AFGALALY محمد عبد الفتاح جلال
AFGALALY محمد عبد الفتاح جلال
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LIST OF STRUCTURES TO IDENTIFY IN THE UPPER LIMB AND BACK
These lists are included as a review of items that you should be able to
identify on a drawing or a cadaver.
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Muscles
|  adductor pollicis |
| palmar interossei (I, II, III) |
| dorsal interossei (I, II, III, IV) | |
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Arteries
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Nerves
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Veins
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Lymphatics
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Vertebral Column and 3 Typical Vertebrae and Their Parts |
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Three curvatures of the vertebral column:
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Parts of a typical vertebra
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The muscles of the back can be broken down into three groups:
| superficial - muscles that act on the upper limb |
| intermediate - muscles of thorax |
| deep - muscles of vertebral column |
There are 5 pairs of muscles in the superficial layer (3 are deep to the trapezius>:
| trapezius |
| latissimus dorsi |
| rhomboid major |
| rhomboid minor |
| levator scapulae |
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| The nerves that supply the muscles in this region are the: |
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| The arteries that supply the muscles in this region are the: |
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| Clavicle |
| Scapula |
| Upper posterior humerus |
Clavicle
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Scapula
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| posterior humerus |
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ARTERIES (red) |
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| NERVES (green) |
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| The origins of the vessels and nerves will be covered later. For now, just remember their names. |
| MUSCLE | ORIGIN | INSERTION | ACTION | INNERVATION |
| trapezius | superior nuchal line of occipital bone nuchal ligament spines of 7th & all thoracic vertebrae |
lateral third of clavicle median margin of acromion scapular spine |
elevates shoulder laterally rotates scapula retracts scapula on thoracic wall |
spinal accessory n. |
| latissimus dorsi | spinous processes of lower thoracic vertebrae lumbodorsal fascia crest of ilium |
floor of intertubercular groove of humerus |
adducts, extends, medially rotates arm | thoracodorsal n. |
| rhomboid major | spinous processes of 2nd thru 5th thoracic vertebrae |
medial border of scapula below root of scapular spine |
retracts and medially rotates scapula | dorsal scapular n. |
| rhomboid minor | spine of 7th cervical and 1st thoracic vertebrae lower part of nuchal ligament |
medial margin of scapula at the root of the scapular spine |
retracts and medially rotates scapula | dorsal scapular n. |
| levator scapulae | transverse processes of C1-C4 | medial border of scapula above root of scapular spine |
raises scapula | dorsal scapular n. |
| supraspinous | supraspinous fossa of scapula | superior aspect of greater tubercle of humerus |
abducts the arm (1st 15 degrees) | suprascapular n. |
| infraspinous | infraspinous fossa of scapula | mid portion of greater tubercle of humerus |
rotates the arm laterally | suprascapular n. |
| teres minor | lateral border of scapula | lower aspect of greater tubercle of humerus | rotates arm laterally | axillary n. |
| teres major | inferior medial border of scapula | crest of lesser tubercle of humerus | adducts and rotates arm medially | lower subscapular n. |
| deltoid | lateral third of clavicle acromion process scapular spine |
deltoid tuberosity of humerus | abduction of arm from 15 degrees to 90 degrees | axillary n. |
| triceps, long head | infraglenoid tubercle of scapula | olecranon process of ulna | extends arm and forearm | radial n. |
You might recall that way back in Lesson 1 we examined the superficial layer of muscles of the back and they consisted of the:
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Once these muscles were reflected, the intermediate layer of muscles can be seen. This layer consists of two muscles that act on the ribs and are, therefore, related to the thorax in function.
Intermediate back muscles |
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Deep Muscles of the Back
The deep muscles of the back (intrinsic muscles) are responsible for keeping the body in the erect position during the waking hours, whether sitting or standing. You can imagine the amount of work that is placed on these muscles and why one of the population's most annoying medical problems is a painful back. You can also imagine how much money is spent to correct back problems. A correct posture and careful use of the back in carrying or picking up heavy objects is all that is necessary to allay most of back problems. The erector spinae group of muscles are the strongest muscles in the back and take on most of the work. The deep back muscles are both extensors and rotators of the axial skeleton. They are supplied segmentally by dorsal rami of the spinal nerves. Because of this segmental innervation, multiple injections of anesthetic are needed to relax these muscles.
