210 upper limb rs

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ANATOMY OF THE UPPER LIMB

Dr. Akram M. Asbeutah, Ph.D

Faculty of Allied Health Sciences

Kuwait University

Dr. Akram Asbeutah

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OBJECTIVES

• You must be familiar with the nerves, bones, joints, muscles, tendons, and blood & lymphatic vessels and their anatomic relationships

• You must know the basic anatomy of the mammary glands (breast)

• You must know the basic anatomy of the upper limb so that as a practicing medical professional he or she will be able to make an accurate diagnosis and initiate prompt treatment

• You must be familiar with common clinical problems of the upper limb

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The pectoral Region & the AxillaMammary Glands (The Breasts)

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Mammary Glands

• Modified sweat glands that produce milk (lactation)– amount of adipose determines size of breast– milk-secreting glands open by lactiferous ducts at the nipple– areola is pigmented area around nipple – suspensory ligaments suspend breast from deep fascia of pectoral

muscles (aging & Cooper’s droop)Dr. Akram Asbeutah

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Dr. Akram Asbeutah

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Histology of the mammary gland

Dr. Akram Asbeutah

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Blood Supply & Lymph Drainage• Arteries:

Perforating branches of the internal thoracic artery

Lateral thoracic & thoracoacromial branches of axillary artery

• Veins: correspond to arteries

• Lymph Drainge:

Lateral quadrants: anterior or pectoral group of nodes

Medial Quadrants: internal thoracic group of nodes

Posterior intercostal nodes Some communicate with the opposite breast and

with those of the anterior abdominal wall

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Bones of the Shoulder Girdle & Arm

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Pectoral (Shoulder) Girdle

• Consists of scapula and clavicle

• Clavicle articulates with sternum (sternoclavicular joint)

• Clavicle articulates with scapula (acromioclavicular joint)

• Scapula held in place by muscle only

• Upper limb attached to pectoral girdle at shoulder (glenohumeral joint)

Dr. Akram Asbeutah

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Clavicle (collarbone)

• S-shaped bone with two curves– medial curve convex anteriorly/lateral one concave anteriorly

• Extends from sternum to scapula above 1st rib• Fracture site is junction of curves • Ligaments attached to clavicle stabilize its position.

Dr. Akram Asbeutah

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Anterior Surface of Scapula

• Subscapular fossa filled with muscle • Coracoid process for muscle attachment

Dr. Akram Asbeutah

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Posterior Surface of Scapula

• Triangular flat bone found in upper back region• Scapular spine ends as acromion process

– a sharp ridge widening to a flat process

• Glenoid cavity forms shoulder joint with head of humerus• Supraspinous & infraspinous fossa for muscular attachments

Dr. Akram Asbeutah

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Upper Extremity

• Each upper limb = 30 bones– humerus within the arm

– ulna & radius within the forearm

– carpal bones within the wrist

– metacarpal bones within the palm

– phalanges in the fingers

• Joints – shoulder (glenohumeral), elbow,

wrist, metacarpophalangeal, interphalangeal

Dr. Akram Asbeutah

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Humerus --- Proximal End

• Part of shoulder joint

• Head & anatomical neck

• Greater & lesser tubercles for muscle attachments

• Intertubercular sulcus or bicipital groove

• Surgical neck is fracture site

• Deltoid tuberosity

• Shaft

Dr. Akram Asbeutah

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Humerus --- Distal End

• Forms elbow joint with ulna and radius

• Capitulum

– articulates with head of radius

• Trochlea

– articulation with ulna

• Olecranon fossa

– posterior depression for olecranon process of ulna

• Medial & lateral epicondyles

– attachment of forearm muscles

Dr. Akram Asbeutah

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The Axilla

• Armpit is a pyramidal-shaped space between the upper part of the arm and the side of the chest

• It has an apex and base

• The apex is directed into the root of the neck and is bounded front by the clavicle, behind by the upper border of the scapula, medially by the outer border of the first rib

• The base is the lower border and is bounded front by the anterior axillary fold (formed by the lower border of pectoralis

major muscle) behind by the posterior axillary fold (formed by the tendon of latissimus dorsi

and teres major muscle medially by the chest wall

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The Axillary WallsWall side Made up

Anterior Pectoralis major, subclavius, & pectoralis minor muscles, the clavipectoral fascia, & suspensory ligamnet of the axilla

Posterior Subscapularis, latissimus dorsi, & teres minor muscles

Medial Upper four to five ribs & the intercostal spaces covered by serratus anterior muscle

Lateral Coracobrachialis & biceps muscles

Clavicopectoral Fascia is a strong sheet of connective tissue that is attached above to the clavicle. Below it splits to enclose the pectoralis minor muscle and then continue downward as the suspensory ligament of the axilla and joins the fascial floor of the armpit

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Inlet, Walls, & Outlet of Axilla

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Muscles Connecting the Upper Limb to the Thoracic Wall

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Muscles Connecting the Upper Limb to the Vertebral Column

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Muscles Connecting the Scapula to the Humerus

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Stabilizing the Pectoral Girdle

• Anterior thoracic muscles– Subclavius extends from 1st rib

to clavicle– Pectoralis minor extends from

ribs to coracoid process– Serratus anterior extends from

ribs to inner surface of scapula

• Posterior thoracic muscle– Trapezius extends from skull &

vertebrae to clavicle & scapula– Levator scapulae extends from

cervical vertebrae to scapula– Rhomboideus extends from

thoracic vertebrae to vertebral border of scapula

Dr. Akram Asbeutah

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Contents of the Axilla

Structure

Axillary Artery

Axillary Vein

Brachial Plexus

Lymph Nodes

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Axillary Artery• It begins at the lateral border of

first rib as a continuation of the subclavian artery

• It ends at the lower border of the teres major muscle and continue as the brachial artery

• It is enclosed in the axillary sheath together with the cords of the brachial plexus

• It is divided into three parts by the pectoralis minor muscle

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First Part of the Axillary Artery• It extends from the lateral border of the

