The upper limb

山东大学医学院 解剖教研室李振华

The muscles of backSuperficial group Trapezius 斜方肌 Latissimus dorsi 背阔肌 Levator scapulae 肩胛提肌 Rhomboideus 菱形肌

Deep group Erector spinae 竖脊肌 Splenius 夹肌 Thoracolumbar fascia 胸腰

筋膜

The muscles of thoraxExtrinsic muscles Pectoralis major 胸大肌 Pectoralis minor 胸小肌 Serratus anterior 前锯肌

Intrinsic muscles Intercostales externi

肋间外肌 Intercostales interni

肋间内肌 Intercostales intimi

肋间最内肌

Major muscles of the trunkTrapezius Origin: superior nuchal line, external o

ccipital protuberance, ligamentum nuchae and spinous processes of seventh cervical and all thoracic vertebrae

Insertion: lateral third of clavicle, acromion, and spine of scapulartery

Acton: upper fibers elevate scapula, lower fibers depress scapula; if scapula is fixed, one side acting along, draws head toward the same side, and turn face to opposite side; both sides together, draw head directly backward

Latissimus dorsi Origin: spinous processes

of lower six thoracic and all lumbar vertebrae, median sacral crest, and posterior part of iliac crest.

Insertion: floor of intertubercular groove of humerus.

Action: trunk fixed, extends, adducts and medially rotates arm ; arm fixed, elevates trunk.

Erector spinae Position: fills the vert

ebral groove on each side of the spine

Action: extends vertebral column (draw head backwar)

Pectoralis major Origin: medial half of clavi

cle,sternum,1th-6th costal cartilages.

Insertion: crest of greater tubercle of humerus.

Action: flexes, adducts and rotates arm medially; arm fixed, elevates trunk; elevates ribs 1-6,aidding in forced inspiration.

The Muscles of Upper Limb

Muscles of shoulder Deltoid supraspinatus Infraspinatus Teres minor Teres major subscapularis

Muscles of arm Antererior group

Biceps brachii 肱二头肌

Coracobrachialis喙肱肌

Brachialis 肱肌

Posterior group – triceps brachii肱三头肌

Muscles 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

Third layer Flexor digitorum profund

us 指深屈肌 Flexor pollicis longus 拇

长屈肌 Fourth layer － pronato

r quadratus 旋前方肌Action: flex radiocarpal j

oint and fingers, pronate forearm

Second layer － flexor digitorum superficials 指浅屈肌

Posterior group (10) Superficial layer (5)

Extensor carpi radialis longus 桡侧腕长伸肌

Extensor carpi radialis brevis 桡侧腕短伸肌

Extensor digitorum 指伸肌

Extensor digiti minimi 小指伸肌

Extensor carpi ulnaris 尺侧腕屈肌

Deep layer (5) Supinator 旋后肌 Abductor pollicis longus

拇长展肌 Extensor pollicis brevis

拇短伸肌 Extensor pollicis longus

拇长伸肌 Extensor indicis 示

指伸肌 Action: extend radiocapr

al joint and fingers, and supinate forearm

Muscles of hand Lateral group － thenar 鱼际 (4)

Abductor pollicis brevis 拇短展肌 Flexor pollicis brevis 拇短屈肌 Opponens pollicis 拇对掌肌 Adductor pollicis 拇收肌

Action: flex, abduct, adduct and oppose thumb

Medial group － hypothenar (3) Abductor digiti minimi 小指展肌 Flexor digiti minimi brevis 小指短屈

肌 Opponens digiti minimi 小指对掌肌

Action: flex, abduct , and oppose little finger

Intermedial group Lumbricales 蚓状肌 (4) －

flex fingers at MP joints; extend fingers at IP joints

Palmar interossei 骨间掌侧肌 (3) － adduct fingers towards middle finger at MP joints

Dorsal interossei 骨间背侧肌 (3) － abduct fingers away from middle finger at MP joints