Deep Back Muscles |
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The axilla, or armpit, is a localized region of the body between the upper humerus and thorax. It provides a passageway for the large, important arteries, nerves, veins and lymphatics which insure that the upper limb functions properly.
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The apex is pointing toward the root of the neck. It is formed by the convergence of the clavicle (anterior), the scapula (posterior) and the first rib (medially). All the nerves and vessels of the upper limb pass through this interval.
| Bones | Muscles | ||||||
| anterior | posterior | medial | lateral | anterior | posterior | medial | lateral |
| clavicle | scapula | ribs | humerus (intertuber- cular sulcus) |
pectoralis major pectoralis minor subclavius |
subscapularis teres minor teres major latissimus dorsi |
serratus anterior | tendon of long head of biceps |
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With one exception, all of the muscles of the upper limb are supplied by branches of the brachial plexus. The exception is the trapezius m. which is supplied by the cranial nerve (XI), spinal accessory.
| The brachial plexus starts in the neck from the ventral rami of
spinal nerves C5 - T1 (5th cervical to 1st thoracic spinal cord
segments). These rami are called roots. The roots will continue
through the neck and, some of them merge, to form trunks. C5 and C6
form the upper trunk, C7 continues as the middle trunk and C8 and T1
for the lower trunk. While still in the neck, the trunks divide into
anterior and posterior divisions. The divisions then reunite in
different patterns. The anterior divisions of the upper and middle
trunks merge to form the lateral cord. The anterior division of the
lower trunk continues as the medial cord. The posterior divisions of
all trunks merge to form the posterior cord. At this point, the cords
are in the axilla. The cords are named according to their relationship
with the axillary artery. Medial to it, lateral to it or posterior to
it. Finally, the cords give rise to various branches that supply the
upper limb structures. I want to point out that although most of the
branches to the upper limb muscles arise from the plexus in the axilla,
some arise from the cervical (neck) part of the plexus. These nerves
are the dorsal scapular, nerve to subclavius, long thoracic, and
suprascapular.
Needless to say, the brachial plexus is a very important structure
in the axilla and can be injured here through various types of
trauma (athletic injuries, humeral dislocations, crutch injuries,
surgical injuries), carcinomas and other pathological problems.
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| The brachial plexus starts in the neck from the ventral rami of
spinal nerves C5 - T1 (5th cervical to 1st thoracic spinal cord
segments). These rami are called roots. The roots will continue
through the neck and, some of them merge, to form trunks. C5 and C6
form the upper trunk, C7 continues as the middle trunk and C8 and T1
for the lower trunk. While still in the neck, the trunks divide into
anterior and posterior divisions. The divisions then reunite in
different patterns. The anterior divisions of the upper and middle
trunks merge to form the lateral cord. The anterior division of the
lower trunk continues as the medial cord. The posterior divisions of
all trunks merge to form the posterior cord. At this point, the cords
are in the axilla. The cords are named according to their relationship
with the axillary artery. Medial to it, lateral to it or posterior to
it. Finally, the cords give rise to various branches that supply the
upper limb structures. I want to point out that although most of the
branches to the upper limb muscles arise from the plexus in the axilla,
some arise from the cervical (neck) part of the plexus. These nerves
are the dorsal scapular, nerve to subclavius, long thoracic, and
suprascapular.
Needless to say, the brachial plexus is a very important structure
in the axilla and can be injured here through various types of
trauma (athletic injuries, humeral dislocations, crutch injuries,
surgical injuries), carcinomas and other pathological problems.
