The Anterior Region The Anterior Region of the Upper Limbof the Upper Limb

Ling ShucaiLing Shucai

Regional anatomy of upper limb

Parts and regions Parts and regions Shoulder regionShoulder region －－ junction junction of arm and trunk of arm and trunk ArmArm －－ between should and between should and elbowelbowElbowElbow －－ bend of arm, joint bend of arm, joint between arm and forearmbetween arm and forearmForearmForearm －－ between elbow between elbow and handand handHandHand

The Anterior Region of the Upper The Anterior Region of the Upper LimbLimb

1. Surface anatomy 1. Surface anatomy 表面解剖 表面解剖 2. The superficial structures 2. The superficial structures 浅层结构浅层结构

Superficial veins Superficial veins 浅淋巴管浅淋巴管Superficial lymph vessels Superficial lymph vessels 浅静脉浅静脉Cutaneous nerves Cutaneous nerves 皮神经皮神经

3. The deep structures 3. The deep structures 深层结构深层结构The deep fascia The deep fascia 深筋膜深筋膜The muscles The muscles 肌肉肌肉The vessels The vessels 血管血管The nerves The nerves 神经神经

4. Regional anatomy 4. Regional anatomy 局部解剖局部解剖Cubital fossa Cubital fossa 肘窝肘窝The carpal canal The carpal canal 腕管腕管The palmar fascial space The palmar fascial space 手掌筋膜间隙手掌筋膜间隙

1.Surface anatomy1.Surface anatomy

Surface anatomySurface anatomyShoulder regionShoulder region: acromion, spine of scapula, : acromion, spine of scapula, coracoid process, greater tubercle, anterior coracoid process, greater tubercle, anterior and posterior axillary folds and posterior axillary folds ArmArm －－ medial and lateral biceps brachii medial and lateral biceps brachii furrow, deltoid tuberosity furrow, deltoid tuberosity ElbowElbow －－ medial and lateral epicondyles, head medial and lateral epicondyles, head of radius, olecranon, tendon of biceps brachiiof radius, olecranon, tendon of biceps brachiiForearmForearm －－ between elbow and handbetween elbow and handHandHand －－ styloid process, dorsal tuberclestyloid process, dorsal tubercle

1650 ～ 1700

Carring angle 提携角

2.The superficial structures

Superficial veinsSuperficial veinsCephalic vein Cephalic vein 头静脉头静脉 Basilic veinBasilic vein 贵要静脉贵要静脉Median cubital vein Median cubital vein 肘正中肘正中静脉静脉

The superficial structuresCephalic vein

Basilic vein

Median cubital vein

The lymphatic drainage of upper The lymphatic drainage of upper limblimb

Lymphatic vesselsLymphatic vesselsSuperficialSuperficial －－ follow the follow the superficial veins, drain into superficial veins, drain into supratrochlear(supratrochlear( 滑车上淋巴滑车上淋巴结）结） and axillary lymph and axillary lymph nodesnodes （腋淋巴结）（腋淋巴结）DeepDeep －－ accompany main accompany main vessels, end in axillary lymph vessels, end in axillary lymph nodesnodes

lymph nodeslymph nodesSuperficial cubital lymph Superficial cubital lymph nodenode

(Supratrochlear lymph (Supratrochlear lymph node): node): 肘浅淋巴结（滑车上淋巴肘浅淋巴结（滑车上淋巴结）结）Axillary lymph nodeAxillary lymph node －－arranged in five groupsarranged in five groups

Median cubital v肘正中静脉 .

Lateral antebrachial cutaneous n. & cephelic v.前臂外侧皮神经和头静脉 Medial antebrachial cutaneous

n. & basiic v.前臂内侧皮神经和贵要静脉

Cutaneous nerves

3. The deep structures

Muscles of armMuscles of armAntererior groupAntererior group Biceps brachii Biceps brachii

肱二头肌肱二头肌 CoracobrachialiCoracobrachiali

ss 喙肱肌喙肱肌 Brachialis Brachialis

肱肌肱肌Posterior group –Posterior group –

triceps brachiitriceps brachii 肱三头肌肱三头肌

Ⅰ.The Muscles

Muscles of forearmMuscles of forearm

Superficial layer Brachioradialis 肱桡肌 Pronator teres 旋前圆肌 Flexor carpi radialis 桡侧腕屈

肌 Palmaris longus 掌长肌 Flexor carpi ulnaris 尺侧腕屈

肌

Second layerSecond layer

Flexor digitorum Flexor digitorum superficials superficials

指浅屈肌指浅屈肌

Third layerThird layer Flexor digitorum Flexor digitorum

profundus profundus 指深屈肌指深屈肌 Flexor pollicis longus Flexor pollicis longus 拇长屈肌拇长屈肌Fourth layerFourth layer

