Upper Limb anatomy(Matary surgical anatomy) Flashcards
(165 cards)
1
Q
What are the features of the clavicle?
A
.2 ends: (1)Sternal end(bulky) (2)Acromial end(flattened)
.2surfaces: (1)upper(smooth) (2)lower(shows subclavius groove)
2
Q
What is the surgical importance of the clavicle?
A
(1) The clavicle carries the weight of the upper limb
(2)the clavicle transmits the weight of the trunk through its
articulation with the sternum(sternoclavicular)
(3)it is one of the most commonly fractured bones in the body:
-cause:direct violence as falling on outstretched hand
-site:the junction between the 2 curvatures
-effect:shoulder drop;the lateral fragment is displaced downwards by the
weight of the limb
3
Q
What are the ends of the clavicle?
A
2surfaces
1) sternal end(bulky
(2) acromial end(flattened
4
Q
What are the surfaces of the clavicle?
A
2surfaces
1) upper(smooth
(2) lower(shows subclavius groove)
5
Q
What is the cause of clavicular fracture?
A
Direct violence as falling on outstretched hand
6
Q
What is the common site for clavicular fracture?
A
The junction between 2 curvatures
7
Q
What is the effect of clavicular fracture?
A
Shoulder drop;the lateral segment is displaced downwards by the weight of the limb
8
Q
What are the features of the scapula?
A
A flat bone having:
.2 surfaces
(1)Ventral(forming sub-scapular fossa)
(2)Dorsal(presenting the spine)
.3 borders
(1)upper
(2)medial
(3)lateral
.3 angles
(1)superior(level of 2nd rib)
(2)inferior(level of 7th rib)
(3)lateral(glenoid cavity)
.3 fossae
(1)subscapular(centrally)
(2)supraspinous(dorsally)
(3)infraspinous(dorsally)
.3 processes:
(1)spine
(2)acromion
(3)coracoid process
9
Q
What are the surfaces of the scapula?
A
2surfaces
1) Ventral(forming subscapular fossa
(2) Dorsal(presenting the spine)
10
Q
What are the borders of the scapula?
A
3borders
(1) upper border
(2) medial
(3) lateral
11
Q
What are the angles of the scapula?
A
3 angles
1) superior(level of 2nd rib
(2) Inferior(level of 7th rib)
(3) lateral(the glenoid cavity)
12
Q
What are the fossae of the scapula?
A
3 fossae
1) subscapular fosaa(ventrally
(2) supraspinous fossa(dorsally)
(3) infraspinous fossa(dorsally)
13
Q
What are the processes of the scapula?
A
3 processes
(1) spine (2) acromion (3) coracoid process
14
Q
What are the features of the humerus?
A
Upper end: consists of:
Head: articulates with the glenoid cavity.
2 necks: anatomical neck & surgical neck.
2 tuberosities: greater (carrying 3 muscles facets)
lesser(carrying 1 muscular facet).
Bicipital groove: (1)having medial lip, lateral lip & floor.
(2)separates the greater and lesser tuberosities
(3)it houses the tendon of the long head of
Shaft: has:
3 borders: anterior, medial & lateral.
3surfaces. antero-medial, antero-lateral & posterior surfaces.
Lower end: consists of:
Trochlea: for articulation with ulna.
Capitulum: for articulation with radius.
Medial epicondyle: more prominent.
Lateral epicondyle: less prominent.
3 fossae: olecranon (posterior), radial & coronoid (anterior).
15
Q
What are the anatomical landmarks of the upper end of humerus?
A
(1) Head:articulates with the glenoid cavity
(2) 2 necks
- anatomical neck
- surgical neck
(3) 2 tuberosities
- greater tuberosity(carrying 3 muscular facets)
- lesser tuberosity(carrying 1 muscular facet)
(4) Bicipital(intertubercular)groove(sulcus)
- having medial and later lips and floor
- separates the greater and lesser tuberosities
- it houses the tendon of the long head of the biceps brachii muscle
- extends into the upper 1/3rd of the shaft of the humerus
16
Q
What are the anatomical landmarks of the shaft of the humerus?
A
(1) 3 borders:anterior,medial and lateral
(2) 3 surfaces:anteromedial,anterolateral and posterior surfaces
17
Q
What are the anatomical landmarks of the lower end of the humerus?
A
Trochlea:for articulation with ulna Capitulum:for articulation with radius Medial epicondyle:more prominent Lateral epicondyle:less prominent 3 fossae:olecranon (posterior),radial and coronoid(anterior)
18
Q
What is the surgical importance of the humerus?
A
(1)Surgical exposure
-upper 1/3:incision along deltopectoral groove
-lower 2/3:incision along the medial or lateral inter-muscular
septum
(2)Fractures
-At surgical neck: being a weak point after the upper end
-At middle of the shaft:being weakened by spiral groove
-At the medial epicondyle
19
Q
What are the nerves which may be injured with fractures of humerus?
A
Site The injured nerve Effect of injury
Axillary nerve Around the surgical neck Flattened
shoulder
Radial nerve In spiral groove at the Drop-hand or wrist
middle of the shaft
Ulnar nerve Behind the medial epicondyle Claw hand
20
Q
What are the features of the ulna?
A
o Upper end: shows:-
. 2 processes (olecranon &coronoid)
. 2 notches (trochlear & radial).
. 2 muscurar impressions (urnar tuberosity &supinator fossa).
o shaft: has 3 surfaces (anterior, posterior & medial) separated by 3 borders.
o Lower end:- presents a small rounded head & a blunt styloid process.
21
Q
What are the anatomical landmarks of the upper end of the ulna?
A
. 2 processes (olecranon &coronoid)
. 2 notches (trochlear & radial).
. 2 muscurar impressions (urnar tuberosity &supinator fossa).
22
Q
What are the anatomical landmarks of the shaft of the ulna?
A
3 surfaces (anterior, posterior & medial) separated by 3 borders.
23
Q
What are the anatomical landmarks of the lower end of the ulna?
A
presents a small rounded head & a blunt styloid process.
24
Q
What is the surgical importance of the ulna?
