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Upper extremity, MEMBRUM SUPERIUS 

SUBCLAVIAN AREA, REGIO INFRACLAVICULAR "

Subclavian region applies to the chest and the upper extremity. However, sections of the subclavian region involved in the formation of the axillary fossa, and it adjoins directly to the main neurovascular bundle of the upper extremity -

axillary. In this connection, in topographic anatomy subclavian region is considered as part of the shoulder girdle, or shoulder girdle.

External benchmarks. Clavicle, sternum, pectoral muscle, the front edge of the

deltoid muscle. Below the clavicle, between the clavicular portion of large pectoral muscle and the anterior edge of the deltoid muscle, on the border between the outer and middle third of the clavicle, often revealed subclavian fossa, fossa in-fraclavicularis, or fossa Morengeyma [Mohrenheim |, passing distally into the deltoid, thoracic furrow, sulcus deltopectoralis,, reaching the anterior edge of the deltoid muscle to the shoulder lateral grooves (Fig. 3.1).

Deep furrows on 1,5-2 cm below the clavicle can propal-opy coracoid blade, processus coracoideus.

Boundaries. Upper - clavicle; m edialnaya - outer edge of the sternum, the bottom - the horizontal line, corresponding to the third intercostal space, lateral - the front edge of the deltoid muscle.

Projections. With external reference points can be made projections of the following entities.

From the front ends of III-V ribs to subcoracoid small triangle projected pectoralis

minor, ie pectoralis minor (Fig. 3.2). With this muscle on the skin under 

clavicular region can cause the projection of three triangles: clavicular, thoracic, breast, and brisket (trigonum clavipecto-rale, trigonum pectorale and trigonum subpectorale).

Within these triangles are usually considered the topography of the axillary

neurovascular bundle: a., v. axillaris, plexus brachialis and its branches (for details, see the section on the armpit).

The projection of the axillary neurovascular bundle in this area is carried out from the medial half of the middle third of the clavicle downwards and outwards to the

boundary between the lower and middle third of the deltoid-pectoral sulcus. The

projection of v. axillaris occupies the medial part of the beam. By sulcus

deltopectoralis projected v. cephalica.

 Layers

The skin is thin, moderately mobile.

Subcutaneous adipose tissue without features developed individually. There are supraclavicular nerves of cervical plexus.

Superficial fascia in the upper third of the field forms a pouch for platysma (platysma), starting from its own fascia chest. At the level of P-III edges of fascia condenses, forming a suspensory ligament of the breast, or bundles of Cooper

[Cooper]. On all boundaries of the subclavian fascia transferred to the neighboring area.

Own fascia area, fascia pectoralis, surrounds the pectoral muscle in the front and

rear of the superficial and deep leaves. Between them, sharing the large pectoral muscle fibers, there are numerous fascial bridge.

As a result, the spread of suppurative processes in the muscle occurs from the

surface to depth. Along the jumpers are also lymphatic vessels, which explains the

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Глава 3spread of metastases in breast cancer at the deep surface of the large pectoral muscle.

Superficial and deep fascia pectoralis at the top of the sheets are attached to the fascia of the subclavian muscle, as well as to the superficial fascia sheet own neck

(second fascia on Shevkunenko). Downstairs they accrete on the outer edge of the

large pectoral muscle, thus forming a closed case for it. Behind the clavicle to the I part of the fifth rib is attached the fascia of the neck (prespinal), covering the scalenus anticus.

The next layer (Fig. 3.3) is a fiber subpektoral-space, spatium subpectorale (detail of its wall will be described below).

Deeper still lies clavicular-pectoral fascia, fascia clavipectoralis. At the top it starts from the clavicle and the rostral process of the scapula, with the medial side - at the beginning of low breast -

     I - clavicula; 2 - m. sub-clavius; 3 - m. pectoralis major, 4 -

m. pectoralis minor, 5 - spatium subpectorale; 6 - fascia tho-racica; 7 - fascia clavipectoralis; 8 - cellulose axillary fossa, 9 - fascia axillaris; 10 - fascia

endothoracica; 11 - fascia thoracica; 12 - m. serratus anterior; 13 - pleura

parietalis; 14 - a. et v. axilkres.

Noah muscle (III-Vrebra), bottom and outside of it is attached to the deep fascia

sheet m. pectoralis major at its outer edge. Thick bundles of clavicular-grutsnoy fascia at this point form a bundle that attach to the axillary fascia, fascia axillaris (Fig. 3.4).

These bundles are called suspensory ligament, lig. suspensorium axillae, or a bunch of poles [Gerdy].

About clavicular fascia is also sealed. Here it is adjacent to the subclavian Vienna, which with a sharp derivation hands can be squeezed between the fascia, clavicle and rib with the possibility of acute thrombosis of the vein.

F. clavipectoralis makes case for the pectoralis minor and subclavian

muscles, m. subclavius.

 Thus subpektoralnoe klegchatochnoe space located between the major and minor pectoral muscles and their fascial veils.

The front wall of the space - a deep piece of fascia pectoral muscle.

Rear - clavicular-pectoral fascia, covering the small pectoral muscle.

Above it is closed at the clavicle, where both fascia fused.

Medially it is locked in place of the beginning of the two muscles of the ribs.

Lateral and bottom of the space is closed fusion fascia of the pectoral muscle and the clavicular-pectoral fascia on the outer edge of the pectoral muscle.

The next layer - fiber upper division axillary fossa, which is the main neurovascular bundle - axillary vessels and the first beams, and then the branches of the brachial plexus (sometimes this layer is called a deep subpektoralnym space).

Behind this fiber has its own pectoral fascia, fascia thoracica, covering the serratus anterior and intercostal space (see Fig. 3.3).

Topography of the neurovascular bundle

In the subclavian region is considered the topography of that part of the armpit of the beam, which passes within-clavicular and thoracic triangle (between the clavicle and the upper edge of pectoralis minor).

In this triangle just below the clavicular-pectoral axillary fascia

is Vienna, v. axillaris, emerging from beneath the upper edge of the pectoralis OMOP.SU ]

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Глава 3minor and in an oblique direction going from the bottom up to a point located at

2.5 cm medially from the middle of the clavicle. The area between the rib and clavicle I already called subclavian Vienna. Fascial sheath veins are closely associated with the subclavian muscle fascia and periosteum I edge that serves as an obstacle to spadeniyu its walls.

In this regard, if damaged veins there is a danger of air embolism. However temhoroshaya fixation veins can produce at this stage of its puncture.

Axillary artery, a. axillaris, lies laterally and deeper veins. In clavicular-pectoral

triangle from the axillary artery leaves the upper thoracic artery, a. thoracica superior, branching in the first and second intercostal space, and

grudoakromialnaya artery, a. thoracoacromialis, almost immediately falls into

three branches: the deltoid, chest and acromion. They pierced Klyucharev-

chichno-thoracic fascia and sent to the appropriate muscles. On the same site through the fascia of the deltoid-pectoral sulcus in the axillary fossa is lateral

subcutaneous Vienna hands, v. cephalica, and empties into the axillary vein (see Fig. 3.4).

Bunches of the brachial plexus are located laterally and deeper into the artery.

Thus, in the direction from front to back, and with the medial side of the lateral elements of the neurovascular bundle are the same: first Vienna, then the artery, then the brachial plexus (a method for storing - VAPleks).

At the medial margin of the axillary vein is located apical group of lymph nodes under the arm pits.

Communication cellulose subclavian region with neighboring areas

1. With fiber axillary fossa through a defect in the rear wall (f. clavipectoralis) subpektoralnogo space, along the branches of

a. thoracoacromialis.

2. In the course of tissue that accompanies the main neurovascular bundle, purulent process may spread to the lateral triangle of the neck.

3. Along the same fiber bundle associated with the lower-lying parts of the axillary fossa.

SHOULDER AREA, REGIO SCAPULARIS

External benchmarks. The top edge of the scapula is located on level II edge (medial angle reaches a level I rib), the bottom corner - at the level VIII

ribs. Arista shoulder corresponds roughly III edge.

The most accessible to palpation, and therefore the most reliable external landmarks are the medial edge of the blade, its lower corner, barb and scapula acromion. The line connecting the lateral part of the acromion and the bottom corner of the blade corresponds to the lateral margin of the scapula, which is often not possible to palpate because for the cover up his muscles.

Boundaries. Upper - line from acromion-Klyucharev-chichnogo junction perpendicular to the backbone, the lower - the horizontal line running through the lower angle of scapula, medial - the inner edge of the scapula to the intersection with the upper and lower boundaries; lateral - from the lateral end of the acro-Mioni vertically down to the lower limit.

Projections of the major neurovascular structures field. A. et n. suprascapularis projected on a line running from the middle of the clavicle to the point corresponding to the base of the acromion, ie the boundary of the outer and middle

third of the scapula spine. The projection line, the profundus a. transversae colli (a. scapularis dorsalis, PNA) is along the inside edge of the scapula 0,5-1 cm inwards

from it. Place of entrance a. circumflexa scapulae in the infraspinatus box projected on the projection of mid-lateral margin of the scapula.

Layers

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Глава 3The skin is thick, physical inactivity, it hardly can be gathered into the

fold. Sometimes the male skin is covered with hair. If contamination of skin friction of clothing in the places, the elderly and malnourished people with diabetes in this area may have boils (furunculosis). In the skin of many of the sebaceous glands, with their occlusion in this area often arise sebocystoma - atheroma requiring surgical removal.

Subcutaneous fat-layer, dense, mesh because the connective tissue partitions, reaching from the skin in depth, to its own fascia.

Superficial fascia can be represented by several sheets of different

densities. Nadfastsialnyh entities there is little, thin subcutaneous nerves are branches of the axillary and supraclavicular nerves (Fig. 3.5).

Own superficial fascia of the muscles (m. trapezius, so deltoideus, so latissimus dorsi) makes their cases.

Fascia supraspinata et fascia infraspinata - its own deep fascia of shoulder muscles, starting from its rear surface. These are dense fascia, have aponeurotic

structure. As a result of their attachment to the edges of the scapula and spine formed by two bone-fibrous space - supraspinous and infraspinatus.

Topography over-and infraspinatus spaces blade (Fig. 3.6)

Supraspinous fossa supraspinata space corresponds to the scapula. Above it is

closed as a result of attachment f. supraspinata to 

upper edge of the blade, to the fascial sheath subclavian muscle and

lig. coracoclaviculare. Below it is closed scapular spine. Outside, the grounds and under the acromion acromion-Klyucharev-chichnym joints, supraspinatus space

open in podos-Local and subdeltoid kletchatochnye space. Content supraspinal

space (box) is m. supraspinatus, as well., v. et n. suprascapulares.

Infraspinatus fibrous-osseous space formed by its own fascia and the scapula

below the scapular spine. Fascia infraspinata adherent to the medial margin of the

scapula, the scapular spine and the lateral edge of the scapula. Contents of the base

are so infraspinatus, m. teres minor, a small layer of tissue located between the

muscles and bones, as well as vessels and nerves: a. et v. suprascapularis,

a. circumflexa scapulae, n. suprascapularis. Also included are the branches, the

profundus a. transversae colli, butting their own

   fascia at the medial edge of the scapula. artery, the envelope of the blade, on the way of the axillary fossa is also pierced this fascia, but the lateral margin of the scapula.

These three branches of arteries anastomose with each other in the infraspinatus

tissue and thicker infraspinatus muscles. The result is a so-called scapulohumeral collateral arterial circle. If a loss or cessation of blood flow in the trunk - arm - above the artery (proximal to) the place of a discharge from her subscapularis artery (a. subscapularis) by anastomosis of the blade circle of blood circulation can

be maintained throughout the upper extremity. More information stated in the section "collateral circulation in the areas of shoulder girdle.

From the angle of the scapula and the lower half of its lateral margin and on the

outer surface of the infraspinatus fascia begins a large round muscle. Its upper edge adjoins the bottom of the veiled infraspinatus fascia small circular muscle;

gap between them is formed. In the middle of a circular muscle during most of its crosses behind the long head tendon of triceps, which extends anteriorly, a small

circular muscle. The gap between the circular muscle is divided thus into two divisions: the medial (triangular hole) and lateral (four hole) (Fig. 3.7).

Edges of the triangular aperture blades are below - a large, round muscle, top - a

small, round, and with the lateral side - the long head tendon of triceps. Through

this hole in blade area of the armpit is a. circumflexa scapulae. Then she pierced fascia-tial case of small circular muscle and the branches in the muscles infraspinatus fossa.

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Глава 3Quadripartite hole is located outside the shoulder area and is seen in the section "Axillary Region.

 

Fig. 3.7. Tripartite and quadripartite holes from the blade (on Shpalteholtsu, as amended).

1 - acromion; 2 - tuber-culum majus humeri; 3 - m. teres minor; 4 - foramen

quadrilateram; 5 - foramen trilateram; 6 - caput laterale m. tricipitis brachii; 7 -

caput longum m. tricipitis brachii; 8 - m. teres major; 9 - m. infraspinatus; 10 -

spina scapulae; 11 - m. supraspina-tus.

The next layer - blade (scapula).

Subscapularis space. M. subscapular ^ located on the front side of the blade in the bone-fascial bed, formed by fusion subscapularis fascia with the edges of the

scapula. Subscapularis, moving in a fairly strong tendon, is sent to subdeltoid

space in which the tendon is attached to a small tubercle humerus. Before attaching the tendon is closely adjoins to the anterior capsule of the shoulder

joint. Under the subscapularis tendon is a fairly large synovial bag, bursa synovialis subscapularis, permanently connected to the cavity of the shoulder joint capsule. The front of the subscapularis muscle with its fascia is involved in the formation of posterior wall of the axillary fossa and the posterior wall prescapular kletchatoch-dimensional space, which is a continuation of the

axillary space in the dorsal direction. Front wall of this space is the serratus anterior, covered with its own fascia, fascia thoracica.

