Топографическая анатомия PDF

 МИНИСТЕРСТВО ОБРАЗОВАНИЯ И НАУКИ РФ Федеральное государственное бюджетное образовательное учреждение высшего профессионального образования «ПЕНЗЕНСКИЙ ГОСУДАРСТВЕННЫЙ УНИВЕРСИТЕТ» (ПГУ) О. В. Калмин, И. В. Бочкарева, О. А. Калмина ТОПОГРАФИЧЕСКАЯ...

 МИНИСТЕРСТВО ОБРАЗОВАНИЯ И НАУКИ РФ Федеральное государственное бюджетное образовательное учреждение высшего профессионального образования «ПЕНЗЕНСКИЙ ГОСУДАРСТВЕННЫЙ УНИВЕРСИТЕТ» (ПГУ) О. В. Калмин, И. В. Бочкарева, О. А. Калмина ТОПОГРАФИЧЕСКАЯ АНАТОМИЯ Учебное пособие O. V. Kalmin, I. V. Bochkareva, O. A. Kalmina TOPOGRAPHIC ANATOMY Tutorial Пенза Издательство ПГУ 2015 УДК 611.9 (075.8) К17 Рецензенты: доктор медицинских наук, профессор, заведующий кафедрой анатомии человека Ульяновского государственного университета Р. М. Хайруллин; доктор медицинских наук, профессор, заведующий кафедрой нормальной анатомии с курсами судебной медицины, топографической анатомии и оперативной хирургии Мордовского государственного университета им. Н. П. Огарева И. Н. Чаиркин Калмин, О. В. К17 Топографическая анатомия : учеб. пособие / О. В. Калмин, И. В. Боч- карева, О. А. Калмина = Topographic anatomy : Tutorial / O. V. Kalmin, I. V. Bochkareva, O. A. Kalmina. – Пенза : Изд-во ПГУ, 2015. – 250 с. ISBN 978-5-94170-957-1 Пособие содержит обобщенные и систематизированные данные о границах, содержимом и сообщениях клетчаточных пространств тела человека, топографии различных областей тела, внутренних органов, содержимом отверстий и каналов черепа, мышечных каналов и борозд. Издание предназначено для аудиторной и внеаудиторной работы студентов медицинских специальностей вузов. The tutorial contains a detailed and systematic data on the boundaries, the content and communications fat tissue spaces of human body, the topography of different areas of the body, internal organs, the content of-holes and channels of the skull, muscle and fur- rows. The tutorial is made for classroom and extracurricular work for students of medical universities. УДК 611.9 (075.8) Рекомендовано к изданию методической комиссией Медицинского института Пензенского государственного университета (протокол № 3 от 13.11.2014). ISBN 978-5-94170-957-1 © Пензенский государственный университет, 2015 2  CONTENT Topographic anatomy of the upper limb.............................................................................................. 6 Topographic anatomy of the shoulder girdle................................................................................... 6 Topography of the subclavian region (regio infraclavicularis).................................................... 6 Topography of the deltoid region (regio deltoidea)..................................................................... 8 Topography of the axillary region (regio axillaris)...................................................................... 8 Topography of the scapular region (regio scapularis)................................................................ 11 Topography of the shoulder joint (articulatio humeri / articulatio glenohumerale)................... 16 Topographic anatomy of the arm................................................................................................... 18 Topography of the anterior region of the arm (regio brachii anterior)...................................... 19 Topography of the posterior region of the arm (regio brachii posterior)................................... 21 Topography of the anterior cubital region (regio cubiti anterior).............................................. 24 Topography of the posterior cubital region (regio cubiti posterior).......................................... 27 Topography of the elbow joint (articulatiо cubiti)..................................................................... 28 Topographic anatomy of the forearm............................................................................................. 30 Topography of the anterior region of the forearm (regio antebrachii anterior)......................... 30 Topography of the posterior region of the forearm (regio antebrachii posterior)...................... 34 Topography of the wrist joint (articulatio radiocarpea)............................................................. 36 Topographic anatomy of the hand region (regio manus)............................................................... 37 Topography of the palmar region of the hand (regio palmare manus)...................................... 37 Topography of the dorsal region of the hand (regio dorsi manus)............................................. 43 Topography of the wrist (regio carpi)........................................................................................ 45 Topography of the wrist joint (articulatio radiocarpea)............................................................. 46 Topography of the fingers (regio digiti)..................................................................................... 48 Nerve injury............................................................................................................................... 50 Topographic anatomy of the lower limb............................................................................................ 52 Topographic anatomy of the buttocks and thighs.......................................................................... 52 Topography of the gluteal region (regio glutea)........................................................................ 52 Topography of the hip joint (articulatio coxae)......................................................................... 56 Topography of the anterior and posterior femoral (thigh) region (regiones femoris anterior et posterior)...................................................................................... 57 Topographic anatomy of the knee (regio genus)............................................................................ 63 Topography of the anterior region of the knee (regio genus anterior)....................................... 64 Topography of the popliteal region (regio genus posterior)...................................................... 65 Topographic anatomy of the leg (regio cruris).............................................................................. 69 Topography of the anterior region of the leg (regio cruris anterior).......................................... 69 Topography of the posterior region of the leg (regio cruris posterior)...................................... 71 Topographic anatomy of the foot (regio pedis).............................................................................. 74 Topography of the plantar region of the foot (regio plantae pedis)........................................... 75 Topography of the dorsal region of the foot (regio dorsi pedis)................................................ 78 Topographic anatomy of the head...................................................................................................... 83 Topographic anatomy of the cerebral part of the head.................................................................. 83 Topography of the fronto-parieto-occipital region (regio frontoparietooccipitalis).................. 83 Topography of the temporal region of the head (regio temporalis)........................................... 87 Topography of the mastoid region of the head (regio mastoidea)............................................. 87 Topography of the anterior cranial fossa (fossa cranii anterior)................................................ 89 Topography of the middle cranial fossa (fossa cranii media).................................................... 89 Topography of the posterior cranial fossa (fossa cranii posterior)............................................ 90 Topography of the brain............................................................................................................. 93 Topography of the facial skull..................................................................................................... 102 3  Topography of the lateral region of the face (regio facialis lateralis)...................................... 102 Topography of the superficial lateral region of the face (regio facialis lateralis superficialis)........................................................................................ 102 Topography of the cheek region (regio buccalis).................................................................... 103 Topography of the parotid-masseteric region (regio parotideomasseterica)........................... 105 Topography of the deep facial region (regio facialis profunda).............................................. 107 Topography of the parotid gland (glandula parotis)................................................................ 111 Topographic anatomy of the neck.................................................................................................... 116 Sternocleidomastoid region...................................................................................................... 126 Topography of the larynx......................................................................................................... 126 Topography of the trachea....................................................................................................... 129 Topography of the pharynx...................................................................................................... 129 Topography of the oesophagus................................................................................................ 133 Topography of the thyroid gland............................................................................................. 135 Fatty spaces of the neck........................................................................................................... 136 Topographic anatomy of the thorax................................................................................................. 140 Topographic anatomy of the chest wall....................................................................................... 140 Topography of the mammary gland......................................................................................... 143 Topography of the diaphragm.................................................................................................. 144 Topographic anatomy of the chest cavity.................................................................................... 146 Topography of the mediastinum.............................................................................................. 147 Topography of the heart........................................................................................................... 149 Topography of the pericardium................................................................................................ 150 Topography of the thoracic aorta............................................................................................. 151 Topography of the thymus....................................................................................................... 