Upper Extremity Anatomy PDF

TOPOGRAPHIC ANATOMY OF THE UPPER LIMB The upper limb includes the following regions: the shoulder regions, the regions of the arm, the cubital regions, the regions of the forearm, the regions of the hand and joints. THE SHOULDER REGION Is divided into four par...

TOPOGRAPHIC ANATOMY OF THE UPPER LIMB The upper limb includes the following regions: the shoulder regions, the regions of the arm, the cubital regions, the regions of the forearm, the regions of the hand and joints. THE SHOULDER REGION Is divided into four parts: the scapular region, the deltoid region, the subclavian region, the axillary region. Surface landmarks of shoulder regions. The clavicles is situated at the root of the neck and can be palpated throughout its length. The deltopectoral triangle is a small triangular depression situated below the outer third of the clavicle; it is bounded by the pectoral major and deltoid muscles. The tip of the coracoid process of the scapula can be felt on deep palpation in the lateral part of the deltopectoral triangle, it is covered by the anterior fibers of the deltoid. The acromion process of the scapula forms the lateral extremity of the spine of the scapula. It is subcutaneous and easily located. Immediately below the lateral edge of the acromion process, the smooth rounded curve of the shoulder is produced by the deltoid muscle, which covers the greater tuberosity of the humerus. The inferior angle of the scapula can be palpated opposite the seventh thoracic spine and the level of seventh rib. The anterior axillary fold, which is formed by the level margin of the pectoralis major muscle, can be palpated between the finger and thumb. The posterior axillary fold, which is formed by the tendon of latissimus dorsi winding around the lower border of the teres major muscle, can be similarly palpated between finger and thumb. The axilla should be examined with the forearm supported and the pectoral muscles relaxed. With the arm by the side, the inferior part of the head of the humerus can be easily palpated through the floor of the axilla. The pulsation of the axillary artery may be felt high up in the axilla. The scapular region includes soft tissues which lie on posterior surface of scapula. The skin is thick and less mobile. The skin is supplied by posterior  2 supraclavicular nerves and posterior branches of the posterior intercostal nerves. The proper fascia is less developed. Beneath the proper fascia the trapezius and latissimus dorsi are located. Under the trapezius and latissimus dorsi the thick aponeurotic levels are located. They are called the supraspinous fascia and infraspinous fascia. These fasciae and posterior surface of the scapula form two osteofibrous beds. They are supraspinous and infraspinous beds. The posterior surface of the scapula is divided by the spine into the supraspinous fossa and infraspinous fossa below. The supraspinous bed is formed by supraspinous fossa – anteriorly and by supraspinous fascia – posteriorly. These beds contain the muscles, fat, vessels and nerve. Supraspinatus arises from the supraspinous fossa of the scapula and the tough overlying supraspinous fascia. The belly fills the fossa and almost hides it, but with the wasting of this muscle that is often associated with a painful shoulder joint the fossa can soon be recognized. The tendon of supraspinatus passes under the acromion and over the top of the shoulder joint to reach the highest of the facets on the greater tubercle of the humerus. The tendon fuses with the capsule of the shoulder joint and is separated from the overlying acromion by the subacromial bursa. Supraspinatus is supplied by the suprascapular nerve and its action is to stabilize the shoulder joint, prevent the head of the depended humerus slipping down off the glenoid cavity and with the deltoid muscle abduct the arm away from the body. Infraspinatus arises from the infraspinatus fossa and the overlying infraspinous fascia. Its fibers are directed up toward the shoulder joint and its tendon reinforces the capsule before becoming inserted into the middle facet on the greater tubercle. Infraspinatus is supplied by the suprascapular nerve through a branch that reaches it through spinoglenoid notch. Its action is to rotate the arm laterally and with the other short muscles stabilize the shoulder joint. Teres minor is a slender muscle arising from the upper two-thirds of the dorsal surface of the lateral margin of the scapula. Its fibers pass upward  3 toward the posterior aspect of the shoulder joint where they are replaced by a tendon which becomes fused with the capsule of the lowest of the three fasets on the greater tubercle of the humerus and to the shaft for a short distance below this. Teres minor is supplied by a branch of the axillary nerve. It joins the other short muscles in stabilizing the shoulder joint and, in