Major muscles of upper limbDeltoid Origin: lateral third of clavicl

e, acromion, and spine of scapula

Insertion: deltoid tuberosity of humerus

Action: abducts ， flexes and medically rotates, extends, and laterally rotates arm

Teres major Origin: dorsal surface

of inferior angle of scapula

Insertion: crest of lesser tubercle of humerus

Action: medially rotates and adducts arm

Biceps brachii Origin: long head, supraglen

oid tubercle; short head, coracoid process

Insertion: radical tuberosity Action: supinator of forearm,

flexor of elbow joint, weak flexor of should joint

Pronator teres Origin: medical epicondyle of

humerus and deep fascia of forearm

Insertion: middle of lateral surface of radius

Action: pronation of forearm and flexion of elbow

Triceps brachii Origin: long head, infraglen

oid tubercle; lateral head, above groove for radical n., medical head, below groove for radical n.

Insertion: olecranon of ulna Action: extends elbow joint),

long head can extend and adduct shoulder joint

Supinator Origin: lateral epicondyle

of humerus and upper part of lateral border of ulna

Insertion: upper third of anterior surface of radius

Action: supination of forearm

Arteries of upper limbAxillary artery Continuation of subclavian artery at

lateral border of first rib Becomes brachial artery at lower bo

rder of teres major Divided into three parts by overlying

pectoralis minor First portion, above muscle － gives ris

e to thoracoacromial a. 胸肩峰动脉 Second portion, behind muscle － give

s rise to lateral thoracic a. 胸外侧动脉 Third portion, below muscle － gives ri

se to subscapular a. 肩胛下动脉 , anterior and posterior humeral circumflex a. 旋肱前、后动脉 ; the former then divides into throcodorsal a. 胸背动脉 and circumflex scapular a. 旋肩胛动脉

Brachial artery Continuation of axillary art

ery Divides into radial and uln

ar arteries at level of neck of radius

Branches Deep brachial a. 肱深动脉

－ accompanies with radial nerve

Superior ulnar collaeral a. 尺侧上副动脉－ accompanies with ulnar nerve

Inferior ulnar collateral a.尺侧下副动脉

Radial artery and branches Radial recurrent a. 桡侧返动脉 Superfical palmar branch 掌浅支 Principal artery of thumb 拇主要动脉Ulnar artery and branches Ulnar recurrent a. 尺侧返动脉 Common interosseous artery

骨间总动脉 Anterior interossous a. 骨间前动脉 Posterior interosseous a. 骨间后动脉

Deep palmar branch 掌深支

Superficial palmar arch 掌浅弓

Formed by ulnar artery and superficial palmar branch of radial artery

Curve of arch lies across the palm, level with the distal border of fully extended thumb

Gives rise to three common palmar digital arteries each then divides into two proper palmar digital arteries

Deep palmar arch 掌深弓 Formed by radial artery an

d deep palmar branch of ulnar artery

Curve of arch lies across upper part of palmar at level with proximal border of extended thumb

Gives rise to three palmar metacarpal arteries

Veins of the upper limb

Deep veins: accompany the arteries of the same region and bear similar names

Superficial veins Cephalic vein 头静脉

Arises from the lateral side of the dorsal venous rete of hand

Ascends on radial side of the forearm to the elbow and then in the lateral side of biceps brachii furrow, continues up the arm in the deltopectoral groove and then to the infraclavicular fossa, where it pierces clavipectoral fascia to drain into axillary vein

Basilic vein 贵要静脉 Arises from the medial side o

f the dorsal venous rete of hand

Ascends on the ulnar side of forearm to the elbow and then in the medial bicepital brachii furrow to middle of the arm where it pierces the deep fascia and joins the brachial vein or axillary vein

Median cubital vein 肘正中静脉

links cephalic vein and basilic vein in the cubital fossa. It is a frequent site for venipuncture to remove a sample of blood or add fluid to the blood

The lymphatic drainage of upper limbLymphatic vessels

Superficial － follow the superficial veins, drain into supratrochlear and axillary lymph nodes