1st rib to the upper border of the pectoralis minor m

• Relations

Anterior: pectoralis major & skin. Cephalic vein crosses it

Posterior: long thoracic nerve Lateral: three cords of the brachial

plexus Medial; axillary vein

• Branches:

highest thoracic artery

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Second Part of the Axillary Artery• It lies behind the pectoralis minor

muscle

• Relations

Anterior: pectoralis minor, Major & skin

Posterior: posterior cord of the brachial plexus, subscapularis m, & shoulder joint

Lateral: lateral cord of the brachial plexus

Medial: axillary vein and the medial cord of brachial plexus

• Branches

Thoracoacromial artery Lateral thoracic artery

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Third Part of the Axillary Artery• It extends from the lower border of the

pectoralis minor m to the lower border of the teres major m

• Relations

Anterior: pectoralis major and medial root of the median nerve

Posterior: subscapularis, latissimus dorsi, & teres major. The axillary & radial nerves

Lateral: coracobrachialis, biceps, & humerus. The lateral root of the median nerve & musculocutaneous nerves

Medial; ulnar nerve, axillary vein, & medial cutaneous nerve of the arm

• Branches

Subscapular artery Anterior & posterior circumflex humeral

arteries

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Axillary Vein• It is formed at the lower border of the

teres major muscle by union of the venae comitantes of the brachial artery and the basilic vein

• It runs upward on the medial side of the axillary artery and ends at the lateral border of the first rib by becoming the subclavian vein

• It receives tributaries, which correspond to the branches of the axillary artery, and the cephalic vein

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Brachial Plexus• Sensory innervation to the

skin and deep structures (joints)

• Motor innervation to the muscles

• Influence over the diameters of the blood vessels by the sympathatic vasomotor nerves

• Sympathatic secretomotor supply to the sweat glands

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Axillary Lymph Nodes• 20-30 in number

• Drain lymph vessels from the lateral quadrants of the breast, the superficial lymph vessels from the thoracoabdominal walls above the level of the umbilicus, and vessels from the upper limb

• The lymph nodes are arranged in six groups

Anterior (pectora) group Posterior (subscapualr) group Lateral group Central group Infraclavicular (deltopectoral) group Apical group

• The apical nodes drain into the subclavian lymph trunk. On the leftside, this trunk drains into the thoracic duct; on the right side, it drains into the right lymph trunk

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The Superficial Part of the back & the Scapular

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Skin• The sensory nerve supply to the skin of the back is

from the posterior rami of the spinal nerves and the posterior rami of the L1-L3 run down to supply the skin over the buttock

• The blood supply to the skin is from the posterior branches of the posterior intercostal arteries and the lumbar arteries. The veins correspond to the arteries and drains into the azygos veins and the inferior vena cava

• The lymph drainage of the back above the level of the iliac crests is upward into the posterior group of the axillary lymp nodes

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Bones of the back

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Muscles

Muscles Connecting the Upper Limb to the Thoracic Wall

Muscles Connecting the Upper Limb to the Vertebral Column

Muscles Connecting the Scapula to the Humerus

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Rotator Cuff Muscles

• Tendons off Subscapularis Supraspinatus Infraspinatus Teres minor

• The cuff plays a very important role in stabilizing the shoulder joint

• The tone of these muscles assists in holding the head of the humerus in the glenoid cavity of the scapula during movements at the shoulder joint

• The cuff lies on the anterior, superior, and posterior aspect of the joint

• The cuff is deficient inferiorly

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Rotator Cuff Muscles

• Attach humerus to scapula• Encircle the joint supporting the capsule• Hold head of humerus in socket

Dr. Akram Asbeutah

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Quadrangular Space

• It is an intermuscualr space, located immediately below the shoulder joint

• Boundaries

Superior: subscapularis & capsule of the shoulder joint

Inferior: teres major m Medial: long head of the triceps m Lateral: surgical neck of the humerus

• Contents

Axillary nerve Posterior circumflex humeral vessels

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Suprascapular nerve

• It arises from the upper trunck of brachial plexus (C5-C6) in the posterior triangle of the neck

• It passes beneath the suprascapular ligament which bridges the suprascapular notch to reach supraspinous fossa

• It supplies the supraspinatus and infraspinatus muscles and the shoulder joint

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Axillary Nerve• It arises from the posterior cord of the

brachial plexus (C5-C6) in the axilla

• It enters the quadrangular space with the posterior circumflex humeral vessels

• It is very close to the inferior aspect of the capsule of the shoulder joint and with the medial side of the surgical neck of the humerus

• It terminates by dividing into anterior and posterior branches

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Arterial Anastomosis Around the Shoulder Joint

• Subclavian artery branches

Suprascapular aSuperficial cervical a

• Axillary artery branches

Subscapular aAnterior circumflex aPosterior circumflex a

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Sternoclavicular Joint• Articulation: It occurs between the sternal end of the clavicle, the

manubrium sterni, and the first costal cratilage• Type: Synovial double-plane joint• Capsule: It surrounds the joint and is attached to the margins of the

articular surfaces• Ligaments: sternoclavicular ligaments• Accessory ligaments: costoclavicular ligaments• Articular disc: flat fibrocartilagenous disc that divides the joint into two

compartments• Synovial membrane: lines the capsule & is attached to the cartilage

covering the articular surfaces• Nerve supply: supraclavicular nerve and nerve to subclavius m• Movements: forward & backward movement of the calvicle in the medial

compartment. Elevation & depression in the lateral compartment• Muscles producing movement

Forwar: serratus anterior Backward: trapezius & rhomoid muscles Elevation: trapezius, sternocleidomastoid, levator scapulae, &

rhomboid muscles Depression; pectoralis minor & subclavius muscles

• Imporatnt relations: Anterior Skin & sternocleidomastod and pectoralis major muscles. Posterior: Sternohyoid muscle. On the right, the Bracheiocephalic artery; on the left, the left brachicephalic vein & left common carotid artery

