UPPER LIMB SIXTH BATCH 21_240713_213719.pdf

 ‫شكر وعرفان‬ ‫معالً رئٌس الجامعة األستاذ الدكتور‪ /‬مجاهد معصار‬ ‫من صمٌم قلوبنا ووجداننا ٌشرفنا وٌسعدنا أن نتقدم لكم بخالص‬ ‫الشكر واإلمتنان على جهودكم الجبارة والمشرفة فً خدمة‬ ‫الجامعة بكلٌا...

 ‫شكر وعرفان‬ ‫معالً رئٌس الجامعة األستاذ الدكتور‪ /‬مجاهد معصار‬ ‫من صمٌم قلوبنا ووجداننا ٌشرفنا وٌسعدنا أن نتقدم لكم بخالص‬ ‫الشكر واإلمتنان على جهودكم الجبارة والمشرفة فً خدمة‬ ‫الجامعة بكلٌاتها عامة وبكلٌة الطب البشري بوجه الخصوص‬ ‫معالً عمٌد كلٌة الطب البشري االستاذ الدكتور‪ /‬سلوى الغمٌري‬ ‫بأي لغة ٌمكن أن نقدم لكم بها شكرنا‪ ،‬و بأي ثناء ٌمكن أن نعبر‬ ‫به لكم عن تقدٌرنا لكل ما فعلتموه من أجلنا‪ ،‬و بأي نثر سنوافٌكم‬ ‫به حقكم‪ ،‬شكرا لكم و دمتم دائما وأبدا‬ ‫كقمر ٌضًء لنا دروبنا الحالكة فً مشوارنا الطبً‪....‬‬ ‫دكاترنا األعزاء‪....‬‬ ‫رئٌس قسم التشرٌح االستاذ الدكتور‪ /‬عارف عبدالمغنً وجمٌع الكادر التعلٌمً‬ ‫‪.‬لكم منا كل الحب واالحترام والتقدٌر‪ ،‬فأنتم الذٌن أناروا طرٌقنا بالمزٌد من العلم والمعرفة‬ ‫فالعمل أمانة وتكلٌف وأنتم أهل األمانة والمسئولٌة‪ ،‬فلكم منا كل الشكر والعرفان بهذا الدور العظٌم‬ ‫والجهود الرائعة‪.‬‬ ‫أعضاء اللجنة العلمٌة للدفعة السادسة بكلٌة الطب البشري وكل زمٌل وزمٌلة فً الدفعة‬ ‫لكل من ساعد فً إنجاز هذا العمل المتواضع‬ ‫لكم منا كل الشكر واإلمتنان‬  ‫اإلهداء‪....‬‬ ‫الى كل من تجافت جنوبهم عن المضاجع بحثا ً عن العلم‬ ‫الى كل من كان الطب حلمه فحارب الواقع لٌصبح حلمه حقٌقة‬ ‫إلى كل من أراد بحلمه وعلمه أن ٌحًٌ أمة أنهكتها األسقام واآلهات‬ ‫إلى كل من هجر أقرانه وأحبابه لٌعٌش فً حٌاة الطب‬ ‫هاقد وصلت إلى أولى خطوات مبتغاك‬ ‫وهذا الكتاب ُكتِب من أجلك‪......‬‬ ‫اللجنة العلمٌة للدفعة السادسة‬ INDEX OF CONTENTS 1-BONES OF THE UPPER LIMB --------------------------------------------------------------------- 1-32 2-PECTORAL REGON-------------------------------------------------------------------33-36 3-MUSCLES OF THE SHOULDER AND SCAPULAR REGION-----------37-43 4- INTERMUSCULAR SPACES IN THE SHOULDER REGION-------------44 5-AXILLA --------------------------------------------------------------------------------45-46 6-THE ARM-------------------------------------------------------------------------------47-50 7- SUPERFICIAL MUSCLES OF THE FRONT OF FOREARM------------51-54 8- DEEP MUSCLES OF THE FRONT OF FOREARM------------------------54-55 9- UBITAL FOSSA---------------------------------------------------------------------56 10-FLEXOR RETINACULUM AND CARPAL TUNNEL--------------------57-58 11-SUPERFICIAL MUSCLES OF THE BACK OF FOREARM -----------59-61 12-DEEP MUSCLES OF THE BACK OF FOREARM-----------------------62-63 13-ANATOMICAL SNUFF BOX AND EXTENSOR RETINACULUM---63-64 14- THE HAND------------------------------------------------------------------------65-74 15-ARTERIES OF THE UPPER LIMB-----------------------------------------75-87 16-VEINS OF THE UPPER LIMB -----------------------------------------------88-89 17- NERVES---------------------------------------------------------------------------90-113 18-JOINTS ----------------------------------------------------------------------------114-130 19-LYMPHATIC DRAIN OF UPPER LIMB ---------------------------------131-132 20- THE BREAST -----------------------------------------------------------------133-136 21-OSSIFICATION OF THE BONE OR U.L---------------------------------137-138 ‫ سبتمبر‬21 ‫ جامعة‬- ‫كلٌة الطب البشري‬ ‫تم التحوٌل بواسطة اللجنة العلمٌة للدفعة السادسة‬ Anatomical abbreviations Rt.= right a. = artery V. = Vein m. = muscle ant= anterior med = medial sup.= Superior L.N.= lymph node Lig.= ligament Flex= Flexor abd.