsule, it is frequently lible to inferior dislocation( the capsule here is least protected by muscles.This dislocation may cause injury or pressure on the Axillary nerve. 2- Osteoarthritis & Rheumatoid arthritis which may needs artificial joint replacement, 3- Supraspinatous tendinitis is usually secondary to subacromial bursitis,thus results in the inability to initiate abduction. THE ELBOW JOINT - Is a compound synovial joint of hinge variety, includes 2 articulations a Humeroulnar & Humeroradial. - The Trochlea of the humerus articulates with the Trochlear notch of Ulna. - The Capitulum of Humerus articulates with head of Radius, they are covered by hyaline cartilage. - The capsule is attached 1- (above ) in front to the medial epicondyle and upper margins of Coronoid & Radial fossa, 2- but from behind along the trochlear margin, margin of Olecranon fossa & over the Capitulum. 3- Below along the margins of the Coronoid & Olecranon processes and to the Annular ligament around the head of the Radius. 4- The inner surface of the Capsule & the 3 fossae are lined by synovial membrane. Ligaments are the followings: 1- Ulnar collateral (Medial) ligament. It is triangular band with anterior, posterior & inferior thick bands and middle thin part. 2- Radial collateral (lateral) ligament .It extends from lateral epicondyle of the Humerus to the Annular collateral ligament. 3- Anterior & posterior ligaments which strengthen the capsule in front &behind. The main relations are as follows: 1- Anteriorly by Brachialis, tendon of Biceps, Median N & Brachial artery. 2- Posteriorly by Anconeus & insertion of Triceps. 3- Medially by common Flexor origin & the Ulnar nerve. 4- Laterally by common Extensor origin & Supinator M. - The joint are supplied by articular (sensory) branches from Radial & Musculocutaneous nerves. - The blood supply by branches from the anastomosis around the Elbow joint. The main movements at the joint are the followings: 1- Flexion movement is performed by Brachialis & Biceps . 2- Extension is performed by Triceps & Anconeus. Applied Anatomy includes the following cases: 1- Dislocation which is usually a posterior one &is often associated with fracture of the Coronoid process. Here the Anatomical Triangular relation ship between the Olecranon & the 2 Epicondyles is lost. 2- Subluxation of the head of Radius(pulled elbow) occurs in children when the F.A is suddenly pulled in Pronation movement.The head of the Radius slips away from the Annular ligament.The Elbow is kept fixed in slight Flexion & Pronation,while Supination is limited and is painfull. 3- Tennis Elbow.Any abrupt Pronation may lead to pain & tenderness over the lateral epicondyle.This is possibly due to the following factors: A- The sprain of Radial collateral ligament. B- Tearing of the fibers of Extensor carpi Radialis Brevis. C- Inflamation of the Bursa related to M tendon. 4- Student's Elbow: Repeated excessive friction may cause inflammation of subcutaneous Olecranon Bursa.Gout may cause subcutaneous Bursitis. 5- Effusion of the joint,leads to distension which occurs posteriorly ,because here the Capsule is weak&the covering deep fascia is thin.Aspiration is done on any side of the Olecranon to remove the fluids Anastomosis Around scapula: 1- Suprascapular a. (from subclavian a.). 2- Transverse cervical a. (from thyrocervical trunk). 3- Circumflex scapular a. (from the subscapular of 3rd part of axillary a.). 4- Thoracodorsal a. (from the subscapular of 3rd part of axillary a.). 5- Posterior intercostal. Around elbow joint: 1- Around the medial epicondyle: From above: Superior ulnar collateral a. Inferior ulnar collateral a. From below: Anterior ulnar recurrent a. Posterior ulnar recurrent a. Interosseous a. 2- Around lateral epicondyle: From above: Radial collateral a. Middle collateral a. From below: Radial recurrent a. Part7: Arteries Subclavian artery axillary a. brachial Radial a. (laterally) and ulnar a. (medially) deep palmar arch and superficial palmar arch. Axillary artery: 1- First part: Supreme thoracic (highest thoracic, superior thoracic). Supply first and second intercostal spaces and superior part of serrotus anterior. 2- Second part: Thoraco-acromial (medial) clavicular, acromial, pectoral, deltoid. Lateral thoracic (lateral) supplies lateral aspect of breast. 3- Third part: Circumflex humeral (anterior and posterior). Subscapular circumflex scapular, thoracodorsal. Note: thoracodorsal a. + thoracodorsal nerve both enter latisimuss dorsi. Brachial artery: 1- Profunda brachii ascending branch (deltoid), middle collateral, radial collateral. 2- Superior Ulnar collateral. 3- Inferior Ulnar collateral. 4- Common unterosseous artery (superior of interosseous membrane) anterior and posterior. Radial artery: Start in the elbow rejoin at the level of head of radius. Course: 1- Runs inferolaterally under cover of brachioradials. 2- Then it lies lateral to flexor carpi radialis tendon distal forearm. 3- Finally it winds around lateral aspect of radius and crosses the floor of snuff box to pass between the 2 heads of first dorsal interosseous muscle. 4- Take part in forming the deep palmar arch. Branches of radial artery: 1- In the forearm radial recurrent a. – palmer carpal branch – superficial palmer branch. 2- At the wrist dorsal carpal branch – first dorsal metacarpal artery. 3- In the hand princeps pollicis – radialis indicis – deep palmer arch. Ulnar artery: Disappears from the cubital fossa by passing deep to the deep head of pronator teres and beneth flexor digitorum superficialis near the median nerve. Leaves the median nerve and lies on flexor digitorum profunds with the ulnar nerve to its medial side and passes down over the front wrist into the palm where it continues as the superficial palmer arch. Part8: Make it easy!