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Acromioclavicular Joint• Articulation: Acromion and the lateral end of the

clavicle• Type: Synovial plane• Capsule: It surrounds the joint and is attached to the

margins of the articular surfaces• Ligaments: Superior & inferior acromiolavicular

ligaments• Accessory ligaments: coracocalvicular ligaments• Articular disc: flat fibrocartilagenous disc projects into

the cavity from above• Synovial membrane: lines the capsule & is attached to

the cartilage covering the articular surfaces• Nerve supply: suprascapular nerve• Movements: A gliding movements takes place when the

scapula rotates or when the clavicle is elevated or depressed

• Important relations; Anterior: deltoid m Posterior: trapezius m Superior: skin

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Shoulder Joint• Articulation: head of humerus and the

gelnoid cavity of scapula. The glenoid cavity is deepened by the presence of the fibrocartlagenous rim called the gelnoid labrum

• Type: Synovial ball-and-socket joint

• Capsule: it surrounds the joint and is attached medially to the margin of the glenoid cavity outside the labrum; laterally it is attached to the anatomic neck of the humerus. It is thin and lax, allowing a wide range of movement. It is strengthened by fibrous slips from the rotator cuff tendons

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Shoulder Joint

• Head of humerus and glenoid cavity of scapula

• Ball and socket

• Articular capsule from glenoid cavity to anatomical neck

• Glenoid labrum deepens socket

• Many nearby bursa (subacromial) Dr. Akram Asbeutah

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Shoulder Joint• Ligaments:

glenohumeral ligaments are three weak bands of fibrous tissue that strengthen the front of the capsule.

The transverse humeral ligament Coracohumeral ligament

• Accessory ligament: coracoacromial that protect the superior aspect of the joint

• Synovial membrane: lines the capsule and is attached to the margins of the articular cartilage surfaces. It form tubular sheath around the long head of biceps and extend through the anterior wall of the capsule to form the subscapularis bursa beneath the subscapularis muscle and subdeltoid (subacromial) bursa beneath the deltoid muscle and supraspinatus tendon

• Nerve supply: Axillary & Suprascapular nerves

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Shoulder Joint• Flexion: anterior deltoid fibers, pectoralis major, biceps,

and coracobrachialis muscles

• Extension: posterior deltoid fibers, latissimus dorsi, and teres major muscles

• Abduction: middle deltoid fibers and assissted by supraspinatus muscle

• Adduction: pectoralis major, latissimus dorsi, teres major, and teres minor muscles

• Lateral rotation: infraspinatus, teres minor, and posterior fibers of deltoid muscle

• Medial rotation: subscapularis, latissimus dorsi, teres major, anterior fibers of deltoid muscle

• Circumduction: a combination of all of the above movements

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Shoulder Joint• Important relations

Anterior: subscapularis m, axillary vessels & brachial plexus

Posterior: infraspinatus and teres minor muscles

Superior: the supraspinatusmuscle, subacromial bursa, coracoacromial ligament, and deltoid muscle

Inferior: lomg head of triceps muscle, the axillary nerve, posterior circumflex humeral vessels

• The tendon of the long head of biceps muscle passes through the joint and emerges beneath the transverse humeral ligament (extrsynovial and intracapsular structure)

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The Upper Arm

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Superficial Veins

• Deep & superfacial veins• Deep veins comprise the venae comitantes, which

accompany all the large arteries, usually in pairs, and the axillary vein

• Superficial veins of the arm lie in the superficial fascia Cephalic vein: Lateral side of the arm and drain into the

axillary vein by piercing the deltopectoral fascia (infracalvicular fossa)

Basilic vein: medial side of the arm, halfway pierces the deep fascia and at the lower border of the teres major joins the venae comitantes of the brachial artery to form the axillary vein

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Superficial Lymph Vessels

• Form the lateral side of the arm follow the cephalic vein to the infraclavicular group of nodes

• From the medial side follow the basilic vein to the lateral group of axillary nodes

• Deep lymphatic vessels draining the muscles and deep structures of the arm drain into the lateral group of axillary lymph nodes

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Facial Compartments of the Upper Arm• The upper arm is enclosed in a

sheath of deep fascia, one on the medial side and the other one on the lateral side

• Extend from this sheath and are attached to the medial and lateral supracondylar ridges of the humerus, respectively

• By this means, the upper arm is dividied into an anterior and a posterior fascial compartments, each having its muscles, nerves, & arteries

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Facial Compartments of The Upper Arm Anterior Compartment

• Muscles: Bicpes brachii, coracobrachialis, & brachialis

• Blood supply: Brachial artery

• Nerve supply to the muscles: Musculocutaneous nerve

• Structures passing through the compartment: musculocutaneous, median, and ulnar nerves and (radial nerve is present in the lower part); brachial artery and basilic vein

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Anterior Fascial Compartment Brachial Artery

• It begins at the lower border of teres major muscle as a continuation of the axillary artery

• It provides the main arterial supply to the arm

• It terminates opposite the neck of the radius by dividing into the radial and ulnar arteries

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Anterior Fascial Compartment- Brachial Artery Relations

• Anterior: It is superifical & is overlapped from lateral side by the coracobrachialis & biceps. The medial cutaneous nerve of the forearm lies in front of the upper part; the median nerve crosses its middle part; and the bicipital aponeurosis crosses its lower part

• Posterior: It lies on the triceps, the coracobrachialis insertion, & the brachialis

• Medial: ulnar nerve & basilic vein in the upper part of the arm; in the lower part of the arm, the median nerve lies on its medial side

• Lateral: median nerve, and the coracobrachialis and biceps above; the tendon of biceps lies laterally in the lower part of its course

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Anterior Fascial Compartment- Brachial Artery Branches

• Muscular to the muscles

• Nutrient to the humerus

• Profunda artery: arises near the beginning of the brachial artery and follows the radial nerve into the spiral groove

• Superior ulnar collateral artery: arises near the middle of the upper arm and follows the ulnar nerve