addition, will produce lateral rotation of the dependent arm. Teres major arises from an area on the dorsal surface of the lateral border of the scapula below teres minor and from angle of the scapula, and passes upward and laterally into the anterior surface of the humerus where it is attached to the medial lip of the intertubercular sulcus. It is supplied by the lower subscapular nerve and its action is to adduct and medially rotate the arm. The scapular region has two neurovascular bundles. One of bundle is composed by the suprascapular nerve and vessels. The suprascapular nerve is an important and large nerve which runs deep to trapezius to reach the supraspinous fossa by passing through the scapular notch below the suprascapular ligament that bridges it. In the supraspinous fossa it supplies supraspiatus and then passes with the suprascapular artery through the spinog- lenoid notch to supply infraspinatus in the infraspinous fossa. The suprascapular artery is branch of the thyrocervical trunk of the subclavian artery passes above the suprascapular ligament. It is distributed to both the supraspinous and infraspinous fossa of the scapula and forms anastomosis with circumflex scapular artery. The circumflex scapular artery is the large branch of the subscapular artery. It passes posteriorly around the lateral border of the scapula through the triangular space to reach the infraspinous fossa. Anterior bundle consist of the deep branch of transverse cervical artery (branch of the thyrocervical trunk of the subclavian artery) and the dorsal scapular nerve. The deep branch of transverse cervical artery runs down the medial border of the scapula in company with the dorsal scapular nerve. This artery takes part in forming the arterial anastomosis around the scapula. The arterial anastomosis around the scapula is penitential collateral anastomosis that may bypass obstruction or injuries of the first and second part of the axillary artery.  4 Fat spaces of the scapular region communicate with fat spaces of adjacent region. Upper part of the scapular region has superficial fat space between the trapezius and supraspinatus. It communicates with fat space of lateral triangle of the neck. The fat of supraspinous bed communicates with fat of infraspinous bed along the suprascapular vessels and nerve. Nearby of neck of scapula the supraspinous and infraspinous fascia are thinner and, here fat of supraspinous and infraspinous beds communicates with fat of subdeltoid space. Along the circumflex scapular through the triangular space the fat of infraspinous bed with the fat of the axillary fossa. Deltoid region The deltoid region corresponds the disposition of the deltoid muscle. The deltoid muscle forms the rounded contour of the shoulder and covers the shoulder joint. The skin is supplied by supraclavicular nerves and by upper lateral cutaneous nerve (branch of axillary nerve). The subcutaneous tissue contains the cutaneous nerves. The superficial fascia is thing. The proper fascia form sheath of deltoid muscle. The fascia gives off septa which divided muscle into three parts: anterior fibers, middle fibers, posterior fibers. Anterior fibers arise from the lateral third of the anterior border of the clavicle. Middle fibers arise from the lateral border of the acromion process. Posterior fibers arise from the lower border of the spine of the scapula. Its fibers converge to be inserted into the deltoid tuberosity, on the middle of the lateral surface of the shaft of the humerus. The deltoid muscle is supplied on its deep surface by the axillary nerve, a branch of the posterior cord of the brachial plexus. It is this nerve that may be damage when the shoulder joint is dislocated or while the dislocation is being reduced. The V-shaped origin of the deltoid allows its fibers to approach the humerus anteriorly, laterally and posteriorly. This fact, coupled with freedom of movment at the shoulder joint gives the muscle a wide range of actions. The anterior fibers are able to flex the arm, that is swing it forward, and the posterior fibers can extend it behind the body. The intermediate fibers arising from the acromion are powerful adductors of the arm. Beneath the deltoid  5 muscle between the muscle and humerus the subdeltoid space is located. This space contains fat, tendons of muscles, synovial bursae, vessels and nerve. The axillary nerve is branch of the posterior cord of the passing posteriorly through a quadranqular space in company the posterior circumflex humeral arteries. Then the nerve and artery lie on surgical neck of the humerus in deltoid region. The anterior circumflex humeral artery and posterior circumflex humeral artery form an anastomotic circle around the surgical neck of the humerus. The anterior is small. The arteries supply the shoulder joint and surrounding muscles. The fat of subdeltoid space communicates: 1) whit