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Branches of Brachial Plexus |
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| Roots | Trunks | Cords | |||
| Lateral | Medial | Posterior | |||
| dorsal scapular (2) long thoracic (1) nerve to subclavius (3) |
suprascapular (4) | lateral pectoral (5) lateral head of median n. (6) musculocutaneous |
medial pectoral (8) medial cutaneous of arm (9) medial cutaneous of forearm(10) medial head of median n.(11) ulnar(12) |
upper subscapular(14) thoracodorsal(15) lower subscapular axillary(17) radial(18) |
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Branches of Brachial Plexus |
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| Roots | Trunks | Cords | |||
| Lateral | Medial | Posterior | |||
| dorsal scapular (2) long thoracic (1) nerve to subclavius (3) |
suprascapular (4) | lateral pectoral (5) lateral head of median n. (6) musculocutaneous |
medial pectoral (8) medial cutaneous of arm (9) medial cutaneous of forearm(10) medial head of median n.(11) ulnar(12) |
upper subscapular(14) thoracodorsal(15) lower subscapular axillary(17) radial( |
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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 pectoralis minor 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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Branches | |||||||
| First Part (1 branch) |
Second Part (2 branches) |
Third Part (3 branches) |
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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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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. The cephalic v. joins the axillary v. just before it becomes the subclavian. We won't give any further details here. This doesn't mean that it isn't important for maintaining proper function of the upper limb. I may be injured in sports as well as when a person uses a crutch. Penetrating wounds in the larger upper part are serious because air might enter into the venous system.
| 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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| This is the first time we have mentioned the lymphatic system so we need to consider an overview of the system to understand how it works. Without going into a detailed description, the following diagram shows the general makeup of a lymph node and its afferent and efferent vessels. The lymphatic system is part of the vascular system but it is very special in its ability to take in larger particles than the vascular system (i.e., bacteria, cancer cells, carbon). It is also part of the immune system of our body and, therefore, serves as a first line of protection against foreign bodies. This protection is subserved by cells of the immune system.
In general, lymph is picked up peripherally from
blind-ended vessels. These vessels are the afferents that lead to the lymph nodes. When the nodes are reached, the lymph percolates through a reticulum and is exposed to immune cells. The lymph then leaves the node by way of efferent vessels which may lead to another node or group of nodes, and re-exposed to immune cells. The efferent vessels from the last group of nodes then become larger and are called lymph trunks. The lymph trunks finally join to form lymph ducts. There are two lymph ducts and they are located in the neck. On the right side, the jugular and subclavian trunks join to form the right lymphatic duct. On the left side, the jugular and subclavian trunks empty into the thoracic duct. The two ducts then enter the venous system at the junction of the jugular vein and subclavian vein which become the brachiocephalic veins. |
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| The last of the axillary contents are the axillary lymph nodes. Lymph from the upper limb, shoulder and scapular regions, pectoral region (including the mammary gland) and upper abdomen drain through the axillary nodes. There are some 15 to 20 nodes usually arranged into to five groups. The groups consist of:
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The efferent lymph vessels from the right group of axillary nodes
finally forms into the subclavian lymphatic trunk which joins the jugular
trunk to form the right lymphatic duct which empties into the venous
system at the junction of the jugular and subclavian veins. On the left side the subclavian lymphatic trunk empties into the thoracic duct and then into the venous system at the junction of the jugular and subclavian veins |
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Muscles of the posterior compartment of arm |
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The arm bone is the humerus and the forearm bones are the radius and ulna.
Arteries of the ArmThe arteries of the anterior and posterior compartments of the arm are branches of the brachial artery which begins at the inferior margin of the teres major as a continuation of the axillary artery. Its branches are:
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.
Palm of the Hand
The hand is one of the most useful structures in the human body and
injuries to the hand should be taken care of carefully and
immediately. Plastic surgery of the hand is a specialty of medicine
and the surgeon must know the anatomy of the hand exceptionally well.
We will approach the anatomy of the hand just as we have the rest of
the upper limb, starting out with the skeleton of the hand, which
consists of 27 bones, more than half of the bones making up the entire
upper limb.