Communication fiber shoulder area with the neighboring areas

1. In the course nadlopatochnogo beam - with the fiber of the lateral triangle of the neck.

2. In the course of a. et v. circumflexae scapulae through a triangular hole - with fiber axillary fossa.

3. In the course of the tendon and infraspinatus muscles - with fiber subdeltoid space.

Deltoid AREA, REGIO DELTOIDEA

The region is located outwards from the shoulder corresponds to the contour of the deltoid muscle covering the shoulder joint and upper third of the humerus.

External benchmarks. Clavicle, acromion and scapula arista, the convexity of the

deltoid muscle, its front and rear edges of the deltoid-pectoral groove. When dislocations in the shoulder joint, the convexity of the deltoid muscle is smoothed out, replaced by the dimple.

Boundaries. Upper - outer third of the clavicle, acromion and the outer third of the scapular spine. The bottom - line on the outer surface of the shoulder that connects the lower edge of pectoral muscles and latissimus dorsi. Front and rear boundaries correspond to the edges of the deltoid muscle.

Projections. In the course of the deltoid-pectoral sulcus projected lateral

subcutaneous Vienna hands, v. cephalica. The vertical line lowered down from the posteroexternal acromion angle to the intersection with the rear edge of the m.deltoideus (average 6 cm in the derivation of the upper extremity of the torso to the right angle, this distance is equal to 2,5-3,0 cm), projected onto the

neurovascular bundle region - n. axillaris et aa. circumflexae humeri anterior et

posterior. At the same level is the surgical neck of the

shoulder. Projection recessus axillaris - protrusion of the lower articular bags shoulder joint is determined by a point situated on the same vertical line at 4 cm below the posterior angle of acromion, ie, 2 cm above the projection of the axillary

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Глава 3

nerve. Here in inflammation (arthritis), the shoulder joint is determined at a

pressure sore. This point is located under the rear edge of the deltoid muscle.

Layers

Leather relatively thick, inactive.

Subcutaneous adipose tissue is well defined, especially near caudineural border region, has a cellular structure. Approximately in the middle of the rear edge of the deltoid muscle in the subcutaneous fat from under their own fascia beyond the

axillary nerve branch, n. cutaneus brachii lateralis superior.

Superficial fascia is poorly developed.

Own fascia, fascia deltoidea, the upper boundary of the region is firmly fused

with the clavicle, acromion and spine of the scapula. At the front and the bottom

line, it freely passes into the fascia pectoralis and the fascia brachii. At the front of the border area, in the sulcus deltopectoralis, in the cleavage of its own fascia is

v. cephalica, which goes further into the subclavian region.

Own fascia is superficial and deep sheets, which form the case for the deltoid

muscle. Both leaf bind numerous spurs that divide the individual muscle fibers. In two places the spurs are particularly well developed: they share the three portions of the deltoid muscle to the places of their attachment - clavicular, pars clavicularis, acromion, pars acromialis, and spinous processes, pars spinalis.

P oddeltovidnoe kletchatochnoe space located between the deep leaf of fascia deltoidea (at the deep surface of the deltoid muscle) and the proximal end of the

humerus with the shoulder joint and its capsule. In the fiber space is the neurovascular bundle, as well as subdeltoid synovial bag, bursa subdeltoidea,

surrounding a large tubercle humerus. This tubercle attached to the tendon-

dostnoy, infraspinatus and a small circular muscle. Almost as a rule, subdeltoid bag communicates with the other mucosal pouch, located under the acromion (bursa subacromial).

Subdeltoid kletchatochnoe space goes up under the acromion and more posteriorly in podtrapetsievidnoe space.

Topography of vessels and nerves. The main element of the neurovascular bundle

- n. axillaris, branch of the posterior bundle of the brachial plexus. It innervates the

deltoid muscle. Fascial sheath of the beam associated with a piece of deep fascia

of the deltoid muscle. Passing of the axillary fossa through the foramen quadrilaterum, it adjoins to the armpit volvulus, recessus axillaris, capsule of the shoulder joint, and then goes around the surgical neck, shoulder, back to front.

N. axillaris lies proximal posterior artery, the envelope of the humerus.

On the deep surface of the deltoid muscle a. circumflexa humeri posterior anastomose with a. circumflexa humeri anterior, coming also from the

axillary fossa, but on the front surface of the surgical neck of the shoulder. The two arteries anastomose well as with the deltoid branch of

a. thoracoacromialis. These anastomoses provide collateral circulation in a loss of blood flow to the axillary artery at the site between grudoakro-mialnoi artery and the two arteries, the envelopes of the humerus. Anastomosis is also an important anastomosis between the deltoid branch of the same name grudoakromialnoi artery

and a branch of the deep artery of the shoulder. This anastomosis plays an important role at a loss of blood flow in the arm - the brachial artery in the area between the subscapularis artery and the deep artery of the shoulder.

At the turn of the humerus at the surgical neck of possible infringement of the axillary nerve. Sometimes the nerve is involved in developing callus and

compressed it. It is also possible involvement of the nerve in the inflammatory process in suppurative disease of the shoulder joint, and the breakthrough of pus

from the capsule through the recessus axillaris. In all such situations there is an infringement of cutaneous sensitivity in the area of its branches, and most

importantly, develops paresis or paralysis of the deltoid muscle. It will be apparent inability abduction of shoulder to the horizontal level (loss of function of

the deltoid muscle). 

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Глава 3Communication fiber subdeltoid space with neighboring regions

1. In the course of the neurovascular bundle and then through the four-sided hole subdeltoid space associated with axillary.

2. In the course of supraspinal and infraspinatus tendons, muscles associated with supraspinal and infraspinatus spaces scapula.

3. Above fiber is continuing under the acromion and more posteriorly in podtrapetsievidnoe space.

FRONT shoulder problems, REGIO BRACHII ANTERIOR

External benchmarks. Attaching to shoulder a big chest and latissimus dorsi, biceps brachii, the inner and outer nadmyschelki shoulder, medial and lateral grooves in the

respective edges of the biceps muscles of the shoulder. Sylvian fissure proximally moves

in the deltoid, thoracic furrow. Distally both furrows pass in front elbow. In the course of the medial sulcus can palpate the humerus and here clung to her brachial artery with

bleeding. For this reason, the imposition of harness most effectively, it is in the shoulder.

Boundaries. The upper boundary of the region is on the line connecting the point of attachment to shoulder a big chest and latissimus dorsi, the lower boundary is drawn through the points located at 4 cm above nadmyschelkov shoulder, the two lateral boundaries correspond to vertical lines drawn from the nadmyschelkov.

Projections on the skin major neurovascular structures

Projection a. brachialis and n. medianus conducted from a point on the border of the anterior and middle third of the line defining the upper boundary of the region until the middle of the elbow or, more precisely, about 1 cm medial to the tendon of the biceps

muscles of the shoulder. If sulcus bicipitalis medialis well defined, the projection line of

the brachial neurovascular bundle with it the same. By the same line is

projected v. basilica.

Projection n. ulnaris in the upper third of the shoulder corresponds to the projection of the main neurovascular bundle, and from a point between the upper and middle third of the declines in the medial side to a point 1 cm lateral tip-over of the medial condyle (at the base nadmyschelka).

N. radialis projected onto the front surface of the skin in the lower third of the shoulder

along the Sylvian fissure. (Portion of the lateral fissure shoulder on examination revealed poorly because of excessive growth of subcutaneous adipose tissue. In such cases, the projection lines use the lateral border of the front side of the shoulder.)

Layers

The skin in front of the shoulder on a thin, especially in the medial part of the region,

quite moving. In the skin of the medial surface of the upper half of the arm medial cutaneous nerve branches shoulder, P. cutaneus brachii medialis, the medial bundle of the brachial plexus.

Subcutaneous adipose tissue is loose. Superficial fascia is well expressed in the lower third of the field, where it forms a pouch for the surface of neurovascular structures in the rest of the field is weak.

Surface area of education: from the medial side (along the sulcus bicipitalis medialis) in the

bottom third of the shoulder is located medial subcutaneous Vienna hands, v. basilica, and

next to her branch subsection cutaneus antebrachii medialis. On the lateral side, along the

sulcus bicipitalis lateralis, in its entirety is lateral subcutaneous Vienna hands, v. cephalica, which is near the upper boundary of the region goes into sulcus deltopectoralis.

Own fascia, fascia brachii, around the shoulder as a whole. On the border of the middle and lower third of the shoulder to shoulder in the medial sulcus own fascia has a hole

through which the splitting of the fascia (the channel Pirogov) enters v. basilica, and from it comes forth cutaneus antebrachii medialis. From the inner surface of its own fascia with the medial and lateral side of the humerus depart intermuscular partitions (septa intermusculare laterale et mediale), resulting in a shoulder formed two fascial floor: front and rear.

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Глава 3The walls of the anterior fascial bed shoulder, compartimentum brachii anterius, are: front - own fascia, rear - are attached to the humerus to her intermuscular septa (Figure 3.16).

The contents of the front floor muscles are: lying deeper rostral-brachial (upper third of the shoulder), short head biceps arm and shoulder (bottom two-thirds of the shoulder), and the

surface - long head of the biceps brachii. Shoulder muscles, or muscle Kasserib [Casserio], covers the deep fascia.

 Fig. 3.16. Fascial floor shoulder to the cross section of the middle third. 1 - m. biceps brachii; 2

- t. brachialis; 3 - n. mus-culocutaneus; 4 - n. medi-anus; 5 - a. bracliialis; 6 - v. basilica et

n. cutaneus an-tebrachii medial is in the channel Pirogov, 7 - n. ulnaris; 8 - septum intermusculare

mediale; 9 - fascia brachii; 10 - m. triceps brachii; 11 - n. radialis et a. collaterals radialis; 12 - septum intermusculare laterale.

On the inside the first rostral-shoulder, then arm the biceps muscle in its entirety in the fascial case, formed by the medial intramuscular partitioning is the main neurovascular bundle of the field - brachial artery, accompanying veins and the median nerve. Rear shoulder fastsialyyue bed, conipartirnenturn brachii posterius, limited front humerus

with partitions, in the back - its own fascia. In the back of the box is m. triceps brachii.

Topography of the vessels and nerves of the anterior fascial bed

In the upper third of the shoulder n. medianus located next to the artery laterally from

it. Medially from the artery is n. ulnaris and more medial - n. cutaneus antebrachii

medialis. Medially from the main beam and the most medial surface lies v. basilica, which is joined to the beam at the boundary of the upper and middle thirds, immediately upon

emerging from the channel Pirogov. In the upper third of the shoulder, the Vienna falls either in one of the brachial vein, or goes into the axillary region and empties into the axillary vein (Figure 3.17).

 Fig. 3.17. Perednevnugrennyaya povfhnost shoulder. 1 - v. brachialis; 2, 5 - a. bracliialis; 3 -

v. sfpaIsa 4 - n. musculocutaneus; 6 - a. profunda brachii; 7 - n. radialis; 8 - channel Pirogov, 9 - n.

ulnaris; 10 - n. medianus; 11 - v. basilica; 12 - n. cutaneus antebrachii medialis.

N. musculocutaneus goes with the lateral side rostral-shoulder muscles, which he pierced on its way from the axillary fossa to the anterior surface of the shoulder, and goes underneath the long head biceps shoulder, and on the border with the middle third of the

responsibility of the deep fascia that covers the shoulder muscles. On its way it gives branches to all muscles of the front fascia-vidual bed.

At the border of the front of the shoulder and underarm area just below the lower edge of

latissimus dorsi tendon behind the artery is determined by a large trunk n. radialis. Almost immediately, he sent to the rear fascial bed between the long and lateral heads of triceps brachii.

Brachial artery in the upper third of the shoulder gives a large branch - deep artery of

arm, a. profunda brachii, which almost immediately goes along with the radial nerve in the

back fascial bed. On the border of the upper and middle third of the shoulder of the

brachial artery departs another branch: the upper ulnar collateral artery, a. collate-ralis ulnaris superior, which is then accompanied by ulnar nerve.

In the middle third of the shoulder n. medianus located in front of the brachial artery (intersecting it). N. ulnaris shifted more medially from the arteries and on the border with the upper third

pierced the medial intermuscular wall, passing into the rear bed of the shoulder. Along

with him, and goes well. collateralis ulnaris superior.

N. cutaneus antebrachii medialis and left anterior fascial bed, going to the splitting of its

own fascia (channel Pi-horns), where in a fascial space goes v. basilica.

N. musculocutaneus directed obliquely downward and outward from the inside between the biceps and shoulder muscles.

In the lower third of the shoulder n. medianus is already medial artery, but next to it. From

here departs artery, another branch of: a. collateralis ulnaris inferior. It comes down sideways on the surface of the shoulder muscles in the elbow region (the name of the artery is not associated with ulnar nerve, which is in the front bed is gone, and only refers to elbow aside of course), which participates in the formation of ulnar collateral network.

On the lateral side of the lower third of the shoulder in the front box

reappears n. radialis. which pierced the lateral intermuscular partition and passes from the

rear bed in the front. It is located deep between the muscles: the humerus and the lateral

head triceps. At the border with the elbow, he is just as deeply, but between the first and

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Глава 3brachioradialis muscles. In these cracks intermuscular nerve is accompanied by radial

collateral artery, a. collateralis radialis, - the terminal branch a. profunda brachii.

Here, on the border of the lower third of the shoulder with the front elbow, from the biceps shoulder out a finite branch of the musculo-cutaneous nerve, which here is called the lateral cutaneous nerve of forearm, n. cutaneus antebrachii lateralis. From under their own fascia in subcutaneous he goes dis-experimental, within the front elbow.