A
-Surqical exposure: by an incision along its subcutaneous
posterior border
- The tip of the olecranon process forms an equidistant triangle
with the 2 humeral epicondyles in the normal elbow & also in the
supracondylar fracture.ln elbow dislocation,this triangle is no longer
equidistant.
25
What are the features of the radius?
Upper end: consists of (head, neck & radial tuberosity)
Shaft: has 3 surfaces (anterior, posterior & lateral)separated by
3borders.
Lower end: expanded'& presents:
styloid process laterally, ulnar notch medially & articular surface
(below).
26
What is the anatomical landmarks of the upper end of the radius?
Upper end: consists of (head, neck & radial tuberosity)
27
What is the anatomical landmarks of the shaft of the radius?
Shaft: has 3 surfaces (anterior, posterior & lateral)separated by
3 borders.
28
What is the anatomical landmarks of the lower end of the radius?
Lower end: expanded'& presents:
styloid process laterally, ulnar notch medially & articular surface
(below).
29
What is the surgical importance of the radius?
Surqical Exposure:
By an incision arong the ant. border of brachioradiaris.
N.B. ln Pronation & Supination
Ulna is fixed.
Lower end of radius crosses in front of ulna
Pronation by: pronator teres & pronator quadratus.
Supination by : biceps (with elbow flexed) & supinator (with elbow extended)
30
What is the surgical importance of the carpal bones?
Surqical importance: Fracture of the scaphoid
- lt is the most frequently fractured carpal bone
- Presents clinically with tenderness over the anatomical snuffbox.
- Has high incidence of avascular necrosis and non union.
31
What is the function of the sternoclavicular and acromioclavicular joints?
Both are responsible for movements of the shoulder girdle.
32
What is the type of the shoulder joint?
Synovial ball and socket
33
What are the bones of the shoulder joint?
Head of the humerus and glenoid cavity of the scapula
34
What are the factors maintaining stability of the shoulder joint?
(1)coracoacromial arch
(2)Rotators cuff muscles(supraspinatus,infraspinatus,teres minor,
subscapularis.
35
What are the factors maintaining the instability of the shoulder joint?
(1) shallow glenoid cavity
(2) large head of the humerus
(3) laxity of the capsule
(4) wide range of movement
36
What are the movements of the shoulder joint and the principal muscles acting on it?
-Flexion:normal flexion is about 90 degrees and is performed by:
MNEMONIC;BCDP
-chief—(1)pectoralis major
(2)deltoid(anterior fibres)
-accessory—(1)biceps brachii
(2)coracobrachialis
-extension:normal extension is about 45 degrees & is performed by:
MNEMONIC;DOGS LAPSE TO TENSION
-chief—(1)deltoid(posterior fibres)
(2)latissimus dorsi
-accessory—(1)teres major
(2)triceps brachii(long head)
-abduction
-from 0-30 degrees—supraspinatus(initiates abduction)
-from 30-90 degrees—deltoid(middle fibres)
-from 90-120 degrees—deltoid
-from 90-180 degrees—no movement of shoulder
—scapula rotation by—1)serratus anterior
(lower 5 digits)
2)trapezius
(upper and lower fibres)
-adduction:normally,the upper limb can be swung 45 degrees across the front
of the chest.This is performed by:-
MNEMONIC;LADY BETWEEN 2 MAJORS TO CONTINUE BAD THINGS
SUSTAINABLY
-chief—(1)latissimus dorsi
(2)pectoralis major
-accessory—(1)teres major
(2)teres minor
(3)coracobrachialis
(4)biceps brachii(short head)
(5)triceps brachii(long head)
(6)subscapularis
-lateral rotation:normal lateral rotation is 40 to 45 degrees &is performed by:
MNEMONIC;TIP
(1)teres minor
(2)infraspinatus
(3)posterior fibres of deltoid
-medial rotation:normal medial rotation is about 55 degrees &is performed by:
MNEMONIC;SPLAT or SPALT
-chief—(1)pectoralis major
(2)latissimus dorsi
(3)anterior fibres of deltoid
(4)teres major
-accessory—subscapularis
-elevation:further movement to 180 degrees(elevation)is brought about by
rotation of the scapula upwards by:-
(1)serratus anterior(lower 5 digits)
(2)trapezius(upper and lower fibres)
-circumduction:this is a combination of the above movements
37
What are the principal muscles responsible for shoulder Flexion?
normal flexion is about 90 degrees and is performed by:
MNEMONIC;BCDP
-chief—(1)pectoralis major
(2)deltoid(anterior fibres)
-accessory—(1)biceps brachii
(2)coracobrachialis
38
What are the muscles responsible for shoulder extension?
normal extension is about 45 degrees & is performed by:
MNEMONIC;DOGS LAPSE TO TENSION
-chief—(1)deltoid(posterior fibres)
(2)latissimus dorsi
-accessory—(1)teres major
(2)triceps brachii(long head)
39
What are the principal muscles responsible for shoulder abduction?
-from 0-30 degrees—supraspinatus(initiates abduction)
-from 30-90 degrees—deltoid(middle fibres)
-from 90-120 degrees—deltoid
-from 90-180 degrees—no movement of shoulder
—scapula rotation by—1)serratus anterior
(lower 5 digits)
2)trapezius
(upper and lower fibres)
40
What are the principal muscles responsible for shoulder adduction?
normally,the upper limb can be swung 45 degrees across the front of the chest.This is performed by:-
MNEMONIC;LADY BETWEEN 2 MAJORS TO CONTINUE BAD THINGS
SUSTAINABLY
-chief—(1)latissimus dorsi
(2)pectoralis major
-accessory—(1)teres major
(2)teres minor
(3)coracobrachialis
(4)biceps brachii(short head)
(5)triceps brachii(long head)
(6)subscapularis
41
What are the principal muscles responsible for shoulder lateral rotation?
normal lateral rotation is 40 to 45 degrees &is performed by:
MNEMONIC;TIP
(1)teres minor
(2)infraspinatus
(3)posterior fibres of deltoid
42
What are the principal muscles responsible for shoulder medial rotation?
normal medial rotation is about 55 degrees &is performed by:
MNEMONIC;SPLAT or SPALT
-chief—(1)pectoralis major
(2)latissimus dorsi
(3)anterior fibres of deltoid
(4)teres major
-accessory—subscapularis
43
What are the principal muscles responsible for shoulder elevation?
further movement to 180 degrees(elevation)is brought about by rotation of the scapula upwards by:-
(1) serratus anterior(lower 5 digits)
(2) trapezius(upper and lower fibres)
44
What is circumduction of the shoulder?