• Inferior ulnar collateral artery: arises near the termination of the artery and takes part in the anastomosis around the elbow joint

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Facial Compartments of The Upper Arm Posterior Compartment

• Muscle: The three heads of the triceps muscle

• Nerve supply to the muscle: radial nerve

• Blood Supply: Profunda brachii and ulnar collateral arteries

• Structures passing the through the compartment: radia nerve & ulnar nerve

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Cross-Section Through Arm

Dr. Akram Asbeutah

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Posterior Facial Compartments of The Upper ArmProfunda Brachii Artery

• It arises from the brachial artery near its origin

• It accompanies the radial nerve through the spiral groove, supplies the triceps, and takes part in the anastomosis around the elbow joint

• Superior & inferior ulnar collateral arteries arise from the brachial artery and takes part in the anastomosis around the elbow joint

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The Cubital Fossa

• It is a triangular depression that lies in front of the elbow

• Boundaries: Lateral: the brachioradialis m; Medial: the pronator teres m

• The base is formed by an imaginary line drawn between the two epicondyles of the humerus. The floor is formed by the supinator m laterally & the brachialis m medially. The roof is formed by the skin and fascia and is reinforced by the bicipital aponeurosis

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The Cubital Fossa

• It contains the following structures from medial to lateral side: The median nerve The bifurcation of the brachial artery The tendon of the biceps m The radial nerve and its deep branches

• The supratrochlear ly mph nodes lies in the superficial fascia over the upper part of the fossa, above the trochlea

• Afferent lymph vessels receives from 3-5 fingers; medial part of the hand; and the medial side of the forarm. The efferentlymph vessels pass up the axilla and enter the lateral group of nodes

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The Forearm

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Ulna & Radius --- Proximal End• Ulna (on little finger side)

– trochlear notch articulates withhumerus & radial notch with radius

– olecranon process forms point of elbow

• Radius (on thumb side)

– head articulates with capitulum of humerus & radial notch of ulna

– tuberosity for muscle attachment

Dr. Akram Asbeutah

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Ulna and Radius - Distal End

• Ulna --styloid process– head separated from wrist joint by fibrocartilage disc

• Radius – forms wrist joint with scaphoid, lunate & triquetrum– forms distal radioulnar joint with head of ulna

Dr. Akram Asbeutah

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8 Carpal Bones (wrist)• Proximal row - lat to med

– scaphoid - boat shaped– lunate - moon shaped– triquetrum - 3 corners– pisiform - pea shaped

• Distal row - lateral to medial– trapezium - four sided– trapezoid - four sided– capitate - large head– hamate - hooked process

• Carpal tunnel--tunnel of bone & flexor retinaculum

Dr. Akram Asbeutah

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Metacarpals and Phalanges• Metacarpals

– 5 total----#1 proximal to thumb

– base, shaft, head– knuckles

(metacarpophalangeal joints)

• Phalanges– 14 total: each is called

phalanx– proximal, middle, distal on

each finger, except thumb– base, shaft, head

Dr. Akram Asbeutah

Forearm, Wrist, & Hand Bones

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Superficial Veins

• Deep & superfacial veins• Deep veins comprise the venae comitantes, which

accompany all the large arteries, usually in pairs, and the axillary vein

• Superficial veins of the arm lie in the superficial fascia Cephalic vein: Lateral side of the arm and drain into the

axillary vein by piercing the deltopectoral fascia (infracalvicular fossa). Median cubital vein joins the basilic vein at cubital fossa

Basilic vein: medial side of the arm, halfway pierces the deep fascia and at the lower border of the teres major joins the venae comitantes of the brachial artery to form the axillary vein

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Superficial Lymph Vessels

• Form the lateral side of the arm follow the cephalic vein to the infraclavicular group of nodes

• From the medial side follow the basilic vein to the lateral group of axillary nodes and drain into the supratrochlear lymph node


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Facial Compartments of the Forearm

• Deep fascia (fascial sheath), that is attached to the posterior subcatneous border of the ulna, together with the interosseous membrane and fibrous intermuscular septa, divides the forearm into anterior, posterior, and lateral fascial compartments, each having its own muscles, nerves, and blood supply

Interosseous Membrane• It is a strong membrane that unites the

shafts of the radius and the ulna

• It is attached to their interosseous borders

• Its fibers run obliquely downward and medially (transmit force from radius to ulna to humerus to scapula)

• Its fibers are taut when the forearm is in the midprone position

• It provides attachement for neighboring muscles

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Retinaculum

• Tough connective tissue band that helps hold tendons in place • Extensor & Flexor retinaculum cross wrist region attaching from bone

to bone (carpal tunnel syndrome = painful compression of median nerve due to narrowing passageway under flexor retinaculum

Dr. Akram Asbeutah

Flexor Retinaculum

• It is a thickening of deep fascia that holds the long flexor tendons in position at the wrist

• It turns the concave anterior surface of the hand into an osteofascial tunnel (carpal tunnel) for the passage of the median nerve and the flexor tendons of the thumb and fingers

• It is attached medially to the pisiform bone & hook of hamate and laterally to the scaphoid tubercle and the trapezium bones. The attachment to trapezium consists of superfical and deep parts and forms a synovial-lined tunel for the passage of the flexor carpi radialis tendon

• Its upper border corresponds to the distal transverse skin crease in front of the wrist and is continuous with the deep fascia of the forearm. Its lower border is attached to the palmar aponeurosis

Extensor Retinaculum

• It is thichening of deep fascia that stretches across the back of the wrist and hold the long extensors tendons in position

• It converts the grooves on the posterior surface of the distal ends of the radius and ulna into six separate tunnels for the passage of the long extensor tendons. Each tunnel is lined with a synovial shaeth. The tunnels are separated from one another by fibrous septa that pass from the deep surface of the retinaculum to the bones

• It is attached medially to the pisiform and the hookof hamate and laterally to the distal end of the radius