fat of axillary fossa along neurovascular bundle, 2) with fat of supraspinous and infraspinous beds of scapular region along fat around tendons of supraspinatus and infraspinatus. In phlegmon of subdeltoid space the pus reach the deltopectoral sulcus and triangle. Infraclavicular region This region include the soft tissues forming anterior wall of axillary fossa. The boundaries of the region are: superiorly – clavicule, inferiorly – horizontal line, passing through III rib in the male and through superior border of the mammary gland in the female, medially – lateral border of the sternum, laterally – anterior margin of the deltoid muscle. The skin is thin and mobile and supplied by supraclavicular nerves and anterior and lateral branches of the intercostal nerves. The subcutaneous tissue is good developed and contains fibers of platysma. The superficial fascia forms suspensory ligament for mammary gland. The deep fascia covers the pectoral major and serratus anterior muscles and forms the sheath of the pectoralis major. This fascia is continuation of the second fascia of the neck. Below it passes in deep fascia of the abdomen. In axillary region it is connected with axillary fascia. In deltoid region it passes in deltoid (proper) fascia. Under deep fascia the pectoralis major muscle is located. It consist of three parts: clavicular, sternocostal, abdominal. The muscle converges on the arm where it is inserted into the outer lip of the intertubercular sulcus of the humerus. Pectoralis major is supplied by both medial and lateral pectoral  6 nerves. It adducts the arm and rotates it medially; the clavicular fibers also flex the arm. The deltoidopectoral sulcus is formed between deltoid and pectoralis major muscles. It contains the cephalic vein which is directed into deltoidopectoral triangle and drained to axillary vein. Beneath the pectoralis major muscles the superficial subpectoral fat space is located. Before the pectoralis minor muscle the clavipectoral fascia is located. The clavipectoral fascia is a strong sheet of connective tissue, which is split above to enclose the subclavius muscle and is attached to the clavicle. Below it splits to enclose the pectoralis minor muscle and then continues downward as the suspensory ligament of the axilla and joints the fascial floor of the armpit. It protects the contents of the axilla by filling in the internal between the clavicle and the pectoralis minor muscle. The suspensory ligament of the axilla is responsible for raising the skin of the armpit when the clavicle is elevated. Pectoralis minor is found beneath pectoralis major arising from the third, fourth and fifth ribs close to their costal cartilages. Its fibers converge on the coracoid process of the scapula. It is supplied by the medial pectoral nerve and its action is to help in pulling the scapula forward around the chest wall. In acute respiratory difficulty its action may be reversed and it is used to raise the ribs when the shoulder girdle is fixed. Between the posterior surface of pectoralis minor and deep layer of the clavipectoral fascia the deep subpectoral space is located. Deep layer of infraclavicular region is divided into tree triangles where the neurovascular bungle including the axillary vessels, cords of the brachial plexus and their nerves pass. 1) Clavipectoral triangle is limited superiorly – by clavicle and subclavius muscle, inferiorly – by superior border of the pectoralis minor muscle. The base of this triangle is lateral border of sternum. 2) The pectoral triangle corresponds to contours of pectoralis minor muscle.  7 3) The subpectoral triangle is limited by inferior border of the pectoralis minor muscle – superiorly and by the inferior border of the pectoralis major muscle – inferiorly. The base of this triangle is limited by deltoid muscle. Three parts of axillary artery correspond to these triangles. In clavipectoral triangle the clavipectoral fascia is pierced by 1)the cephalic vein in order that it may enter the axillary vein; 2)the thoracoacromioal artery, a branch of the axillary artery; 3)lymph vessels from the infraclavicular nodes and 4)the lateral pectoral nerve as it passes to the pectoralis major muscle. Along these vessels and nerves the fat of superficial subpectoral space communicates with fat of clavipectoral triangle. Along vessels and nerves piercing deep layer of the clavipectoral fascia the fat of deep subpectoral space communicaties with fat space of the axillary fossa. In both subpectoral spaces the subpectoral phlegmons may be located. But in deep subpectoral space the phlegmons are rare as it is more closed. Phlegmons may be formed as a result of suppurative lesion of an apical group or subclavian lymph nodes. The pus passes under the pectoralis major muscle along vessels and nerve piercing the clavipectoral fascia. However, subpectoral phlegmon is often developed as