Is the combination of all the movements that can be done by shoulder circumduction.
45
What is the type of elbow joint?
Synovial hinge joint
46
What are the bones forming the elbow joint?
Lower end of the humerus and upper end of radius and ulna
47
What is the student’s elbow?
Inflammation of the subcutaneous olecranon bursa
48
What is the type of the superior and inferior radioulnar joint?
Synovial pivot joint
49
What is the type of the wrist joint?
Synovial ellipsoid
50
What are the bones forming the wrist joint?
Lower end of radius and carpal bones(scaphoid,lunate and triquetrium)
51
Discuss the development of the breast
It arises from the milk line,which extends from the axilla to the midinguinal point of the inguinal region.
The epithelium is ectoderm(parenchyma)
The connective tissue is stroma(mesenchyme)
52
From where the breast develops?
It arises from the milk line which extends from the axilla to the midinguinal point
of the inguinal region
53
What is the location of the milk line?
Extends from the axilla to the midinguinal point of the inguinal region
54
What is the histology of the breast?
The epithelium is ectoderm(parenchyme)
| The connective tissue is stroma(mesenchyme)
55
What is the histological structure of the breast epithelium?
The epithelium is ectoderm(parenchyme)
56
What is the histological structure of the breast connective tissue?
The connective tissue is stroma(mesenchyme)
57
What is the site of the breast?
The breast is formed of fibro-fatty tissue,lies in front of the chest wall.
It is considered as sebaceous gland,so it lies in SUPERFICIAL FACIA
58
What is the extension of the breast?
It extends from the 2nd to 6 th rib and from the sternum to the midaxillary line
59
Discuss the axillary tail of spence
Arises from the superolateral quadrant of the mammary gland.
Passes through a defect in the deep fascia known as foramen of langer to the 3rd rib.
It lies close to the axillary vessels.
60
From which part of the breast the axillary tail of spence arises?
Arises from the superolateral quadrant of the mammary gland.
61
Define the foramen of langer?
The axillary tail of spence passes through a defect in the deep fascia known as foramen of langer to the 3rd rib
62
What is the location of the axillary tail of spence?
In the deep fascia,to the 3rd rib and it lies close to the axillary vessels
63
What is the relation of the axillary tail of spence?
It lies close to the axillary vessels
64
What are the muscles over which the breast lie?
(1) pectoralis major(2/3)
(2) serratus anterior(1/3)
(3) external oblique
(4) rectus sheath
65
Discuss pectoralis major
Origin:(1)clavicular head-med 1/2 of front of clavicle
(2)sternocostal head-1)anterior surface of the sternum
2)upper 6 costochondral junction
3)external oblique aponeurosis
Insertion:lateral lip of bicipital groove of the humerus
Nerve supply:medial and lateral pectoral nerve
Action:(1)Flexion
(2)Adduction
(3)Medial(internal)rotation
(4)To press her hands against her waist
Surgical importance
(1)In radical mastectomy,the sternocostal head is removed and the clavicular head is
preserved(to protect the cephalic vein and prevent the infra-clavicular hollowness).
(2)In modified radical mastectomy the whole muscle is preserved and only the
pectoral fascia is removed(as it contains LNs).
(3)It forms the anterior wall of the axilla
(4)It is the underlying muscle of the breast
66
What is the origin of the pectoralis major?
(1) Clavicular head:from mid 1/2 of front of the clavicle
(2) Sternocostal head:
1) anterior surface of the sternum
2) upper 6 costochondral junctions
3) external oblique aponeurosis
67
What is the insertion of pectoralis major?
Lateral lip of bicipital groove of humerus
68
What is the nerve supply of pectoralis major?
Medial and lateral pectoral nerves
69
What is the action of pectoralis major?
(1) Flexion
(2) Adduction
(3) Medial(internal)rotation
(4) To press her hands against her waist
70
What is the surgical importance of pectoralis major?
(1)In radical mastectomy,the sternocostal head is removed while the clavicular
head is preserved(to protect the cephalic vein and to prevent the infra-
clavicular hollowness).
(2)In modified radical mastectomy,the whole muscle is preserved and only the
pectoral fascia is removed as(it contains LNs).
(3)It forms the anterior wall of the axilla.
(4)It is the underlying muscle of the breast.
71
Discuss serratus anterior
Origin:8 digitations from the outer surfaces of upper 8 ribs
Insertion:Medial border of the the scapula(ventral surface)
Nerve supply:Long thoracic nerve(nerve to serratus or nerve of bell)from roots C5,6,7
Action:(1)protraction
(2)rotation of the scapula(90-180)
(3)keeps the stability of the scapula with the use of upper limb
Surgical importance:(1)long thoracic nerve(nerve to serratus or nerve of bell) should
be preserved during radical mastectomy.
(2)injury to long thoracic nerve leads to winging of the scapula
72
What is the origin of serratus anterior?
8 digitation from outer surface of upper 8 ribs
73
What the insertion of serratus anterior?
Medial border of the scapula(ventrally)
74
What is the nerve supply of serratus anterior?
Long thoracic nerve(nerve to serratus or nerve of bell)from roots C5,C6 and C7
75
What is the action of serratus anterior?
(1) protraction
(2) rotation of the scapula(90-180)
(3) keeps the stability of the scapula with the use of upper limb
76
What is the surgical importance of the serratus anterior?
(1)Long thoracic nerve(nerve to serratus or nerve of bell) should be preserved
during radical mastectomy.
(2)Injury to long thoracic nerve leads to winging of the scapula.
77
Discuss external oblique muscle?
Origin:fleshy digitations from the lower 8 ribs(the upper 5 slips interdigitate
with the serratus anterior
Insertion:(1)Fleshy fibres
-inserted in the outer lip of the iliac crest
-form the anterior boundary of the inferior lumbar triangle
(2)Aponeurosis
-Medial part:inserted into linea alba from xiphoid process to
symphysis pubis.