154 Topography of the trachea....................................................................................................... 154 Topography of the oesophagus................................................................................................ 155 Topography of the azygos and hemyazygos veins................................................................... 157 Lymph nodes and vessels of the thorax................................................................................... 158 Topography of the thoracic duct.............................................................................................. 159 Topography of the vagus nerve (nervus vagus)....................................................................... 160 Topography of the sympathetic trunk (truncus sympathicus).................................................. 160 Topography of the splanchnicus nerve.................................................................................... 161 Topography of the lung............................................................................................................ 161 Topography of the root of the lung.......................................................................................... 165 Topographic anatomy of the abdomen............................................................................................. 166 Topographic anatomy of the abdominal walls............................................................................. 166 Anterolateral abdominal wall................................................................................................... 166 Topographic anatomy of the abdominal cavity (cavitas abdominis)........................................... 176 Peritoneum............................................................................................................................... 178 Topography of the stomach..................................................................................................... 183 Topography of the duodenum.................................................................................................. 185 Topography of the liver............................................................................................................ 187 Topography of the pancreas..................................................................................................... 189 Topography of the spleen......................................................................................................... 189 Topography of the gall bladder................................................................................................ 190 Topography of the common bile duct...................................................................................... 191 Topography of the jejunum and ileum..................................................................................... 192 Topography of the appendix.................................................................................................... 194 Topography of the ileocaecal angle......................................................................................... 195 Topography of the large intestine............................................................................................ 195 4 Topographic anatomy of the pelvis.................................................................................................. 198 Topography of the rectum............................................................................................................ 206 Topography of the urinary bladder.............................................................................................. 208 Topography of the ureter.............................................................................................................. 212 Topography of the prostate.......................................................................................................... 213 Topography of the deferent duct.................................................................................................. 214 Topography of the seminal vesicle.............................................................................................. 215 Topography of the ejaculatory ducts............................................................................................ 216 Topography of the ovary.............................................................................................................. 216 Topography of the uterine tube.................................................................................................... 217 Topography of the uterus............................................................................................................. 218 Topography of the vagina............................................................................................................ 220 Topography of the perineum............................................................................................................ 222 Topography of the scrotum.......................................................................................................... 227 Topography of the testis............................................................................................................... 229 Topography of the penis............................................................................................................... 229 Topography of the clitoris............................................................................................................ 230 Superficial features of the external genitalia................................................................................ 231 Topographic Anatomy of the lumbar region (regio lumbalis)......................................................... 232 Topographic anatomy of the retroperitoneal space.......................................................................... 234 Fasciae and fatty layers of the retroperitoneal space................................................................... 234 Topography of the kidney............................................................................................................ 236 Topography of the ureter.............................................................................................................. 238 Topography of the adrenal gland................................................................................................. 240 Topography of the abdominal aorta............................................................................................. 240 Topography of the inferior vena cava.......................................................................................... 241 Topography of the lumbar plexus................................................................................................ 242 Retroperitoneal lymphatics.......................................................................................................... 243 Topographic anatomy of the vertebral column and spinal cord....................................................... 246 Topography of the vertebral column............................................................................................ 246 Topography of the spinal cord..................................................................................................... 246 References........................................................................................................................................ 249 5  TOPOGRAPHIC ANATOMY OF THE UPPER LIMB Topographic anatomy of the shoulder girdle The upper extremities, or upper limbs, can be divided into the shoulder (junction of the trunk with the arm), arm, elbow, forearm, wrist and hand. The borders of an upper extremity are:  anteriorly - deltoidpectoral sulcus;  posteriorly - posterior deltoid sulcus;  interiorly - the imaginary line of the lateral thoracic wall between the lower edges of the great- er pectoral and latissimus dorsi muscles. The shoulder contains four regions: axillary region; scapular region; deltoid region; infra- clavicular region. The scapular and infraclavicular regions are common regions for the shoulder and thorax. These regions are constituted by the posterior and anterior walls of the axilla. Topography of the subclavian region (regio infraclavicularis) Landmarks: - Sternum. - Clavicle. - Coracoid process. - 3rd rib. - Cephalic vein. - Pectoralis major muscle. - Deltoid muscle. - Border between pectoralis major and deltoid muscles (sulcus deltoideopectoralis). Borders: - Superior: Clavicle. - Inferior: Horizontal line drawn through the 3rd rib (in men); upper margin of the mammary gland (in women). - Medial: Lateral margin of the sternum. - Lateral: Anterior margin of the deltoid muscle. Layers: Skin: - It is thin, easily movable; - It contains sebaceous glands; - It is innervated by the supraclavicular nerve (branch of the cervical plexus). Subcutaneous tissue: - It is well-developed, especially in women; - It contains the cutaneous nerves and superficial veins. Superficial fascia: - It is thin and firm. - It forms sheath for platysma, - It goes to mammary gland, and forms the Cooper’s suspensory ligaments of the mammary gland (ligamentum suspensorium mammae). 6 Proper fascia (fascia pectoralis): - It covers the pectoralis major muscle. - It divides the pectoralis major muscle into 3 parts: clavicular, sternocostal, abdominal. - Borders:  Superior: Clavicle.  Inferior: Fascia of the serratus anterior and rectus abdominis muscles.  Medial: Sternum.  Lateral: Deltoid and axillary fasciae. Superficial subpectoral space (spatium subpectorale). Fig. 1. Course of the right axillary artery (Shuenke M., Schulte E., Schumacher U., 2010). Proper fascia (clavipectoral fascia) - It is attached to the lower margin of the clavicle, coracoid process and 1st rib. - It covers the subclavian and pectoralis minor muscles. - It connects with axillar fascia and forms the suspensory ligaments of the axilla. Deep subpectoral space - It is divided on three triangles: clavipectoral, pectoral, subpectoral (the last two are in the axillary region); - It contents axillary vessels and cords of brachial plexus (Fig. 1). 