Bones of the hand
Flexor Retinaculum and Palmar AponeurosisWhen you first examine the wrist and hand you should examine the skin of the hand to identify any unusual marks. When the skin is removed, there are two dense connective tissue structures identifiable. The first crosses over the carpal bones, forming a bony tunnel and the second crosses over the long tendons of the fingers coming into the hand from the forearm.
The flexor retinaculum forms a space between it and the unerlying carpal
bones called the carpal tunnel. I am sure most of you have heard of or
have had the carpal tunnel syndrome. In this syndrome, the structures
under the retinaculum are compressed by swelling caused by irritation
and inflammation and the median nerve is weakened. If left untreated,
major paralysis to the small muscles of the hand can occur.
Yahoo! Music Unlimited - Access The details of the humerus are shown in the adjacent diagram.
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| The details of the radius and ulna are shown in the diagram. The structures you should be able to identify are:
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| There are two arteries entering the hand and these are
the: 1. radial 2. ulnar.
Together, the branches of these arteries form two
arterial arches: 1. superificial 2. deep.
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 and is finished by the deep branch of the ulnar artery.
These arteries and the branches of the
arches are shown in the adjacent diagrams. |
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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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| Muscle | Origin | Insertion | Nerve supply | Action |
| brachioradialis | lateral supracondylar ridge of humerus | styloid process of radius | radial | flexes forearm and supinates hand |
| extensor carpi radialis longus | lateral supracondylar ridge of humerus | base of 2nd metacarpal | radial | extends and abducts the wrist |
| extensor carpi radialis brevis | lateral epicondyle of humerus | base of 3rd metacarpal | radial | extends and abducts the wrist |
| extensor carpi ulnaris | lateral epicondyle of humerus posterior border of ulna |
base of 5th metacarpal | radial | extends and adducts the hand |
| extensor digitorum | lateral epicondyle of humerus | extensor expansion over fingers | radial | extends fingers, hand and forearm |
| extensor digiti minimi | lateral epicondyle of humerus | extensor expansion of little finger | radial | extends little finger |
| anconeus | back of lateral epicondyle of humerus | olecranon process poster surface of ulna |
radial | extends forearm |
| supinator | lateral epicondyle of humerus crest of ulna |
upper third of radius | radial | supinates the hand |
| abductor pollicis longus | posterior surface of ulnar middle aspect of radius |
base of 1st metacarpal | radial | abducts thumb |
| extensor pollicis brevis | middle 1/3rd of radius | base of proximal phalanx of thumb | radial | extends thumb |
| extensor pollicis longus | middle 1/3rd ulna & interosseous membrane | base of distal phalanx of thumb | radial | extends thumb |
| extensor indicis | posterior surface of ulna | extensor expansion of index finger | radial | extends index finger |
| abductor pollicis brevis (thenar muscle) | flexor retinaculum of wrist scaphoid & trapezium |
proximal phalanx of thumb | median | abducts the thumb |
| flexor pollicis brevis (thenar muscle) | flexor retinaculum trapezium |
proximal phalanx of thumb | median | flexes the thumb |
| opponens pollicis (thenar muscle) | trapezium & flexor retinaculum | lateral border of 1st metacarpal | median | opposes thumb to other digits |
| adductor pollicis | capitate 2nd & 3rd metacarpals |
proximal phalanx of thumb | ulnar | adducts the thumb |
| abductor digiti minimi (hypothenar muscle) | pisiform | proximal phalanx of little finger | ulnar | abducts little finger |
| flexor digiti minimi (hypothenar muscle) | flexor retinaculum hook of hamate |
proximal phalanx of little finger | ulnar | flexes little finger |
| opponens digiti minimi (hypothenar muscle) | flexor retinaculum hook of hamate |
5th metacarpal | ulnar | opposes little finger to other digits |