-Lateral part:folds upwards and backwards upon itself to form
the inguinal ligament(ASIS—pubic tubercle).
Direction of fibres:downwards,forwards and medially
Nerve supply:(1)lower 5 intercostal nerve(T7-T11)
(2)subcostal nerve(T12)
Action: (1)Supports abdominal contents
(2)Compresses abdominal contents
(3)Assists in flexing and rotation of trunk
(4)Assists in
1)forced expiration
2)micturition
3)parturition
4)vomiting
78
What is the origin of external oblique muscle?
Fleshy digitations from the lower 8 ribs(the upper 5 slips interdigitate with serratus anterior muscle)
79
What is the insertion of external oblique muscle?
(1)Fleshy part:
-inserted in the outer lip of the iliac crest
-forms the anterior boundary of the inferior lumbar triangle
(2)Aponeurosis:
-medial part-inserted in linea alba from xiphoid process to symphysis pubis
-lateral part-folds upwards and backwards on itself to form the inguinal
ligament(ASIS—pubic tubercle)
80
What is the direction of fibres of external oblique muscle?
Downwards,forwards and medially
81
What is the nerve supply of external oblique muscle?
(1) lower 5 Intercostal nerve(T7-T11)
| 2) Subcostal nerve(T12
82
What is the action of external oblique muscle?
(1) Supports abdominal contents
(2) Compresses abdominal contents
(3) Assists in flexing and rotation of trunk
(4) Assists in
1) forced expiration
2) micturition
3) parturition
4) vomiting
83
Discuss rectus sheath
Definition:It is an envelope-like sheath for rectus abdominis muscle.
Site:Between linea alba(medially)and linea semilunaris(laterally).
Formation:
Anterior wall Posterior wall
(1) above costal margin Ext.oblique 5th,6th & 7th costal cartilages
(2)From costal margin to -Ext.oblique Posterior layer of int.oblique
Midway between -Ant.layer of internal. Transversus abdominis(it’s lower
umbilicus and SP oblique border is the arcuate line)
(3)Below the level. -Ext.oblique Absent and is replaced by fascia
midway between -Int.oblique transversalis
umbilicus and SP -Transversus abdominis
Contents:
- 2 muscles: (1)rectus abdominis
(2) pyramidalis
- 4 vessels: (1)superior epigastric vessels
(2) inferior epigastric vessels
- 6 nerves: (1)lower 5 intercostal nerves(T7-T11)
(2) subcostal nerve(T12)
84
Define rectus sheath
It is an envelope-like sheath for the rectus abdominis muscle
85
What is the site of rectus sheath?
Between linea alba(medially)and linea semilunaris(laterally)
86
What are the structures forming the rectus sheath?
Formation:
Anterior wall Posterior wall
(1) above costal margin Ext.oblique 5th,6th & 7th costal cartilages
(2)From costal margin to -Ext.oblique Posterior layer of int.oblique
Midway between -Ant.layer of internal. Transversus abdominis(it’s lower
umbilicus and SP oblique border is the arcuate line)
(3)Below the level. -Ext.oblique Absent and is replaced by fascia
midway between -Int.oblique transversalis
umbilicus and SP -Transversus abdominis
87
What are the contents of rectus sheath?
- 2 muscles: (1)rectus abdominis
(2) pyramidalis
- 4 vessels: (1)superior epigastric vessels
(2) inferior epigastric vessels
- 6 nerves: (1)lower 5 intercostal nerves(T7-T11)
(2) subcostal nerve(T12)
88
Discuss the architecture or structure of the breast gland
-The breast is formed of acini that make up lobules & lobes of the gland which
are radially-arranged
-Each lobe is drained by a separate duct.
-All the collecting ducts (10 -15) open into the nipple.
-Liqaments of Cooper:
The breast is anchored to the overlying skin & to the pectoral fascia by bands of CT
called Liqaments of Copper.
89
What is the number of collecting duct of the breast and where do they open?
All the collecting ducts(10-15)open into nipple.
90
Discuss ligament of Cooper?
Definition:The breast is formed of glands and bands of fibro-fatty connective
where thickening in the fibrous tissue called Cooper ligament
Function:anchors the breast to the
(1)overlying skin
(2)pectoral fascia
91
Define ligament of Cooper?
The breast is formed of glands and bands of fibro-fatty connective tissue where thickening of the fibrous tissue is called Cooper ligament
92
What is the function of ligament of Cooper?
Anchors the breast to the
(1) overlying skin
(2) pectoral fascia
93
Discuss the blood supply of the breast
1st/Arterial supply:-
1.The lateral thoracic artery—from 2nd part of the axillary artery.
2. The perforating cutaneous branches of internal mammary artery —to the 2nd, 3'd &
4th spaces (medial perforator).
3. Lateral branches of the 2nd, 3rd & 4th intercostal arteries (lateral perforators)
2nd/Venous Drainage:-
1. Superficial Veins-cross the midline.
2. Deep veins-accompany the int. mammary & intercostals arteries.
3. lntercostal veins-drain into the azygous system on the Rt. side & hemiazygous on
the Lt. Side, & vertebral veins, so cancer breast spreads to axial
skeleton.
N.B. Phlebitis of the superficial veins is called Mondor's disease (superficial thrombophlebitis of the breast)
3rd/Lymph Drainage:
o Skin without nipple & areola—radial manner.
o Nipple, areola and breast tissue —axillary LNs ((anterior —) —)medial —) apical))
o Deep part of breast —) lymphatics through pectoralis major —) internal mammary
LN —) posterior lntercostal LN.
o Lower medial part—lymphatics in rectus sheath & falciform ligament —) metastasis
in liver.
94
Discuss the arterial supply to the breast
1.The lateral thoracic artery-from 2nd part of the axillary artery.
2. The perforating cutaneous branches-of internal mammary artery to the 2nd, 3'd &
4th spaces (medial perforator).