a result of suppurative lesion of a pectoral group of lymph nodes. In a neglicted cases pus (in subpectoral phlegmon) melting tissues may penetrate through the intercostal space into pleural cavity or between fibers of the pectoralis major muscle under the skin; also the pus passes between the pectoralis major and pectoralis minor muscle and reaches of free border of the anterior wall of the axillary fossa. Axillary region Regions contains soft tissues, disposing between the shoulder joint with proximal part of humerus and the thorax. The axilla or armput is a pyramidshaped space. It forms an important passage for nerves, blood and lymph vessels as they travel from the root of the neck to the upper limb. The upper end of the axilla, or apex, is directed into root of the neck and is founded in front by the clavicle, behind- by the upper border of the scapula and medially- by the outer border of first rib.  8 The lower end, or base, is bonded: in front- by the anterior axillary fold (formed by two lower border of the pectoralis major muscle), behind- by the posterior axillary fold (formed by the tendon of latissimus dorsi and the teres major muscle), medially – by conditional line connecting these folds on thoracic wall and laterally – by conditional line connecting these folds on the arm. The axilla should be examined with the forearm supported and the pectoral muscles relaxed. With the arm by the side, the inferior part of the humerus can be easily palpated through the floor of the axilla. The pulsation of the axillary artery may be felt high up in the axilla and around the artery may be palpated the cord of the brachial plexus. The skin of this region is thin and hair-bearing and contains numerous sebaceous and subdoriferous glands. The skin is supplied by the intercostobrachial nerve and the medial cutaneous nerve of the arm. The subcutaneous tissue contains the superficial lymph nodes and the cutaneous nerves. The superficial fascia is faintly developed and connected with proper fascia. The proper fascia is the more thick at the borders of the axilla and thin in center where it is perforated by lymph vessels, arteries, nerves. After removing proper fascia the muscles limiting the axillary fossa are explosed. The muscles form four walls of axillary fossa: anterior, posterior, medial and lateral. Anterior wall is formed by the pectoralis major, subclavius and pectoralis minor muscles, the clavipectoral fascia and the suspensory ligament of the axilla. Posterior wall is formed by the subscapularis, latissimus dorsi and teres major muscle from above down. Medial wall is formed by the upper four or five ribs and the intercostal space covered by the serratus anterior muscle. Lateral wall is formed by the coracobrachialis and biceps muscles in the bicipital groove of the humerus. The anterior wall has three triangles: clavipectoral, pectoral and subpectoral. On posterior wall two spaces are formed between muscles.  9 Through these spaces the vessels and nerve surrounding by fat pass from axillary region into deltoid and scapular regions. The medial space is called triangular space. It is bounded above- by the subscapularis and teres minor, below- by the teres major and latissimus dorsi and laterally- by the long head of the triceps muscle. The circumflex scapular artery passes backward through this space to enter the infraspinous fossa. The lateral space is called quadrilateral space. It space is bounded above by the subscapularis – in front and the teres minor behind, below – by the teres major and latissimus dorsi, medially – by 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. The axilla contains the axillary artery and its branches, which supply blood to the upper limb, the axillary vein and its tributaries, which drain blood from the upper limb, and lymph vessels and lymph nodes, which drain lymph from the upper limb and the mammary gland and from the skin of the trunk, down as far as the level of the umbilicus. Lying among these structures in the axilla is an important nerve plexus, the brachial plexus, which innervates the upper limb. The above structures are embedded in fat. The fat of axillary fossa is located: 1)in walls and between walls, 2)under proper fascia, 3)within sheath of neurovascular bundle or axillary sheath. 1) The fat of walls and between of walls is superficial and deep subpectoral fat spaces and fat of antescapular slits. Between the thoracic wall and anterior surface of the scapula the space is located. The anterior surface of the scapula is concave and form the shallow subscapular fossa. The subscapclaris muscle occupies this fossa and is covered by fascia. The space is divided by serratus anterior which is attached to medial or vertebral border of the scapula into two parts: antescapular slit and posterior antescapular slit. Anterior antescapular slit is limited by the thoracic wall- anteriorly and by the serratus anterior - posteriorly. This fat space is closed.  