Deep － accompany main vessels, end in axillary lymph nodes

lymph nodes Cubital lymph node: lies above

medial epicondyle of humerus Axillary lymph node － arranged

in five groups

Axillary lymph nodes 腋淋巴结－ arranged in five groups

Lateral lymph nodes 外侧淋巴结－ lie around the distal end of axillary vein , receiving drainage from the arm, forearm, and hand

Pectoral lymph nodes 胸肌淋巴结－ lie along lateral thoracic vessels, receive afferents from anterior thoracic wall including central and lateral portion of mamma

Subscapular lymph node 肩胛下淋巴结－ along subscapular vessels, receive lymph from nape and scapular region

Efferents above three groups pass to central lymph node

Central lymph node 中央淋巴结－ lie in fat of axillary fossa, receive drainage from all the above nodes, efferents pass to apical lymph node

Apical lymph node 尖淋巴结 Lie in the apex of the axilla, a

long the proximal end of axillary vessels

Receive drainage chiefly from central lymph node , upper portion of mamma

Efferents form subclavian trunk, the right subclavian trunk joints the right lymphatic duct; left usually drains directly into thoracic duct

Brachial plexus 臂丛Formation: Five roots: formed by anterior ra

mi of C5-C8 and T1 spinal nerves, roots C5 ～ C7give rise to long thoracic n. 胸长神经

Three trunks The upper trunk is formed by the j

oining of root C4,C5,C6. The middle trunk is the continuati

on of root C7. The lower trunk is formed by the j

oining of root C8 and T1. Six divisions: above clavicle, trun

ks form anterior and posterior divisions

Three cords: below clavicle, divisions form three cords that surround the second portion of axillary a.

Position: passes through the scalene fissure to post

erosuperior of subclavian artery, then enters the axilla to form lateral, medial and posterior cords

Main branches Lateral cord

Musculocutaneous n. 肌皮神经 Lateral root to median n. 正中神经外侧根

Medial cord Medial root to median n. 正中神经内侧根 Ulnar n. 尺神经 Medial brachial cutaneous n. 臂内侧皮神

经 Medial antebrachial cutaneous n.

前臂内侧皮神经

Posterior cord radial n. 桡神经 axillary n. 腋神经 thoracodorsal n. 胸

背神经

Musculocutaneous 肌皮神经

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

Median 正中神经 Distribution: Flexor of for

earm except brachioradialis, flexor carpi ulnaris and ulnar half of flexor digitorum profundus, thenar except adductor pollicis, first two lumbricals; skin of thenar, central part of palm, palmar aspect of radial three and one-half fingers, including middle and distal fingers on dorsum

Injury: Apehand 猿手produces sign of benediction,

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

Ulnar nerve Distribution: Flexor carp

i ulnaris, ulnar half of flexor digitorum profundus, hypothenar muscles, interossei, 3rd and 4th lumbricals and adductor pollicis; skin of hypothenar, palmar surface of ulnar one and one-half fingers, ulnar half of dorsum of hand, posterior aspect of ulnar two and one-half fingers

Injury: clawhand

Radial 桡神经 Distribution: Extensor

muscles of arm and forearm, brachioradialis; skin on back of arm, forearm, and radial side of dorsum of hand and radial two and one-half fingers

Injury: Wristdrop

Axillary 腋神经 Distribution: Deltoid

and teres minor muscle; skin over deltoid and upper posterior aspect of arm

Injury: result in deltoid andteres minor paralysis (loss of shoulser abdution and weel external rotation) with loss of sensation over the deltoid

Regional anatomy of upper limb

山东大学医学院 解剖教研室李振华

Parts and regions Shoulder region － junction of ar

m and trunk Arm － between should and elbo

w Elbow － bend of arm, joint betw

een arm and forearm Forearm － between elbow and h

and Hand

Surface anatomy Shoulder region: acromion, spine of scapula,

coracoid process, greater tubercle, anterior and posterior axillary folds

Arm － medial and lateral biceps brachii furrow, deltoid tuberosity

Elbow － medial and lateral epicondyles, head of radius, olecranon, tendon of biceps brachii

Forearm － between elbow and hand Hand － styloid process, dorsal tubercle

Anatomical snuff box 鼻烟壶

When the thumb is abducted and extended, a triangular hollow appears between the tendon of the extensor pollicis longs medially and the tendons of the extensor pollicis brevis and abductor pollicis longus laterally.