7  Topography of the deltoid region (regio deltoidea) The borders of the deltoid region correspond to the shape of the deltoid muscle. Layers: Skin: - It is not movable. Subcutaneous adipose tissue: - It is feebly marked. - It contains of superficial blood vessels and nerves. Superficial fascia: - It is closely connected with the deltoid fascia. Deltoid fascia (proper fascia of the region): - It is sends processes among the fibers of the deltoid muscle. Deltoid muscle: - It is innervated by the axillary nerve, which is a branch of the posterior cord of the brachial plexus. - The axillary nerve and associated blood vessels (the posterior circumflex humeral artery and vein) enter the deltoid by passing posteriorly around the surgical neck of the humerus. Subdeltoid space: - It includes adipose tissue, subdeltoid bursa, blood vessels, nerves. - Communicating with the adipose spaces other regions of the shoulder. The main neurovascular fascicle of the region: the posterior circumflex humeral artery and vein; axillary nerve. Topography of the axillary region (regio axillaris) Landmarks: Outlines of the pectoralis major, latissimus dorsi and coracobrachialis muscles. Axillary fossa is shown by lifting up the upper extremity. Borders: - Anterior: Lower margin of the pectoralis major muscle - Posterior: Lower margin of the latissimus dorsi muscle - Medial: Line connecting the margin of the pectoralis major and latissimus dorsi muscles along the sagittal section of the lateral surface of the thorax at the level of the 3rd rib - Lateral: Line connecting the margin of the pectoralis major and latissimus dorsi muscles on the medial surface of the arm Layers: Skin: - It is thin and easily movable. - It contains lots of sweat glands, sebaceous glands and hair. - It is innervated by intercostobrachial nerve. Subcutaneous tissue: - It contains the superficial axillary lymph nodes. - It is innervated by the intercostal nerve of the medial cutaneous nerve of the arm. Superficial fascia Proper fascia (axillary fascia): - It contains nerve and vessels. 8  - It contains the suspensory ligament of the axilla. - It separates and forms the pectoral fascia anteriorly, thoracolumbar fascia posteriorly and brachial fascia laterally. Axillary cavity Borders: - Anterior: Pectoralis major muscle and clavipectoral fascia - Posterior: Subscapularis, latissimus dorsi, teres minor and teres major muscles Medial: Thoracic wall, serratus anterior muscle and 1st until 4th intercostal muscles - Lateral: Surgical neck of the humerus, short head of the biceps brachii muscle and coraco- brachialis muscle Contents: Axillary artery is divided into 3 parts and gives branches according to (Fig. 2): - Clavipectoral triangle: Thoracoacromial artery, arteria thoracica suprema, lateral and medi- al pectoral nerves. - Pectoral triangle: Lateral thoracic artery and long thoracic nerve. - Subpectoral triangle: Subscapular artery, anterior and posterior circumflex humeral arteries. Fig. 2. Right shoulder, anterior view. (Shuenke M., Schulte E., Schumacher U., 2010). Axillary vein: - It is formed at the lower border of the teres major muscle by the union of the venae comi- tantes of the brachial artery and the basilic vein. 9 - It runs upward on the medial side of the axillary artery and ends at the lateral border of the first rib by becoming the subclavian vein. - The vein receives tributaries, which correspond to the branches of the axillary artery, and the cephalic vein. Brachial plexus: - Lateral cord. - Posterior cord. - Medial cord. Axillary lymph nodes: - Anterior (pectoral) group: lying along the lower border of the pectoralis minor behind the pectoralis major, these nodes receive lymph vessels from the lateral quadrants of the breast and superficial vessels from the anterolateral abdominal wall above the level of the umbili- cus (Fig. 3). - Posterior (subscapular) group: lying in front of the subscapularis muscle, these nodes re- ceive superficial lymph vessels from the back, down as far as the level of the iliac crests. - Lateral group: Lying along the medial side of the axillary vein, these nodes receive most of the lymph vessels of the upper limb (except those superficial vessels draining the lateral side - see infraclavicular nodes below). - Central group: Lying in the center of the axilla in the axillary fat, these nodes receive lymph from the above three groups. - Infraclavicular (deltopectoral) group: These nodes are not strictly axillary nodes because they are located outside the axilla. They lie in the groove between the deltoid and pectoralis major muscles and receive superficial lymph vessels from the lateral side of the hand, fore- arm, and arm. Fig. 3. Regional lymph nodes of the right upper limb (Shuenke M., Schulte E., Schumacher U., 2010). 10  - Apical group: Lying at the apex of the axilla at the lateral border of the first rib, these nodes receive the efferent lymph vessels from all the other axillary nodes. The efferent vessels of the apical nodes drain into the subclavian lymph trunk. On the left side this trunk drains in- to the thoracic duct and on the right side it drains into the right lymph duct. Alternatively, the lymph trunks may drain directly into one of the large veins at the root of the neck. Fatty tissue. Topography of the scapular region (regio scapularis) The borders of the scapular region corresponds to the shape of the scapula. Layers: Skin: - It is very movable. - The sensory nerve supply to the skin of the back is from the posterior rami of the spinal nerves. - The blood supply to the skin is from the posterior branches of the posterior intercostal arter- ies and the lumbar arteries. - The veins correspond to the arteries and drain into the azygos veins and the inferior vena cava. - The lymph drainage of the skin of the back above the level of the iliac crests is upward into the posterior group of axillary lymph nodes. Subcutaneous adipose tissue: - It is well expressed. - It contains of superficial blood vessels and nerves. Superficial fascia. Proper fascia of the region. Muscles: - The scapular region contains four muscles, which pass between the scapula and proximal end of the humerus: the supraspinatus, infraspinatus, teres minor and teres major muscles. - The posterior scapular region also contains part of one additional muscle, the long head of the triceps brachii, which passes between the scapula and the proximal end of the forearm. This muscle, along with other muscles of the region and the humerus, participates in form- ing a number of spaces through which nerves and vessels enter and leave the region. - The supraspinatus, infraspinatus, and teres minor muscles are components of the rotator cuff, which stabilizes the glenohumeral joint. Supraspinatus and infraspinatus spaces of supraspinous and infraspinous fossae: - Respectively, which includes adipose tissue, blood vessels, nerves; - Communicating with the adipose spaces of other regions of the shoulder. Gateways to the posterior scapular region: The suprascapular foramen: - It is the route through which structures pass between the base of the neck and the posterior scapular region. - It is formed by the suprascapular notch of the scapula and the superior transverse scapular (suprascapular) ligament, which converts the notch into a foramen. 11  - The suprascapular nerve passes through the suprascapular foramen; the suprascapular artery and the suprascapular vein follow the same course as the nerve, but normally pass immedi- ately superior to the superior transverse scapular ligament and not through the foramen. Fig. 4. The triangular and quadrangular spaces of the axilla (Shuenke M., Schulte E., Schumacher U., 2010). Quadrilateral (quadrangular) space: - The quadrilateral space is an intermuscular space bounded above by the subscapularis and capsule of the shoulder joint and below by the teres major muscle. - It is bounded medially by the long head of the triceps and laterally by the surgical neck of the humerus. - The axillary nerve and the posterior circumflex humeral vessels pass backward through this space (Fig. 4). Trilateral (triangular) space: - It is an area of communication between the axilla and the posterior scapular region. - Posteriorly, when viewed from the posterior scapular region, the trilateral space is formed by:  medial margin of the long head of triceps brachii;  superior margin of teres major;  inferior margin of teres minor.  The circumflex scapular artery and vein pass through this gap. 12 Nerves The two major nerves of the posterior scapular region are the suprascapular and axillary nerves, both of which originate from the brachial plexus in the axilla. The suprascapular nerve: - It originates in the base of the neck from the superior trunk of the brachial plexus. - It passes posterolaterally from its origin, through the suprascapular foramen to reach the posterior scapular region, where it lies in the plane between bone and muscle. - It innervates the supraspinatus muscle, then, passes through the greater scapular (spinogle- noid) notch, between the root of the spine of the scapula and the glenoid cavity, to termi- nate in and innervate the infraspinatus muscle. - Generally, the suprascapular nerve has no cutaneous branches. The axillary nerve: - It originates from the posterior cord of the brachial plexus. - It exits the axilla by passing through the quadrangular space in the posterior wall of the ax- illa, and enters the posterior scapular region. - Together with the posterior circumflex humeral artery and vein, it is directly related to the posterior surface of the surgical neck of the humerus. - The axillary nerve innervates the deltoid and teres minor muscles. - In addition, it has a cutaneous branch, the superior lateral cutaneous nerve of the arm, which carries general sensation from the skin over the inferior part of the deltoid muscle. Arteries Three major arteries are found in the posterior scapular region: the suprascapular, posterior circumflex humeral and circumflex scapular arteries. These arteries contribute to an interconnected vascular network around the scapula. The suprascapular artery: - It originates in the base of the neck as a branch of the thyrocervical trunk, which in turn, is a major branch of the subclavian artery. The vessel may also originate directly from the third part of the subclavian artery. - The suprascapular artery normally enters the posterior scapular region superior to the su- prascapular foramen, whereas the nerve passes through the foramen. In the posterior scapu- lar region, the vessel runs with the suprascapular nerve. - In addition to supplying the supraspinatus and infraspinatus muscles, the suprascapular ar- tery contributes branches to numerous structures along its course. The circumflex scapular artery is a branch of the subscapular artery: - It is also originates from the third part of the axillary artery in the axilla. - It leaves the axilla through the triangular space and enters the posterior scapular region, passes through the origin of the teres minor muscle and forms anastomotic connections with other arteries in the region. The posterior circumflex humeral artery: - It originates from the third part of the axillary artery in the axilla. - The posterior circumflex humeral artery and axillary nerve leave the axilla through the quadrangular space in the posterior wall and enter the posterior scapular region. - The vessel supplies the related muscles and the glenohumeral joint. 