Thus, within the anterior fascial bed shoulder throughout the pass, only brachial artery with

a vein (closest to the bone), median nerve and musculo-cutaneous nerve. Median nerve

branches to the shoulder does not. The rest of the neurovascular education or go back to bed (radial nerve with the deep artery of the arm in the upper third, ulnar nerve from the upper ulnar collateral artery in the lower third) or in the subcutaneous tissues of the shoulder.

Communication fiber front of the shoulder with the neighboring areas In the course of tissue surrounding the main neurovascular bundle, fiber anterior fascial bed shoulder proximally related to the fiber axillary fossa. In the distal direction it is connected with fiber front elbow. In the course of radial nerve - with the rear fascial bed shoulder. Through the channel Pirogov - with subcutaneous adipose tissue.

REVERSING the shoulder, REGIO BRACHII POSTERIOR 

External benchmarks. Latissimus dorsi, where it is attached to the shoulder, the deltoid muscle, the convexity of triceps brachii, medial and lateral nadmyschelki humerus.

Boundaries. The upper boundary runs obliquely to the posterior edge of the deltoid muscle to the latissimus dorsi. The bottom is located at 4 cm above nadmyschelkov humerus. Lateral boundaries are vertical lines going up from nadmyschelkov.

Projection n. radialis corresponds to the spiral line drawn from the lower edge of

m. latissimus dorsi to the point located on the border of the middle and lower thirds of the lateral boundaries of the region.

Layers

The skin is thicker than on the front of the shoulder, m & topodvizhna.

Subcutaneous adipose tissue are often developed considerably. After subcutaneous to the skin area are cutaneous nerves: n. cutaneus brachii lateralis superior (from P. axillaris),

n. cutaneus brachii lateralis inferior and posterior cutaneous nerve of the shoulder, n. cutaneus brachii posterior (from n. radialis), innervate nelateralnuyu rear surface of the

shoulder. At the boundary of the back of the shoulder and the back elbow goes through its

own rear fascia of the forearm cutaneous nerve, n. cutaneus antebrachii posterior (from n.

radialis). The abundance of cutaneous nerves in this area explains the frequent painful intramuscular injection in the triceps brachii.

Own fascia covers m. triceps brachii. However, as mentioned the medial and lateral intermuscular septa own fascia forms the rear fascial bed shoulder, compartimentum

brachii posterior. Content fastsialnogo rear bed are m. triceps brachii and radial nerve with

the accompanying deep artery of the shoulder. In the lower third of the shoulder in the

back of the bed are n. ulnaris and the a. collateralis ulnaris superior. Right under their own

fascia determined with the medial side of the long head of m. triceps brachii. and with the

lateral - lateral. The medial head is deeper.

Topography of the neurovascular bundle

Radial nerve comes on the back surface of the shoulder from the front fastsialnogo bed

through the gap between the long and lateral heads of triceps. He then located in plechemyshechnom canal, canalis humeromuscularis, helically envelope of the humerus in

its middle third. One wall of the channel formed bone, the other - the lateral head triceps (Fig. 3.18).

In the middle third of the shoulder in the canalis humeromuscularis radial nerve adjoins directly to the bone, which explains the appearance of paresis or paralysis after applying tourniquet at mid-shoulder for a long time, or in cases of injury with fractures of the diaphysis of the humerus.

However, the nerve is deep artery of arm, a. profunda brachii, which soon after the start gives important for collateral circulation between the areas of shoulder girdle and shoulder ramus deltoi-deus, anastomosing with the deltoid branch grudoakromial-Term arteries and

arteries, envelopes humerus. In the middle third of the shoulder a. profunda brachii is

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Глава 3

divided into two terminal branches: a. collateralis radialis and a. collateralis media. Radial nerve with a.collateralis radialis on the border of the middle and lower third of the area pierced the lateral intermuscular wall and returns to the front bed of the shoulder, and then

to the front elbow. There artery anastomose with a. recurrens radialis.A. collateralis media

anastomose with a. interossea recurrens.

In the lower third of the shoulder in the posterior fascial bed passes ulnar nerve with

a. collateralis ulnaris superior. Then they are sent to the back elbow. 

 Fig. 3.18. Povfhnost Rear shoulder

1 - m. irifra ^ inatus; 2 - t. teres minor; 3 - t. teres major, 4 - a brachialis; 5 -, the

muscularis a profundae brachii; 6 - n. cutaneus brachii medial is; 7 - m. triceps brachii

(caput longum); 8 - r. muscularis n. radialis; 9 - m. triceps brachii (caput laterale); 10 -

m. triceps brachii (caput mediale); 11 - tendo m. tricipitis brachii; 12 - n. ulnaris et a

collateralis ulnaris superior, 13 - n. cutaneus antebrachii posterior; 14 - a collateralis

media; 15 - m. anconeus; 16 - m. flexor carpi ulnaris; 17 - m. trapezius; 18 - spina

scapulae; 19 - m. del-toideus; 20 - n. axillaris et a circumflexa humeri posterior, 21 - a

circumflexa scapulae; 22 - humerus; 23 - n. radialis et a profunda brachii. 

Communication fiber rear of the shoulder with the neighboring areas

1. In the course of radial nerve proximally linked to the cellulose fiber anterior fascial floor of the shoulder.

2. Distal - with fiber cubital fossa.

3. In the course of the long head triceps brachii is related to fiber axillary fossa.

FRONT elbow, REGIO CUBITI ANTERIOR

External benchmarks. Epicondyli medians et lateralis, tendon m. biceps brachii,

m. brachioradialis, lateral elbow crease. Three elevation - the lateral (from m. brachioradialis), the mean (ie biceps brachii) and medial (due to muscle-flexors, starting from the medial nadmyschelka) - limit the deepening called cubital fossa, fossa

cubiti. Between them visible front lateral and medial ulnar grooves, sulci cubitales

anteriores lateralis et medialis, which are a continuation of the grooves of the shoulder. At the lower boundary fossa cubiti continues in a radial sulcus, sulcus radialis.

Boundaries. The horizontal line drawn at 4 cm above and below the line connecting nadmyschelki arm (elbow line), separate front elbow from the front of the shoulder at the top and from the front of the forearm at the bottom. The two vertical lines drawn through

both nadmyschelka, anterior ulnar region is separated from the posterior elbow. Line elbow (lateral skinfold) divides the region into two parts - upper and lower.

Projections. A. brachialis is projected at the medial margin m. biceps brachii, and P. medianus of 0,5-1,0 cm medial to the artery. (It is worth recalling that the terms "medial" and "lateral" indicate the position of anatomical education for the middle axis of the whole body, not legs. Thus, artery lies closer to the tendon, and the median nerve - closer to the medial nadmyschelku.) At the level of the medial nadmyschelka near the inner edge of

m. biceps brachii to take the pulse on a. brachialis. This place is also for the auscultation of tones in the measurement of blood pressure.

Place division of the brachial artery to radiation, a. radialis, and second, a ulnaris, the artery is projected at 1-2 cm below the elbow.

N. radialis projected in the upper half of the area along the medial margin of the

m. brachioradialis.

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Глава 3Layers

The skin is thin, through it often reveals the subcutaneous veins, which become strained

when you apply tourniquet on his shoulder. Keep in mind the mobility of the skin when performing intravenous injections (good record with fingers).

Subcutaneous adipose tissue is developed individually, from a very thin layer to a

thickness of several centimeters. It is loose, layered. This explains the fact that the hematoma, particularly after intravenous injection, spread wide, sometimes taking the form of extensive bruising in the antecubital fossa.

In the deep layer of subcutaneous fat are the superficial veins and nerves (Fig. 3.19).

On the medial side is v. basilica, next to which are branches of subsection cutaneus

antebrachii medialis. At the level of the medial nadmyschelka inwards from v. basilica are

superficial ulnar lymph nodes, nodi lymphoidei cubitales superficiales. On the lateral side

is v. cephalica. These veins connect going sideways medial ulnar Vienna, v. mediana

cubiti. Anastomosis with a form letter and or N. Sometimes, instead of v. mediana cubiti

here are v. mediana cephalica and v. mediana basilica, originating from v. mediana

antebrachii. Anastomosis in this case has the shape of the letter M. In any case, the superficial veins are connected branch, perforating its own fascia, with deep veins.

Intravenous injection produced in v. mediana cubiti or v. mediana cephalica and

v. mediana basilica no two reasons. The first - with deep vein anastomosis, resulting in these veins are fixed to its own fascia and become inactive. Second, in addition to these

superficial veins is no subcutaneous nerves, in contrast to v. cephalica and v. basilica.

 Figure 3.19. Topography of the surface (subcutaneous) formations front elbow.

I - n. cutaneus brachii medialis; 2 - septum intermusculare brachii mediale; 3 - branch

subsection cutaneus antebrachii medialis; 4 - v. basilica;- 5-Nodi cubitales (surface

groups);- 6-Epicondylus medialis; 7 - m. pronator teres; 8 - aponeurosis m. bicipitis

brachii; 9 - v. mediana antebrachii; 10 - v. basilica; II - m. extensor carpi radialis longus;

12 -v. cephalica; 13 - m. brachioradialis; 14 -- n. cutaneus antebrachii lateralis;

15 - v. mediana cubiti; 16 - n. cutaneus antebrachii medialis, ramus ant. et ramus ulnaris;

17 - v. cephalica; 18 - m. biceps brachii.

At the level of the elbow from under their own fascia in the subcutaneous branches come forth cutaneus antebrachii lateralis (continued p. musculocutaneus), which are in the distal

direction close to v. cephalica.

Own fascia over the medial group of muscles is of the form aponeurosis, as the fascia is strengthened radiating surface of the tendon of the biceps muscle fibers aponeurosis

(aponeurosis bicipitalis, or bicipital aponeurosis Pirogov [Pirogoff]). At the edge of the medial elbow fascia fused with the ulna.

From own fascia by the retreating deep into the sulci medial and lateral intermuscular

septum. Medial attached to the humerus and the medial nadmyschelku, lateral - to the

elbow joint capsule and fascia of the m. supinator. At the lower boundary of these partitions are joined, forming the front wall beam intermuscular forearm.

Own fascia and walls form three fascial bed: medial, middle and lateral.

In the medial bed located muscles, starting from the medial nadmyschelka: in the first layer is the most medial (closer to the edge of the elbow) is an elbow flexor wrists, so flexor carpi ulnaris, laterally from it - a long palmar muscle, m.palmaris longus, flexor wrists and

then radiotherapy, m. flexor carpi radialis, and the most laterally, closer to the center field -

a round pronator, m. pronator teres, attach to the radial bone. Deeper is a superficial flexor

of fingers, m. flexor digitorum superficialis. It should be noted that in the elbow to separate these muscles can be difficult, to trace their progress can already distally, in front of the forearm.

On average, the bed surface is m. biceps brachii, attach to the radius, and deeper -

m. brachialis, attach to the ulna. Shoulder muscle covers the deepest layer of the area - the elbow with its capsule.

In the lateral bed is brachioradialis muscle, so brachioradialis, supinator and under it,

m. supinator.

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Глава 3

Topography of neurovascular structures

A. brachialis with accompanying veins located near the inner edge of the tendon of the

biceps muscle in the splitting of the medial wall at the m. brachialis, and n. medianus lies 0,5-1,0 cm medial (Fig. 3.20).

 Fig. 3.20. Topography of the deep (podfastsialnzh) formations of the front elbow. 1 -

m. biceps brachii; 2 - n. ulnaris et a collateralis ulnaris superior; 3 - n. medianus; 4 - a

brachialis; 5 - m. brachialis; 6 - nodus cubi-talis (deep), 7 - aponeurosis m. bicipitis

brachii; 8 - m. pronator teres; 9 - a ulnaris; 10 - a radians; 11 - n. radialis (ramus super-

ficialis et ramus profundus); 12 - connecting branch v. mediana cubiti with deep veins.

Under the aponeurosis m. bicipitis brachii 1-2 cm below the line connecting over the

condyle humerus, brachial artery divided into a. radialis and a.

ulnaris. A. radialis. crossing the tendon of the biceps muscles of the shoulder in front, is directed laterally into the crack between v. pronator teres and so

brachioradialis. A. ulnaris goes under the m. pronator teres, and then placed between the

superficial and deep flexor of fingers. N. medianus first at a short distance adjoins to the

ulnar artery, and then moves to the forearm, passing between the two heads of m. pronator teres.

Within the cubital fossa of the radial artery departs returnable radial artery, a recurrens

radialis, but from the ulnar artery - general intercostals artery, a. interossea communis, and

then returnable ulnar artery, a. recurrens ulnaris. The latter is divided into two branches:

the front and rear; g. anterior to the fissure between the medial and secondary muscle

groups anastomose with a. collateralis ulnaris inferior, and posterior in the back, the medial ulnar groove - with a.collateralis ulnaris superior. Returnable and collateral arteries, Anas-

tomoziruya together, form the front and rear elbow arterial network, rete articulare cubiti,

providing blood supply to the elbow joint. These anastomoses are the collateral pathways of blood supply of limbs at different levels of damage and ligation of the brachial artery.

A. interossea communis on the border with the anterior area of the forearm is divided into anterior and posterior intercostals arteries.

In place of bifurcation of a brachialis are nodi lymphoidei cubitales, taking deep lymphatics of the distal limb tion department.

N. cutaneus antebrachii lateralis out of the gap between the m. biceps brachii and brachialis in so lateral margin of the final section of the biceps muscle and will soon pierced own

fascia, leaving in the subcutaneous fatty tissue, which is located next to v. cephalica.