| palmar interosseus I | medial side of 2nd metacarpal | medial base of index finger | ulnar | adducts index finger towards middle finger |
| interosseous II | lateral side of 4th metacarpal | lateral base of ring finger | ulnar | adducts ring finger towards middle finger |
| interosseous III | lateral side of 5th metacarpal | medial base of little finger | ulnar | adducts little finger towards middle finger |
| dorsal interosseous I | adjacent sides of metacarpal bones | lateral aspect of extensor expansion of ring finger | ulnar | abducts ring finger away from middle finger |
| dorsal interosseous II | adjacent sides of metacarpal bones | medial aspect of extensor expansion of middle finger | ulnar | abducts the middle finger away from its long axis |
| dorsal interosseous III | adjacent sides of metacarpal bones | lateral aspect of extensor expansion of middle finger | ulnar | abducts the middle finger away from its long axis |
| dorsal interosseous IV | adjacent sides of metacarpal bones | lateral aspect of extensor expansion of index finger | ulnar | abducts the index finger away from the middle finger |
| lumbricals I & II | tendons of flexor digitorum superficialis | lateral aspect of extensor expansion | median | flex the metacarpophalangeal joint extend the interphalangeal joints |
| lumbricals III & IV | tendons of flexor digitorum superficialis | lateral aspect of extensor expansion | ulnar | flex the metacarpophalangeal joint extend the interphalangeal joints |
When the skin, palmar aponeurosis and flexor retinaculum are removed, the tendons of the flexor digitorum superficialis can be seen. Medial to the tendons is a group of muscles that act on the little finger, the hypothenar muscles. Lateral to the tendons is a group of muscles that act on the thumb (pollux), the thenar muscles. These two muscle groups are covered with deep fascia.
Muscles of the Hand From Superficial to Deep |
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| Palmar aponeurosis |
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Flexor digitorum superficialis |
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| Lumbricals |
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Palmar interossei |
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| Dorsal interossei |
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Muscles of the Thenar Eminence |
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Muscles of the Hypothenar Eminence |
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The nerve supply to a region is usually broken down into a superficial (or cutaneous) group and a motor group. In the hand, we will examine the superficial nerves first. A knowledge of the territories supplied by specific nerves is important clinically in order to solve nerve damage problems.
| posterior antebrachial cutaneous |
| radial |
| ulnar |
| median |
| dorsum of the hand |
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| superficial nerves of palm of hand |
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deep nerves of palm of hand |
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The classical distribution of the cutaneous nerves of the hand are as follows:
| posterior antebrachial cutaneous | skin of dorsum of wrist |
| radial nerve | skin of dorsum of thumb and 2 1/2 digits as far as the distal interphalangeal joint |
| ulnar nerve | ulnar 1 1/2 digits and adjacent part of dorsum of hand |
| ulnar nerve | sensory to skin of ulnar 1 1/2 digits motor to muscles of hypothenar eminence motor to ulnar two lumbricals motor to 7 interossei motor to adductor pollicis muscle |
| median nerve | sensory to skin of palmar aspect of thumb and 2 1/2 digits including the skin on the dorsal aspect of the distal phalanges motor to muscles of thenar eminence motor to radial two lumbrical muscles |
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Cutaneous nerves of forearm | Origin |
| lateral cutaneous nerve (antebrachial) | musculocutaneous | |
| posterior cutaneous nerve of forearm | radial | |
| medial cutaneous nerve of forearm | medial cord of brachial plexus | |
| dorsal ulnar nerve | ulnar | |
| superficial radial | radial |
The final items to examine in the upper limb are the joints.