10 Posterior antescapular slit is limited by serratus anterior - anteriorly and by subscapularis - posteriorly. This slit is continuation of axillary fossa backward and medially. The fat of this slit communicates with subfascial fat of the axilla. 2) The subfascial fat space is located under proper or axillary fascia. This spase is separated by clavipectoral fascia from subpectoral space and by axillary sheath from fat around neurovascular bundle. Along vessels and nerves this space communicates with fat of infraspinous fossa and subdeltoid space through triangular and quadrilateral spaces. The subfascial fat space contains the lymph nodes. 3) The fat around neurovascular bundle or axillary sheath communicates above with fat space of neurovascular bundle of lateral triangle of neck, below- with fat of anterior fascial compartment of the arm and posterior fascial compartment of the arm along brachial artery and profunda artery, respectively. The axillary region contains 20-30 deep lymph nodes. The lymph nodes are surrounded in five groups: 1) A lateral group around the axillary vein which drains the deep and much of the superficial tissues of the upper limb. 2) A subscapular group (posterior) arranged along the supscapular vessels. These drain the back of the shoulder, trunk and lower neck. 3) A pectoral group (anterior) lying at the lateral border of pectoralis minor which drain the anterior thoracic wall and breast. 4) A central group which receives afferents from all other groups and, in addition, afferents from the upper limb which accompany the cephalic vein. 5) An apical group which again receives afferents from all other groups and, in addition, afferents from the upper limb which accompany the cephalic vein. The efferents from the apical group join to form the subclavian trunk which opens into the junction of the subclavian and internal jugular veins. The lymph vessels of axillary fossa is source of adenophlegmon. The pus in adenophlegmon may spread along fat into adjacent regions: through quadrangular space into deltoid region,  11 through triangular space into scapular region, along main neurovascular bundle into compartments of the arm and subclavicular region. The neurovascular bundle of axilary fossa lies at medial border of coracobrachialis and short head of biceps brachii muscle. The axillary vein lies medial to artery and superficially. The axillary artery begins at inferior border of first rib and passes in brachial artery at inferior border of the latissimus dorsi. The relation of nerves and vessels in axilla change depending on level. The axillary artery is divided into three parts by pectoralis minor. The firs part lies above the muscle or in clavipectoral triangle, the second- behind it or in pectoral triagle and the third- below it or in subpectoral triangle. The first part of axillary artery. Here the vein is located below and medially, the cords of the plexus brachialis- above and laterally. The axillary artery lies between the vein and cords of plexus brachialis. The apical or subclavian lymph nodes adjoin to the axillary vein anteriorly and medially. The superior thoracic artery and the thoracoacromial artery arise from the firs part of axillary artery and supply the deltoid muscle, shoulder joint and pectoralis muscles. The second part of axillary artery. The cords of the plexus become rearranged over the second part of the artery and assume around this the position implied by their names. The medial cord separates the axillary artery from the axillary vein. The posterior cord is located behind artery and the lateral cord lies lateral to artery. The lateral thoracic artery arises from the se- cond part of the axillary artery and appears at the lateral border of the pectoralis minor and follows this onto the thoracic wall to supply the pectoral muscles and serratus anterior. This artery passes in company the long thoracic nerve. The third part of axillary artery. The main terminal branches of the cord are related to the third part of the artery. The vein lies medial to artery and nerves.  12 The musculocutaneous nerve and lateral root of the median nerve arise from the lateral cord of the brachial plexus. The medial cutaneous nerve of the arm, the medial cutaneous nerve of forearm, the ulnar nerve, the medial root of the median nerve arise from the medial cord of the brachial plexus. The axillary nerve and radial nerve arise from the posterior cord of the brachial plexus. The musculocutaneous nerve and the lateral root of the median nerve lie lateral to the artery. The medial cutaneous nerve of the forearm and the ulnar nerve lie medial to the artery and between it and vein. The medial root of the median nerve crosses in front of the artery. The median nerve itself is formed anterior to or just lateral to the artery. Posterior