N. radialis and a. collateralis radialis in the splitting of the lateral intramuscular

partitioning in the upper half of the area run deep between m. brachioradialis, and so brachialis, and at the level of the lateral nadmyschelka directly on the capsule of the

joint. Here radial nerve divides into two branches: the superficial and deep. R. superficialis

n. radialis continues to move the nerve and becomes intermuscular slit formed

m. brachioradialis, and so pronator teres. R.profundus n. radialis is directed laterally and goes to the canalis supinatorius between the superficial and deep parts of the

m. supinator, skirting along with the muscle of the neck radius. From the deep branch of the channel goes back between the muscles of the forearm, which innervate.

When fractures of the neck radius may suffer and deep branch of radial nerve. This function drops the extensor muscles, but still skin sensitivity in the areas innervated by the superficial branch. More proximal radial nerve damage - to the point of division on the

branches - like leading to paralysis of muscles, and the spillage of skin sensitivity. 

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Глава 3

BACK elbow, REGIO CUBITI POSTERIOR

External benchmarks. The medial and lateral nadmyschelki humerus, ulna tine ulna and located on either side of his rear medial and lateral elbow sulcus, sulcus cubitalis posterior medialis et lateralis.

Boundaries. Cyclotomic line drawn at 4 cm above and below mezhnadmyschelkovoy lines on the sides - the vertical line drawn through nadmyschelki.

Projections. N. ulnaris projected to sulcus cubitalis posterior medialis. In the middle of the sulcus cubitalis posterior lateralis palpable, especially in supination and pronation of the forearm, the head of the radius, and slightly higher - articular gap brachioradialis joint.

Layers

The skin is thick, mobile.

In subcutaneous adipose tissue over the tip of the olecranon, is synovial bag, bursa subcutanea olecrani (Figure 3.21).

Bag may be inflamed (bursitis) prolonged pressure on it (at the engravers, watchmakers, etc.) and with the injury.

 Figure 3.21. Topography posterior elbow. I - fascia bracliii; 2 - n. cutaneus

antebracliii posterior, 3 - m. anconeus; 4 - margo posterior ulnae; 5 - flexor forearm, b -

bursa subcutanea olecrani; 7 - ring tendon m. flexor carpi ulnaris; 8 - n.ulnaris; 9 - a

collateralis ulnaris superior, 10 - m. triceps bracliii.

Visible rear arterial network of elbow

Own fascia is a dense, fibrous reinforced beams from the fibers of the tendon m. triceps

brachii. Fascia is firmly adherent with nadmyschelkami shoulder and the back edge of the ulna.

Under the fascia in the upper half of medially located medial head triceps brachii, which merges into a strong tendon.

On the lateral side it forms the tendon of the lateral head muscles. The tendon is attached to

the olecranon, olecranon. Under a tendon, in place of its attachment to the olecranon, is

bursa subtendinea m. tricipitis brachii.

From the lateral nadmyschelka start-extensor muscles of the hand and fingers.

N. ulnaris, accompanied by a. collateralis ulnaris superior out of the thick medial head

triceps. At the level of the condyles, he is placed under the fascia in the sulcus cubitalis posterior medialis, in the osteo-fibrous canal formed by the medial nadmyschelkom,

olecranon and its own fascia. Here it is closely adjacent to the elbow joint capsule. At the

lower boundary of the region goes under subsection ulnaris m. flexor carpi ulnaris, and so flexor digitorum superficialis, heading for the front bed of the forearm.

Being close to the surface and bone formation, ulnar nerve is often injured, that may manifest itself well to all the well-known short-term burning pain, and in more severe cases

- falling out of its functions. 

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Глава 3

Elbow, ARTICULATIO CUBITI

Main external benchmarks are tine ulnar, olecranon, and nadmyschelki humerus. Note that the lateral epicondyle is located at 1 cm below the medial.

The projection of the articular gap corresponds to a transverse line drawn at 1 cm below the lateral and 2 cm below the medial nadmyschelka.

Articulatio cubiti formed humerus, ulna and radius bones that make up the complex joint,

having a common capsule. Block of the lower epiphysis humerus articulated with the semilunar notch ulna, forming ginglymoid humeroulnar joint, articulatio humeroulnaris (Figure 3.22).

 Head condyle humerus, capitulum humeri, articulated with a dimple on the head of

the radius, forming a spherical joint brachioradialis, articulatio humeroradialis. Incisura radialis articulated with the lateral surface of the head radius, forming a cylindrical

proximal radioulnar joint, articulatio radioulnaris proximalis. Form of the joints allows movement along two axes: flexion and extension, and rotation (pronate-supination).

Fibrous capsule fibers elbow attached to the periosteum of the radius arm front and crown holes, in the back - over the cubital fossa, and lateral parts - the base of both nadmyschelkov. Nadmyschelka Both humerus remain outside the joint cavity.

At the radius and ulna capsule is attached on the edges of articular cartilage, as well as the neck radius.Synovium front

Fig. 3.22. Sagittal cross-section of Th-U coronary fossa humerus, and Res elbow (on the back-sleepers, the olecranon fossa, teholygu, as amended). fossa olecram, does not reach the place

1 - humerus' 2 - fossa olec-attachment of a fibrous capsule and rani; 3 - capsula articularis; 4 - wrapped in the bone. Promezhut - olecranon; 5 - ulna; 6 - ha-tion between the fibrous and sinovial - dius; 7 - processus coronoideus Noah shell in these places are busy ulnae; 8 - recessus sacciformis; loose fat. 9 - trochlea humeri; 10 - fossa through the radius and ulnar side of the recoronoidea dny and posterior joint cavity connected only by narrow slits, which are at an inflammation of the synovial membrane can close the joint and completely isolate the anterior joint cavity from the rear.

In place of attachment of fibrous capsule to the neck radius synovium forms a katabatic

inversion, called saccular volvulus, recessus sacciformis. Fibrous capsule is thinned, so this section is called "weak spot" capsule of elbow joint inflammation when it accumulates a purulent exudate, and in his break purulent process may extend into the deep fiber forearm.

Outside the capsule is strengthened ulnar and radial collateral ligaments, ligg. collateralia

ulnare et radiale, as well as a bunch of ring radius, lig. anulare radii.

The front of the bag is almost completely covers the joint m. brachialis, with the exception

of the lateral area. Here the lateral margin m. brachialis directly on the capsule is

n. radialis. The outer capsule is covered by Section m.supinator (Fig. 3.23, 3.24).

 Behind in the upper joint is covered tendon m. triceps brachii, and in the inferolateral

- m. anconeus. On the medial side the capsule is not protected by muscle and covered only

property      Noah fascia. Here in the posterior medial sulcus of the bag joint

adjoins n. ulnaris.

Front caudineural capsules on each side of the olecranon, where the capsule is not enhanced by any muscle, is the second "weak point".

Directly under the distal end of the tendon m. triceps brachii is a spacious plot glenoid

cavity, corresponding fossa olecrani humeri. This department is the joint cavity over the tip of the olecranon is the most convenient place for the puncture.

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Глава 3Synovial bags back of the elbow with the joint cavity are not reported. Blood supply to the

joint via rete articulare cubiti, formed by the branches of a. brachialis, a. radialis and

a. ulnaris. Venous outflow is the same name on the veins.

Innervation of the branches carried nn. radialis, medianus and n. ulnaris.

The outflow of lymph occurs in deep lymphatic vessels in the elbow, and axillary lymph nodes.

ARTERIAL COLLATERALS elbow

In the elbow, as well as in the shoulder, there is a collateral arterial network, compensating the loss function of the main vessel (a. brachialis) as a result of stenosis, occlusion or injury, followed by ligation. It can be seen (Figure 3.25), the largest number of collaterals, begins operations in violation of blood flow in the area between a discharge from the

brachial artery a. collateralis ulnaris inferior and a place of division and radial artery at the elbow.

Immediately anastomosing with each other branches are presented below. 

Top a. collateralis a. collateralis

a. collateralis a. collateralis

radialismedia ulnaris superior ulnaris inferior

Below a. recurrens a. interossea ramus posterior ramus anterior

radialis recurrens a. recurrens a. recurrensulnaris ulnaris

The most unfavorable end of the main blood flow in the area above the deep artery of the

shoulder. 

 Fig. 3.25. Arterial collaterals elbow.

I - a. brachialis; 2 - a. collareralis radialis; 3 - a. collateralis media; 4 - a. recurrens radialis;

5 - a. interossea recurrens; 6 - a. interossea communis; 7 - a. radialis; 8 - a. ulnaris; 9 -

a. recurrens ulnaris; 10 - ramus anterior a. recurrens ulnaris;II - ramus posterior

a. recurrens ulnaris; 12 -- a. collateralis ulnaris inferior; 13 - a. collateralis ulnaris superior; 14 - a. profunda brachii. 

Anterior Forearm, REGIO ANTEBRACHII ANTERIOR 

External benchmarks. M. brachioradialis, radial groove, sulcus radialis, ulnar groove,

sulcus ulnaris, tendon m. flexor carpi radialis and m. palmaris longus, subulate appendages radiotherapy and ulna, pisiform bone.

Boundaries. Upper - horizontal line at 4 cm distal to the level of the elbow, lower - the

transverse line drawn at 2 cm proximal to the top subulate sprouts radius. Vertical lines connecting lifted up, pussy-shoulder with awl-shaped appendages share the forearm to the front and rear area.

Projections. N. medianus projected on a line running from the middle distance between

the tendon and the medial nadmyschelkom m. biceps braehii the middle distance between

the awl-shaped appendages. In the lower third of the guideline for § medianus a groove

formed by tendons m. flexor carpi radialis, and so palmaris longus.

N. ulnaris is projected along the line connecting the base of the medial nadmyschelka shoulder with the lateral edge pisiform bone.

Ramus superficialis n. radialis projected on a line running from the middle of the distance between the medial and lateral lifted up, snapping to the boundary between the middle and distal radius edge of the forearm.

The projection line a. radialis is the direction from the middle of the elbow to the medial margin subulate sprouts radius and corresponds to the radial groove.

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Глава 3A. ulnaris in the upper third of the forearm is projected along the line connecting the middle of the elbow, to connect to a line drawn from the medial nadmyschelka shoulder to the lateral edge of the pisiform bone on the border of the upper and middle third of the forearm, and then goes on this line.

Layers

The skin is thin, often through her shine in the lateral edge of v. cephalica and at the

medial - v. basilica. The best they can be seen upon application of tourniquet on his shoulder (Figure 3.26).

 Subcutaneous adipose tissue developed individually. It is loose, layered. Superficial

fascia is poorly developed. For injuries skin flap with subcutaneous fiber easily and at length may delaminate from its own fascia, as if scalped wounds on the vault of the skull.

In the subcutaneous tissue at the inner edge of m. brachioradialis is v. cephalica accompanied by branches of the n. cutaneus antebrachii lateralis, and at the medial edge of

the area - v. basilica with branches subsection cutaneus antebrachii medialis.

Own fascia, fascia antebrachii, in the proximal thick and shiny and thinner distally. With

ulnar hand it all over fused with the ulna. From his own depart two intermuscular fascia walls that attach to the radius: front radial wall musculature passes along the medial edge so brachioradialis, and back - along the lateral. Bones of the forearm, fascia and intermuscular own partitions separate the forearm into three fascial box: front, outside and back, hundred-partimenti antebrachii anterius, pos-terius et lateralis.

Lateral fascial bed limited to the front and laterally

- Own fascia medially - front beam intramuscular septum and the radius, the rear - the rear beam intramuscular septum.

In the lateral bed is m. brachioradialis, which is in the middle of the forearm moves in a long tendon, and in the lower third is attached to the radial bone. In the upper third of the

muscle under the belly m. brachioradialis is m. supinator, covered with deep fascia. In the thicker muscle passes deep branch of radial nerve.

Front fascial bed is limited: its own front fascia, rear - the bones of the forearm and

intercostals membrane; laterally - the front beam intramuscular septum and medial - own fascia, fused with the rear edge of the ulna.

In the front bed under its own muscle and fascia are the neurovascular education. Muscles are arranged in 4 layers.

In the first layer (Fig. 3.27) are 4 muscles: the most medial - m. flexor carpi ulnaris, and

then - m. palmaris longus, m. flexor car - 

10 

Fig. 3.27. Superficial layers of anterior forearm. Fascia of the forearm partially removed and turn visible superficial muscles, blood vessels and nerves.

1 - skin with subcutaneous adipose tissue, 2 - m. pronator teres; 3 - Vol flexor carpi

radialis; 4 - Vol palmaris longus; 5 - Vol flexor carpi ulnaris; 6 - n. ulnaris; 7 - a. et

w. ulnares; 8 - m. flexor digito-rum superficialis; 9 - n. medianus; 10 - a.et w. radialis; 11 -

ramus superficialis n. radialis; 12 - m. brachioradialis; 13 - fascia antebrachii.

pi radialis and the most laterally, closer to the middle of the forearm, m. pronator

teres. They all start from the medial nadmyschelka humerus and initially appear as a single muscle head, only more distally, on the border between the upper and middle third, they are

seen as self-education. M. flexor carpi radialis covers outgoing depth to the radius distal

m. pronator teres, and then at an angle close to the m. brachioradialis and then runs parallel

to it. M. palmaris longus is often absent.

In the second layer is m. flexor digitorum superficialis. It also starts from the medial nadmyschelka. It is a wider muscle, so in the middle and lower third of the forearm, it is

visible in the lumen "between the muscles and tendons of the first layer. Behind, from the deep surface of the muscle to it adjoins a deep piece of fascia, which separates the first two layers from the third (Figure 3.28).