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| Joint | Muscles that act on the joint | Action |
| sternoclavicular | sternomastoid subclavius trapezius |
moves in many directions like a ball and socket joint |
| acromioclavicular | moves with the movements of the upper limb | rotates and slides anterior and posterior |
| scapulothoracic | levator scapulae rhomboid minor rhomboid major serratus anterior trapezius pectoralis minor |
protraction retraction medial & lateral rotation |
| glenohumeral (shoulder) | pectoralis major latissimus dorsi teres major supraspinatus infraspinatus teres minor subscapularis coracobrachialis long and short heads of biceps brachii long head of triceps |
flexion extension abduction adduction medial rotation lateral rotation circumduction |
| elbow (radiohumeroulnar) | biceps brachii coracobrachialis brachialis triceps brachii brachioradialis anconeus superficial flexors of forearm superficial extensors of forearm |
flexion extension |
| superior and inferior radiounlar joints | pronator teres pronator quadratus supinator brachioradialis biceps |
pronation supination |
| radiocarpal (wrist) | flexor carpi radialis palmaris longus flexor carpi ulnaris flexor digitorum superficialis flexor digitoroum profundus flexor pollicis longus extensor carpi radialis longus extensor carpi radialis brevis extensor digitorum |
flexion extension abduction adduction |
| carpometacarpal | flexor digitorum superficialis flexor digitorum profundus lumbricals extensor indicis extensor digitorum palmar interossei dorsal interossei |
flexion extension |
| interphalangeal | flexor digitorum superficialis flexor digitorum profundus lumbricals extensor digitorum |
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This is an anteroposterior view of the right shoulder. The items to identify are obvious if you have learned your skeleton of this region. |
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The upper end of the humerus can be seen with its parts:
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Again, if you know your skeleton, you should be able to identify the structures on a radiograph. |
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Identify the:
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Now, identify those structures that you know from the study of the hand: |
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Every now and then you will see an extra bone and these are called sesamoid bones (S) |
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One of the things you should be able to do is to palpate
arteries in order to check to see if the heart is still beating or not.
There are several places in the upper limb that the arteries can be felt:
Other considerations are the anastomses that are found in the upper limb. An arterial anastomsis is one where a number of arteries coming from different sources communicate around a special organ or region. The details of these anastomoses will be added at a later time. In the upper limb there are three regions where important anastomoses occur:
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The hand is such an important part of the upper limb that we will
present its anastomoses. It is rather simple -- there are two palmar
arterial arches that are interconnected:
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Superficial veins are probably used more in a clinical situation that
any other part of the body. They are used for venipuncture, transfusion, and
catheterization. It important to be able to identify the location of the
major available veins in the upper limb. In an emergency situation, a
patient may arrive in shock, in which case, the veins are usually totally
collapsed. It might be up to you to find a vein to get into even if you have
to perform a cut down. These are the veins that you should be able to locate
or see:
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| Sometimes, when the superficial veins have collapsed, and you have to
transfuse, you must perform what is known as a cutdown. In the upper limb,
the best place to perform this is at the wrist, either laterally in the
cephalic vein (1) or medially in the cephalic vein (2) as they arise from
the dorsal venous arch. |
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| Lymph drainage of the upper limb usually follows the cephalic or basilic
veins. The thumb, index finger and lateral part of palm usually drains along
the path of the cephalic vein and empties into the infraclavicular group of
lymph nodes of the axillary group. Lymph drainage from the little finger and ring finger and medial palm travels through vessels along the basilic vein and is first filtered by the supratrochlear node just above the medial epicondyle of the humerus. From this node, the lymph reaches the lateral group of axillary lymph nodes where is again filtered. Therefore, if, during a physical examination, you feel an enlarged node just above the medial epicondyle of the humerus, you should suspect some sort of infection in the medial part of the hand. Usually when there is lymphadenitis the lymph vessels draining the area are appear as reddened streaks. |
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A very important structure that should be examined is the mammary gland.
Early detection of changes in this structure is of prime importance in cases
of malignancy. A knowledge of the lymph drainage of the mammary gland can
help as part of the diagnosis of mammary disease. For the purpose of
discussing the lymph drainage, the gland is subdivided into 4 quadrants (2
medial, 2 lateral). The lymph drainage of the mammary gland is:
The anterior group of lymph nodes are easily palpated and should always be part of a general examination in females. |
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Upper Lesions of the Brachial Plexus
|
| the suprascapular nerve (1) |
| musculocutaneous nerve(2) |
| axillary(3) |
| supraspinatus |
| infraspinatus |
| teres minor |
| biceps brachialis |
| brachialis |
| deltoid |
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