13 Veins Veins in the posterior scapular region generally follow the arteries and connect with vessels in the neck, back, arm and axilla. Arterial anastomosis around the shoulder joint The extreme mobility of the shoulder joint may result in kinking of the axillary artery and a temporary occlusion of its lumen. To compensate for this, an important arterial anastomosis exists between the branches of the subclavian artery and the axillary artery, thus ensuring that an ade- quate blood flow takes place into the upper limb irrespective of the position of the arm. Branches from the Subclavian Artery: - The Suprascapular artery, which is distributed to the supraspinous and infraspinous fossae of the scapula. - The superficial cervical artery, which gives off a deep branch that runs down the medial border of the scapula. Branches from the Axillary Artery: - The subscapular artery and its circumflex scapular branch supply the subscapular and in- fraspinous fossae of the scapula, respectively. - The anterior circumflex humeral artery. - The posterior circumflex humeral artery. Both the circumflex arteries form an anastomosing circle around the surgical neck of the humerus. Joints There are three joints in the shoulder complex: the sternoclavicular, acromioclavicular, and glenohumeral. Sternoclavicular joint - It occurs between the proximal end of the clavicle and the clavicular notch of the manubri- um of sternum together with a small part of the first costal cartilage. - It is synovial and saddle-shaped. - The articular cavity is completely separated into two compartments by an articular disc. - The sternoclavicular joint allows movement of the clavicle, predominantly in the anteropos- terior and vertical planes, although some rotation also occurs. - The sternoclavicular joint is surrounded by a joint capsule and is reinforced by four ligaments:  the anterior and posterior sternoclavicular ligaments are anterior and posterior, respec- tively, to the joint;  an interclavicular ligament links the ends of the two clavicles to each other and to the superior surface of the manubrium of sternum;  the costoclavicular ligament is positioned laterally to the joint and links the proximal end of the clavicle to the first rib and related costal cartilage. Acromioclavicular joint - It is a small synovial joint between a small oval facet on the medial surface of (the acro- mion and a similar facet on the acromial end of the clavicle. It allows movement in the an- teroposterior and vertical planes together with some axial rotation. 14  - It is surrounded by a joint capsule and is reinforced by:  the small acromioclavicular ligament superior to the joint and passing between adjacent regions of the clavicle and acromion;  the much larger coracoclavicular ligament, which is not directly related to the joint, but is an important strong accessory ligament, providing much of the weightbearing support for the upper limb on the clavicle and maintaining the position of the clavicle on the acromion it spans the distance between the coracoid process of the scapula and the infe- rior surface of the acromial end of the clavicle and comprises an anterior trapezoid lig- ament (which attaches to the trapezoid line on the clavicle) and a posterior conoid liga- ment (which attaches to the related conoid tubercle). Glenohumeral joint: - It is a synovial ball-and-socket articulation between the head of the humerus and the gle- noid cavity of the scapula. - It is multiaxial with a wide range of movements provided at the cost of skeletal stability. - Joint stability is provided, instead, by the rotator cuff muscles, the long head of the biceps brachii muscle, related bony processes, and extracapsular ligaments. - Movements at the joint include flexion, extension, abduction, adduction, medial rotation, lateral rotation and circumduction. - The articular surfaces of the glenohumeral joint are the large spherical head of the humerus and the small glenoid cavity of the scapula. Each of the surfaces is covered by hyaline carti- lage. - The glenoid cavity is deepened and expanded peripherally by a fibrocartilaginous collar (the glenoid labrum), which attaches to the margin of the fossa. Superiorly, this labrum is continuous with the tendon of the long head of the biceps brachii muscle, which attaches to the supraglenoid tubercle and passes through the articular cavity superior to the head of the humerus. - The synovial membrane attaches to the margins of the articular surfaces and lines the fi- brous membrane of the joint capsule. - The synovial membrane protrudes through apertures in the fibrous membrane to form bur- sae, which lie between the tendons of surrounding muscles and the fibrous membrane. The most consistent of these is the subtendinous bursa of subscapularis, which lies between the subscapularis muscle and the fibrous membrane. - The synovial membrane also folds around the tendon of the long head of the biceps brachii muscle in the joint and extends along the tendon as it passes into the intertubercular sulcus. - All these synovial structures reduce friction between the tendons and adjacent joint capsule and bone. - In addition to bursae that communicate with the articular cavity through apertures in the fi- brous membrane, other bursae are associated with the joint but are not connected to it. - These occur:  between the deltoid and supraspinatus muscle and the joint capsule (the subacromial bursa);  between the acromion and skin;  between the coracoid process and the joint capsule;  in relationship to tendons of muscles around the joint (coracobrachialis, teres major, long head of triceps brachii, and latissimus dorsi muscles). 15  - The fibrous membrane of the joint capsule attaches to the margin of the glenoid cavity, out- side the attachment of the glenoid labrum and the long head of the biceps brachii muscle, and to the anatomical neck of the humerus. - On the humerus, the medial attachment occurs more inferiorly than the neck and extends onto the shaft. In this region, the fibrous membrane is also loose or folded in the anatomical position. This redundant area of the fibrous membrane accommodates abduction of the arm. - Openings in the fibrous membrane provide continuity of the articular cavity with bursae that occur between the joint capsule and surrounding muscles and around the tendon of the long head of the biceps brachii muscle in the intertubercular sulcus. - The fibrous membrane of the joint capsule is thickened:  anterosuperiorly in three locations to form superior, middle, and inferior glenohumeral ligaments, which pass between the superomedial margin of the glenoid cavity to the lesser tubercle and inferiorly related anatomical neck of the humerus;  superiorly between the base of the coracoid process and the greater tubercle of the hu- merus (the coracohumeral ligament);  between the greater and lesser tubercles of the humerus (transverse humeral ligament) - this holds the tendon of the long head of the biceps brachii muscle in the intertubercular sulcus. - Joint stability is provided by surrounding muscle tendons and a skeletal arch formed supe- riorly by the coracoid process and acromion and the coracoacromial ligament. - Tendons of the rotator cuff muscles (the supraspinatus, infraspinatus, teres minor and sub- scapularis muscles) blend with the joint capsule and form a musculotendinous collar that surrounds the posterior, superior, and anterior aspects of the glenohumeral joint. This cuff of muscles stabilizes and holds the head of the humerus in the glenoid cavity of the scapula without compromising the arm’s flexibility and range of motion. The tendon of the long head of the biceps brachii muscle passes superiorly through the joint and restricts upward movement of the humeral head on the glenoid cavity. - Vascular supply to the glenohumeral joint is predominantly through branches of the ante- rior and posterior circumflex humeral and suprascapular arteries. - The glenohumeral joint is innervated by branches from the posterior cord of the brachial plexus, and from the suprascapular, axillary, and lateral pectoral nerves. Topography of the shoulder joint (articulatio humeri / articulatio glenohumerale) Projection of the joint: - Anterior: Coracoid process of the scapula - Posterior: Inferior to the acromion, between the acromial and spinal ends of the deltoid muscle - Lateral: Line drawn between the acromial end of the clavicle and coracoid process of the scapula Types of joint: - Diarthrosis / true / interrupted / cavitated / synovial / movable joint. - Ball-and-socket joint. 16  - Multiaxial joint. - Simple joint. Bones involved: - Spherical head of the humerus. - Glenoid cavity of the scapula. Articular capsule: - It extends from the labrum glenoidale of the scapula to the anatomical neck of the humerus. - Greater and lesser tubercles of the humerus are situated inside capsule. - On the internal surface of humerus, this capsule extends to the surgical neck of the hu- merus. Contents surrounding the capsule: - Anterior: subscapularis muscle, coracobrachial muscle and short head of the biceps brachii muscle. - Posterior: supraspinatus, infraspinatus and teres minor muscles. - Lateral: deltoid muscle and tendon of the long head of the biceps brachii muscle. - Inferior: axillary recess (recessus axillaris). This capsule consists of 2 layers, which are the fibrous and synovial layers. Ligaments: Coracohumeral ligament: - It stretches from the coracoid process of the scapula to the greater tubercle of the humerus. Glenohumeral ligament: - Superior glenohumeral ligament: From the apex of the glenoid cavity to the small depres- sion above the lesser tubercle. - Middle glenohumeral ligament: From the middle margin of the glenoid cavity to the lower part of the lesser tubercle. - Inferior glenohumeral ligament: From the inferior margin of the glenoid cavity to the inte- rior part of the anatomical neck of the humerus. Transverse humeral ligament: - It bridges the upper part of the bicipital groove. - It converts the intertubercular groove into a canal. Stability of the joint: Coracoacromial arch, vault of joint (secondary socket for the head of the humerus): - It is formed by the acromion, coracoacromial ligament and coracoid process. Musculotendinous cuff / rotator cuff muscles’ tendon: - It is formed by the supraspinatus, infraspinatus, teres minor and subscapularis muscles. Labrum glenoidale: - It encircles the margin of the glenoid cavity. Long head of the biceps and triceps brachii muscles. Atmospheric pressure. Movements: - Flexion, Extension - around the frontal axis. - Abduction, Adduction – around the sagittal axis. - Supination, Pronation - around the vertical axis. - Circumduction - combined movement. 