Fig. 3.28. Deep layers of anterior forearm. Superficial muscles partially removed. There

are deep muscles, blood vessels and nerves. 1 - m. pronator teres; 2 - Vol flexor carpi

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Глава 3radialis; 3 - Vol palmaris longus; 4 - Vol flexor digitorum superficialis; 5 - n. ulnaris; 6 -

m. flexor carpi ulnaris; 7 - a. et w. interosseae anterior; 8 - a. et w. ul-nares; 9 - m. flexor

digitorum profundus; 10 - n. median us; 11 - m. pronator quadratus; 12 - m. flexor pollicis

longus; 13 - n. interosseus anterior; 14 - ramus superficialis n. radiales; 15 -

m. brachioradialis; 16 - a. etw. radialis; 17 - fascia antebrachii; 18 - skin with subcutaneous fatty tissue.

In the third layer is laterally m. flexor pollicis longus, and medial - ie flexor digitorum profundus. Both muscles begin from the bones of the forearm and intercostals membrane at the boundary between the upper and middle third.

In the fourth layer in the bottom third of the forearm is so pronator quadratus (Fig. 3.29).

Between the muscles of the third and fourth layer is a deep part of the anterior fascial floor of the forearm, or kletchatochnoe space Paron [Ragopa] - Pirogov. Its walls are:

front  back (deep) surface of the m. flexor pollicis longus, and so on flexor digitorum profundus;

Rear  - membrana interossea and so pronator quadratus from its fascia; lateral  - anterior radial musculature partition separating the space of

m. brachioradialis; medially  - own fascia of the forearm, fused with the ulna;

 fig. 3.29. The deep fascial floor of the anterior forearm. Superficial muscles

removed. Round pronator dissected and turn away. We see the division of the brachial artery, derogation obshey intercostals artery, median nerve along its entire length, deep muscle, blood vessels and nerves.

1 - m. pronator teres; 2 - a. interossea communis; 3 - n. ulnaris; 4 - n. interosseus anterior;

5 - Vol flexor carpi ulnaris; 6 - a. et w. ulnares; 7 - a. et w. interosseae anterior; 8 -

m. flexor digitorum profundus; 9 - n. medianus; 10 - m. pronator quadratus; 11 - m. flexor

pollicis longus; 12 - a. et w. radiates; 13 - m. brachioradialis; 14 - ramus superficialis

n. radialis; 15 - ramus profundus n. radialis; 16 a. brachialis.

- Top - a place of attachment to the intercostals membrane m. flexor

poUicis longus, and so on flexor digitorum profundus.

Lower wall space in Paron - Pirogov no: it turns your wrist into the canal, canalis carpi, where the tendons are superficial and deep flexors of the fingers, as well as the long flexor of the thumb of the brush. This circumstance makes the space of great practical importance,

since it applies here suppurative processes of the lateral and middle floor brush. The amount of space Paron - Pirogov is big enough: it can accommodate from 100 to 300 ml of fluid (exudate).

Topography of neurovascular structures

Under its own front fascia of the forearm floor there are 4 neurovascular bundle.

The radiation beam, a. radialis with accompanying veins and the city superficialis n.

radialis, is the most superficially and laterally. In the upper third of the vessels and nerves

are located between m. brachioradialis laterally and the m.pronator teres medially, and in

the middle and lower thirds - respectively, between m. brachioradialis, and so flexor carpi

radialis. From a. radialis in the lower third of the forearm deviates ramus carpalis palmaris,

which goes towards this branch of the well. ulnaris. On the border with the anterior area of

the wrist the radial artery passes outwards under the tendons of mm. abductor pollicis longus et extensor pollicis brevis and falls into the so-called anatomical snuffbox of the wrist.

R. superficialis n. radialis lies laterally from the artery and accompanies her to the border

between the middle and lower third of the forearm. At this level the nerve deviates

outward, passes under the tendon m. brachioradialis, pierced his own fascia and enters the subcutaneous layer of the wrist and the rear of the brush.

Elbow neurovascular bundle is formed at the boundary of the upper and middle third of the

area. In the upper third of the ulnar nerve and ulnar artery run separately. A. ulnaris passes from the middle of the cubital fossa obliquely to the medial side of the front surface of the

forearm, having a m. pronator teres, and so flexor digitorum superficialis. At the boundary between the upper and middle third of the forearm, it is with the ulnar nerve lies between the flexor carpi ulnaris so medially, and so flexor digitorum superficialis dateralno. Next ulnar neurovascular bundle is in the depth between the muscles anterior to the deep flexor

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Глава 3

of fingers, and the border with the wrist - anterior to the m. pronator quadratus.

At the upper border of the forearm from a. ulnaris starts overall intercostals

artery, a. interossea communis, which soon divided into aa. interosseae anterior et

posterior. Last through the hole in the intercostals membrane goes into the rear bed of the forearm.

On the border of the middle and lower third of the forearm from a. departs ulnaris ramus

carpalis dorsalis, which passed under the tendon m. flexor carpi ulnaris medially, pierced his own fascia and enters the subcutaneous tissues towards the rear of the wrist of the same

name the branches of the radial artery. Together they form a rete carpale dorsale.

N. ulnaris in the upper third lies between the heads so flexor carpi ulnaris, and only on the edge of the middle third united with the arteries in the beam and the rest of the medially located for her.

N. medianus accompanied by a small artery of the same name, departing from a. interossea

anterior, located in the upper third of the forearm between the heads of m. pronator teres, and on exit from this interval passes in front of the ulnar artery, emerging from under the

round pronator. In the middle third of the nerve lies between the superficial and deep flexor

of fingers, firmly fixing to the rear of the fascial its case m. flexor digitorum superficialis. Often it is difficult to find, because the nerve will blend together with the delays the

superficial flexor of fingers. In the lower third of the forearm median nerve is out of the muscle and lies directly under their own fascia in the median sulcus, sulcus medianus,

formed m. flexor carpi radialis and m. palmaris longus. Because of the surface location of

this portion of the nerve is particularly vulnerable to injury. Distal median nerve goes along with the flexor tendons in the canalis carpi.

Fourth beam - the deepest, it is front intercostals neurovascular bundle, a. et v. interossea anterior, with the same nerve (from section medianus) on the front surface of the intercostals membrane.

Artery, reaching m. pronator quadratus, through a hole in the membrana interossea goes back to bed, where it participates in the rear of the arterial network of the wrist, rete carpale dorsale.

Contact kletchatochnogo space with neighboring regions

Kletchatochnoe space Paron - Pirogov, which may accumulate a considerable amount of

pus, relatively closed. There is one natural opening through which pus can spread to the

back of the forearm fascial bed. The hole in the intercostals membrane through which the space Paron - Pirogov to the rear area of the forearm passes anterior intercostals artery. Spread of pus along the course of the same artery, but in the proximal direction, it is very rare, as the artery of its adventitia fused with the muscles, starting from intercostals membrane.

Distally, as already mentioned, the space is directly connected with the canal of the wrist and palmar surface of the brush.

Collateral blood flow

On the front surface of the forearm are three fairly large artery: radial, ulnar and anterior intercostals. They go hand in hand, have a lot of muscular branches, anastomosis between the pol-a, which may well compensate for the difficulty, or even a complete cessation of blood flow in one of them.

Such a situation arises in contemporary clinical practice, when for coronary artery bypass

surgery as a material for the shunt using a radial artery. 

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Глава 3

Posterior regions of the Forearm, REGIO ANTEBRACHII POSTERIOR 

External benchmarks. Lateral and medial nadmyschelki shoulder edge ulna, subulate appendages radiotherapy and ulna.

Boundaries. The upper limit is on the line, a distance of 4 cm from the line connecting nadmyschelki shoulder. Lower limit - on a transverse line drawn 2 cm above the tops of the

appendix subulate radius. The rear area is separated from the front of the vertical lines from shoulder to nadmyschelkov subulate appendages bones of the forearm.

Projections. Ramus profundus n. radialis projected on a line running from a point at the

lateral margin of tendon of m. biceps brachii in the front elbow to a point on the border of

the upper and middle thirds of the median line of the rear surface of the forearm. Next but this line is projected onto the entire neurovascular bundle: Rear intercostals artery and deep branch of radial nerve.

Layers

The skin is thicker than on the front surface of the forearm, has hair, enough fluid.

Subcutaneous adipose tissue are relatively weak, as the superficial fascia. In the subcutaneous tissue is a network of veins, which is bringing blood to the front surface, in

the main subcutaneous veins - v. cephalica and v. basilica.

N. cutaneus antebrachii posterior originates on n. radialis in canalis humeromuscularis, and

in subcutaneous out at the beginning of m. brachioradialis. The rest of the innervation of the dorsum of the forearm are involved sprigs of n. cutaneus antebrachii medialis et lateralis.

Own fascia in the upper half looks aponeurosis. With ulnar sides proper fascia tightly

adherent to the posterior edge of the ulna. Since radiation side of the fascia to its own radius departs beam rear wall musculature, which separates the muscle from the back

surface of the forearm m. brachioradialis. The result is a rear bed fascial forearm, compartimentum antebrachii posterius, having the following wall.

Front - the bones of the forearm and intercostals membrane. Rear - own fascia.

Lateral - rear radial wall musculature.

Medial - symphysis own fascia with the rear edge of the ulna.

Under its own fascia in two layers are the extensor muscles of the wrist and fingers.

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Глава 3All the muscles of the surface layer starts from the lateral nadmyschelka

shoulder. Since the medial side, the ulna, they are located in the following order (Figure 3.30):

1) ulnar wrist extensor, m. extensor carpi ulnaris, attach to the base of the V metacarpal bone;

 Fig. 3.30. Muscles of the back surface of the forearm (on Shpalteholtsu, as amended).

1 - t. brachioradialis; 2 - Vol extensor carpi radialis longus; 3 - epicondyius lateralis; 4 -

m. extensor carpi radialis brevis; 5 - m. extensor digitoram; 6 - m. abductor pollicis

longus; 7 - m. extensor pollicis brevis; 8 - processus styloideus radii; 9 - m. extensor

pollicis longus; 10 - m. extensor carpi radialis brevis; 11 - m. extensor carpi radialis

longus; 12 - m. extensor pollicis brevis; 13 - retinaculum musculorum extensorum; 14 -

processus styloideus ulnae; 15 - m. extensor digiti minimi; 16 - m. extensor carpi ulnaris;

17 - m. flexor carpi ulnaris; 18 - ulna; 19 - m. anconeus; 20 - olecranon; 21 - epicondyius

medialis. 

2. little finger extensor, m. extensor digiti minimi, going to the little finger and the accession to the finger extensor tendon;

3. finger extensor, m. extensor digitorum, the tendons that go to all the fingers except the large;

4. short wrist extensor, m. extensor carpi radialis brevis, attach to the back surface of the base III metacarpal bone;

5. long wrist extensor, m. extensor carpi radialis longus, is the most laterally and is attached to the back surface of the base of metacarpal II bone.

In the deep layer (Fig. 3.31), almost all the muscles begin from the bones of the forearm

and intercostals membrane. The most medial (closer to the ulna) are:

6) the index finger extensor, m. extensor indicis, начина - yuschiysya from the lower third of the ulna;

7) the long extensor of the thumb brushes, m. extensor pollicis longus, which starts from the middle third of the ulna 

and intercostals membrane, its the tendon out from under the time - gibatelya fingers, obliquely crosses the tendons of long and short extensors of the wrist, while more superficially. Attaches - Hsia to the base of the second (distal) phalanx of the thumb.

Fig. 3.31. The muscles of the deep layer of the back of the forearm (on Shpalteholtsu, as amended).

1 - m. extensor carpi radialis longus; 2 - epicondylus lateralis; 3 - m. supinator; 4 -

m. extensor carpi radialis brevis; 5 - m. abductor pollicis longus; 6 - m. extensor pollicis

brevis; 7 - m. extensor pollicis longus; 8 - m. extensor indi-cis; 9 - processus styloideus radii; 10 - retinaculum musculorum extensorum; 11 - m. extensor carpi radialis longus; 12 -

m. extensor carpi radialis brevis; 13 - tendo m. extensoris carpi ulnaris; 14 - channel so extensor digiti minimi; 15 - processus styloideus ulnae; 16 - channel so extensor digitorum

et m. extensor indicis; 17 - m. extensor carpi ulnaris; 18 - m. flexor carpi ulnaris; 19 - ulna;

20 - m. anconeus; 21 - olecranon; 22 - epicondylus medialis. 

Even more laterally, from the radius, a number are two muscles:

8) short extensor of the thumb brushes, m. extensor pollicis brevis, are attached to the base of the proximal fa - Lango thumb;

9) long arm, tapping thumb, m. abductor pollicis longus. It is partially attached to the base I-Piast Noah bone, in part to the beginning of a short tendon diverter muscles of the thumb. Tendons 8 th and 9 th muscles and ne - rekreschivayut tendon of long and short extensor of - wrist, passing over the surface, but the proximal tendon long extensor of the thumb;

10) m. supinator, located in verhnenaruzhnom department pre - shoulders, partly related to the muscles of the lateral fascial 

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Глава 3bed, partially - to the back muscles.

The muscles of both layers are separated by fascia lining the deep (anterior) surface of the muscles of the first layer and the surface (rear) surface of the muscles of the second layer. Between the fascia is kletchatochnoe space, which is the neurovascular bundle.

Topography of neurovascular structures

Neurovascular bundle posterior area of the forearm are the deep branch of radial nerve, the

profundus n. radialis, and rear intercostals artery and nerve, a. interossea posterior with accompanying veins and n. interosseus posterior, the continuation of deep branch of radial

nerve. R. profundus n. radialis comes back in a bed of canalis supinatorius, the envelope radius, while the rear intercostals vessels - from the upper hole intercostals membrane.

A. interossea posterior medial nerve is located. In the bottom third in the same box comes

a. interossea anterior, passing through the intercostals membrane. This artery caliber often

not inferior to a. radialis and participates in collateral circulation in case of damage and tying the major arteries of the forearm, including the posterior intercostals arteries (Fig. 3.32, 3.33).

 

Figure 3.32. The deep vessels and nerves of the back of the right forearm.