to the artery lie the radial nerve and part of the axillary nerve. Branches from the third part are: 1)subscapular artery is the largest branch of the axillary artery; 2)anterior circumflex artery; 3)posterior circumflex artery which is directed into quadrilateral space in company axillary nerve. The subscapular artery passes along lateral border of subscapularis and give off the terminal branches circumflex subscapular artery and thoracodorsal artery. The musculocutaneous nerve pierces the coracobrachialis muscle and passes on anterior fascial compartment of the arm. On anterior surface of subscapularis muscle the subscapular nerve and thoracodorsal nerve pass. They arise from brachial plexus above clavicle. The subscapular nerve supplies the subscapularis muscle and the teres muscle. The thoracodorsal nerve supplies the latissimus dorsi. THE REGION OF THE ARM OR BRACHIUM The boundaries of the arm are: superiorly- conditional line connecting the lower borders of the pectoralis major muscle and latissimus dorsi; inferiorly- conditional line passing above epicondyles on two transverse fingers. The region is divided into two parts: anterior and posterior by two vertical lines drowing up from epicondyles. On skin, laterally and medially , the sulcuses are located. They are correspond to boundaries between muscles  13 of anterior and posterior fascial compartment. Here the humerus may be palpated. The pulse of the brachial artery may be felt at medial border of the biceps muscle. The deep fascia form sheath for muscles and neurovascular bundles. The deep fascia give off two fascial septa. Deep fascia, two septa and humerus form two fascial compartments. Anterior region of the arm The skin is thin and mobile. The skin over the lateral surface of the arm below the deltoid is supplied by the lower lateral cutaneous nerve of the arm (a branch of the radial nerve). Skin of the medial side of the arm is supplied by the medial cutaneous nerve of the arm and the intercostobrachial nerves. The subcutaneous tissue contains cutaneous nerves. The superficial veins of the arm lie between superficial and deep fascia. The cephalic vein ascends on the lateral side of the biceps and, on reaching the infraclavicular fossa, pierces the clavipectoral fascia to drain into the axillary vein or subclavian vein. The basilic vein ascendens on the medial side of the biceps. Halfway up the arm it pierces the deep fascia and contributes to the formation of the axillary vein. 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 interclavicular group of nodes, those from the medial side follow the basilic vein to the lateral group of axillary nodes. The deep lymphatic vessels draining the muscles and deep structures of the arm drain into the lateral group of axillary nodes. The brachial fascia surrounding the arm is thin over the anterior aspect but thicker over the posterior. From the brachial fascia is given off a lateral intermuscular septum that extends to the body of the humerus from the lateral lip of the intertubercularis sulcus to the lateral epicondyle. A medial intermuscular septum extends from the medial lip of the sulcus to the medial epicondyle. It is these septa that define the anterior flexor compartment and the posterior extensor compartment. Each compartment has its muscles, nerves and  14 arteries. The anterior fascial compartment is limited anteriorly by deep fascia, posteriorly – by humerus, medially and laterally – by intermuscular septa. The anterior fascial compartment or flexor compartment contains the biceps brachii, coracobrachialis and brachialis muscles. Structures passing through the compartment are musculocutaneous, median and ulnar nerves, brachial artery and basilic vein. The radial nerve is present in the lower part of the compartment. Topography of these structures look in the table. Posterior region of the arm The skin is thick but mobile. The skin of the back of the arm is supplied by the upper lateral cutaneous nerve of the arm, a branch of the axillary nerve and by the posterior cutaneous nerve of the arm, a branch of the radialis nerve. The superficial fascia is thin. The deep or brachial fascia is thicker than on anterior region and forms posterior fascial compartment or extensor compartment. The posterior fascial compartment is limited anteriorly – by the humerus, posteriorly- by the deep fascia, medially and laterally – by intermuscular septa. The posterior fascial compartment contains the there heads of the triceps muscle. Structures passing through the compartment are profunda brachii artery and its branch, veins and radial nerve. The ulnar nerve is present in the lower part of the compartment. Names of Superior third Middle third of the Inferior third vessels and of the brachium brachium of the brachium nerves Brachial artery Neurovascular bundle passes in medial Neurovascular bundle and vein, bicipital sulcus overlapped by the medial is located imme- median nerve. border of the biceps muscle. Posterior layer diately medial to Nerve doesn't of sheath of the biceps muscle forms sheath medial border of the give branches for neurovascular bundle. Basilic vein in biceps muscle in on brachium company medial cutaneous nerve of the medial bicipital forearm pass in separate fascial sheath sulcus. medial to main neurovascular bundle.  