PronatorPronator quadratus quadratus 旋前方肌旋前方肌

Muscles of handMuscles of handLateral groupLateral group －－ thenar thenar 鱼际鱼际 (4)(4) Abductor pollicis brevisAbductor pollicis brevis 拇短展肌拇短展肌 Flexor pollicis brevis Flexor pollicis brevis 拇短屈肌拇短屈肌 Opponens pollicis Opponens pollicis 拇对掌肌拇对掌肌 Adductor pollicis Adductor pollicis 拇收肌拇收肌Medial groupMedial group －－ hypothenar (3)hypothenar (3) Abductor digiti minimi Abductor digiti minimi 小指展肌小指展肌 Flexor digiti minimi brevisFlexor digiti minimi brevis 小指短屈肌小指短屈肌 Opponens digiti minimiOpponens digiti minimi 小指对掌肌小指对掌肌

Lumbricales Lumbricales 蚓状肌蚓状肌 (4)(4) Palmar interossei Palmar interossei 骨间掌侧肌骨间掌侧肌 (3)(3) Dorsal interossei Dorsal interossei 骨间背侧肌骨间背侧肌 (4)(4)

Intermedial groupIntermedial group

Ⅱ. The vessels

Arteries

Brachial arteryBrachial arteryContinuation of axillary arteryContinuation of axillary arteryDivides into radial and ulnar Divides into radial and ulnar arteries at level of neck of radiusarteries at level of neck of radiusBranches Branches Deep brachial a. Deep brachial a. 肱深动脉肱深动脉 － － accompanies with radial nerveaccompanies with radial nerve Superior ulnar collaeral a. Superior ulnar collaeral a. 尺侧上副动尺侧上副动

脉脉 －－ accompanies with ulnar nerveaccompanies with ulnar nerve Inferior ulnar collateral a. Inferior ulnar collateral a. 尺侧下副动脉尺侧下副动脉

Radial artery and branchesRadial artery and branches Radial recurrent a. Radial recurrent a. 桡侧返动脉桡侧返动脉Superfical palmar branchSuperfical palmar branch 掌浅支掌浅支Principal artery of thumb Principal artery of thumb 拇主要动拇主要动脉脉

Ulnar artery and branchesUlnar artery and branchesUlnar recurrent a. Ulnar recurrent a. 尺侧返动脉尺侧返动脉Common interosseous artery Common interosseous artery 骨间总动脉骨间总动脉 Anterior interossous a.Anterior interossous a. 骨间前动脉骨间前动脉 Posterior interosseous aPosterior interosseous a. . 骨间后动脉骨间后动脉

Deep palmar branch Deep palmar branch 掌深支掌深支

Muscolocutaneous n.

Brachial a.

Radial n.

Radial recurrent a.

Radial a.

Median n.

Ulnar recurrent a.

Common interosseous a.

Ulnar a., v. & n.

Superficial palmar arch Superficial palmar arch 掌浅弓掌浅弓Formed by ulnar arteryFormed by ulnar artery （尺动（尺动脉）脉） and superficial palmar and superficial palmar branch of radial arterybranch of radial artery （桡动（桡动脉）脉）Curve of arch lies across the Curve of arch lies across the palm, level with the distal palm, level with the distal border of fully extended thumb border of fully extended thumb Gives rise to three common Gives rise to three common palmar digital arteriespalmar digital arteries （指掌侧总（指掌侧总动脉）动脉） each then divides into each then divides into two proper palmar digital two proper palmar digital arteriesarteries （指固有动脉）（指固有动脉）

Deep palmar arch Deep palmar arch 掌深弓掌深弓Formed by radial artery Formed by radial artery and deep palmar branch and deep palmar branch of ulnar arteryof ulnar arteryCurve of arch lies across Curve of arch lies across upper part of palmar at upper part of palmar at level with proximal border level with proximal border of extended thumbof extended thumbGives rise to three palmar Gives rise to three palmar metacarpal arteriesmetacarpal arteries

The deep veins of upper limb: accompany the arteries of the same region and bear similar names

Deep veins

MusculocutaneousMusculocutaneous 肌皮神经肌皮神经

Distribution: Distribution: Biceps Biceps brachii, brachalis brachii, brachalis and coracobrachialis and coracobrachialis ‘BBC nerve’;‘BBC nerve’; skin on skin on anterior aspect of anterior aspect of forearmforearm

Ⅲ. Nerves

MedianMedian nerve nerve 正中神经正中神经 Distribution:Distribution: InjuryInjury: : Apehand Apehand 猿掌猿掌 produces sign of produces sign of

benediction, in which the benediction, in which the index and middle fingers index and middle fingers cannot be flexed and the cannot be flexed and the thumb cannot be opposedthumb cannot be opposed

Ulnar nerveUlnar nerve Distribution: Distribution: InjuryInjury: : Clawhand Clawhand 爪形手爪形手

Radial recurrent a.

Radial a.

Radial n.

Median n.

Ulnar n.

Ulnar a.

Ulnar recurrent a.

Ulnar n.

Brachial a.

InnervationInnervation of hand of hand

Median n.Median n. Ulnar n.Ulnar n. Radial n.Radial n.

Median n.Median n. Ulnar n.Ulnar n. Radial n.Radial n.