1. - N. cutaneus antebrachii posterior;

2. - N. cutaneus antebrachii lateralis;

3. - M. supinator; 4 - m. extensor carpi radialis brevis; 5 - m. extensor carpi radialis

longus; 6 - fascia antebrachii; 7 - skin with subcutaneous fat, 8 - m. abductor

pollicis longus; 9 - m. extensor pollicis brevis; 10 - membrana interossea; 11 -

ramus superficialis n. radialis; 12 - radius; 13 - a. interossea anterior; 14 -

m. extensor pollicis longus (cut), 15 - n. interosseus posterior; 16 - m. extensor

digitorum; 17 - rami musculares; 18 - a. interossea posterior; 19 - m. extensor carpi ulnaris; 20 - ulna.

 Fig. 3.33. Transverse sections of the right forearm at the top, middle and lower thirds.

1 - m. palmaris longus; 2 - n. medianus; 3 - a. ulnaris et w. ulnares; 4 - Vol flexor carpi

ulnaris; 5 - n. ulnaris; 6 - m. flexor digitorum profundus; 7 ulna; 8 a. interossea communis;

9 - ramus dorsalis manus n. ulnaris; 10 - m. flexor digitorum superficialis; 11 - m. pronator

quadratus; 12 - m. extensor carpi ulnaris; 13 a. et v. interossea posterior; 14 - m. extensor

pollicis longus; 15 - membrana interossea; 16 - radius; 17 - m. flexor pollicis longus; 18 -

m. abductor pollicis longus; 19 m. extensor carpi radialis brevis; 20 - ramus superficialis

n. radialis; 21 - a. et w. radiales; 22 - m. flexor carpi radialis; 23 - m. supinator; 24

m. extensor carpi radialis longus; 25 m. brachioradialis; 26 - m. pronator teres; 27 - space Paron - Pirogov.

The deep branch of radial nerve innervates all muscles of the rear bed of the forearm, as well as the muscles of the lateral bed, so in case of damage to this branch paralysis of the

extensor, and wrist hangs. 

HEAD area of the wrist, REGIO CARPALIS ANTERIOR

External benchmarks. Subulate appendages radiotherapy and ulna (subulate appendage radius of 1 cm below the elbow).

In the ulnar edge palpable pisiform bone, 1 cm lateral of the median sulcus of the forearm,

continuing in the region wrist palpated hook hamate bone. On the front surface is often

clearly visible tendons of m. palmaris longus (benchmark for ae medianus on the border of

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Глава 3

the forearm), and so flexor carpi radialis. At the edge beam at the wrist lead I finger visible

fossa, called the anatomical snuffbox. The skin defines three transverse folds of the wrist.

Boundaries. The front area of the wrist is separated from the forearm of the transverse line

drawn 2 cm above the subulate sprouts radius. Radial and cubital margins it is separated

from the back of the wrist. From the palm is separated transverse line at a distance of 2 cm below the appendix subulate radius.

Projections. In the lateral margin of pisiform bone projected ulnar neurovascular bundle. It may perform nerve block ulnar nerve. In the lateral (radial) edge of the wrist at 0,5-1 cm

lateral tendon t. flexor carpi radialis projected radial artery. Since in this region, it lies directly on the radius, it is palpable pulse.

Average transverse wrist crease is the projection line of wrist.

Layers

Own fascia in the front area of the wrist before it thickened distal forearm fascia. Splitting own fascia in the lateral margin of pisiform bone forms the canalis ulnaris, or channel Guyon [Guyon], which houses the ulnar neurovascular bundle: artery - superficially and laterally, the nerve - deeper and medial. Under the fascia with the ulnar side is a tendon

m. flexor carpi ulnaris, attach to the pisiform bone (sesamoid bone) and then to the V

metacarpal bone. With radiation to the base of metacarpal II is tendon m. flexor carpi

radialis, surrounded by a synovial sheath. The upper end of the vagina is 1-2 cm above the

upper edge of the retinaculum musculorum flexorum. On the midline of the tendon is

m. palmaris longus, passing on the palmar surface of the wrist in palmar aponeurosis (Figure 3.34).

The next layer is very thick and strong bunch brush - retinaculum flexor tendons, retinaculum muscu -

 Figure 3.34. Carpal tunnel (for Netter, as amended). 1 - radius; 2 - tendo m. palmaris

longus; 3 - a. radialis; 4 - ramus palmaris superficialis a. radialis; 5 - tendo m. flexor carpi

radialis; 6 - n. medianus; 7 - tendo m. flexor pollicis longus; 8 - aponeurosis palmaris; 9 - tuberculum ossis scaphoidei; 10 - tuberculum ossis trapezii; 11 - retinaculum musculorum flexorum; 12 - hamulus ossis hamati; 13 - ramus palmaris profundus a ulnaris; 14 - ramus

profundus n. ulnaris; 15 - os pisiforme; 16 - tendines m. flexor digitorum superficialis; 17 -

tendines m. flexor digitorum profundus; 18 - tendo m. flexor carpi ulnaris; 19 - n. ulnaris;

20 - a ulnaris; 21 - membrana interossea; 22 - ulna. 

lorum flexorum. This ligament consists of strong transverse fibers, radius sides are attached to the navicular bone, os scaphoideum, and the bone-trapezoid, os trapezium, but with your

elbow - to the pisiform bone, os pisiforme, and kryuchkovidoy bone, os hama - tum. Bunch has a superficial and deep sheets.

Retinaculum musculorum flexorum with the bones of the wrist makes the wrist canal, canalis carpi, through which the flexor tendon and forth medianus pass from the forearm to the palm and fingers. The front wall of the carpal canal is the surface, the most powerful part of the retinaculum musculorum flexorum, and back - a deep piece of bone and

wrist. Medial part of the canal space occupied by the tendon superficial and deep flexor of

fingers II-V. Laterally from them is tendon m. flexor pollicis longus, and more surfactants

and between them in tissue is n. medianus (see Fig. 3.34). 

REVERSING the wrist, REGIO CAR PALIS POSTERIOR

External benchmarks. Subulate processes of radiation and ulnar bones, tendons, muscles I long finger.

Boundaries. Cross the line, a distance of 2 cm above and below the line passing through the tip of the appendix subulate radius.

Projections. In the top subulate sprouts ulna projected g. dorsalis n. ulnaris. Apex subulate

sprouts radius corresponds to the situation, the superficialis n. radialis. Projection wrist is on an arc, whose peak is located at 1 cm above the line connecting the tops subulate appendages.

Layers

The skin is thin, agile.

Subcutaneous adipose tissue is loose, moderately developed. It is easily accumulated edematous fluid.

Own fascia dorsum of the wrist thickened and forms the extensor uderzhivatel, OMOP.SU ]

22

Глава 3retinaculum musculorum extensorum.

Beneath that are 6 bone-fibrous canals, resulting from a discharge from the retinaculum

mm. Extensorum fascial partitions are attached to bones and ligaments wrist. The channels are tendons muscles - extensors of the wrist and fingers, surrounded by synovial sheaths (Figure 3.35).

Since the medial (ulnar) side, this is the following channels.

1. Canal elbow wrist extensor, m. extensor carpi ulnaris. His synovial sheath extends from the head of ulna to attach the tendon to the base of V metacarpal bone.

 Fig. 3.35. Synovial sheath of muscles, the extensor tendons of the wrist and fingers (for Spalt-Holtz, as amended). 1,5 - vag. Tendinum mm. Extensoris digitorum et extensoris

indicis; 2 - retinaculum mm. Extensorum; 3 - vag. tendinis m.extensoris carpi ulnaris; 4 - vag. tendinis m. extensoris digiti minimi; 6 - vag. tendinis m. extensoris pollicis longi; 7 -

vag. tendinum mm. extensorum carpi ra-dialium; 8 - vag. tendinum mm. abductoris longi et extensoris pollicis brevis; 9 - vag. tendinis m. extensoris pollicis longi.

2. Chat little finger extensor, m. extensor digiti minimi. Synovial sheath proximal extensor little finger is at the level of the distal radio-ulnar joint and distal - below the middle of V metacarpal bone.

3. Channel tendon m. extensor digitorum, and so extensor indicis, prisoners in the triangular synovial sheath with the base, facing toward the toes, vagina tendinum mm. Extensoris digitorum et extensoris indicis. It ends blindly in the middle of the metacarpal bones and proximal extends 10 mm above the retinaculum mm. extensorum.

4. Channel m. extensor pollicis longus. The tendon of this muscle in the ownership of the synovial sheath, vagina tendinis m. extensoris pollicis longi, turns at an acute angle in the lateral direction and crosses the front of the radial extensor tendons of the hand, mm. extensores carpi radiales longus et brevis.

5. Osteo-fibrous canal radial wrist extensors, mm. Extensores carpi longus et brevis, is lateral and deeper than the previous one. Their common synovial sheath, vagina tendinum mm. Extensorum carpi radialium, begins at 20-30 mm above the retinaculum extensorum, but below the extensor retinaculum are located in separate sheaths, continuing to the place of attachment of tendons. Synovial sheath of tendons of these muscles can communicate with thecavity wrist.

6. Canal m. abductor pollicis longus and extensor pollicis brevis so located on the lateral surface of the appendix subulate radius. Their common synovial sheath, vagina tendinum mm. Ab-ductoris longi et extensoris pollicis brevis, begins at 20-30 mm above the retinaculum mm . extensorum and continues to the navicular bone.

Under the extensor tendons located rete carpale (carpi) dorsale. It is formed from a combination of dorsal wrist branches of radial and ulnar arteries and branches of the

intercostals arteries. From a network go to the nearest branch of the joints, as well as in the second, third and fourth intercostals spaces - aa. Metacarpals (metacarpeae) dorsales.

BEAM of your wrist

If a strong lead I finger on the radial side of the wrist between the tendons of mm. Abductor pollicis longus et extensor pollicis brevis with radiation side and m. extensor pollicis longus with ulnar form a triangular hollow "anatomical snuff box (Figure 3.36).

In the subcutaneous tissue there are v. cephalica and ramus superficialis n. radialis. under their own fascia is a. radialis, closely adjacent to the navicular bone. Here you can palpate her pulse and press it with the bleeding.

HAND, PALM A

External benchmarks. On hand, there are two elevations - thenar with radiation side and hypothenar - with an elbow. They are formed by the muscles I and V fingers. Between them is a triangular palmar depression facing apex proximal.Palmar basin is separated from the longitudinal thenar skinfold. There are also two lateral skin folds - proximal and distal. Approximately 1 cm proximal interdigital folds are visible 3 interdigital pads (Figure 3.37).

Boundaries. Proximal - cross the line at 2 cm below the top subulate sprouts radius, distal -

interdigital folds. 

Fig. 3.36. Nerves, arteries and veins of the left hand (radial surface). 1 a. digitalis palmaris

propria; 2 p. digitalis proprius; 3 - m. adductor pollicis; 4 - nn. digitals dorsales; 5 - tendo m. extensoris pollicis brevis; 6 - tendo m. extensoris pollicis longi; 7 - a. radialis; 8 ramus

superficialis n. radialis; 9 -- v. cephalica; 10 - retinaculum mm. extensorum; 11 - tendo in. extensoris carpi radialis longi; 12 - ramus carpalis dorsalis a. radialis; 13 a. radialis; 14 rete venosum dorsale; 15 - m. interosseus dorsalis I; 16 - a. metacarpalis dorsalis I.

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 Fig. 3.37. Skin folds his hands - external benchmarks. 1 - proximal transverse crease, 2 - center line, 3 - distal transverse wrist crease, 4 - line thenar 5 - distal transverse crease.

Projections

In the proximal third of the folds projected thenar motor branch of the median nerve, which runs to short muscles I finger. You can not make cuts, so this area is called the forbidden (exclusion zone Kanavela).

Palmar aponeurosis is projected in the form of a triangle, the apex turned towards the

middle of the wrist, and the reason - to interdigital gap. His lateral side of thenar crease and the medial - hypothenar.

The top of the superficial palmar arterial arch is projected on the proximal transverse fold of the palm. This is projected distal end of common synovial tendon sheath of muscles-flexor II-V fingers.

I flexor tendon of long finger is projected on the line, the proximal point of which is the beginning of thenar crease, and the distal - reason I (main) phalanx of the thumb.

At the distal transverse crease palm projected proximal ends of the synovial sheaths of flexor tendons, muscles II - PG-fingers and the metacarpophalangeal joints falangovte.

Inter-digital pads correspond to commissural holes palmar aponeurosis. In the grooves between the pads are projected tendon flexor muscles II-IV fingers.

Layers

The skin is thick, it is particularly developed stratum corneum. From the skin to a depth of palmar aponeurosis leaves many connective jumper, because of what the skin palm inactive.

Subcutaneous adipose tissue has a cellular structure due to the jumpers, located in between

the adipose tissue. Cellular structure of cellulose makes the spread of suppurative processes

from the surface to depth.

Surface fascia in the palm of there (at the expense formed by vertical connective jumper). In the subcutaneous tissue palms are numerous small-caliber venous vessels and superficial nerves.

Own fascia is a thin plate covers thenar and hypothenar muscles, and the section palmar depression adherent of a palm aponeurosis.

Palmar aponeurosis, aponeurosis palmaris, has a triangular shape. It starts from the bottom

of the retinaculum mm. Tlexorum. It interwoven tendon bundles long palmar muscle (Fig. 3.38).

 Fig. 3.38. Surface layers of the palm.

1 - a. digitalis propria; 2 - a. digitalis communis; 3 - n. digitalis palmaris proprius; 4 -

aponeurosis palmaris; 5 - m. palmaris brevis; 6 - ramus cutaneus palmaris n. ulnaris; 7 -

a. ulnaris; 8 - ramus cutaneus palmaris n. mediani; 9 - ramus n.cuta-nei antebrachii lateralis.