= abductor N.S= nerve supply U.L= upper limb C. = Cervical L.= lumbar br.= branch Lt.= left aa = arteries VV. = Veins nn = nerves mm= muscles lat= lateral post = posterior inf.= inferior L-Ns-lymph nodes Ligs.= Ligaments Ext-extensor add.= adductor // = inch (2-5cm.) L.L= lower limb T= thoracic S=Sacral brs.=branches ‫ سبتمبر‬21 ‫ جامعة‬- ‫كلٌة الطب البشري‬ ‫تم التحوٌل بواسطة اللجنة العلمٌة للدفعة السادسة‬  UPPER LIMB BY DR.SAMEH DOSS (PH.D) Bones of the Upper Limb The bones of the upper limb consist of: Bones of the Shoulder or pectoral girdle: these are the bones which connect the upper limb to the trunk and include: A-the clavicle : anteriorly B- the scapula: posteriorly. N-B : 1-the shoulder girdle: is completed anteriorly by the upper end of the sternum which articulates with the med ends of the 2 clavicles →scapula 2- Posteriorly: the 2 scapulae are widely separated From each other & are connected to the axial skeleton by muscles only. I-Bone of the upper arm :the humerus 2-Bones of the forearm: (1) Radius (the lat. bone): (2) ulna (the med. bone) 3-Bones of the hand: include: 1-Carpal bones: present in the wrist 2- metacarpal bones: present in the palm 3- phalanges : present in the fingers. 1 ‫الصفحة‬ ‫مت التحويل بواسطة اللجنة العلمية للدفعة السادسة – طب بشري‬  UPPER LIMB BY DR.SAMEH DOSS (PH.D) 1-THE SCAPULA It is the post bone of the shoulder girdle. -Type: it is a flat bone developing by: Cartilagenous ossification - Anatomical Position: 1-it lies on the posterolateral aspect of the chest wall Covering the backs of the ribs 2-7. 2- its med. border lies parallel to the vertebral Column &5 cm. away from the spines 3-its surfaces lie in a plane midway between front to back &side to side. 4- the coracoid process projects forwards & slightly laterally below the junction between the lat. & the med-3/4 of the clavicle 1- GENERAL FEATURES OF THE SCAPULA the scapula has: 1- 2 Surfaces: ant. & post. 2- 3 borders: sup, med. &lateral 3- 3 angles: sup, inf. & lateral 4- 3 fossae: Subscapular, supraspinous &infraspinous 5- 3 processes: spine, acromion & coracoid process. 6- 3 notches: Suprascapular, Spinoglenoid & circumflex scapular. (7) 3 tubercles: supraglenoid, infraglenoid & tubercle of the spine A- SURFACES OF THE SCAPULA(2) 1-Costal Surface: (anterior or ventral (.it is slightly concave forming the subscapular fossa. it is directed forwards & medially 2-Dorsal (posterior) Surface: Faces backwards & laterally. it is divided by the attachment of the spine into a small supraspinous fossa above the spine a large infraspinous fossa below. 2 ‫الصفحة‬ ‫مت التحويل بواسطة اللجنة العلمية للدفعة السادسة – طب بشري‬  UPPER LIMB BY DR.SAMEH DOSS (PH.D) Ventral surface of right scapula Dorsal surface of right scapula 3 ‫الصفحة‬ ‫مت التحويل بواسطة اللجنة العلمية للدفعة السادسة – طب بشري‬  UPPER LIMB BY DR.SAMEH DOSS (PH.D) (B) BORDERS OF THE SCAPULA Superior border (1) Superior border: -it is the shortest & sharpest border. - it extends from the sup. angle to the root of the coracoid pro. -it presents a suprascapular notch near the root of the coracoid process. (2) medial (vertebral) border: Lateral border -it is the longest border &lies parallel to the vertebral spines - it is extends from the sup. angle above to the inf.angle below. Medial border - it is shows an obtuse angle opposite the root of the spine. (3) lateral (axillary) border: -it is the thickest border because it gives attachments to muscles & acts as a fulcrum for rotation of the scapula. -it extends