• The upper and lower border of the retinaculum are continuous with the deep fascia of the forearm and hand

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Facial Compartments of the Forearm Anterior Compartment

• Muscles: A superficial group, pronator teres, flexor carpi radialis, palmaris longus, and flexor carpi ulnaris; an intermediate group: flexor digitorum superficialis; and deep group: flexor pollicis longus, flexor digitorum profundus, and the pronator quadratus

• Blood supply: ulnar & radial arteries

• Nerve supply to the muscles: all muscles are supplied by the median nerve and its branches, EXCEPT the flexor carpi ulnaris and the medial part of the flexor digitorum profundus, which are supplied by the ulnar nerve

Arteries of the Anterior Fascial Compartment of the Forearm Ulnar Artery

• It is the larger of the two terminal branches of the brachial artery

• It begins in the cubital fossa at the level of the neck of the radius

• It descends through the anterior compartment of the forearm and enters the palm in front of the flexor retinaculum in company with the ulnar nerve

• It ends by forming the superficial palmar arch by anastomosis with the superficial palmar branch of the radial artery

• In the upper part of its course, it lies deep to most of the flexor muscles, it become superficial and lies between the tendons of FCU & tendons of FDS. In front of the flexor retinaculum, it lies lateral to pisiform bone and ulnar nerve and is covered by skin and fascia

• Branches: muscular, recurrent (anastomosis around the elbow joint), branches that take part in the arterial anastomosis around the wrist, common interosseous aretry (anterior & psoterior interosseous arteries)

Arteries of the Anterior Fascial Compartment of the Forearm Radial Artery

• It is smaller than the ulnar artery• It begins at the level of radial neck in the cubital

fossa• It psaases downward and laterally beneath the

brachioradialis mand resting on the deep muscles of the forearm

• In the middle third of its course, the superficial branch of the radial nerve lies on its lateral side

• In the distal part, it lies on the anterior surface of the radius and is only cobvered by skin & fascia. The artery has the tendon of brachioradialis on its lateral side and FCR tendon on its medial side

• It leveas the forearm by winding around the lateral aspect of the wrist to reach the poterior surface of the hand

• Branches; muscular, recurrent (anastomosis around elbow joint), and superficial palamr branch) which usually join ulnar artery to form the superficial palmar arch

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Facial Compartments of the Forearm- Lateral Compartment

• It is regarded as part of the posterior fascial compartment

• Muscles: Brachioradialis and extensor carpi radialis longus

• Blood supply: radial & brachial arteries

• Nerve supply to the muscles: Radial nerve

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Facial Compartments of the Forearm- Posterior Compartment

• Muscles: Superficial group includes the extensor carpi radialis brevis, extensor digitorum, extensor digiti minim, extensor carpi ulnaris, and anconeus ( all posses a common tendon of origin from lateral humeral epicondyle). The deep group includes the supinator, abductor pollicis longus, extensor pollicis brevis, extensor pollicis longus, and extensor indicis

• Blood supply: anterior & posterior interosseous arteries from the common interosseous artery from the ulnar artery. The end by taking part in the amastomosis around the wrist joint

• Nerve supply to the muscles: deep branch of the radial nerve

Arteries of the Posterior Facial Compartments of the Forearm

• Anterior & posterior interosseous arteries from the common interosseous artery from the ulnar artery. The end by taking part in the amastomosis around the wrist joint

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The Region of the Wrist• Before learning the anatomy of the hand and the fingers, it is

essential that you should have a sound knowledge of the arrangement of the tendons, arteries, and nerves in the region of the wrist

• You should identify the structures from medial to lateral and vis versa

• You should examine your own wrist and identify as many of the structures as possible

• From a clinical standpoint, the wrist is a common site for injury

Structures on the Anterior Aspect of the Wrist

• Structures passing superficial to the flexor retinaculum from medial to lateral:

Flexor carpi ulnaris tendon Ulnar nerve Ulnar artery Palmar cutaneous branch of the ulnar n Palmaris longus tendon Palmar cutaneous branch of the median nerve

• Structures passing beneath the flexor retinaculum from medial to lateral:

Flexor digitorum superficialis tendons Median nerve Flexor pollicis longus tendon Flexor carpi radialis tendon

Structures on the Posterior Aspect of the Wrist

• Structures passing superficial to the extensor retinaculum from medial to lateral:

Dorsal cutaneous branch of the ulnar nerve Basilic vein Cepalic vein Superficial branch of the radial nerve

• Structures passing beneath the extensor retinaculum from medial to lateral:

Extensor carpi ulnaris tendon Extensor didgiti minimi tendon Extensor digitorum and extensor indicis tendons Extensor pollicis longus tendon Extensor carpi radialis longus and brevis tendons Abductor pollicis longus and extensor pollicis brevis tendons

The Palm of the Hand

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The Palm of the Hand• It is thick & hairless• It is bound down to the underlying deep

fascia by numerous fibrous bands• The skin shows many flexure creases• Sweat glands are presents in large numbers• The palmaris brevis muscle arises from the

flexor retinaculum and palmar aponeurosis and inserted into the skin of the palm. It is innervated by the superficial barnch of the ulanr nerve. Its funcation is to corrugate the skin at the base of the hypothenar eminence and improve the grip of the palm in holding a rounded object

• The plamar cutaneous bracnch of the medial nerve (lateral part) and palmar cutaneous nerve of the ulnar nerve (medial part) supply the skin of the palm.