Longitudinal tendon aponeurosis fibers are combined in 4 bunches, heading to the grounds

II-V fingers. In the dis-tal department aponeurosis (the base of the triangle) between the longitudinal and transverse bundles, fasciculi transversi, there are three gaps, which are called commissural holes. They are filled with fatty tissue, which vybuhaet and on the skin

in the form of pads. After commissural opening in the subcutaneous tissues of lateral surfaces of the fingers extend from the aponeurosis own finger artery.

From the edges of the palmar aponeurosis deep depart two fastsial-WIDE intermuscular partitions - lateral and medial. Musculature lateral wall is initially vertically inwards, towards the II metacarpal bone, and then changes its course to the horizontal direction, as

well as falls on the front surface of the muscles resulting in 1 finger and with it attached to the III metacarpal bone. musculature medial septum is attached to the V metacarpal

bone. Thus, in the palm there are three fascial floor: lateral, middle and medial (Fig. 3.39).

 The average bed palm, compartimentum palmaris medius, has four walls: the front formed palmar aponeurosis, the lateral - the vertical part of the lateral intramuscular wall, medial - medial intramuscular septum, the back - the deep fascia covering the Palmar intercostals muscles, and the horizontal part of the lateral intramuscular septum.

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Глава 3Proximal middle floor is directly related to carpal canal, from whence come the median nerve, tendons, muscles, finger flexors (superficial and deep) and the long flexor tendon of the thumb.

Long flexor tendon of the thumb brushes the average bed is located laterally, and only in its upper third, and then pierced the lateral intermuscular wall and goes into the lateral

bed. The tendon is enclosed in the radiation of the synovial sheath, vagina tendinis

m. flexoris pollicis longi, proximal blind end of which is located in the space of Paron -

Pirogov 2 cm above the retinaculum mm. flexorum. Distally it continues to the base of the distal phalanx.

Tendons flexor muscles of fingers II-V are in general (elbow) synovial flexor sheath,

vagina communis tendinum musculorum flexorum. Its proximal end is located in the space of Paron - Pirogov, 3-4 cm above the retinaculum mm.flexorum, and distal tendons along

the II-IV fingers reaches the middle metacarpal bones. The medial side of the general continues along the tendon sheath V finger and ends at the base of the distal phalanx (Fig. 3.40).

In 10% of the proximal ulnar (general) and radiation synovial sheaths communicate with each other, which may be the cause of the so-called cross, or V-shaped, phlegmon.

On the fingers of synovial tendon sheath of fingers II-IV, vaginae synoviales digitorum manus, starting proximally at the level of heads of metacarpal bones under the longitudinal beams of palmar aponeurosis, between commissural holes, and ends at the base distachnyh

phalanges. Thus, land-flexor muscle tendons of the fingers located in the middle bed of tissue between the vagina and the common finger sheaths are not covered by synovial membrane.

Tendons flexor muscles of fingers divide the average couch for two spaces: subgaleal and podsuhozhilnoe.

Subgaleal space is limited palmar aponeurosis in the front, on both sides - the lateral and medial intermuscular septa, and rear - flexor tendons of the fingers.

In subgaleal space kletchatochnom most superficially located superficial palmar

arch, arcus 

palmaris superficialis, formed by the barrel a. ulnaris and superficial branch of a. radialis (Fig. 3.41).

From her start general Palmar finger artery, aa. digitales palmares communes, which are

divided into their own Palmar finger artery, aa. digitales palmares propriae. At the level of commissural holes they go through them in the subcutaneous layer on the fingers.

Under the surface of an arterial dutoy are 4 common finger nerve (nn. digitales palmares communes). Three of them are separated from subsection medianus immediately after

leaving him out of the carpal tunnel. The first branch almost immediately pierced the lateral intermuscular

Fig. 3.41. Vessels and nerves of the left hand.

1 - a digitalis propria; 2 - a digitalis communis; 3 - n. digitalis palmaris proprius n. ulnaris;

4 - arcus palmaris superficialis; 5 - n. digitalis palmaris communis n. ulnaris; 6 -

m. abductor digiti rmnimi; 7 - m. flexor digiti minimi brevis; 8 - ramus palmaris profundus

a ulnaris; 9 - ramus palmaris profundus n. ulnaris; 10 - ramus palmaris n. ulnaris; 11 - a

ulnaris; 12 - w. ulnares; 13 - n. medianus; 14 - a radialis; 15 - ramus cutaneus palmaris

n. medi-ani; 16 - ramus palmaris superficialis a. radialis; 17 - retinaculum mm. flexorum;

18 - m. abductor pollicis brevis; 19 - m flexor pollicis brevis; 20 - n. digitalis palmaris

communis n. mediani; 21 - m. adductor pollicis; 22 - m. lumbricalis I; 23 - tendo

m. flexoris digitorum superficialis; 24 - vagina tendinis.

partition and innervates the thenar muscles and the skin I finger. The level of its passage at the border corresponds to the upper and middle third of the plica thenaris (exclusion

zone). The second and third run along the second and third mezhpyastnyh intervals and

divided into their own Palmar finger nerves, nn. digitales palmares proprii, which went through commissural holes together with the arteries and innervate the skin I-III and the beam surface PG fingers. GIs common finger nerve departs from the ramus superficialis n. ulnaris in the medial subgaleal space and are divided into three nn. digitales palmares

propriae , V innervates the skin surface and second fingers of PG (Fig. 3.42). If you read the first letters of the names of the nerves from the medial surface of the palm, they are easy to remember (UMRU).

Subgaleal space associated with subcutaneous adipose tissue through commissural holes,

along the la OMOP.SU ]

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Глава 3

 

Bottom metacarpal artery - with fiber podsuhozhilnogo space.

In the proximal part of the average bed and in the carpal canal myshp-flexor tendon fingers

very tightly prilezhat the palm aponeurosis and the retinaculum mm. flexorum, therefore, direct communication with the space Paron - Pirogov in podaponevrotiches-whom space is usually no.

Podsuhozhilnoe kletchatochnoe limited space in front of deep flexor tendons of the fingers on the sides - the lateral and medial intermuscular septa, behind - the horizontal part of the lateral walls and intramuscular fascia volar intercostals muscles.

Immediately below the distal end of the general (an elbow) synovial bags (at the level of the proximal transverse folds his hands) from the deep flexor tendons of the fingers

begin lumbrical 4, mm. lumbricales. Heading to the fingers, flex the head lumbrical metacarpal bones with radial side and attached to the back of the proximal phalanx to the

common extensor tendon stretching fingers. Lumbrical bend and straighten the proximal

middle and distal phalanges II-V fingers. Two muscles with radiation side-innervate ARE median nerve, but with cubital - ulnar nerve.

It is because of the attachment sites lumbrical tendon flexor muscles II-IV fingers located in the fat middle floor, not covered by synovial sheath. Tendons in general, the synovial sheath and located between the lumbrical well isolated podsuho-veined from subgaleal space.

Fiber podsuhozhilnogo space is deep carpal arch, arcus palmaris profundus, formed by the a. radialis, arriving here through the first period of mezhpyastny "anatomical snuffbox",

and the city palmaris profundus a. ulnaris (Fig. 3.43).From the deep arc depart Palmar

metacarpals artery, aa. metacarpales (metacarpeae) palmares, which are connected with common palms finger arteries in the commissural holes.

Figure 3.43. The deep arteries and nerves of the left hand.

1 - a digitalis palmaris propria; 2 - n. digitalis palmaris proprius; 3 - a digitalis palmaris

communis; 4 - tendines flexorum; 5 - in. lumbricalis; 6 - m. inter-osseus palmaris; 7 - a

metacarpal is palmaris; 8 - m. opponens digiti niininii; 9 - m.abductor digiti minimi; 10 -

ramus palmaris profundus a ulnaris; 11 - ramus palmaris profundus n. ulnaris; 12 - ramus

palmaris superficialis n. ulnaris; 13 - n. ulnaris (ramus palmaris); 14-a. ulnaris; 15 -

m. flexor carpi ulnaris; 16 - rete carpi palmare; 17 - m. pronator quadratus; 18 - a radialis;

19 - tendo m. flexoris carpi radialis; 20 - ramus palmaris superficialis a radialis; 21 -

retinaculum mm. flexorum; 22 - m. abductor pollicis brevis; 23 - m. opponens pollicis; 24

- m. flexor pollicis brevis; 25 - m. adductor pollicis; 26 - arcus palmaris profundus; 27 - a

princeps pollicis; 28 - m. interosseus dorsalis I.

The deep branch of the n. ulnaris, arriving at podsuhozhilnoe middle floor space of the

medial, innervates all intercostals muscles (and the palm, and back), mm. interossei

palmares et dorsales, third and fourth lumbrical, m. adductor pollicis and the deep head of

t. flexor pollicis brevis.

Podsuhozhilnoe kletchatochnoe space communicated with the proximal carpal canal and continue with the space Paron - Pirogov; distally - the course of worm-like muscles with

subcutaneous fiber rear fingers; along aa. metacarpales palmares - with subgaleal space.

These relationships can serve as a cellular pathways purulent processes.

The next layer is the deep fascia covering the three Palmar intercostals muscles of the

second, third and fourth mezhpyastnyh intervals. Palmar intercostals muscles begin from

metacarpal bones and lead V, PG II and III fingers to the finger. They are attached, as well as worm-like muscles, to the backing aponeurosis extensor of fingers at 11, PG and V fingers, so they just bend and unbend the proximal phalanx of the middle and distal.

Lateral bed, compartimentum palmaris lateralis, or bed thenar, limited to its own front fascia, rear - the deep fascia on the back I intercostals muscles, and I metacarpal bone, medial - lateral intramuscular septum laterally and closes by its own fascia attachment to the I metacarpal bone (see Fig. 3.39).

There are muscles I thumb: superficially and laterally - short arm, tapping 1 finger brushes,

etc. abductor pollicis brevis, deeper - muscle, opposing 1 finger brushes, m. opponens pollicis, medially from them - short I thumb flexor, m.flexor pollicis brevis, between the

superficial and deep heads of which are long flexor tendon I thumb. These muscles are innervated by the motor branch of the n. medianus, passing through a bed of thenar lateral intermuscular septum. Inwards from flexors under the horizontal part of the lateral

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Глава 3

intramuscular partitions, is a muscle, causing I finger brushes, m. adductor pollicis,

consisting of oblique and transverse heads. As noted above, it starts from the III metacarpal bone and innervi zero tolerance of deep branch of the ulnar nerve.

Tendon m. flexor pollicis longus enclosed in a synovial sheath, the proximal blind end of which is located in the space of Paron - Pirogov 2 cm above the retinaculum

mm. flexorum. After going into the carpal canal, it goes in the distal proximal middle floor palms, and then pierced the lateral intermuscular partition runs in pasterns in thenar tissue between the short head I finger flexor and then continue to the base of the distal phalanx.

A. princeps pollicis separated from the radial artery in the first mezhpyastnom interval. It is directed downward and outward so between adductor pollicis, and so along the flexor pollicis brevis tendon so flexor pollicis longus. At the level of metacarpophalangeal joint I thumb it is divided into 3 branches, reaching on both sides of fingers I and II radiation side finger.

Medial thenar (closer to the lateral intramuscular septum) took slit kletchatochnoe space bounded by the front of the horizontal part of the lateral intramuscular walls, and behind -

m. adductor pollicis (see Fig. 3.39). In the lateral direction, it continues until the synovial

tendon sheath m. flexor pollicis longus, and the distal - to the first interdigital folds, which communicates with the deep The cells chatochnym space located between the rear surface of the muscles resulting in finger I and the front surface of the back of the first intercostals muscles.

Medial bed, compartimentum palmaris medialis, or bed hypothe / iar, bounded in front and medially own fascia that attach to the V metacarpal bones, in the back - V metacarpal

bone, lateral - medial intramuscular septum (see Fig. 3.39). It houses the V finger muscles:

muscle, finger tapping, m. abductor digiti minimi, muscle, opposing finger, m. opponens

digiti minimi, and the little finger, short flexor, m. flexor digiti minimi brevis.

Back of the hand, REGIO DORSALIS MANUS

External benchmarks. On the back surface of the brush well palpable all the

metacarpals. At the maximum unbending fingers under the skin are visible strained finger extensor tendons.

I metacarpal bone is situated at an angle to the rest of the metacarpal bone, resulting in the

formation widest mezhpyastny gap and interdigital fold. In the first mezhpyastnom gap is clearly visible bulge the back of the first intercostals muscles.

Projections. The joint gap metacarpophalangeal joints of line, located at 8-10 mm below the heads of metacarpal bones.

The skin is thin, mobile, contains the hair sacs and sebaceous glands, which may be a place of furuncles.

Subcutaneous cellular tissue is loose, it can accumulate edematous fluid, including patients

with inflammatory processes in the palm. In the subcutaneous layer of the venous network

located in the rear of the brush through numerous anastomoses. With radiation side they

form v. cephalica, but with cubital - v. basilica. On the border with the back of the wrist

v. cephalica accompanies g. superficialis n. radialis, v. basilica - g. dorsalis n. ulnaris (Fig. 3.44).

Figure 3.44. Superficial veins and nerves of the back surface of the left hand.

I - nn. digitales dorsales; 2 - w. in-tercapitulares; 3 - v. cephalica; 4 - ramus superficialis

n. radialis; 5 - v. basilica; 6 - ramus dorsalis n. ulnaris; 7 - arcus venosi digitales.

At the top subulate sprouts ulna from the city dorsalis n. ulnaris wastes 5 dorsal finger

nerves, nn. digitales dorsales, en route to innervation of the skin V, IV and III ulnar side of

your finger. At the top subulate sprouts radius from the city superficialis n. radialis wastes 5 dorsal finger nerves innervating the skin-ing I, II and radial sides of fingers III finger.