3. Lateral branches of the 2nd, 3rd & 4th intercostal arteries (lateral perforators)
95
Discuss the venous drainage of the breast and what is Mondor’s disease and what it is also called
Venous Drainage:-
1. Superficial Veins-cross the midline.
2. Deep veins-accompany the int. mammary & intercostals arteries.
3. lntercostal veins-drain into the azygous system on the Rt. side & hemiazygous on
the Lt. Side, & vertebral veins, so cancer breast spreads to axial
skeleton.
N.B. Phlebitis of the superficial veins is called Mondor's disease (superficial thrombophlebitis of the breast)
96
Discuss the lymph drainage of the breast
Lymph Drainage:
o Skin without nipple & areola—radial manner.
o Nipple, areola and breast tissue —axillary LNs ((anterior —) —)medial —) apical))
o Deep part of breast —) lymphatics through pectoralis major —) internal mammary
LN —) posterior lntercostal LN.
o Lower medial part—lymphatics in rectus sheath & falciform ligament —) metastasis
in liver.
97
Discuss the axillary groups of lymph nodes?
The axillary groups of lymph nodes:-
1. Pectoral group (anterior)—behind the pectoralis major.
2. Humoral group (lateral)—along the axillary vein.
3. Sub-scapular group (posterior)—over the subscapularis muscle.
4. Central group (medial)—over the floor of the axilla.
5. Apical group (infra-clavicular)—at the apex of the axilla.
98
What parts of the body do the axillary LNs drain?
The axillary LNs drain: MNEMONIC;BUM
(1) Body wall above the umbilicus
(2) Upper limb
(3) Mammary gland
99
Define the axilla?
It is a pyramidal space between upper part of arm and thorax
100
Discuss the boundaries of the axilla?
(1)Walls
Anterior wall:
.1st layer: pectoralis major muscle.
.2nd layer:
- Subclavius muscle.
- Clavi-pectoral fascia.
- Pectoralis minor.
- Suspensory ligament of the axilla.
Posterior wall: Subscapularis, teres major & latissimus dorsi muscles.
Medial wall:
Upper 4 ribs & serratus anterior muscle with long thoracic nerve running over it.
Lateral wall:
Formed by narrow strip of the intertubercular groove of the humerus, (with the
origin of biceps & coracobrachialis muscles).
(2)APEX:-
.Through which the neck (posterior triangle) is connected with the axilla (i.e.: the
nerves & vessels pass through it).
.lt bounded by:
- ln front: middle Thirds of the clavicle.
-Medially: outer border of the 1st rib.
- Behind: upper border of the scapula.
(3)Base:closed by the axillary fascia.
101
What are the walls bounding the axilla?
- Anterior wall
(1) subclavius
(2) clavipectoral fascia
(3) pectoralis minor
(4) suspensory ligament of the axilla
- Posterior wall
(1) subscapularis
(2) teres major
(3) latissimus dorsi
- Medial wall
(1) upper 4 ribs
(2) serratus anterior
(3) long thoracic nerve(over the serratus anterior)
- Lateral wall
(1) narrow strip of intertubercular groove
(2) origin of biceps
(3) origin of coracobrachialis
102
Discuss apex of the axilla
-Through which the posterior triangle of the neck is connected with the
axilla(i.e,the nerves and vessels pass through it).
-It is bounded by:
In front: middle 1/3 of clavicle
Medially: outer border of 1st rib
Behind: upper border of the scapula
103
Discuss base of the axilla
Closed by axillary fascia
104
What are the contents of the axilla?
MNEMONIC:SAC
(1) cords of the brachial plexus
(2) axillary vessels(cephalic vein joins the axillary vein in the axilla)
(3) several groups of L.Ns
105
Define quadrangular and triangular spaces
These are muscular spaces,situated just below the lateral border of the scapula
106
What is the location of the quadrangular space in relation to the triangular space?
The quadrangular space is lateral to the medial triangular space with long head of triceps in between.
107
What are the triangular spaces there?
(1)upper triangular space(AKA;medial triangular space)
(2)lower triangular space(AKA;lateral triangular space,
triangular interval or triceps hiatus)
108
What are the boundaries of the quadrangular space?
(1) Medially: long head of triceps
(2) Laterally: surgical neck of humerus
(3) Superiorly(Posteriorly): teres minor
(4) Inferiorly: teres major
(5) anteriorly: subscapularis
109
What are the contents of quadrangular space?
(1) axillary nerve
| (2) posterior circumflex humeral vessels
110
What are the boundaries of the upper(medial)triangular space?
(1) Inferiorly: superior border of teres major
(2) Superiorly: 1)teres minor
2) subscapularis
(3) Laterally: long head of triceps
111
What are the contents of the upper(medial)triangle?
Circumflex scapular artery(unlike quadrangular space or triangular interval,no major nerve passes through triangular space)
112
What are the other names for the lower triangular space?
(1) lateral triangular space
(2) triangular interval
(3) triceps hiatus
113
What are the boundaries of the lower(lateral)triangular space?
(1) Superiorly: inferior(lower)border of teres major
| (2) Medially: long head of triceps
114
What are the contents of the lower(lateral) triangular space?
MNEMONIC;PR
(1) profunda brachii artery
(2) radial nerve
115
Discuss the cubital fossa?
DEFINITION:-
The cubital fossa is a triangle space located in front of the elbow; its base lies above while its apex extends downwards for a short distance in the forearm.
BOUNDARIES:-
-Above: an imaginary line passing between the 2 epicondyles of the humerus.
-Laterally: the brachioradialis muscle
-Medially: the pronator teres muscle.
-Below: the meeting of lateral & medial borders forms the apex but
brachioradialis overlaps pronator teres.
ROOF:-
- Formed by the skin, superficial & deep fascia of the forearm reinforced on the
medial side by the bicipital aponeurosis.
- The superficial fascia contains parts of cephalic vein, basilic vein, median
cubital vein, anterior branch of medial cutaneous nerve of the forearm &
lateral cutaneous branch of the forearm.
- The deep fascia is pierced by a connection between the median cubital vein
& the deep veins.
FLOOR:-
Formed by the lower part of the brachialis (on the medial side) & the anterior
part of the supinator (on the lateral side).
CONTENTS:-
From medial to lateral, the cubital fossa contains:
1. The median nerve.
2. The end of the brachial artery(palpated here medial to the tendon) & the
origin of radial & ulnar arteries.