17 Bursae: Subscapular bursa: - It is lodged between the tendon of the subscapularis muscle and scapular neck. - It protects the subscapular tendon. - It is connected with the shoulder joint cavity. Subdeltoid bursa: - It is located between the deltoid, supraspinatus muscles and fibrous capsule. Subacromial bursa: - It is found inferior to the acromion and coracoacromial ligament; between them and su- praspinatus muscle. - It facilitates the movement of the supraspinatus muscle. Infraspinatus bursa: - It communicates with the joint cavity. Vagina synovialis intertubercularis: - It is a synovial sheath for the tendon of the long head of the biceps brachii muscle. - It lies in the anterolateral surface, proximal to the edge of humerus (sulcus intertubercu- laris). - At the level of the surgical neck of the humerus, synovial membranes form a covering for the tendons. The inflammatory process may spread from the joint cavity to the space around the shoulder joint: through the axillary recess to the axillary cavity; from the subscapular bursa to the subscapular osseofibrous space: through the vagina synovialis intertubercularis to the fascial sheath of biceps brachii muscle. The surrounding muscles which cover the shoulder joint have 7 synovial bursae, in which the inflammatory process around the shoulder joint may develop. Arterial supply: - Anterior and posterior circumflex humeral arteries. - Thoracoacromial artery (deltoid and acromial branches). Venous drainage: - Anterior and posterior circumflex humeral veins. - Thoracoacromial vein Lymphatic drainage: - Supraclavicular nodes (superomedial region). - Axillary nodes (posteroinferior region). Nerve supply: - Axillary nerve. - Suprascapular nerve. Topographic anatomy of the arm The arm is the region of the upper limb between the shoulder and the elbow. The superior aspect of the arm communicates medially with the axilla. Inferiorly, a number of important struc- tures pass between the arm and the forearm through the cubital fossa, which is positioned anterior to the elbow joint. 18  The arm is divided into two compartments by medial and lateral intermuscular septa, which pass from each side of the humerus to the outer sleeve of deep fascia that surrounds the limb. Topography of the anterior region of the arm (regio brachii anterior) Landmarks: - Deltoid muscle - Pectoralis major muscle - Latissimus dorsi muscle - Biceps brachii muscle - Triceps brachii muscle - Medial and lateral epicondyles of the humerus - Greater tubercle of the humerus - Sulci bicipitales lateralis et medialis Borders: - Superior: horizontal line drawn from the pectoralis major and latissimus dorsi muscles. - Inferior: imaginary line drawn with 2 fingers above the lateral and medial epicondyles of the humerus. - Medial and lateral: vertical lines drawn on medial and lateral epicondyles of the humerus respectively. Layers: Skin: - Lateral is thicker than the medial one. It is slightly movable. - It is innervated by the medial cutaneous nerve of the arm, lateral cutaneous nerve of the arm, superior lateral cutaneous nerve of the arm and inferior lateral cutaneous nerve of the arm. Subcutaneous tissue: - It contains the cephalic and basilic veins (at the lateral and medial margins of the biceps brachii muscle respectively). - It contains the cubital lymph nodes. Superficial fascia: - It forms a covering for the superficial veins and cutaneous nerves. Deep fascia (brachial fascia): - It forms 2 septa which are connected to the humerus, namely the lateral and medial inter- muscular septa. - These 2 septa divide the brachial region into anterior (flexor) and posterior (extensor) parts. - Transverse septum separates the biceps brachii muscle from the brachialis muscle and en- closes the musculocutaneous nerve. - Medial septum is pierced by the ulnar nerve and superior ulnar collateral artery to the poste- rior surface of the medial epicondyle. - Lateral septum is pierced by the radial nerve and anterior descending branch of profun- da brachii artery (arteria collateralis radialis) to the anterior surface of the lateral epi- condyle. 19  - Anteroposterior septum separates the brachialis muscle from the muscles attached to the lateral supracondylar ridge. This septum also encloses the radial nerve and anterior de- scending branch of the deep artery of arm (arteria profunda brachii). Fig. 5. Main neurovascular tract of the arm: the medial bicipital groove (Shuenke M., Schulte E., Schumacher U., 2010). Muscles: - Coracobrachialis muscle. - Biceps brachii muscle. - Brachialis muscle. Blood supply: - brachial artery (Fig. 5). Nerve supply to the muscles: - musculocutaneous nerve. Bone: - Humerus. Cubital fossa: - The cubital fossa lies anterior to the elbow joint, and contains the biceps brachii tendon, the brachial artery and the median nerve. - The base of the cubital fossa is an imaginary line between the readily palpable medial and lateral epicondyles of the humerus. 20  - The lateral and medial borders are formed by the brachioradialis and pronator teres mus- cles, respectively. The margin of the brachioradialis can be found by asking a subject to flex the semipronated forearm against resistance. The margin of pronator teres can be esti- mated by an oblique line extending between the medial epicondyle and the midpoint along the length of the lateral surface of the forearm. - The approximate apex of the cubital fossa is where this line meets the margin of the brachi- oradialis muscle. - Contents of the cubital fossa, from lateral to medial, are the tendon of biceps brachii, the brachial artery, and the median nerve. The tendon of biceps brachii is easily palpable. - Often the cephalic, basilic, and median cubital veins are visible in the subcutaneous fascia overlying the cubital fossa. - The ulnar nerve passes behind the medial epicondyle of the humerus and can be “rolled” here against the bone. - The radial nerve travels into the forearm deep to the margin of the brachioradialis muscle anterior to the elbow joint. Topography of the posterior region of the arm (regio brachii posterior) Landmarks: - Deltoid muscle. - Pectoralis major muscle. - Latissimus dorsi muscle. - Biceps brachii muscle. - Triceps brachii muscle. - Medial and lateral epicondyles of the humerus. - Greater tubercle of humerus. - Sulcus deltoideopectoralis - Sulci bicipitales lateralis et medialis Borders: - Superior: horizontal line drawn from the pectoralis major and latissimus dorsi muscles - Inferior: imaginary line drawn with 2 fingers above the lateral and medial epicondyles of the humerus. - Medial and lateral: vertical lines drawn on the medial and lateral epicondyles of the humer- us respectively. Layers: Skin: - It is thick and well connected with the subcutaneous tissue. Subcutaneous tissue: - It contains the superior lateral cutaneous nerve of the arm, inferior lateral cutaneous nerve of the arm (nervi cutanei brachii lateralis et inferior) and posterior cutaneous nerve of the forearm (nervus cutaneus antebrachii posterior). 21 Superficial fascia: - The superficial veins of the arm lie in the superficial fascia. - The cephalic vein ascends in the superficial fascia on the lateral side of the biceps and, on reaching the infraclavicular fossa, drains into the axillary vein. - The basilic vein ascends in the superficial fascia on the medial side of the biceps. - The superficial lymph vessels draining the superficial tissues of the upper arm pass upward to the axilla. Those from the lateral side of the arm follow the cephalic vein to the infracla- vicular group of nodes; those from the medial side follow the basilic vein to the lateral group of axillary nodes. Deep fascia: - It forms a covering for the triceps brachii muscle and its tendon. Muscle: - Triceps brachii muscle. Bone: - Humerus. Fig. 6. Course of the radial nerve in the radial groove (Shuenke M., Schulte E., Schumacher U., 2010). 22 Superior trilateral foramen (Three-sided opening / upper triangular space, foramen trilaterum superior) Borders: - Medial: Teres minor muscle - Lateral: Medial margin of the long head of the triceps brachii muscle - Inferior: Teres major muscle Contents: - Circumflex scapular artery. Inferior trilateral foramen (Lower triangular space, foramen trilaterum inferior) Borders: - Medial: Long head of the triceps brachii muscle. - Lateral: Medial margin of the Humerus. - Superior: Teres major muscle. Contents: - Radial nerve - Deep artery of the arm Quadrilateral foramen (Four-sided opening / quadrangular space, foramen quadrilaterum) Borders: - Medial: Lateral margin of the long head of the triceps brachii muscle. - Lateral: Surgical neck of the humerus. - Superior: Teres minor muscle (from the posterior aspect). - Subscapularis muscle (from the anterior aspect). - Inferior: Teres major muscle. Contents: - Axillary nerve - Posterior circumflex humeral artery. Canal of the radial nerve (Spiral canal, humeromuscular canal, canalis spiralis, canalis humeromuscularis, canalis nervi radialis) - It is bounded by the humerus and triceps brachii muscle (both long head and lateral head). - It contains the radial nerve, deep artery of the arm (arteria profunda brachii) and its veins (Fig. 6). Ways of spreading of the phlegmon - Phlegmon is the suppurative (purulent) inflammation of the fatty tissue. - Phlegmon passes along the pathway of nerves and vessels. It is because phlegmon has poor blood supply and low metabolic activities compared with muscles. - If the phlegmon is in the cubital fossa, it may either travel down to the wrist joint or up to the axillary region. From the axillary region, it may pass to the scapular region, then to the 23  post compartment of the upper arm. Then, it passes along the pathway to the subclavian re- gion and thoracic cavity. It may pass to the subpectoral space along the branches of the ax- illary artery. At last, it reaches the anterior mediastinum resulting in anterior mediastinitis. - If the phlegmon is in the axillary region, it may pass down to the cubital fossa or the poste- rior region of the upper arm along the deep brachial artery through the humeromuscular ca- nal. - Phlegmon in the thumb or little finger may pass along the ulnar and radial bursae to the Pi- rogov’s space in the forearm. From there it passes up to the cubital fossa and other regions as mentioned above. But this happens rarely. Projection lines of the vessels Axillary artery (arteria axillaris): - It passes 1.5 cm along the anterior margin of the axillary fossa (where the hair is present). Brachial artery (arteria brachialis): - It passes from the axillary fossa to the midpoint between the medial epicondyle of the hu- merus and tendons of the biceps brachii muscle. Radial artery (arteria radialis): - It passes from the medial margin of the tendon of the biceps brachii muscle or the midpoint of the cubital fossa to the pulsation point (or the point on 0.5 cm laterally from the styloid process of the radius) of the radial artery. Ulnar artery (arteria ulnaris): - It passes from the medial epicondyle of the humerus to the lateral margin of the pisiform bone. Topography of the anterior cubital region (regio cubiti anterior) Layers: Skin: - It is thin, movable and non-pigmented. - It contains sweat glands, sebaceous glands and hair. - It is innervated by the lateral and medial cutaneous nerves of the arm, lateral and medial cu- taneous nerves of the forearm. Subcutaneous tissue: - It contains lymphatic vessels with superficial lymphatic nodes and superficial venous net- work. - It contains the cephalic, basilic and median cubital veins. - Superficial cubital nodes (nodi lymphatici cubitales superficiales) are situated at the basilic vein (at the level of the medial epicondyle of humerus). - The connection of the cephalic, basilic and median cubital veins forms a letter “N” (Fig. 7). Superficial fascia: - It is connected with the superficial fascia of the arm and forearm, aponeurosis of biceps brachii muscle (aponeurosis bicipitalis). - It is connected with the deep fascia. 