The floor of the snuff box is the scaphoid and trapezium bones and crossed by the radial a..

1650 ～ 1700

Carring angle 提携角

Mamma 乳房

Position Lie in superficial fascia

over the pectorals major and pectoral fascia

Extend from 3rd to 7th ribs vertically, and from parasternal line to midaxillary line transversally

Structures － contains skin, mammary glands and adipose tissue

Each brest has about 15 ～ 20 lobes of mammary gland

Each lobe radiates out from the nipple and has a lactiferous duct 输乳管 which opens separately on the summit of the nipple and possesses a dilated lactiferous sinuses 输乳管窦 just prior to its termination

Suspensory ligaments of breast 乳房悬韧带 (cooper’s ligaments ) － strands of connective tissue runs between skin and deep fascia and serve to support the mammary glands

Axillary fossa 腋窝

The axillary fossa is a pyramid-shaped space through which major neurovascular structures pass between the thorax and upper extremity

Boundaries The apex is a triangular

space limited by the first rib, the scapula, and the middle third of clavicle.

The base － skin and fascia of the axillary fossa

The anterior wall Pectoralis major, pectoralis minor and subclavius muscles Clavipectoral fascia 锁胸筋膜

The deep faxcia which extends between subclavius, coracoid process and pectoralis minor muscles

The structures pass through the clavipectoral faxcia Cephalic v. Thoracoacromial a. Lateral pectoral n.

The posterior wall － teres major, latissimus dorsi, subscapularis and scapula

Trilateral and quadrilateral foramina 三边孔和四边孔

Between the subscapularis and teres major, there is a long triangular space whose lateral side is surgical neck of humerus. The long head of triceps brachii subdivides this space into a medial trilateral foramen and a lateral quadrilateral foramen.

The posterior humeral circumflex a. and axillary n. pass through the quadrilateral foramen.

The circumflex scapular a. passes through the triangular space to reach the dorsum of the scapula.

The broad medial wall － serratus anterior ， intercostal muscles and upper four ribs

The narrow lateral wall － coracobrachialis, biceps brachii and intertubercular groove

Contents Brachial plexus, axillary a. and principal branches, axillary v. a

nd tributaries, axillary lymph nodes and loose connective tissue

Brachial plexus 臂丛Formation: Five roots: formed by anterior rami of C5-C

8 and T1 spinal nerves, roots C5 ～ C7give rise to long thoracic n. 胸长神经

Three trunks The upper trunk is formed by the joining of r

oot C4,C5,C6. The middle trunk is the continuation of root

C7. The lower trunk is formed by the joining of r

oot C8 and T1. Six divisions: above clavicle, trunks form a

nterior and posterior divisions Three cords: below clavicle, divisions form

three cords that surround the second portion of axillary a.

Position:

passes through the scalene fissure to posterosuperior of subclavian artery, then enters the axilla to form lateral, medial and posterior cords

Main branches Lateral cord

Musculocutaneous n. 肌皮神经 Lateral root to median n. 正中神经外侧根

Medial cord Medial root to median n. 正中神经内侧根 Ulnar n. 尺神经 Medial brachial cutaneous n. 臂内侧皮神经 Medial antebrachial cutaneous n.