3. The biceps tendon.
4. The radial nerve & the beginning of its posterior inter-osseous branch (only
seen when brachioradialis is retracted laterally).
5. The supratrochlear LNs (in the upper & medial parts).
116
Define the cubital fossa
The cubital fossa is a triangle space located in front of the elbow; its base lies above while its apex extends downwards for a short distance in the forearm
117
What are the boundaries of the cubital fossa including roof and floor?
BOUNDARIES:-
-Above: an imaginary line passing between the 2 epicondyles of the humerus.
-Laterally: the brachioradialis muscle
-Medially: the pronator teres muscle.
-Below: the meeting of lateral & medial borders forms the apex but
brachioradialis overlaps pronator teres.
ROOF:-
- Formed by the skin, superficial & deep fascia of the forearm reinforced on the
medial side by the bicipital aponeurosis.
- The superficial fascia contains parts of cephalic vein, basilic vein, median
cubital vein, anterior branch of medial cutaneous nerve of the forearm &
lateral cutaneous branch of the forearm.
- The deep fascia is pierced by a connection between the median cubital vein
& the deep veins.
FLOOR:-
Formed by the lower part of the brachialis (on the medial side) & the anterior
part of the supinator (on the lateral side).
118
What are the boundaries of the cubital fossa excluding floor and roof?
BOUNDARIES:-
-Above: an imaginary line passing between the 2 epicondyles of the humerus.
-Laterally: the brachioradialis muscle
-Medially: the pronator teres muscle.
-Below: the meeting of lateral & medial borders forms the apex but
brachioradialis overlaps pronator teres.
119
Discuss the roof of cubital fossa
ROOF:-
- Formed by the skin, superficial & deep fascia of the forearm reinforced on the
medial side by the bicipital aponeurosis.
- The superficial fascia contains parts of cephalic vein, basilic vein, median
cubital vein, anterior branch of medial cutaneous nerve of the forearm &
lateral cutaneous branch of the forearm.
- The deep fascia is pierced by a connection between the median cubital vein
& the deep veins.
120
Discuss floor of cubital fossa
FLOOR:-
Formed by the lower part of the brachialis (on the medial side) & the anterior
part of the supinator (on the lateral side).
121
What are the contents of cubital fossa?
CONTENTS:-
MNEMONIC; MY BROTHER RADY ULNAR THROWS RAD PARTIES SWIFTLY
From medial to lateral, the cubital fossa contains:
1. The median nerve.
2. The end of the brachial artery(palpated here medial to the tendon) & the
origin of radial & ulnar arteries.
3. The biceps tendon.
4. The radial nerve & the beginning of its posterior inter-osseous branch (only
seen when brachioradialis is retracted laterally).
5. The supratrochlear LNs (in the upper & medial parts).
```
OTHER MNEMONIC; Rady Ulnar(Radial and Ulnar arteries)
Really Needs(Radial Nerve)
Pulling In(Posterior inter-osseous branch)
Beer To(Biceps Tendon)
Be At(Brachial Artery)
My Nicest(Median Nerve)
State Laughing(Supratrochlear L.Ns)
```
122
Discuss anatomical snuff box
-Boundaries:-
(1) Medially: Extensor policis longus
(2) Laterally: 1)Extensor policis brevis
2) Abductor policis longus
- Contents:-
(1) Radial artery
(2) Cephalic vein
(3) Scaphoid
(4) Trapezium
-Surgical importance:-
Fracture scaphoid is the commonest fracture of carpal bones manifested as swelling and tenderness in the anatomical snuff box.Avascular necrosis and non union are common complications.
123
What are the boundaries of the anatomical snuff box?
Medially: Extensor policis longus
Laterally: (1)Extensor policis brevis
(2)Abductor policis longus
124
What are the contents of the anatomical snuff box?
(1) Radial artery
(2) Cephalic vein
(3) Trapezium
(4) Scaphoid
125
What is the surgical importance of the anatomical snuff box ?
Fracture scaphoid is the commonest fracture of the carpal bone.
It is manifested as swelling and tenderness in the anatomical snuff box.
Avascular necrosis and non union are common complications.
126
Discuss flexor retinaculum
- DEFINITION:Thick band stretches distal to wrist joint.
- ATTACHMENTS:
Medially: attached to pisiform bone & hook of hamate.
Laterally:tubercle of scaphoid bone & crest of trapezium.
Superiorly:to the deep fascia of the forearm.
lnferiorly:central portion of palmar fascia.
-CONTENTS:-
.SUPERFlCIALLY(medial to lateral )
1. Ulnar nerve.
2. Ulnar vessels.
3. Palmar cutaneous branch of ulnar nerve.
4. Tendon of palmaris longus muscle.
5. Palmar cutaneous branch of median nerve.
N.B. Radial artery does not pass superficialto flexor retinaculum
.DEEPTO lT :The carpal tunnel containing:
1. Flexor digitorum superficialis tendons.
2. Flexor digitorum profundus tendons.
3. Ulnar bursa enclosing flexor digitorum superficialis & profundus tendons (tendons
of superficialis are arranged in two starta).
4. Flexor pollicis longus tendon.
5. Radial bursa enclosing flexor pollicis longus tendon.
6. Median nerve.
7. Flexor carpi radialis tendon & its synovial sheath (SPECIAL CANAL).
127
Define flexor retinaculum
Thick band stretches distal to wrist joint.
128
What are the boundaries and attachments of the flexor retinaculum?
Medially:attached to pisiform bone & hook of hamate.
Laterally:tubercle of scaphoid bone & crest of trapezium.
Superiorly:to the deep fascia of the forearm.
lnferiorly:central portion of palmar fascia.
129
What are the contents of the flexor retinaculum?
Superficially: medial to lateral
(1) ulnar nerve
(2) ulnar vessels
(3) palmar cutaneous branch of ulnar nerve
(4) tendon of palmaris longus muscle
(5) palmar cutaneous branch of median nerve
Deep to it: the carpal tunnel containing
(1)flexor digitorum superficial tendons
(2)flexor digitorum profundus
(3)ulnar bursa enclosing flexor digitorum superficial and profundus tendons
(tendons of superficialis are arranged in strata)
(4)flexor policis longus tendon
(5)radial bursa enclosing policis longus tendon
(6)median nerve
(7)flexor carpi radialis tendon and its synovial sheath (SPECIAL TENDON)
130
What is the location of carpal tunnel?