24  Fig. 7. Cutaneous veins and cutaneous nerves of the right elbow (Shuenke M., Schulte E., Schumacher U., 2010). Deep fascia: - Fascia of the biceps brachii and brachialis muscles forms the lateral and medial intermuscu- lar septa. - These septa are fixed to the medial and lateral epicondyles of the humerus. - It forms a covering for the muscles of the arm and forearm. - Inferior to the radial tuberosity, the fixation for the tendon of the biceps brachii muscle takes place. - Intermuscular septa continue to form the anterior radial intermuscular septa of the forearm. Muscles (3 groups of muscles): - Lateral: Brachioradialis muscle and supinator muscle. - Median: Biceps brachii muscle (superficial) and brachialis muscle (deep). - Medial: (1st layer) Pronator teres, flexor carpi radialis, palmaris longus and flexor carpi ul- naris muscles. - Medial: (2nd layer) Flexor digitorum superficialis muscle. 25  Fig. 8. Deep dissection of the cubital fossa (Shuenke M., Schulte E., Schumacher U., 2010). Neurovascular bundles: 2 neurovascular bundles are found between groups of muscles and septa, which are lateral bundle (radial nerve and radial collateral artery) and medial bundle (brachial artery and median nerve).  Brachial artery: - Brachial artery with its veins is located in the medial margin of the biceps brachii muscle (Fig. 8). - It is divided into radial and ulnar arteries under the bicipital aponeurosis.  Radial artery: - It passes through the tendon of the biceps brachii muscle. - It is lodged between the pronator teres and brachioradialis muscles. 26  Ulnar artery: - It exits inferior to the pronator muscle in the upper part. - It is later located between the superficial and deep flexors of the fingers (flexor digitorum superficialis and flexor digitorum profundus muscles).  Median nerve: - It lies on 0.5-1.0 cm from the medial margin of the biceps brachii muscle. - It lies near to the ulnar artery in the upper part. - It later perforates the pronator teres muscle.  Radial nerve: - It is situated between the brachioradialis and brachialis muscles in the upper level. - It goes downward and is divided into 2 branches, which are the superficial and deep branches of the radial nerve at the level of the lateral epicondyle of the humerus. - Superficial branch innervates the brachioradialis and pronator teres muscles. - Deep branch lies laterally and passes through the supinator canal (canalis supinatorius) be- tween the superficial and deep layers of supinator muscle. Topography of the posterior cubital region (regio cubiti posterior) Landmarks: - Olecranon of ulna. - Sulci cubitales posteriores lateralis el medialis. - Ulnar nerve passing along the sulcus cubitalis posterior medialis. - Head of the radius is palpated in the middle part of sulcus cubitalis posterior lateralis (es- pecially during supination and pronation of forearm). Layers: Skin: - It is thick and movable. - It forms skin folds. Subcutaneous tissue: - It contains the superficial arteries (medial collateral artery, radial collateral artery and recur- rent interosseous artery). - It contains the posterior cutaneous nerve of the arm, medial cutaneous nerve of the arm, posterior cutaneous nerve of the forearm and medial cutaneous nerve of the forearm. - Bursa of the elbow joint is located in the superior part of the olecranon of the ulna. - Bursitis may be precipitated by trauma or long-term compression of this part. Superficial fascia: - It is a thin layer without fixation. Deep fascia: - It is formed by an aponeurosis. - It is fixed to the tendon of the triceps brachii muscle, medial and lateral epicondyles of the humerus and olecranon of the ulna. Muscles: - Superior: Triceps brachii and anconeus muscles. - Lateral: Extensor muscle of the wrist (Extensor carpi radialis longus, extensor carpi radialis brevis and extensor carpi ulnaris muscles) and extensor muscle of the digits (extensor digi- torum and extensor digiti minimi muscles). 27  - Deep: Supinator muscle. - Medial: Flexor digitorum profundus and flexor carpi ulnaris muscles. Topography of the elbow joint (articulatiо cubiti) It consists of the articulatio humeroulnaris, articulatio humeroradialis and articulatio ra- dioulnaris proximalis. Projection of joint: - 1 cm distal to the lateral epicondyle and 2 cm distal to the medial epicondyle of the humer- us. Types of joint: - Diarthrosis / synovial / cavitated/ true / movable / interrupted joint. - Hinge joint - humeroulnar joint. - Pivot joint- proximal radioulnar joint. - Ball-and-socket joint - humeroradial joint. - Trochoid joint. - Combined joint-proximal radioulnar joint. - Compound joint. Bones involved: - Capitulum and trochlea of the humerus. - Head of the radius. - Trochlear notch of the ulna. Articular capsule: - It is attached to the humerus at the margin of the lateral and medial ends of the articular sur- face of the capitulum and trochlea. - It is weak in the anterior and posterior sides but is strengthened on each side by the collat- eral ligament. - Recessus sacciformis is situated at the neck of the radius. In inflammation of the elbow joint, pus may spread to the deep space of the forearm. Contents surrounding the capsule: - Anterior: Brachialis muscle - Posterior: Triceps brachii muscle - Lateral: Radial nerve, supinator muscle, anconeus muscle - Posteromedial: Ulnar nerve Ligaments: - Radial collateral ligament - Ulnar collateral ligament - Annular ligament of radius (ligamentum anulare radii) Movements: - Flexion, extension - around the frontal axis. Bursae: Intratendinous olecranon bursa: - It is located in the tendon of the triceps brachii muscle. Subtendinous olecranon bursa: - It is located between the olecranon and triceps brachii tendon. 28  Subcutaneous olecranon bursa: - It is located in the subcutaneous connective tissue over the olecranon. Bursa subtendinea musculi tricipitis brachii: - It is situated under the ligament which is fixed to the olecranon. Radioulnar bursa: - It is located between the extensor digitorum muscle, humeroradial joint and supinator mus- cle. Bicipitoradial / biceps bursa: - It is located between the biceps tendon and anterior part of radial tuberosity. Arterial supply: - Arteries (brachial, radial and ulnar arteries) forming an anastomosis around the elbow joint. Arterial network of the elbow joint: - It is formed by branches of the brachial, radial and ulnar arteries. - It supplies the ligaments and bones of this joint. Lateral epicondyle of the humerus (sulcus cubitalis lateralis): - Anterior part:  Radial recurrent artery (branch of the radial artery).  Radial collateral artery (branch of the deep artery of the arm). - Posterior part:  Middle collateral artery (terminal branch of the branch of the common interosseous ar- tery deep artery of the arm).  Recurrent interosseous artery. Medial epicondyle of the humerus (sulcus cubitalis medialis): - Anterior part:  Inferior ulnar collateral artery (branch of the brachial artery).  Anterior ulnar recurrent artery (branch of the ulnar artery). - Posterior part:  Superior ulnar collateral artery (branch of the brachial artery).  Posterior ulnar recurrent artery (branch of the ulnar artery). Olecranon fossa: Just superior to it: - Inferior ulnar collateral artery (posterior branch). - Middle collateral artery (branch of the deep artery of the arm). - Posterior ulnar recurrent artery (branch of the ulnar artery). Venous drainage: - Brachial vein. - Radial vein. - Ulnar vein. Lymphatic drainage: - Deep cubital nodes. - Axillary nodes. Nerve supply: - Ulnar nerve. - Radial nerve. - Median nerve. 29  Topographic anatomy of the forearm The forearm is the part of the upper limb that extends between the elbow joint and the wrist joint. Landmarks: - Brachioradialis muscle. - Sulci radialis et ulnaris. - Tendons of the flexor carpi radialis and palmaris longus muscles. - Styloid process of the ulna and radius. Borders: - Upper: Horizontal line drawn 4 cm distal to the level of the wrist joint. - Lower: Transverse line drawn 2 cm proximal to the styloid process of the radius - 2 vertical lines are drawn through the epicondyles and styloid processes, which divide the forearm region into the anterior and posterior regions. The forearm is divided into anterior and posterior compartments. These compartments are separated by: - the lateral intermuscular septum, which passes from the anterior border of the radius to deep fascia surrounding the limb; - the interosseous membrane, which links adjacent borders of the radius and ulna along most of their length; - the attachment of deep fascia along the posterior border of the ulna. Topography of the anterior region of the forearm (regio antebrachii anterior) Layers: Skin: - It is thin. - It contains sweat and sebaceous glands. - It is innervated by the medial and lateral cutaneous nerves of the forearm. Subcutaneous tissue: - It contains the cephalic vein (in the medial margin of the brachioradialis muscle) and basilic vein. - It contains the lateral cutaneous nerve of the forearm and medial cutaneous nerve of the forearm. - Intermediate antebrachial vein passes through the middle line of this region. Superficial fascia: - It is not attached to the bone. - It covers all structures in the subcutaneous tissue. Deep fascia (fascia antebrachii): - It forms a covering for muscles, vessels, nerves and bones. - It is thicker in the proximal part and thinner in the distal part. - It sends two septa to the radius only and divides the forearm into 3 seats for muscles (ante- rior, posterior and lateral) in the upper half of forearm: 30  1. Lateral: Brachioradialis, extensor carpi radialis longus and extensor carpi radialis brevis muscles. 2. Posterior: Extensor digitorum, extensor digiti minimi, extensor carpi ulnaris, anconeus and supinator muscles. 3. Anterior:  (Superficial) pronator teres, flexor carpi radialis, flexor digitorum superficialis, palmaris longus and flexor carpi ulnaris muscles;  (Deep) flexor digitorum profundus and flexor pollicis longus muscles. Borders of the fascia:  Anterior: Strictly fixed to the deep fascia.  Posterior: Interosseous membrane, ulna and radius.  Medial: Posterior margin of ulna.  Lateral: Sulcus radialis. Fig. 9. Transverse section of the forearm 5 cm above the styloid process of the ulna (Kovanov V. V., Anikina T. I., 1961): 1 – proper fascia of the forearm; 2 – superficial cellular space of the palmar surface of the forearm; 3 – medial cellular space of the forearm; 4 – deep cellular space - Pirogov-Parona’s space; 5 – radial fascial node of the forearm; 6 – deep dorsal fascia and dorsal cellular gap of the forearm; 7 – interosseal septum; 8 – ulnar fascial node of the forearm 31  Paron-Pirogov’s space: - It is situated in the lower half of the deep fascia (Fig. 9). - It is a quadrangular space deep in the lower part of the forearm above the wrist. It is located between the 3rd (Fascia of flexor digitorum profundus and pollicis longus muscles) and 4th layers (Fascia of pronator quadratus muscle) of muscles. - Proximal part is connected to the oblique origin of the flexor digitorum superficialis mus- cle. - Distal part is connected to the flexor retinaculum communicating with the midpalmar and thenar spaces. Muscles: Medial margin of the deep fascia is bounded to the posterior margin of the ulna and divides the muscles into 4 layers: - 1st layer: Pronator teres, flexor carpi radialis, palmaris longus, flexor carpi ulnaris and bra- chioradialis muscles. - 2nd layer: Flexor digitorum superficialis muscle. - 3rd layer: Flexor digitorum profundus and flexor pollicis longus muscles. - 4th layer: Pronator quadratus muscle. Grooves: - Sulcus radialis:  It lies between the brachioradialis (laterally) and flexor carpi radialis muscles (medial- ly).  