15 Names of Superior third Middle third of the Inferior third vessels and of the brachium brachium of the brachium nerves Median nerve lies Median nerve crosses Median nerve lies lateral to brachial artery often lies medial to brachial artery anterior to artery artery. (seldom posteriorly) Basilic vein, Vein and nerve pass into separate canal Vein and nerve lie medial cuta- forming by deep fascia medial to medial above deep fascia neous nerve of border of biceps muscle on 1-1,5 cm immediately medial the forearm to brachial artery and Nerve is usually Nerve dividing into 2- median nerve locating located lateral to vein 3 branches is located in medial bicipital on both side of vein sulcus under deep fascia. Branches of nerve surround vein. Ulnar nerve. Ulnar nerve is located Ulnar nerve lies Nerve is located in Nerve doesn't posterior and medial medial to brachial extensor compartment give branches to brachial artery and artery on 2 cm. under deep fascia. on brachium. separated from artery Between nerve and by sheath of basilic artery basilic vein and vein and medial cu- medial cutaneous taneous nerve of the nerve of the forearm forearm surrounding by sheath are located. Below ulnar nerve pierces the medial intermuscular septum and in company superior ulnar col- lateral artery passes in extensor compartment.  16 Names of Superior third Middle third of the Inferior third vessels and of the brachium brachium of the brachium nerves Musculocuta- Musculocutaneous Musculocutaneous Musculocutaneous neous nerve. nerve pierces the nerve is located nerve is located Biceps brachii, coracobrachialis between biceps between biceps brachialis, muscle and is located brachii and brachialis brachii and brachialis coracob- between cora- muscle 1,5 cm lateral muscle at lateral rachialis are cobrachialis and short to brachial artery border intermuscu supplied by the head of biceps brachii lar slit. musculo- muscle cutaneous Nerve.  17 Names of Superior third Middle third of the Inferior third vessels and of the brachium brachium of the brachium nerves Radial nerve, Radial nerve and Radial nerve and pro- Radial nerve pierces profunda profunda brachii funda brachii vessels lateral intermuscular brachii artery vessels below la- are located in the hu- septum and together and veins. tissimus dorsi muscle meromuscular canal radial collateral Radial nerve pass between heads of (or spiral canal, or vessels is located supplies the triceps brachii canal of radial nerve). between brachialis triceps brachii (medial head – Nerve lies medial to muscle and and give off anteriorly, lateral and vessels. In canal the brachioradialis two cutaneous long – posteriorly) profunda brachii arte- muscle. branches: and then enter the hu- ry is divided into two posterior meromuscular canal. terminal branches: ra- cutaneous The canal is formed dial and middle colla- nerve of the by the spiral groove teral arteries. The arm, lower of humerus or groove profunda brachii arte- lateral cuta- for the radial nerve- ry gives off muscular neous nerve of anteriorly, medial and branches which the forearm. lateral heads of anastomose with the triceps brachii- posterior humeral posteriorly. circumflex artery. In going out from canal the nerve in company radial collateral vessels passes along lateral surface of humerus, where it is coverd by lateral head of triceps brachii- posteriorly and by lateral intermuscular septum and brachialis muscle – anteriorly. Nerve lies medial to vessels. THE ELBOW REGION (CUBITAL) The boundaries of this region are drown on two transverse fingers above and below line, connecting medial and lateral epicondyles. By vertical lines  18 passing through epicondyles the region is divided into anterior and posterior regions. Surface landmarks. The medial and lateral epicondyles of the humerus and the olecranon process of the ulna can be palpated. The head of the radius can be palpated in a depression on the posterolateral aspect of the extended elbow, distal to the lateral epicondyle. The head of the radius can be left to rotate during pronation and supination of the forearm. The ulnar nerve can be palpated where it lies behind the medial epicondyle, in sulcus between epicondyle and olecranon process. The tendon of the biceps muscle can be palpated as it passes downward into the fossa, and the bicipital aponeurosis can be felt as it leaves the tendon to joint the deep fascia on the medial sit of the forearm. The tendon and aponeurosis