• The superficial branch of the radial nerve or the lateral nerve of the forearm supplies the thenar eminence

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The Palmar Aponeurosis• The deep fascia of the wrist & the palm is thickened to from the flexor retinaculum & the palmar aponeurosis

• The palmar aponeurosis is triangular and occupies the central area of the palm

• The apex of it is attached to the distal border of the flexor retinaculum and receives the insertion of the palmaris longus tendon

• The base of it divides at the bases of the fingers into four slips. Each slip divides into two bands, one passing superficially to the skin and the other passing deeply to the root of the finger. Each deep band divides into two, which diverge around the flexor tendons and finally fuse with the fibrous flexor sheath and the deep transverse ligaments

• The medial & lateral borders of the palmar aponeurosis are continuous with the thinner deep fascia covering the hypothenar & thenar muscles. From each of these borders, fibrous septa pass posteriorly into the palm and take part in the formation of the palmar sapces

• Its function is to give firm attachment to the overlying skin and so improve the grip and to protect the underlying tendons

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The Carpal Tunnel• It is an anterior deep concave osteofascial tunnel• The long flexor tendons to the fingers and thumb

pass through the tunnel accompanied by the median nerve

• The four separate tendons of the flexor digitorum superficialis muscles are arranged in anterior (Middle & ring fingers) and posterior (index and little fingers). At the lower border of the flexor retinaculum, the four tendons diverge and become on the same plane

• The tendons of the flexor digitorum profundas are at the same plane and lie behind the superficialis tendons

• All eight tendons invaginate a common synovial sheath from the lateral side (ulnar bursa) the tendon of the flexor pollicis longus muscle runs through the lateral part of the tunnel in its own synovial sheath (radial bursa). These two bursae communicated at the level of the wrist joint in about 50% of subjects

• The median nerve passes beneath the flexor retinaculum in a restricted space between the FDS and FCR tendons

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Fibrous Flexor Sheaths• The anterior surface of each finger, from the

head of the metacarpal to the base of the distal phalanx, is provided with a strong fibrous sheath that is attached to the sides of the phalanges

• The proximal end of the fibrous sheath is open, whereas the distal end of the sheath is closed and is attached to the base of the distal phalanx

• The sheath and the bones form a blind tunnel in which the flexor tendons of the finger lie

• In the thumb, the tunnel contains the tendon of FPL, and four medial fingers is occupied by the tendons of the FDS & FDP

• The sheath is thick over the phalanges but thin and lax over the joints

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Synovial Flexor Sheaths• The tendons of FDS & FDP invaginate a common

synovial sheath from the lateral side (ulnar bursa). The medial part of this common sheath extends distally without interruption on the tendons of the little finger. The lateral part of the sheath stops on the middle of the palm, and the dustal ends of the long flexor tendons of the index, the middle, and the ring fingers acquire digital synovial sheath as they enter the fingers.

• The tendon of the flexor pollicis longus muscle runs through the lateral part of the tunnel in its own synovial sheath (radial bursa). These two bursae communicated at the level of the wrist joint in about 50% of subjects

• The vincula longa & brevia are samll vascular folds of synovial membrane that connect the tendons to the anterior surface of the phalanges. They resemble a mesentery and convey blood vessels to the tendons

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Insertion of the long Flexor Tendons• Each tendon of the FDS enters the

fibrous flexor sheath

• Opposite the proximal phalanx it divides into two halves, which pass around the FDP tendons and meet on its deep or posterior surface, where partial decussation of the fibers takes place

• FDS tendons having united again, divides almost at once into two further slips, which are attached to the borders of the middle phalanx

• The tendon of FDP pass through and to be inserted into the base of the distal phalanx

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Arteries of the Palm- Ulnar Artery

• It enters the hand anterior to the flexor retinaculum on the lateral side of the ulnar nerve and the pisiform bone

• It gives off a deep branch then continue into the palm as the superficial palmar arch

• The superficial palmar arch is a direct continuation of the ulnar artery. On entering the palm, it curves laterally behind the aponeurosis and in front of the long flexor tendons

• The arch is completed on the lateral side by joining the superfacial palmar branch from the radial artery. Four digital arteries arises from the convesity of the arch and pass to the fingers

• The deep branch of the ulnar artery arises in front of the flexor retinaculum, passes between the abductor digiti minimi and the flexor digiti minimi, and joins the radial artery to complete the deep palamr arch

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Arteries of the Palm-Radial artery

• The radial artery leaves the dorsum of the hand by turning forward between the proximal ends of the first and second metacarpal bones between the two head of the first dorsal interosseous muscle

• On entering the palm, it curves medially between the oblique and transverse heads of the adductor pollicis and continue as a deep palmar arch by joining the deep branch of the ulnar artery deep to the long flexors tendon and in front of the metacarpal bones

• The deep palmar arch sends branches superiorly, which take part in the anastomosis around the wrist joint, and inferiorly, to join the digital arteries of the superficial palmar arch

• It gives arteria radialis indicis (lateral side of the index finger) and arteria priceps pollicis (lateral & medial side of the thumb)

Vessels of the Palm

Lymph Drainage of the Palm• Form the lateral side of the arm follow

the cephalic vein to the infraclavicular group of nodes

• From the medial side follow the basilic vein to the lateral group of axillary nodes


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Facial Spaces of the Palm

• It is fascial spaces filled with loose connective tissue• Their boundaries are important clinically because they may limit

the spread of infection in the palm• Medial fibrous septum arise from the medial border of the

flexor retinaculum and is attached to the anterior border of the 5th metacarpal bone (medial to it the hypothenar compartment)

• From the lateral border of the flexor retinaculum arises another septum (Oblique septum) usually between the middle and index finger and is attached to anterior border of the 3rd metacarpal bone and this divides the palm into thenar (lateral to septum)and mid-palmar space (medial to the septum)

• These spaces are closed proximally butcontinue distally with the lumbrical canal

The thenar space contains the first lumbrical muscle and lies posterior to the long flexor tendons to the index finger and in front of the adductor pollicis longus muscle

The midpalamar space conatins 2-4 lumbrical muscles and lies posterior to the long flexor tendons of 4-5 fingers. It lies in the front of interossei, and 3-5 metacarpal bones

The lumbrical canal is a potential space surrounding the tendon of each lumbrical muscle and is normally filled with connective tissue. Proxinmally, it is continous with one of the palmar spaces

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Pulp Space of the Fingers• The deep fascia of the pulp of each

finger fuses with the periosteum of the terminal phalanx just distal to the insertion of the long flexor tendons and closes off a fascial compartment known as the pulp space