Deep to the flexor retinaculum
131
What are the contents of the carpal tunnel?
(1)flexor digitorum superficialis tendon
(2)flexor digitorum profundus tendon
(3)ulnar bursa enclosing flexor digitorum superficialis and profundus
(flexor digitorum superficialis tendons are arranged in two starta)
(4)flexor palmaris longus tendon
(5)radial bursa enclosing flexor palmaris longus
(6)median nerve
(7)flexor carpi radialis tendon and its synovial sheath(SPECIAL CANAL)
132
Discuss extensor retinaculum
DEFINITION:
Thickened part of deep fascia which covers the extensor tendons proximal to the wrist joint
THE SPACE IS DIVIDED BY 5 SEPTA INTO 6 COMPARTMENTS:
1"t comp: Abductor pollicis longus & Extensor pollicis brevis.
2nd comp: Extensor carpi radialis longus & Extensor carpi radialis brevis
3rd comp: Extensor pollicis longus
4th comp: Extensor digitorum (4 tendons) & Extensor indices (ant. interosseous A +
post. interosseous n are present).
5th comp: Extensor digiti minimi.
6th comp: Extensor carpi ulnaris.
STRUCTURES SUPERFICIAL TO THE RETINACULUM:-
```
o 2 Veins: cephalic vein (lateral) & basilic vein (medial).
o 2 Nerves: Superficial branch of radial nerve (lateral) & dorsal branch of
ulnar nerve(medial).
```
133
Define extensor retinaculum
Thickened part of deep fascia which covers the extensor tendons proximal to the wrist joint
134
What are the compartments and contents of the extensor retinaculum?
THE SPACE IS DIVIDED BY 5 SEPTA INTO 6 COMPARTMENTS:-
1st comp: (1)extensor pollicis brevis
(2)abductor pollicis longus
2nd comp:(1)extensor carpi radialis longus
(2)extensor carpi radialis brevis
3rd comp: extensor pollicis longus
4th comp: (1)extensor digitorum(4 tendons)
(2)extensor indices(ant. Interosseous A + post. Interosseous n are present)
5th comp: extensor digiti minimi
6th comp: extensor carpi ulnaris
135
What are the structures superficial to the extensor retinaculum?
- 2 veins: (1)cephalic vein(lateral)
(2) basilic vein(medial)
- 2 nerves: (1)superficial branch of radial nerve(lateral)
(2) dorsal branch of ulnar nerve(medial)
136
Discuss spaces of the hand
Pulp Space
It is the subcutaneous compartment which is related to the palmar surface of the distal phalanx,
It is closed proximally by a fibrous septum at the level of epiphyseal line of terminal phalanx.
It is separated from the distal volar space by a deep fascia.
o It contains:
(1)Fat.
(2)Fibrous tissue septa, which extends from the skin to periosteum.
(3)Digital artery which gives epiphyseal branch before it enters the space.
Surgical importance: Pulp space infection may lead to osteomyelitis of the terminal
phalanx except epiphysis.
Web Space:-
o Triangular region between the dorsum & ventral skin present at the bases of the fingers.
o They contain: fat, digital vessels & nerves, lumbricals & interossei.
o They communicate with mid-palmar & thenar spaces.
Thenar space:-
o Anterior-thenar muscle, radial bursa, and flexor pollicis longus.
o Posterior-adductor pollicis & 2nd & 3rd metacarpals.
o Medial-deep mid palmar space (separated from it by a fibrous septum extending
from palmar aponeurosis to 3rd metacarpal bone)
o Distal-extends to the web of the thumb.
Superficial mid palmar space:-
o Anterior-middle part of palmar aponeurosis.
o Posterior-flexor tendons
Deep mid palmar
Anterior-flexor tendon of the medial 3 fingers & ulnar bursa.
Posterior-fascia covering the interossei & 3rd, 4th & 5th metacarpals.
Lateral-fibrous band from palmar aponeurosis to 3rd metacarpal.
Distally-3 lumbrical canals to the medial 3 webs.
Medially-separated from hypothenar muscles by mediar palmar septum.
N.B Duputyren’s contracture
- It is a contracture of palmar aponeurosis.
- It affects its medial part.
- It leads to flexion of MP joint & sometimes proximal lP joint (DlP joint is not affected).
- It is seen in patients with liver cirrhosis.
137
Discuss pulp space
It is the subcutaneous compartment which is related to the palmar surface of the distal phalanx,
It is closed proximally by a fibrous septum at the level of epiphyseal line of terminal phalanx.
It is separated from the distal volar space by a deep fascia.
o It contains:
(1)Fat.
(2)Fibrous tissue septa, which extends from the skin to periosteum.
(3)Digital artery which gives epiphyseal branch before it enters the space.
Surgical importance: Pulp space infection may lead to osteomyelitis of the terminal
phalanx except epiphysis.
138
Define pulp space
It is the subcutaneous compartment which is related to the palmar surface of the distal phalanx.
139
What are the relations of pulp space?
It is closed proximally by a fibrous septum at the level of epiphyseal line of terminal phalanx.
It is separated from the distal volar space by a deep fascia.
140
What are the contents of the pulp space?
(1) Fat.
(2) Fibrous tissue septa, which extends from the skin to periosteum.
(3) Digital artery which gives epiphyseal branch before it enters the space.
141
What is the surgical importance of the pulp space?
Pulp space infection may lead to osteomyelitis of the terminal phalanx except epiphysis.
142
Discuss web space?
o Triangular region between the dorsum & ventral skin present at the bases of
the fingers.
o They contain: fat, digitalvessels & nerves, lumbricals & interossei.
o They communicate with mid-palmar & thenar spaces.
143
Define web space
Triangular region between the dorsum & ventral skin present at the bases of the fingers.
144
What are the contents of the web space?
fat, digitalvessels & nerves, lumbricals & interossei.