from the lat angle (glenoid cavity) to the inf. angle. - its dorsal aspect shows a flattened area for muscular attachment (C) ANGLES OF THE SCAPULA Superior angle (1) Sup. angle: -it is nearly a right angle -it lies opposite the 2nd rib. - it forms the junction between the sup. & the med borders Lateral angle (2) inf. angle: -it is an acute angle. - it lies opposite the 7th rib. -it forms the Junction of the lat & med borders. (3) lateral angle: Inferior angle -it is enlarged to form the head & neck of scapula. -it lies between the sup. & the lat. borders. the head carries a pear-shaped Concavity called the glenoid cavity For articulation with the head of humerus the glenoid cavity is wide below & narrow above. - It's margins give attachment to the labrum glenoidale (fibro. cartilagenous lip). 4 ‫الصفحة‬ ‫مت التحويل بواسطة اللجنة العلمية للدفعة السادسة – طب بشري‬  UPPER LIMB BY DR.SAMEH DOSS (PH.D) (D) FOSSAE OF THE SCAPULA 1- Subscapular fossa: - it is the Concave ventral aspect of the scapula. -it presents a number of transverse ridges. (2) Supra. spinous fossa: -it is the area of the dorsal surface lying above the spine. - it also includes the upper surface of the spine. (3) Infra-spinous fossa: -it is the area of the dorsal surface lying below the spine. - it also includes the lower surface of the spine. (E) PROCESSES OF THE SCAPULA (1) the spine of the scapula: it is a shelf-like projection from the upper part of the dorsal surface. -it is triangular in shape having 3 borders &2 Surfaces: (a) ant. border: Joins the dorsal surface of the scapula along a horizontal line (b) posterior free border: called the crest of the spine & Can be felt beneath the skin. The crest of the spine has upper & lower lips & an intermediate area in between showing a rough tubercle near its med. end. (C) lat border: Free & shares in the formation of the spinoglenoid notch. (d) the upper surface of the spine: completes the supraspinous fossa. (e) the lower surface of the spine: completes the infraspinous fossa. (2) the Acromion: -it is the lat. Continuation of the spine. -it projects forwards & slightly upwards overhanging the glenoid cavity. -it has a tip (ant-end), upper & lower surfaces, lat:& med borders. -the lat. border is continuous with the lower lip of the crest of the spine -the med. border is continuous with the upper lip of the crest of the spine & Carries an oval facet for articulation with the clavicle. 5 ‫الصفحة‬ ‫مت التحويل بواسطة اللجنة العلمية للدفعة السادسة – طب بشري‬  UPPER LIMB BY DR.SAMEH DOSS (PH.D) (3) Coracoid process: -it projects forwards & slightly laterally from the upper aspect of the head of scapula. -it has: (a) tip (b) upper surface (c) lower surface (d) med.border (e) lat.border. (F) NOTCHES OF THE SCAPULA 1-Supra-Scapular notch: -it lies at the lat end of the sup. border close to the root of the coracoid process. -it is transformed into foramen by the suprascapular ligament. -through the foramen passes the suprascapular n. & above the lig. passes the suprascapular vessels. (2) Spino-glenoid notch: -lies between the lat.free border of the spine & the glenoid cavity. - This notch transmits the suprascapular vess.