are most easily left if the elbow joint is flexed against resistance. The anterior elbow region The skin is very thin. In the subcutaneus tissue and under superficial fascia the superficial vein and nerves lie. The cephalic vein and lateral cutaneous nerve of forearm which is continuation of the musculocutaneous nerve lie laterally. The basilic vein and medial cutaneous nerve of forearm lie medially. Both veins form anastomosises. They may be M-shaped and N- shaped. If it is M-shaped the anatomic veins are called median cephalic vein – laterally and median basilic vein – medially. If it is N-shaped the anatomic vein is called median cubital vein. These anastomosises are continuation of the median vein of foream. Superficial layers of this region contain lymph nodes. Deep fascia is thick as it is connected with bicipital aponeurosis. Under deep fascia the muscles lie. The muscles limit the cubital fossa. The cubital fossa is a triangular anatomical region lying anterior to the elbow joint. The boundaries of the cubital fossa are the brachioradial muscle – laterally and the pronator teres – medially. Its base is formed by an imaginary line drown between the two epicondiles of the humerus. The floor of the fossa is formed by the brachialis muscle and tendon of the biceps brachii.  19 The tendon of the biceps brachii is attached to the tuberosity of the radius. The brachialis muscle is inserted into the tuberosity of the ulna. The cubital fossa contain the following structures, enumerated from the medial to the lateral side: the median nerve, the brachial artery, the tendon of the biceps muscle, the radial nerve and its deep branch. The muscles of cubital fossa form two sulcuses: medial and lateral. The medial anterior cubital sulcus is formed by the pronator teres muscle – medially and by tendon of the biceps brachii – laterally. Here the medial neurovascular bundle passes. This bundle includes the brachial artery, two veins and median nerve. Just medial to tendon of the biceps brachii the brachial artery lies beneath the bicipital aponeurosis. The median nerve lies 0,5-1 cm medial to artery. Deep to the bicipital aponeurosis or below it the brachial artery is divided into the radial and ulnar arteries. Then, radial artery passes in sulcus between brachioradialis muscle and ulnar artery passes between the flexor digitorum superficialis and the flexor digitorum profundus. At level cubital fossa the radial and ulnar arteries give off the following branches: radial recurrent artery, anterior ulnar recurrent artery, posterior ulnar recurrent artery, common interosseous artery giving anterior and posterior interosseus arteries and giving off interosseus recurrent artery. These arteries take part in forming the arterial anastomoses around the elbow joint. The medial nerve goes out from cubital fossa between the two heads of pronator teres. The lateral anterior cubital sulcus is formed by brachialis muscle- medially and brachioradialis- laterally. Here the lateral neurovascular bundle passes. This bundle includes the radial nerve and the radial collateral vessels. At level of the lateral epicondyle it divides into superficial and deep branches. Superficial branch is directed further in radial sulcus of the forearm and then on the dorsum of hand. The deep branches lies on capsule of elbow joint and then winds around the neck of the radius, within the supinator muscle or canal and enters the posterior compartment of the forearm.  20 Posterior elbow region The skin is thick but mobile. In subcutaneous tissue above apex of olecranon the subcutaneous olecranal bursa is located. The deep fascia is thick and knitted with lateral and medial epicondyles and with posterior border of the ulna. On posterior elbow region two sulcuses are present: medial posterior cubital sulcus, lateral posterior cubital sulcus. The medial posterior cubital sulcus is formed by medial epicondyle- medially and by olecranon – laterally. This sulcus contains ulnar nerve which lies on capsule of elbow joint. The nerve is covered by deep fascia, that is nerve is located into osteofibrous canal in company superior ulnar collateral artery. Superficial disposition of the ulnar nerve on bones is the cause of frequent trauma of it. At inferior boundary of the region the ulnar nerve directing in anterior region of the forearm passes between heads of flexor carpi ulnaris. Lateral posterior cubital sulcus is formed by lateral epicondyle – laterally and by olecranon – medially. In the middle point of this sulcus the head of the radius may be palpated, especially during pronation and supinaton of the forearm. The tendon of triceps brachii is inserted into the upper surface of the olecranon process of the ulna. Under tendon of the triceps brachii the subtendinous olecranal bursa is located. Under deep fascia from lateral epicondyle the muscles of the extensor compartment arise.