145
What are relations of the web space?
They communicate with mid-palmar & thenar spaces.
146
What are the boundaries thenar space?
o Anterior-thenar muscle, radial bursa, and flexor pollicis longus.
o Posterior-adductor pollicis & 2'd & 3'd metacarpals.
o Medial-deep mid palmar space (separated from it by a fibrous septum extending
from palmar aponeurosis to 3rd metacarpal bone)
o Distal-extends to the web of the thumb.
147
What are the boundaries of the superficial mid palmar space?
Anterior-middle part of palmar aponeurosis.
| Posterior-flexor tendons.
148
What are the boundaries of the deep mid palmar?
Anterior-flexor tendon of the medial 3 fingers & ulnar bursa.
Posterior-fascia covering the interossei & 3rd,4tn & 5th metacarpals.
Lateral-fibrous band from palmar aponeurosis to 3'd metacarpal.
Distally-3 lumbrical canals to the medial 3 webs.
Medially-separated from hypothenar muscles by medial parmar septum.
149
Discuss Duputyren’s contracture
- It is a contracture of palmar aponeurosis.
- It affects its medial part.
- It leads to flexion of MP joint & sometimes proximal lP joint (DlP joint is not affected).
- It is seen in patients with liver cirrhosis.
150
Discuss synovial sheath
Synovial sheath of the middle 3 fingers:-
Each finger of these has a separate synovial sheath
. Proximal end:
- At the level of metacarpo-phalangeal Joint.
- Dilated Cul-de sac.
.Distal end:at base of distal phalanges.
They enclose the flexor tendons.
Synovial sheath of the thumb &little fingers:-
Proximally they continue with radial & ulnar bursae, respectively.
Ulnar bursa Radial bursa
Larger Smaller
Distally connected with synovial Distally connected with synovial sheath sheath of little finger of the thumb
Proximally-runs below the flexor
retinaculum
-extends 1" in the forearm
Envelops the flexor tendons Envelops the tendon of flexor pollicis
of the medial 4 fingers
N.B.The thenar and radial bursa may sometimes communicate.
151
Discuss synovial sheath of the middle 3 fingers
Each finger of these has a separate synovial sheath.
Proximal end:
- At the level of metacarpo-phalangeal Joint.
- Dilated Cul-de sac.
Distal end:at base of distal phalanges.
They enclose the flexor tendons.
152
Discuss synovial sheath of the thumb and little fingers?
Proximally they continue with radial & ulnar bursae, respectively.
153
Compare between ulnar and radial bursa?
Ulnar bursa Radial bursa
Larger Smaller
Distally connected with synovial Distally connected with synovial sheath sheath of little finger of the thumb
Proximally-runs below the flexor
retinaculum
-extends 1" in the forearm
Envelops the flexor tendons Envelops the tendon of flexor pollicis
of the medial 4 fingers
N.B.The thenar and radial bursa may sometimes communicate.
154
Discuss the axillary artery
Begins:at the outer border of 1't rib as a continuation of subclavian artery.
End:at the lower border of the teres major muscle as brachial artery.
Pectoralis minor divides axillary artery into 3 parts:
A- 1st Part:
o Lies above the pectoralis minor muscle. .
B- 2nd Part:
. Lies behind pectoralis minor.
. Branches:1- Thoraco-acromial artery (pierce clavi-pectoral fascia).
It gives acromial,pectoral,clavicular &deltoid branches
2- Lateral thoracic artery (supplies female breast).
C- 3rd Part:
o Lies below pectoralis minor.
o Lies medial to the short head of biceps & coracobrachialis.
o Branches:
i. Sub-scapular: give circumflex scapular (anastomosis around scapula).
ii. Posterior circumflex humoral: around the surgical neck.
iii. Anterior circumflex humeral: around surgical neck and gives
branches to the shoulder joint.
Surgical importance: Exposure:
o The incision used to expose the subclavian artery in the neck can be extended
across the clavicle into the delto-pectoral groove.
o A sub-clavicular incision 1 cm below the clavicle (started at the junction of the
medial 1/4 with the outer 3/4 of the clavicle & extended for 6 cm laterally).
155
Where does the axillary artery begin?
At the outer border of 1st rib as a continuation of subclavian artery
156
Where does the axillary artery end?
At the lower border of the teres major muscle as brachial artery
157
What divides the axillary artery into parts?
Pectoralis minor muscle
158
How many parts does the axillary artery have?
3 parts(1st,2nd and 3rd)
159
Discuss the parts of the axillary artery
1st part:-
- lies above pectoralis minor muscle
- Branches:superior thoracic artery
2nd part:-
-lies behind pectoralis minor muscle
Branches:(1)Thoraco-acromial artery(pierces clavipectoral groove)
MNEMONIC;CADP
1.Clavicular
2.Acromial
3.Deltoid
4.Pectoral
(2)Lateral thoracic artery(supplying female breast)
3rd part:
-lies below pectoral minor
-lies medial to short head of biceps and coracobrachialis
-Branches:(1)subscapular:gives circumflex scapular(anastomoses around scapula)
(2)posterior circumflex humeral:around the surgical neck
(3)anterior circumflex humeral:around the surgical neck and gives branches
to the shoulder joint
160
What is the location of the 1st part of the axillary artery?
Lies above pectoralis minor
161
What are the branches of the1st part of axillary artery ?
Superior thoracic artery
162
What is the location of the 2nd part of axillary artery?
lies behind pectoralis minor muscle
163
What are the branches of the 2nd part of the axillary artery?
(1)thoracoacromial(pierces the clavipectoral fascia)gives:-
MNEMONIC;CADP
1.Clavicular
2.Acromial
3.Deltoid
4.Pectoral
(2)lateral thoracic artery(supplies female breast)
164
What is the location of the 3rd part of the axillary artery?
- lies below pectoral minor
| - lies medial to short head of biceps and coracobrachialis
165
What are the branches of the 3rd part of the axillary artery?
(1)subscapular:gives circumflex scapular(anastomoses around the scapula)
(2)posterior circumflex humeral:around the surgical neck
(3)anterior circumflex humeral:around the surgical neck and gives branches
to the shoulder joint