& n- from the supraspinous fossa to the infraspinous fossa. (3) circumflex scapular notch: -it is a groove on the dorsal aspect of the lat border produced by the circumflex scapular artery. (G) TUBERCLES OF THE SCAPULA (1) Supra-glenoid tubercle: a small rough projection above the glenoid cavity. (2) Infraglenoid tubercle: a rough triangular area just below the glenoid Cavity (3) Tubercle of the crest of spine: a triangular rough projection from the lower lip of the Crest of spine. OSSIFICATION OF THE SCAPULA: see page 137 SUBCUTANEOUS BONY LANDMARKS: (1) the acromion &acromial angle : lie immediately above the smooth bulge of the deltoid (2) Coracoid process: lies deep, 1inch (2.5cm.)below the Junction of the lat.&med.3/4 of the clavicle. (3) the crest of the spine of the scapula. (4) the inferior angle. (5) the lower 2/3 of the med.border. 6 ‫الصفحة‬ ‫مت التحويل بواسطة اللجنة العلمية للدفعة السادسة – طب بشري‬  UPPER LIMB BY DR.SAMEH DOSS (PH.D) FUNCTIONS OF THE SCAPULA (1)Transmission of the weight of the upper limb to the clavicle. (2) provides a wide surface for muscular attachments. ARTICULATIONS OF THE SCAPULA 1-the acromion process articulates with the lat. end of the clavicle in the acromio-clavicular joint 2-the glenoid cavity articulates with the head of humerus in the Shoulder joint. IDENTIFICATION OF THE SIDE OF SCAPULA(RT. OR LT. (1) the glenoid cavity is directed laterally. (2) the post.surface is marked by the spine. (3) the upper border is the shortest border PARTICULAR FEATURES OF THE SCAPULA I-LIGAMENTS ATTACHED (1) Capsule of shoulder joint: attached around the margins of the glenoid cavity. (2) the sup., middle & inf. glenohumeral ligaments:. attached to the ant. margin of the glenoid cavity (3) Coaco-acromial lig. :extends between the tip of the acromion & the lat-border of the coracold process.. (4) Coraco-clavicular lig: has 2 parts: conoid & trapezoid: (a) the conoid part: attached to a tubercle on the med-border of the coracoid process (b) the trapezoid part: attached to the upper surface of the coracoid process. (5) Coraco-humeral lig: attached to the lat. border of the coracoid process (6) Supra-Scapular lig.: attached across the suprascapular notch changing it into foramen -through the foramen passes the suprascapular nerve. –above the foramen passes the suprascapular vessels. 7 ‫الصفحة‬ ‫مت التحويل بواسطة اللجنة العلمية للدفعة السادسة – طب بشري‬  UPPER LIMB BY DR.SAMEH DOSS (PH.D) 2- MUSCLES ATTACHED (A) 2 muscles are attached to the costal surface: (1) Subscapularis muscle: arises from the med. 3/4 of the subscapular fossa. (2)Serratus ant. m. : inserted into the ventral lip of the medial border. (B)2 muscles are attached to the dorsal surface: (1) Supraspinatus m.: arises from the med. 2/3 of the supraspinous fossa. (2)infraspinatus m. : arises from the med. 2/3 of the infraspinous fossa. ( c) 2 muscles are attached to the Spine & the acromion: (1) Deltoid m.: arises from lower lip of crest of spine + the lat.border of acromion. (2) Trapezlus m.: inserted into upper lip of crest of spine+themed border of acromion. (D) 2 muscles are attached above & below the glenoid cavity: (1) long head of biceps m.: arises from the supraglenoid tubercle. (2) long head of triceps m.: arises from the infraglenoid tubercle. (E) 3 muscles are attached to the dorsal aspect of lat -borde (1) teres minor m.: arises from the upper 2/3 of dorsal aspect of lat.border (2) teres major m-: arises from the lower1/3 of dorsal aspect of lat.border (3) latissimus dorsi m-: arises from the dorsal aspect of lat.border at the Inf-angle (F) 3muscles are attached to the dorsal aspect of the medial border: (1) Levator scapulae: it is insertion extends from the sup.angle to the root of spine. (2) Rhomboideus minor: it is Inserted opposite the root of the spine. (3) Rhomboideus major: is inserted into this border from the root of spine to the Inf.angle. (G) 3 muscles are attached to the coracoid process: (1) Pectoralis minor: inserted into med border &upper surface of the coracoid pr. (2) Coracobrachialis m. have common origin from the tip of the coracoid pr. (3) short head of biceps: have common origin from the tip of the coracoid pr. (H) 1 muscle is attached to the upper border of the scapula: (1) inf-belly of omohyoid m. : arises from the suprascapular lig.