• Each pulp space is subdivided by the presence of numerous septa, which pass from the deep fascia to the periosteum

• Pulp is filled with fat, terminal branche sof the digital artery that supplies the diaphysis of the terminal phalanx. Epiphysis receieves its blood supply from more proximally

The Dorsum of the Hand

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Dorsal Venous Arch

• Lateral side: cephalic vein

• Medial side: Basilic vein

• Freely receives digital veins and communivates with the deep veins of the palm

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Insertion of the Long Extensor Tendons• The four tendons of the extensor tendons emerge from under the

extensor retinaculum

• The tendons are embedded in the deep fascia, and together they form the roof of a subfascial space

• Strong oblique fibrous bands connect the tendons to 3-5 fingers proximal to the heads of the metacarpal bones

• The tendons to index finger is joined on its medial side by the tendon of extensor indicis, and the tendon to the little finger is joined on its medial side by the two tendons of the extensor digiti minimi

• On the posterior surface of each finger, the extensor tendon joins the fascial expansion called extensor expansion. Near the proximal interphalangeal joint, the extensor expansion splits into three parts: a central part, which is inserted into the base of the middle phalanx, and two lateral parts, which converge to be inserted into the base of the distal phalanx

• The dorsal extensor expansion receives the tendon of the insertion of the corresponding iterosseous muscle on each side and farther distally receives the tendon of the lumbrical muscle on the lateral side

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The Radial Artery on the Dorsum of the Hand• It winds around the lateral margin of the

wrist joint, beneath the tendons of the abductor pollicis longus and extensor pollicis brevis, and lies on the lateral ligament of the joint

• On reaching the dorsum of the hand, the artery descends beneath the tendon of the extensor pollicis longus to reach the interval between the two heads of the first interossei muscle; here the artery turns forward to enter the palm of the hand

• Branches: anastomaosis around the wrist joint and two other branches arteria radialis indicis (index finger) and arteria picceps pollicis (thumb)

Joints of the Upper Limb

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Elbow Joint

• Articulation: It occurs between the torchlea & cpitulum of the humerus and the trochlear notch of the ulna & head of the radius. The articular surfaces are covered with hyaline cartilage

• Type: Synovial hinge joint• Capsule: Anterior & posterior coverage• Ligaments: lateral & medial ligaments (anterior,

posterior & transverse bands)• Synovial membrane: Lines the capsule and covers fatty

pads in the floors of the coronoid, radial, and olecranonfossa. It is continuous below with the synovial membrane of the proximal radioulnar joint

• Nerve supply: branches from the median, ulnar, musculocutaneous, and radial nerves

• Movements: Flexion (arm flexors) & extension (arm extensors). Carrying angle is 170° in male and 167° in female. It disappear in full flexion

• Important relations: Anterior: brachialis, biceps tendon, median nerve,

& brachial artery Posterior: triceps m, & small bursa Medial: ulnar nerve Lateral: common extensor tendon & the supinator

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Elbow Joint

• Articulation of humerus with ulna and radius• Ulna articulates with trochlea of humerus• Radius articulates with capitulum of humerus• Interosseous membrane between ulna & radius provides

site for muscle attachmentDr. Akram Asbeutah

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Elbow Joint

• Hinge joint– trochlea notch of ulna and trochlea of humerus– flexion and extension of elbow

• Pivot joint– head of radius and capitulum of humerus– supination and pronation of forearm

Dr. Akram Asbeutah

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Articular Capsule of the Elbow Joint

• Radial annular ligament hold head of radius in place• Collateral ligaments maintain integrity of joint

Dr. Akram Asbeutah

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Proximal (Superior) Radioulnar Joint• Articulation: radial head and the annular ligament

and the radial notch of the ulna• Type: synovial pivot joint• Capsule: enclose the joint and continuous with the

elbow joint• Ligaments: annular ligament. It is not attached to

radius• Synovial membrane: continuous with the elbow

above and below is attached radius & ulna

• Nerve supply: branches from the median, ulnar, musculocutaneous, and radial nerves

• Movements: pronation & supination of the forearm• Important relations:

Anterior: supinator muscle and radial nerve Posterior: supinator muscle & common extensor tendon

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Distal (Inferior) Radioulnar Joint• Articulation: ulnar head and ulnar notch on the

radius• Type: synovial pivot• Capsule: encloses the joint but deficient

superiorly• Ligaments: weak anterior and strong posterior• Synovial membrane: lines the capsule• Nerve supply: anterior interosseous nerve and

deep branch of the radial nerve• Movements: pronation & supination• Important relations:

Anterior: tendons of flexor digitorum profundus Posterior: tendon of the extensor digiti minimi

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Wrist (Radiocarpal) Joint• Articulation: distal end of the radius & articular disc

above and the scaphoid, lunate, & triquetrum bones below• Type: synovial elliposoid joint• Capsule: enclose the joint• Ligaments: anterior, posterior, medial, & lateral

ligaments• Synovial membrane: lines the capsule. The joint cavity

does not communicate with the dital radioulnar joint• Nerve supply: anterior interosseous nerve and deep

branch of the radial nerve• Movements: flexion, extension, adduction, abduction, &

circumduction but not rotation (supination & pronation)• Important relations:• Anterior: tendons of FDS, FDP, FPL, FCR, FCU, &

median & ulnar nerves• Posterior: tendons of ECU, EDM, ED, EI, ECRL &B,

EPL & B, APL• Medial: posterior cutaneous nerve of the ulnar nerve• Lateral: radial artery

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Intercarpal Joint• Articulation: between individual bones of the

carpal in the proximal and distal rows and midcarpal between the proximal row carpal bones and distal row carpal bones

• Type: synovial plane joints• Capsule: encloses each joint• Ligaments: anterior, posterior, & interosseous • Synovial membrane: lines the capsule• Nerve supply: anterior interosseous nerve and

deep branch of the radial nerve & deep branch of the ulnar nerve

• Movements: small amount of gliding type of movement is possible

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Carpometacarpal & Intermetacarpal Joints