It contains the superficial branch of the radial nerve, radial artery and vein. - Sulcus ulnaris:  It is lodged between the flexor carpi ulnaris (medially) and flexor digitorum superficial- is muscles (laterally).  It contains the ulnar artery, vein and nerve. - Sulcus medianus:  It lies between the flexor carpi radialis (laterally) and flexor digitorum superficialis muscles (medially).  It contains the medial nerve. Neurovascular bundles: Lateral: 1. Radial artery and vein (Fig. 10). 2. Superficial branch of the radial nerve:  It is located on the sulcus radialis.  In the upper 1/3 of the forearm, it is bounded by the brachioradialis muscle laterally and pronator teres muscle medially.  In the middle and lower 1/3 of the forearm, it follows the brachioradialis and flexor car- pi radialis muscles and passes downward along with radial artery.  Then it passes through the tendon of the brachioradialis muscle. 3. Radial artery:  It passes along the middle part of the elbow joint to the styloid process of the radius and enters the anatomical snuffbox. 32 Fig. 10. Right forearm, anterior view, deep layer (Shuenke M., Schulte E., Schumacher U., 2010). 33 Medial: 1. Ulnar artery:  It passes from the tendon of the biceps brachii muscle.  In the middle 1/3 of the forearm, it passes under the pronator teres muscle, flexor digi- torum superficialis muscle and sulcus ulnaris.  In the lower 1/3 of the forearm, it passes to the medial margin of the styloid process of the ulna and reaches the pisiform bone. 2. Ulnar nerve:  It is located on the sulcus ulnaris and is bounded medially by the flexor carpi ulnaris muscle and laterally b\ the flexor digitorum superficialis in the upper 1/3 of the forearm  Then it passes from the medial epicondyle of the humerus to the medial margin of the pisiform bone.  Dorsal branch of the ulnar nerve starts from the middle and lower 1/3 of the forearm and passes under the tendon of the flexor carpi ulnaris muscle. It passes downward and me- dially to the ulnar artery. 3. Posterior interosseous artery:  Common interosseous artery is a branch of the upper pail of the ulnar artery and is di- vided into the anterior and posterior interosseous arteries.  Posterior interosseous artery passes through the orifice of the interosseous membrane to the posterior region of the forearm. Median (Anterior): 1. Median nerve:  It passes from the middle point between the medial epicondyle of the humerus and ten- don of the biceps brachii muscle, along the anterior interosseous artery to the medial margin of the styloid processes of the ulna and radius.  It goes downward between the pronator teres muscle and exits from the interspace of the pronator teres muscle in the upper third of forearm.  The middle 1/3 of the median nerve passes between the flexor digitorum superficialis and flexor digitorum profundus muscles and is strictly fixed to the posterior wall cover- ing of the flexor digitorum superficialis muscle.  It is located on the sulcus medianus in the lower 1/3 between the tendons of the flexor carpi radialis and palmaris longus muscles. This landmark is ideal for anesthesia of the median nerve during operation. Median (Posterior):  Posterior interosseous artery and nerve. Topography of the posterior region of the forearm (regio antebrachii posterior) Layers: Skin: - It is thick with limited movement. - It is innervated by the medial and lateral cutaneous nerves of the forearm and posterior cu- taneous nerve of the forearm. 34  Subcutaneous tissue: - It contains less fatty tissue. - Superficial veins form the main trunk of the vein (cephalic vein and basilic vein). Superficial fascia: - It is a weak layer. Deep fascia: - It is distinguished by its thickness and is strictly fixed to the ulna and radius. - It is an aponeurosis in the upper half of the forearm. - It extends downward and forms the extensor retinaculum and dorsal carpal canal. - It forms cellular space, which contains deep branch of the radial nerve, posterior interosse- ous artery, posterior interosseous veins and nerve. - Deep branch of the radial nerve passes through the canalis supinatorius. Posterior interosse- ous artery passes medial to the posterior interosseous nerve. Muscles: a) Superficial muscles:  Extensor carpi radialis;  Longus muscle;  Extensor carpi radialis brevis muscle;  Extensor digitorum muscle;  Extensor digiti minimi muscle;  Extensor carpi ulnaris muscle. b) Deep muscles:  Supinator muscle;  Abductor pollicis longus muscle;  Extensor pollicis longus muscle;  Extensor pollicis brevis muscle;  Extensor indicis muscle. “Anatomical Snuffbox" The anatomic snuffbox is a term commonly used to describe a triangular skin depression on the lateral side of the wrist that is bounded medially by the tendon of the extensor pollicis longus and laterally by the tendons of the abductor pollicis longus and extensor pollicis brevis. Its clinical importance lies in the fact that the scaphoid bone is most easily palpated here. Distal radio-ulnar joint - It occurs between the articular surface of the head of the ulna, with the ulnar notch on the end of the radius, and with a fibrous articular disc, which separates the radio-ulnar joint from the wrist joint. - The triangular-shaped articular disc is attached by its apex to a roughened depression on the ulna between the styloid process and the articular surface of the head, and by its base to the angular margin of the radius between the ulnar notch and the articular surface for the carpal bones. - The synovial membrane is attached to the margins of the distal radio-ulnar joint and is cov- ered on its external surface by a fibrous joint capsule. - The distal radio-ulnar joint allows the distal end of the radius to move anteromedially over the ulna. 35  - The interosseous membrane is a thin fibrous sheet that connects the medial and lateral bor- ders of the radius and ulna, respectively. Collagen fibers within the sheet pass predominant- ly interiorly from the radius to the ulna. The interosseous membrane has a free upper mar- gin, which is situated just inferior to the radial tuberosity, and a small circular aperture in its distal third. - Vessels pass between the anterior and posterior compartments superior to the upper margin and through the inferior aperture. The interosseous membrane connects the radius and ulna without restricting pronation and supination and provides attachment for muscles in the anterior and posterior compartments. The orientation of fibers in the membrane is also consistent with its role in transferrin forces from the radius to the ulna and ultimately, then fore, from the hand to the humerus. Topography of the wrist joint (articulatio radiocarpea) Types of joint: - Diarthrosis / interrupted / synovial / true/ cavitated / movable joint. - Complex joint. - Ellipsoid joint-2 axes (sagittal and frontal). - Biaxial joint. Bones involved: - Inferior concave surface of the radius. - Discus articularis of the ulna. - Proximal row of the carpal bone (scaphoideum, lunatum and triquetrum). Articular capsule: - It encloses the joint. - It is attached to the styloid process of the radius, styloid process of the ulnar and proximal row of the carpal bones (scaphoid, lunate and triquetrum). - Synovial membrane lines in the fibrous capsule and is attached to the margins of the articu- lar surface (numerous synovial folds are present). - Protrusion of the synovial membrane is called the prestyloid recess. It lies in front of the styloid process of the ulna and in front of the articular disc. - It is strengthened by the collateral, palmar and dorsal ligaments. - Recessus sacciformis is located between the radius and ulnar which is formed by the syno- vial membrane of the articulatio radioulnaris distalis. - Pronator quadratus muscle is situated anteriorly. - Tendons of the extensor muscles are situated in the dorsal part of the wrist joint. - On the palmar surface, the tendons form the carpal canal. Ligaments: Collateral ligaments:  Radial collateral ligament: It stretches from the tip of the styloid process of the radius to the lateral side of the scaphoid. It assists with adduction.  Ulnar collateral ligament: It stretches from the tip of the styloid process of the ulna to the triquetrum. It assists with abduction. 36  Palmar ligaments:  Palmar radiocarpal ligament: It stretches from the radius to the scaphoid, lunate and tri- quetrum.  Palmar ulnocarpal ligament: It stretches from the ulna to the lunate and triquetrum.  Palmar radiocarpal ligament. Dorsal ligaments:  Dorsal radiocarpal ligament.  Dorsal radioulnar ligament. Movements: - Flexion; Extension - around the frontal axis. - Abduction; Adduction - around the sagittal axis. - Circumduction - combined movement. Arterial supply: - Palmar carpal arches (superficial and deep). Venous drainage: - Palmar carpal arches. Nerve supply: - Anterior and posterior interosseous nerves. Topographic anatomy of the hand region (regio manus) The hand is the region of the upper limb distal to the wrist joint. It is subdivided into three parts: - the wrist; - the metacarpus; - the digits (five fingers). Landmarks: - Styloid processes of the ulna and radius. - Skin fold of the wrist joint. - Metacarpal bones - Phalanges of fingers. Borders: - 2 cm above the styloid process of the ulna. - 2 vertical lines are drawn along the ulna and radius and divide the hand region into the ante- rior (palmar) and posterior (dorsal) regions. Topography of the palmar region of the hand (regio palmare manus) Layers: Skin: - It is thick with limited movement. - Stratum corneum is well developed in this region. - It contains sweat glands and sebaceous glands. - It is innervated by the radial nerve, ulnar nerve and median nerve. 37 Subcutaneous tissue: - It contains vessels, nerves and lymphatic vessels with lymphatic nodes. - It contains the superficial palmar branch of the radial artery. Superficial fascia: - It is a continuation of the superficial fascia of the forearm. - It is slightly movable and fixed to the bones. Deep fascia: - It stretches from the palmaris longus tendon (proximally) to the ligamentum carpi volare (distally). - It forms the palmar aponeurosis, flexor retinaculum (transverse carpal ligament), synovial sheaths of the hand and fingers. - The palmar aponeurosis is triangular and occupies the central area of the palm. The apex of the palmar aponeurosis is attached to the distal border of the flexor retinaculum and re- ceives the insertion of the palmaris longus tendon. The base of the aponeurosis divides at the bases of the fingers into four slips. Each slip divides into two bands, one passing super- ficially to the skin and the other passing deeply to the root of the finger; here each deep band divides into two, which diverge around the flexor tendons and finally fuse with the fi- brous flexor sheath and the deep transverse ligaments (Fig. 11).  