Own fascia, fascia dorsalis manus, well pronounced. With ulnar side it merges with Vpyastnoy bone, but with the beam - with P. Deep fascia covers the second, third and

fourth dorsal intercostals muscles. All intercostals muscles, as the backing and palms, are innervated by the deep branch of the ulnar nerve.

Between the property and the deep fascia is subgaleal space of the rear brush, limited on each side attaching its own fascia to II and V of the metacarpal bones.

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Глава 3In the subgaleal space are the extensor tendons of the fingers, between which at the level of heads of metacarpal bones are mezhsuhozhilnye connection, connexi intertendi-nei, thus

straightening the two middle digits (III and IV) is possible only together. The index finger and little finger are independent in part due to the existence of their own extensor (Figure 3.45).

Podfastsialnye neurovascular branches are represented by a. radialis, which on leaving the anatomical snuffbox is the first mezhpyastnom interval on the back of the first intercostals

muscles. From this site is a. radialis leaves a. meta-carpalis dorsalis prima, which allows 3

branches to 1 and II of the fingers. It is an independent source of blood supply to the finger I ", not receiving branches from the superficial arterial arch. A. radialis then goes through the muscle on the palm, where it participates in the formation of deep palmar arterial arch.

From rete carpale dorsale go in the second, third and fourth periods mezhpyastnye

aa. metacarpals dorsales, each of which is at the base of the finger is divided into

aa. digitales dorsales.

First mezhpyastny interval is well defined first rear intercostals muscles. Its front (palm)

surface adjoins to the resulting muscle I thumb, located in the box thenar. They shared the fascial plate.

Fiber rear subgaleal space communicates with the proximal carpal canal, and through them - with the rear bed of the forearm.

 Figure 3.45. Vessels and nerves of the rear left hand.

1 - nn. digitales dorsales; 2 - aa. digitals dorsales; 3 - a. radialis; 4 - aa metacarpales

dorsales; 5 - tendo m. extensoris pollicis longi; 6 - tendo m. extensoris pollicis brevis; 7 -

ramus carpeus dorsalis a. radialis; 8 - ramus superficialis n.radialis; 9 - tendo m. extensoris

carpi radialis longi; 10 - tendo m. extensoris carpi radialis brevis; 11 - retinaculum

mm. extensorum; 12 - tendines m. extensoris digitorum communis;

13. - Tendo m. extensoris indicis proprii;

14. - Tendo m. extensoris carpi ulnaris;

15. - Ramus dorsalis manus n. ulnaris.

PALM surface with your fingers, FACIES PALMARES DIGITORUM

External benchmarks. On the palmar surface of the skin of the fingers are clearly visible

metacarpophalangeal and interphalangeal creases. They are below the respective joints.

Projections. Articular gap metacarpophalangeal joints of line, located at 8-10 mm below the heads of metacarpal bones. The projection is defined slits interphalangeal joints in the position of full flexion of the fingers of 2-3 mm below the bumps heads phalanges.

Layers

Skin is thick, inactive.

Subcutaneous fiber mesh due to a number of partitions of connective tissue running from

the skin in depth. At the end

(nail) phalanx these walls connect the skin and bone (periosteum), on the other - the skin

and fibrous sheath of tendons flexor muscles. In connection with this, felon (purulent

inflammation of a layer finger) suppurative process extends from the surface to depth. At the nail phalanx that can lead to the rapid emergence of bone felon (Figure 3.46).

In the subcutaneous tissue along the lateral surfaces of the fingers, just below the middle, pass the neurovascular bundle, consisting of the palm own finger blood vessels and

nerves. Skin 1, II, III and IV finger radial side innervate nerves branching off the median nerve. Loktev side IV and V both sides of the fingers branches innervate the ulnar nerve.

 The next layer to the core (proximal) and average phalanges are the bone-fibrous canals, which are formed by phalanxes of the fingers and the tendon bundles: ring at the

diaphysis of the phalanges and cross into the area because of tax-mezhfalan joints. In sections of annular ligament fibrous channels are narrowed, and in cruciform -

expanded. Between the ligaments and bone located only synovial sheath, through the co -

 Fig. 3.47. The cross section of the finger at the level II phalanx.

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Глава 3

I - tendo m. extensoris digitorum; 2 - me-sotendineum; 3 - tendo m. flexoris digitorum profundi; 4 - epitenon; 5 - vagina s synovialis tendinum digitorum; 6 - vagina fibrosa digiti

manus; 7 - peritendineum; 8 - a. digitalis palmaris propria; 9 - a. digitalis dorsalis. 

Thoroe translucent tendon. The most proximal annular ligament is at the metacarpophalangeal joints.

At the level of heads of the main phalanx of superficial flexor tendon divides into two legs that attach to the sides of the middle phalanx, and transmits it to the splitting of the deep flexor tendon that attach to the base of the terminal (distal) phalanges.

Synovial tendon sheath II, III and IV fingers isolated.

Synovial sheath is composed of the parietal leaflet, adjacent to the inner surface of the fibrous sheath and the inner covering the tendon itself (Figure 3.47). In place of transition from one sheet to another formed by tendinous mesentery, mesotendineum. In her column are the vessels and nerves from the periosteum phalanx to the tendon. In the interphalangeal joints is not. mesenteric injury, including during surgery can lead to

necrosis of the relevant part of the tendon. 

Dorsal surface with your fingers, FACIES DORSALES DIGITORUM

Layers

The skin is thinner than on the palmar surface. At the proximal phalanx has a scalp, expressed in varying degrees.

Subcutaneous cellular tissue is weak, it is loose. In the subcutaneous tissue on the lateral

surface closer to the back pass dorsal neurovascular bundle: a., v. et n. digitales dorsales pro-prii, which are branches of the dorsal metacarpal.

Extensor tendon at the back of the middle part of the finger is attached to the base of the

middle phalanx, and two lateral - to the base of the distal phalanx. By aponeurotic tension over the proximal phalanx of the tendon attached worm-like and intercostals

muscles. These muscles bend and unbend the main phalanx of the distal and middle

phalanges. 

OPERATIONS upper limbs

Arthrocentesis used to determine the nature of the contents of the joint cavity for the evacuation of a pathological fluid, introduction of medicinal substances, as well as for the introduction of instruments during arthroscopy. As with all other puncture, the needle is introduced through a biased finger skin over the puncture site to the return of the skin on its place was left direct wound channel through which the infection could get into the joint

cavity. In most cases, a needle injected through a previously anesthetized area of skin on the extensor surface of the joint-tion, where there are no major blood vessels and nerves.

Puncture of shoulder joint. Puncture produced in the position of the patient lying on the healthy side or sitting, it can be done in the front, outside and behind.

Front shoulder joint dotted line, focusing on the coracoid blade, which is palpable in the subclavian fossa at 3 cm down from the acromial end of clavicle. A needle is introduced under the coracoid and pushed backward between him and the capitellum to a depth of 3-4 cm

When arthrocentesis needle is injected down the outside of the most convex part of the acromion in the frontal plane through the thickness of the deltoid muscle.

When the shoulder joint puncture needle is introduced down the back of the acromion, in the recess formed by them and the rear edge of the deltoid muscle, perpendicular to a depth

of 4 -5 cm (Fig. 3.48).

Puncture of the elbow joint.'s Hand bend at the elbow at a right angle. Behind puncture

performed on the tip of the olecranon and guide the needle forward. Behind outside needle injected between lateral nadmyshelkom humerus and ulna olecranon and penetrate into the joint head of the radius (Fig. 3.49).

Figure 3.48. Brachial puncture cycle Fig. 3.49. Puncture elbow cycle - tava (explanation in the text). tava (explanation in the text). 

Transactions in purulent diseases of the hand and fingers

 Panaritium. Panaritium - acute purulent inflammation of the tissues of the

finger. Types panaritiums called under the layer of the finger, which has developed

inflammation. By VK Gostischevu distinguished 12 species panaritiums (Figure 3.50): 1 - OMOP.SU ]

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Глава 3hyponychial felon; 2 - paronychia, 3, 4 - paronychia with a break of pus under the nail, 5 - skin felon; 6 - subcutaneous felon; 7 - subcutaneous felon as a "cuff" 8 - tendinous felon; 9 - articular felon, 10 - bone felon (sequestration of diaphysis of middle phalanx of the finger), 11 - sequestration of the terminal phalanges; 12 - pandaktilit.

Treatment panaritiums, like other suppurative diseases, surgical. The task of the surgeon is to create a purulent outflow, resulting relieves stress, pain and swelling of inflamed tissue, improves flow of antibacterial drugs in purulent.

When subcutaneous panaritiums ungual phalanx good outflow of purulent exudate reached

with klyushkoobraznogo incision (Figure 3.51). Scalpel injected with the side of the phalanx (hooked stick) and lead the direction of the interphalangeal joints in the frontal plane, thus cutting through the connective tissue bands that come from the skin to the

bone. As a result, all the cells filled with pus, break down easily and pus flowing. On the lateral surface of the phalanx is cut (handle sticks), which after elimination of purulent

process heals with the formation of a thin elastic scar. From Fig. 3.51 understand that the holding of the middle section can not be effective, as will reveal only a limited number of

pus cells. In addition, the incision on the palmar surface limits the function of the finger.

Subcutaneous panaritiums 2 nd and 3rd phalanges opened on Clapp anterolateral cuts, as a scalpel slicing through the subcutaneous tissues (Figure 3.52).

 Figure 3 .51. Autopsy subcutaneous Figure 3 .52. The incisions with subcutaneous th panaritiums terminal phalanx panaritiums secondary and primary fa -

klyushkoobrazngm cut. 

Lang (by VK Gostischevu).

Operations on the dorsum of the distal (ungual) phalanges

When paronychia cross-section cut through the skin nail fold (cuticle) and from the ends of the incision in the proximal direction are two parallel slits for purulent infiltration, have

developed in okolonogtevogo bed. The resulting U-shaped flap is giving way proximally and resecting delaminations pus edge nail (Figure 3.53).

Hyponychial felon, which has developed as a result of suppuration hyponychial hematoma, drain through the holes created in the nail plate or a scalpel, removing layers of nail to

purulent focus, or trepanatsionnoy cutter.

When hyponychial panaritiums that grew around the splinters, penetrated under the free edge of the nail, producing wedge-shaped excision of part of the nail plate, the cover splinter and surrounding abscess (Fig. 3.54).

Fig. 3.53. Kanavela operation to total defeat of the nail shaft (for VK Gostishevu).

1 - skin incision, 2, 3 - excision of the nail and the base roller, 4 - look after the operation.

Figure 3 .54. Operation in hyponychial panaritiums (by VK Gostishevu). 1,2 - trepanation nail plate; 3,4 - wedge-shaped excision of the distal part of the nail plate with the instantaneous removal of foreign body

Operations at gnoynyhtendovaginitah

Abscess - an acute purulent inflammation of the synovial tendon sheath. This disease is dangerous, because of the passing-PRINCIPLES FOR GOOD GOVERNANCE feeding vessels may occur necrosis of the tendon. Surgical treatment consists in opening the

synovial sheath and the evacuation of purulent content. When tenosynovitis-max II, III and IV fingers of small incisions of the skin, subcutaneous tissue is produced at the lateral surfaces of the middle and anterior to the main phalanx palpable bony phalanx (Fig. 3.55).

Then expose the bone-fibrous canals and synovial sheath, guided by the brilliant

tendon. These cuts should not go on skin Palmar interphalangeal creases, and the corresponding circular bundles of bone and fibrous channels, which if damaged from the

wound dislocating finger flexor tendon with subsequent desiccation and loss of function. In addition to these cut sections performed at the site of projection of the blind proximal ends

of the synovial sheaths in the palm. Through the side sections of phalanges hold drains anterior to the tendon. The attempt to drain behind the tendon leading to tendon damage mesenteriolum and necrosis.

 Tentsovaginity I and V of the fingers is also called tendobursitami, radial and

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cubital. Their treatment differs from the previous holding of additional cuts in the palm of

the projection of the tendons. Almost always, additional cuts are carried out on the appropriate side of the lower third of the forearm for the opening of the space Paron -

Pirogov, where the blind proximal radius and ulna bags synovial bags. 

Operations at phlegmons brush

On hand there are the following purulent-inflammatory diseases: skin abscess (Namin, chiropodist abscess), subcutaneous (nadaponevroticheskaya) phlegmon palm; podaponevroti-Ceska phlegmon palm; phlegmon thenar, hypothenar abscess, subcutaneous abscess rear brush; subgaleal abscess rear brush.

Opening phlegmon secondary subgaleal fascial bed hand in the war-Yasenetsky - Pico made a longitudinal incision on the rise I finger inwards from the projection of the long flexor tendons of the fingers and over the rise of muscle V finger (Figure 3.56).

 In the mean bed penetrate through the lateral and medial intermuscular walls, destroying their blunt way.

Drainage pipes depending on the location of a phlegmon injected into the subgaleal or

podsuhozhilnuyu middle shelf of the box through both slits. Hands and fingers are fixed on the bus in half-bent position.

Autopsy podfastsialyyuy phlegmon bed thenar. Incision of all layers of 4-5 cm in length produced in parallel and outward from the projection of I flexor tendon of the long

finger. Drainage kletchatochnoy deep fissure between the muscles, resulting

oolypoi finger, and the first back

intercostals muscles perform a cut from I to II finger on the first interdigital fold.

Autopsy phlegmon rear brush. Subcutaneous phlegmon rear brush reveal a cut through the center of fluctuation.

Autopsy subgaleal phlegmon rear brush. Incisions are performed on II and V of the metacarpal bone, which attaches itself to the fascia. In both sections give birth to the

drainage tube.

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