前臂内侧皮神经

Posterior cord radial n. 桡神经 axillary n. 腋神经 thoracodorsal n. 胸背神经

Axillary sheath 腋鞘－ extension of deep cervical fascia of the neck, forming a tubular sheath that surrounds axillary a. and v., and brachial plexus

Axillary artery Continuation of subclavian artery at lat

eral border of first rib Becomes brachial artery at lower borde

r of teres major Divided into three parts by overlying pe

ctoralis minor First portion, above muscle － gives rise t

o thoracoacromial a. 胸肩峰动脉 Second portion, behind muscle － gives r

ise to lateral thoracic a. 胸外侧动脉 Third portion, below muscle － gives rise

to subscapular a. 肩胛下动脉 , anterior and posterior humeral circumflex a. 旋肱前、后动脉 ; the former then divides into throcodorsal a. 胸背动脉 and circumflex scapular a. 旋肩胛动脉

Axillary lymph node － arranged in five groups Lateral lymph nodes － lie around the distal end

of axillary artery vein , receive afferent vessels from upper limb.

Pectoral lymph nodes － lie along lateral thoracic vessels, receive afferents from anterior thoracic wall including central and lateral portion of mamma

Subscapular lymph node － along subscapular vessels, receive lymph from nape and scapular region

Efferents above three groups pass to central lymph node

Central lymph node － lie in fat of axillary fossa, receive lymph from all the above nodes, efferents pass to apical lymph node

Apical lymph node － lie in the apex of the axilla, along the proximal end of axillary vessels, receive afferents chiefly from central lymph node , upper portion of mamma; efferents form subclavian trunk, the right subclavian trunk joints the right lymphatic duct; left usually drains directly into thoracic duct

Cubiral fossa 肘窝Boundaries Base － line drawn through

epicondyles of humerus Apex － brachioradialis later

ally and pronator teres medially

Roof － skin, superficial faxcia, deep faxcia and aponeurosis of biceps

Floor － brachialis, supinator and capsule of elbow joint

Contents － from lateral to medial

Biceps brachii tendon Brachial a. － divides into r

adial and ulnar a.,usually at apex of fossa

Median n.

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

Carpal tunnel 腕管Flexor retinaculum Thickening of deep fascia in

the hand Attached laterally to scaphoi

d and trapeziun and medially to pisiform and hamate

Form an osseofibrous tunnel (carpal tunnel) with carpal groove － transmits median n., flexor digitorum supericialis, flexor digitorum profundus, and flexor pollicus longus from forearm into hand

Common flexor sheath

Teninous sheath of flexor pollicis longus

Skin incisions

Cephalic v.

Lateral cutaneous branch

Anterior cutaneous branch

Superficial fascia

Clavipectoral fascia 锁胸筋膜

The deep faxcia which extends between subclavius, coracoid process and pectoralis minor muscles

The structures pass through the clavipectoral faxcia Cephalic v. Thoracoacromial a. Lateral pectoral n.

Axillary a.

Thoracoacromial a.

Musculocutaneous n.

Median n.

Medial antebrachial cutaneous n.

Ulnar n.

Medial brachial cutaneous n.

Intercostobrachial n.Thoracodorsal n. & a.

Long thoracic n. & lateral thoracic a.

Lateral pectoral n.

Posterior humeral circumflex a. & axillary n.

Radial n.

Circumflex scapular a.

Musculocutaneous n.

Median n.Medial brachial cutaneous n.

Ulnar n.

Medial antebrachial cutaneous n.

Superior ulnar coleteral a.

Deep brachial a.

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.

Median cubital v.

Lateral anterachial cutaneous n. & cephelic v. Medial interracial cutaneous n.

& basiic v.

Radial recurrent a.

Radial a.

Radial n.

Median n.

Ulnar n.

Ulnar a.

Ulnar recurrent a.

Ulnar n.

Brachial a.

Muscolocutaneous n.

Brachial a.

Radial n.

Radial recurrent a.

Radial a.

Median n.

Ulnar recurrent a.

Common interosseous a.

Ulnar a., v. & n.

Palmar aponeurosis

Superficial palmar a.

recurrent n.

Ulnar a.

Posterior region of upper limb

山东大学医学院 解剖教研室李振华

Skin incisions

Cutaneous n. and superificial v.

Trapezium

Deltoid

Triangle of ausculation

Latissimus dorsi

Thoracolumbar fascia

Levator scapular

Rhomboideus

Axillary n.