• They are synovial plane joints possessing anterior, posterior, & interosseous ligaments

• They have common joint cavity

• A small amount of gliding movement is possible

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Carpometacarpal Joint of the Thumb• Articulation: trapezium & first

metacarpal bone base• Type: synovial saddle-shaped

joint• Capsule: surrounds the joint• Synovial membrane: lines the

capsule and forms a separate joint cavity

• Movements: flexion, extension, abduction, adduction, & rotation (opposition)

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Metacarpophalangeal Joints• Articulation: heads of the

metacarpal bones and bases of the proximal phalanges

• Type: synovial condyloid joints• Capsule: surrounds the joint• Ligaments: palamr deep transverse

metacarpal (joining 2-5 heads), & collateral

• Synovial membrane: lines the capsule

• Movements: flexion, extension, abduction & adduction

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Interphalangeal Joints

• They are synovial hinge joints that have a structure similar to that of the MCP joints

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The Hand as a Functional Unit

Position of the Hand

• The position of rest• The position of function

Movements of the Thumb

• Flexion• Extension• Abduction• Adduction• opposition

Movements of the 2-5 Fingers

• Flexion• Extension• Abduction• Adduction

• Cupping of the hand• Making a fist

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Surface Anatomy of the Upper Limb

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Surface Anatomy of the Trunk/Back• Scapulae

• Latissimus dorsi muscle

• erector spinae muscle

• infraspinatus muscle

• trapezius muscle

• teres major muscle

• posterior axillary fold

• triangle of auscutation

Dr. Akram Asbeutah

Surface Anatomy of the Back

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Surface Features of the Chest• Clavicle

• Suprasternal Notch of Sternum

• Manubrium of Sternum

• Sternal Angle of Sternum

• Body of Sternum

• Xiphoid Process of Sternum

• Costal Margin

• Serratus Anterior Angle

• Ribs

• Mammary Glands

• Nipples

• Anterior Axillary Fold

• Pectoralis Major Muscle

Dr. Akram Asbeutah

Surface Features of the Chest

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• Surface features of the Shoulder

– Acromioclavicular Joint

– Acromiun

– Humerus

• Greater Tubercle

– Deltoid Muscle

Dr. Akram Asbeutah

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• Surface Features of the Armpit

– apex

– base

• axillary lymph nodes

– anterior wall

– posterior wall

– medial wall

– lateral wall

Dr. Akram Asbeutah

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Surface Anatomy of the Upper Limb• Surface Features of the Arm

& Elbow

– Humerus

– Biceps brachii muscle

– Triceps brachii muscle

– Medial epicondyle

– Lateral epicondyle

– Olecron

– Ulnar nerve

– Cubital fossa

– Median cubital vein

– Brachial Artery

– Bicipital aponeurosisDr. Akram Asbeutah

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• Surface Features of the Forearm & Wrist

– Ulna

– Radius

– Muscles

– Radial Artery

– Pisiform Bone

– “Anatomical Snuffbox”

– Wrist Creases

Dr. Akram Asbeutah

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• Surface features of the hand

– Knuckles

– Dorsal Venus Arch

– Tendon of extensor digitorum muscle

– Tendon of the extensor pollicis brevis muscle

– Thenar eminence

– Hypothenar eminence

– Palmar flexion creases

– Digial flexion creasesDr. Akram Asbeutah

Surface Anatomy of the Wrist region

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Radiographic Appearances of the Upper Limb

Anterioposterior radiograph of the shoulder joint in the adult

AP projection of the Elbow joint

Lateral Radiograph of the Elbow Joint

PA radiograph of the wrist & distal forearm

PA radiograph of an adult hand & wrist

PA & Lateral radiographs of the Hand

Lateral Radiograph of the Hand

MRI of the upper Forearm

Shoulder MRI

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Arm MRI

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Elbow MRI

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Forearm MRI

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Wrist MRI

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Hand MRI

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Clinical Notes of the Upper Limb

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Fibrocystic Disease of the Breasts

• Most common cause of breast lumps

• Cysts and thickenings of alveoli develop

• Cause– hormonal imbalance

• excess of estrogen or deficiency of progesterone in the postovulatory phase

– result is lumpy, swollen & tender breast a week before menstruation begins

Dr. Akram Asbeutah

Bony Abnormalities

• Fracture clavicle, scapula, humerus, radius & ulna, hand bones

• SCJ dislocation• ACJ dislocation/sublaxation• Shoulder joint dislocation• Elbow joint dislocation• Radioulnar joint diseases• Wrist joint injuries• Hand joints diseases & preservation of function

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Rheumatoid Arthritis

• Autoimmune disorder• Cartilage attacked• Inflammation, swelling &

pain • Final step is fusion of joint

Dr. Akram Asbeutah

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Osteoarthritis• Degenerative joint disease

– aging, wear & tear

• Noninflammatory---no swelling– only cartilage is affected not synovial membrane

• Deterioration of cartilage produces bone spurs– restrict movement

• Pain upon awakening--disappears with movement

Dr. Akram Asbeutah

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Gouty Arthritis

• Urate crystals build up in joints---pain– waste product of DNA & RNA metabolism– builds up in blood– deposited in cartilage causing inflammation &

swelling

• Bones fuse

• Middle-aged men with abnormal gene

Dr. Akram Asbeutah

Vascular Diseases• Axillary vein thrombosis• Axillary artery compression & role of collaterals• Volkmann’s ischemia contracture (brachial artery)• Arterial injuries• Compression of the NV bundle• Allen test for the patency of the radial & ulnar arteries• Raynaud’s disease

Miscellaneous Diseases

• Retracted & supernumery nipples

• Carcinoma of the breast

• Axillary lymphadenopathy

• Fascial spaces of the palm infection

• Pulp-space infection

210 upper limb rs

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Transcript of 210 upper limb rs