The medial and lateral borders of the palmar aponeurosis are continuous with the thin- ner deep fascia covering the hypothenar and thenar muscles. From each of these bor- ders, fibrous septa pass posteriorly into the palm and take part in the formation of the palmar fascial spaces.  The function of the palmar aponeurosis is to give firm attachment to the overlying skin and so improve the grip and to protect the underlying tendons.  The triangular palmar aponeurosis fans out from the lower border of the flexor retinacu- lum. From its medial border a fibrous septum passes backward and is attached to the an- terior border of the fifth metacarpal bone. Medial to this septum is a fascial compart- ment containing the three hypothenar muscles; this compartment is unimportant clini- cally.  From the lateral border of the palmar aponeurosis, a second fibrous septum passes obliquely backward to the anterior border of the third metacarpal bone. Usually, the sep- tum passes between the long flexor tendons of the index and middle fingers. This se- cond septum divides the palm into the thenar space, which lies lateral to the septum (and must not be confused with the fascial compartment containing the thenar muscles) and the midpalmar space, which lies medial to the septum. Proximally, the thenar and midpalmar spaces are closed off from the forearm by the walls of the carpal tunnel. Dis- tally, the two spaces are continuous with the appropriate lumbrical canals. - Flexor retinaculum (retinaculum flexorum):  It is the strongest and thickest fascia which is fixed to the bone. Between the eminentia carpi ulnaris and eminentia carpi radialis, flexor retinaculum converts the sulcus carpi into the canalis carpi. Then the flexor retinaculum forms the canalis carpi radialis and canalis carpi ulnaris. 38  Fig. 11. The palmar aponeurosis and Dupuytren’s contracture (Shuenke M., Schulte E., Schumacher U., 2010). Canalis of the anterior region of the hand:  Canalis carpi ulnaris: - It is formed by a fascia around the pisiform bone. - This canal contains ulnar artery and nerve. Then it passes under the palmaris brevis muscle (Fig. 12).  Canalis carpalis: - It is formed by a fascia between the flexor retinaculum and bones (scaphoid bone, trapezi- um bone, pisiform bone and hamate bone). 39  -This canal contains median nerve, 4 flexor digitorum superficialis tendons and 4 flexor dig- itorum profundus tendons. - There are 2 separate synovial sheaths: 1 for the tendons of the flexor digitorum superficialis and profundus muscles; the other 1 for the tendon of the flexor pollicis longus muscle. - It forms common synovial sheaths of the flexor tendons (4 flexor digitorum superficialis tendons and 4 flexor digitorum profundus tendons) medially and a sheath for the tendon of the flexor pollicis longus muscle laterally.  Canalis carpi radialis contains tendon of the flexor carpi radialis muscle. Fig. 12. View into the carpal tunnel of the right hand (Shuenke M., Schulte E., Schumacher U., 2010). 40  Fig. 13. The palmar synovial sheaths (Lubotsky D. N., 1953): 1 – pronator quadratus; 2 – flexor digitorum profundus; 3 – flexor digitorum superficialis; 4, 9 – abductor digiti mini- mi; 5 – flexor retinaculum; 6 – flexor digiti minimi brevis; 7 – opponens digiti minimi; 8 – tendinous sheath of the flexors digitorum; 10 – tendinous sheath of the flexors digiti minimi; 11 – digital tendinous sheaths; 12 – adductor pollicis; 13, 17 – tendinous sheath of the flexor pollicis longus; 14 – abductor pollicis brevis; 15 – flexor pollicis brev- is; 16 – opponens pollicis; 18 – tendinous sheath of the flexor carpi radialis 41 Synovial sheaths of the hand and fingers: - Synovial sheath of the thumb (Fig. 13):  It is situated laterally.  This long and narrow canal encloses the tendon of the flexor pollicis longus.  Superiorly this sheath protrudes 1-2 cm proximal to the flexor retinaculum.  Inferiorly it extends on the tendon to the base of the distal phalanx of the thumb. - Synovial sheath of the index, middle and ring fingers:  These 3 fingers have common sheaths on the palmar surface.  They have separate sheaths in the segment of the distal halves of the metacarpal bones. These sheaths stretch from the line of the metacarpophalangeal joints to the base of the distal phalanges. - Synovial sheath of the little finger:  It covers the flexor digitorum superficialis and profundus muscles. Superiorly this sheath protrudes 1-2 cm proximal to the flexor retinaculum.  Interiorly it extends on the flexors until the base of the distal phalanx of the little finger. For all fingers (digits): - On the phalangeal shafts, synovial sheaths of the fingers are covered by the dense annular (circular-shaped) fibrous sheaths. - On the phalangeal joints, synovial sheaths of the fingers are covered by the thin cruciform fibrous sheaths. - The tendons are connected with the walls of the thin mesotendineum, which transmit blood vessels and nerves. Muscles: a) Thenar muscles (lateral muscle group) (Fig. 14):  Abductor pollicis brevis muscle;  Opponens pollicis muscle;  Flexor pollicis brevis muscle;  Adductor pollicis muscle. b) Hypothenar muscles (medial muscle group):  Abductor digiti minimi muscle;  Opponens digiti minimi muscle;  Flexor digiti minimi brevis muscle;  Palmaris brevis muscle. c) Median muscle group:  Lumbrical muscles;  Palmar interosseous muscles;  Dorsal interosseous muscles. 42  Fig. 14. Fascial beds and cellular spaces of the palm on the transverse section (Lubotsky D. N., 1953): 1 – palmar aponeurosis; 2 – first lumbrical muscle and tendons of the flexors indicis muscles; 3 – fascial septum be- tween the fascial bed of the thenar’s muscles and bed of tendons of the flexors digitorum muscles; 4 – lateral cellular space of the palm; 5 – tendon of the flexor pollicis longus muscle and its synovial sheath; 6 – adductor pollicis muscle; 7 – Thenar; 8 – first dorsal interosseal muscle; 9, 11 – tendons of the extensor digitorum muscle; 10 – deep palmar arterial arch; 12 – deep palmar branch of the ulnar nerve; 13, 14 – interosseal muscles; 15 – deep compartment of the middle cellular space of the palm; 16 – deep (interosseal) fascia of the palm; 17 – hypothenar; 18 – medial cellular space of the palm; 19 – fascial septum between the beds of the tendon of the flexors digitorum muscles and hypothe- nar’s muscles; 20 – common synovial sheath of flexors digitorum muscles; 21 – tendons of the flexor digitorum super- ficialis and flexor digitorum profundus muscles; 22 – superficial compartment of the middle cellular space of the palm; 23 – superficial arterial arch of the palm Topography of the dorsal region of the hand (regio dorsi manus) Layers: Skin: - It is thin and movable. - It contains hair follicles, sweat glands and sebaceous glands. Furuncles tend to occur in this region. - It is innervated by the ulnar, median and radial nerves. Subcutaneous tissue: - It contains loose connective tissue and phlegmon passes from the palmar space to this re- gion. - It contains the cephalic (radial margin) and basilic veins (ulnar margin) which then form a vascular network between them. - It also contains the radial nerve (superficial branch) and ulnar nerve (dorsal branch). Superficial fascia: - It is fixed to the styloid process and bones of the wrist. 43 Deep fascia: - It forms the extensor retinaculum (retinaculum extensorum). - It has 6 canals (osteofibrous canals) which are formed by the extensor retinaculum with the carpal bones (Fig. 15). Fig. 15. Extensor retinaculum and dorsal carpal tendon sheaths of the right hand (Shuenke M., Schulte E., Schumacher U., 2010). The 6 canals (from medial to lateral) contain: 1) Tendon of the extensor carpi ulnaris muscle; 2) Tendon of the extensor digiti minimi muscle; 3) Tendons of the extensor digitorum and extensor indicis muscles; 4) Tendon of the extensor pollicis longus muscle; 5) Tendons of the extensor carpi radialis brevis and extensor carpi radialis longus muscles; 6) Tendons of the extensor pollicis brevis and abductor pollicis longus muscles. 44  On dorsal part of the fingers, tendons of the extensors consist of 3 parts (median, medial and lateral). Tendons from the median part are fixed to the middle phalanges, while tendons from the medial and lateral parts are fixed to the distal phalanges. Aponeurotic tension is located above the proximal phalanges (around the interosseous muscles). Distal and middle phalanges can be flexed simultaneously. Patients suffering from the ulnar nerve palsy may show this pose: extension of the proximal phalanges, flexion of the distal and middle phalanges. Topography of the wrist (regio carpi) - It is divided into the anterior and posterior compartments. Anterior compartment of the wrist Landmarks: 1. Structures passing superficial to the flexor retinaculum (from medial to lateral): - Flexor carpi ulnaris tendon; - Ulnar nerve (palmar branch); - Ulnar artery; - Palmar cutaneous branch of the ulnar nerve; - Palmaris longus tendon; - Palmar cutaneous branch of the median nerve; 2. Structures passing deep to the flexor retinaculum (from medial to lateral): - Flexor digitorum superficialis tendon ; - Median nerve; - Flexor pollicis longus tendon; - Flexor carpi radialis tendon;  Median duo: 1. Palmaris longus tendon; 2. Median nerve;  Radial trio: 1. Radial artery; 2. Flexor carpi radialis tendon; 3. Flexor pollicis longus tendon in the tendon sheath (radial bursa);  Ulnar trio: 1. Ulnar artery; 2. Ulnar nerve; 3. Flexor carpi ulnaris tendon;  Tendon quartets: 1. Flexor digitorum superficialis tendon; 2. Flexor digitorum profundus tendon; Posterior compartment of the wrist  Structures passing superficial to the extensor retinaculum (from medial to lateral): - Ulnar nerve (dorsal / posterior branch); 45  - Basilic vein; - Cephalic vein; - Radial nerve (superficial branch);  Structures passing beneath the extensor retinaculum (from medial to lateral): - Tendon of the extensor carpi ulnaris muscle; - Tendon of the extensor digiti minimi muscle; - Tendons of the extensor digitorum and extensor indicis muscles; - Tendon of the extensor pollicis longus tendon muscle; - Tendons of the extensor carpi radialis longus and extensor carpi radialis brevis muscles; - Tendons of the extensor pollicis brevis and abductor pollicis longus muscles; Topography of the wrist joint (articulatio radiocarpea) Types of joint: - Diarthrosis / interrupted / synovial / true/ cavitated / movable joint - Complex joint - Ellipsoid joint-2 axes (sagittal and frontal) - Biaxial joint Bones involved: - Inferior concave surface of the radius. - Dis