4. Regional anatomy

Musculocutaneous n.

Median n.Medial brachial cutaneous n.

Ulnar n.

Medial antebrachial cutaneous n.

Superior ulnar coleteral a.

Deep brachial a.

Ⅰ. Medial bicepital brachii furrow 肱二头肌内侧沟

Musculocutaneous n.

Median n.

Axillary a.

Brachial a.

Medial antebrachial cutaneous n.

Medial brachial cutaneous n.

Deep brachial a.

Superior ulnar coleteral a.& Ulnar n.

Inferior ulnar coleteral a.

ⅡⅡ. . Cubiral fossa Cubiral fossa 肘窝肘窝Boundaries Boundaries

BaseBase －－ line drawn through line drawn through epicondylesof humerus epicondylesof humerus （肱骨（肱骨上髁） 上髁） ApexApex －－ brachioradialis brachioradialis laterally and pronator teres laterally and pronator teres mediallymediallyRoofRoof －－ skin, superficial faxcia, skin, superficial faxcia, deep faxcia and aponeurosis deep faxcia and aponeurosis of bicepsof biceps （肱二头肌腱膜）（肱二头肌腱膜）FloorFloor －－ brachialis, supinatorbrachialis, supinator（旋后肌） （旋后肌） and capsule of and capsule of elbow jointelbow joint

aponeurosis of biceps

ContentsContents －－ from lateral from lateral to medialto medialBiceps brachii tendonBiceps brachii tendonBrachial a.Brachial a. －－ divides into divides into radial and ulnar radial and ulnar a.,usually at apex of a.,usually at apex of fossafossaMedian n.Median n.

Lateral to the biceps brachii Lateral to the biceps brachii tendontendon －－ radial n. and radial n. and lateral antebrachial lateral antebrachial cutaneous n.cutaneous n.

ⅢⅢ. . Carpal tunnel Carpal tunnel 腕管腕管Flexor retinaculum 屈肌支持带

Thickening of deep fascia in the handAttached laterally to scaphoid and trapeziun and medially to pisiform and hamate

Carpal tunnel 腕管Formed by flexor retinaculum and carpal grooveTransmits

Median n. Flexor digitorum superficialis

and flexor digitorum profundus enclosed by common flexor sheath

Flexor pollicus longus enclosed by tendinous sheath of flexor pollicus longus

Common flexor sheath

Teninous sheath of flexor pollicis longus

Ⅳ. Teninous sheath 腱鞘

ⅤⅤ. The palmar fascial space . The palmar fascial space 手掌筋膜间隙手掌筋膜间隙

Deep palmar fascia Deep palmar fascia 掌部深筋膜掌部深筋膜Superficial layerSuperficial layer

Thenar fascia Thenar fascia 鱼际筋膜鱼际筋膜Hypothenar fascia Hypothenar fascia 小鱼际筋膜小鱼际筋膜Palmar aponeurosis Palmar aponeurosis 掌腱膜掌腱膜 thick triangular membrane thick triangular membrane

Deep layerDeep layer palmar interosseous fascia palmar interosseous fascia

骨间掌侧筋膜骨间掌侧筋膜

Osseofascial compartments of palmOsseofascial compartments of palm手掌骨筋膜鞘手掌骨筋膜鞘Lateral compartment Lateral compartment 外侧鞘外侧鞘Medial compartment Medial compartment 内侧鞘内侧鞘Intermediate compartment Intermediate compartment 中间鞘中间鞘

Intermediate compartment Intermediate compartment 中间鞘中间鞘FormedFormed byby palmar aponeurosis, Laeral and medial palmar aponeurosis, Laeral and medial intermuscular septum, palmar interosseous fascia and intermuscular septum, palmar interosseous fascia and abductor policis fasciaabductor policis fasciaContentsContents:: superficial palmar arch, a., v.,n., tendons of flexor superficial palmar arch, a., v.,n., tendons of flexor digitorum superficialis and profundus, lumbricales, common digitorum superficialis and profundus, lumbricales, common flexor sheathflexor sheath

Laeral intermuscular septumMedial intermuscular septum

Palmar aponeurosis

Palmar interosseous fascia

Adductor pollicis

Hypothenar fascia Thenar fascia

Fascia spaces Fascia spaces 筋膜间隙筋膜间隙Thenar space Thenar space 鱼际间隙鱼际间隙Midpalmar spaceMidpalmar space 掌中间隙掌中间隙

Midpalmar space掌中间隙

Thenar space鱼际间隙

Midplmar septum掌中隔

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

Skin incisions

思考题思考题1. 试述肘窝的境界、内容及排列关系。2. 试述腕管的境界及穿行结构。3. 试述掌中间隙和鱼际间隙的境界及炎症蔓延途径。4. 由浅入深叙述手掌的层次结构。5. 试述手的神经支配情况（包括皮支和肌支）。6. 名词解释：肱骨肌管、前臂屈肌后间隙、腕尺侧管、桡侧囊、

尺侧囊、指髓间隙。