Posterio humeral circumflex a.

Deep brachial a.

Radial n.

Suprascapular n.& a.

Supraspinatus

Infraspinatus

Teres minor

Teres major

Radial n. Deep brachial a.

Posterior interosseousa.

Posterior interosseous n.

Hand

山东大学医学院 解剖教研室李振华

Palm of hand 手掌Flexor retinaculum 屈肌支持带 Thickening of deep fascia in the han

d Attached laterally to scaphoid and tr

apeziun and medially to pisiform and hamate

Carpal tunnel 腕管 Formed by flexor retinaculum and ca

rpal groove Transmits

Median n. Flexor digitorum superficialis and flex

or digitorum profundus enclosed by common flexor sheath

Flexor pollicus longus enclosed by tendinous sheath of flexor pollicus longus

Common flexor sheath

Tendinous sheath of flexor pollicis longus

Deep palmar fascia 掌部深筋膜Superficial layer Thenar fascia 鱼际筋膜 Hypothenar fascia 小鱼际筋膜 Palmar aponeurosis 掌腱膜 t

hick triangular membrane

Deep layer － palmar interosseous fascia 骨间掌侧筋膜

Osseofascial compartments of palm 手掌骨筋膜鞘

Lateral compartment 外侧鞘 Medial compartment 内侧鞘 Intermediate compartment 中间鞘

Laeral intermuscular septumMedial intermuscular septum

Palmar aponeurosis

Palmar interosseous fascia

Adductor pollicis

Hypothenar fascia Thenar fascia

Intermediate compartment 中间鞘 Formed by palmar aponeurosis, Laeral and medial intermuscul

ar septum, palmar interosseous fascia Contents: superficial palmar arch, a., v.,n., tendons of flexor di

gitorum superficialis and profundus, lumbricales, common flexor sheath

Fascia spaces 筋膜间隙 Thenar space 鱼际间隙 Midpalmar space 掌中间隙

Midpalmar space

Thenar space

Midplmar septum掌中隔

Dorsum of hand 手背Extensor retinaculum

伸肌支持带 Thickening of deep faxcia of fore

arm a wrist Attached laterally to radius and

medially to styloid process of ulna and triquetrum

Forms six fibrous compartments for extensor tendons passing from forearm into hand:

① tendons of abductor pollicis longus and extensor pollicis brevis and their synovial sheaths;

② tendons of extensor carpi radialis longus and brevis and their synovial sheaths;

③ tendon of pollicis longus and its synovial sheath; ④ tendons of extensor digitorum, extensor indicis and the

ir synovial sheaths; ⑤ tendon of extensor digiti minimi and its synovial sheath

s; ⑥ tendon of extensor carpi ulnaris and its synovial sheath

s

Fascia of the dorsal hand

The superficial fascia Deep fascia － the dorsal

fascia of hand Superficial layer (dorsal a

poneurosis) 手背腱膜 Deep layer (dorsal intero

sseous fascia) 骨间背侧筋膜

Two spaces The dorsal subcutaneous space 手背皮下间隙 The dorsal subaponeurotic space 手背腱膜下间隙

Superficial fascia

Dorsal aponeurosis

Dorsal interosseous fascia

Dorsal subcutaneous space

Dorsal subaponeurotic space

Nerves of hand Median n. － thenar except adductor pollicis, first two lumbricals;

skin of thenar, central part of palm, palmar aspect of radial three and one-half fingers, including middle and distal fingers on dorsum

Ulnar n. － hypothenar muscles, interossei, 3rd and 4th lumbricals and adductor pollicis; skin of hypothenar, palmar surface of ulnar one and one-half fingers

Radial n. － skin of radial side of dorsum of hand and radial two and one-half fingers

Fingers 手指 Pulp space 指髓间隙 On

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

vessels : 有 2 条指掌侧固有动脉和 2 条指背动脉，分别走行于手指的两侧。 Nerves ： 神经与同名动脉伴行。