&the adjoining part of the sup. border. 8 ‫الصفحة‬ ‫مت التحويل بواسطة اللجنة العلمية للدفعة السادسة – طب بشري‬  ‫)‪UPPER LIMB BY DR.SAMEH DOSS (PH.D‬‬ ‫الصفحة ‪9‬‬ ‫مت التحويل بواسطة اللجنة العلمية للدفعة السادسة – طب بشري‬  UPPER LIMB BY DR.SAMEH DOSS (PH.D) 2-THE CLAVICLE -It is the ant.bone of the Shoulder girdle 1-Type: it is a non-typical long bone as: (1) it has no medullary Cavity. (2) it develops by membranous ossification 2-structure: it is formed of spongy bone Covered by a layer of Compact bone. 3-Anatomical position: it lies horizontally at the root of the neck. Almost all its parts can be felt subcutaneously. 3-Identification of the Side (Rt-or Lt.): (1) the lateral (acromial) end is flatte ned. (2) the medial (sternal) end is thick & rounded (3) the upper surface is almost smooth. (4) the lower surface is rough & shows a shallow groove in its intermediate1/3. (5) the med. 2/3 of the shaft is convex forwards. (6) the lat. 1/3 of the shaft is Convex backwards 4-Functions of the clavicle: 1) it transmits weight & forces from the upper limb to the axial skeleton 2) it braces back the shoulder thus allowing the upper limb to be suspended free away from the trunk. 5-Articulations of the Clavicle: (1) its medial or sternal end articulates with the clavicular notch of the manubrium Sterni (sternoclavicular Joint) (2) its lateral or acromial end articulates with the acromion process of the scapula (acromio-clavicular joint). 11 ‫الصفحة‬ ‫مت التحويل بواسطة اللجنة العلمية للدفعة السادسة – طب بشري‬  UPPER LIMB BY DR.SAMEH DOSS (PH.D) GENERAL FEATURES OF THE CLAVICLE -the clavicle has a shaft & 2 ends (med- & lat.) (I) the medial (sternal) end : 1- is large, rounded or quadrangular in shape. 2-it presents a smooth facet for articulation with the clavicular facet of the manubrium sterni. 3-the lower part of the facet extends slightly on the inf-surface of the med end for articulation with the 1st costal cartilage (Fibrous Joint). 4- the rough area above the articular facet gives attachment to the inter clavicular ligament. (2)-the lateral (acromial) end: 1-is Flattened & Carries an oval facet for articulation with the acromion process of scapula. at the acromioclavicular joint (3) the Shaft of the clavicle: 1-presents a double curvature resembling the letter S. 2- its med. 2/3 is convex Forwards while its lat.a is Convex backwards 11 ‫الصفحة‬ ‫مت التحويل بواسطة اللجنة العلمية للدفعة السادسة – طب بشري‬  UPPER LIMB BY DR.SAMEH DOSS (PH.D) The rt. Clavicle (reflected to show it's lower surface) Lateral 3 of the shaft Medial 2/3 of the Shaft it is convex backwards to it is convex Forwards to widen the space behind it Direction meet the acromial process of for the passage of the vessels & nerves passing the scapula. from the root of the neck to the axilla t is flattened, having ant- it is cylindrical in form having ant post. upper & &post. borders, upper & lower surfaces: shape lower surfaces: Ant. aspect it's ant.border is rough & It's ant. surface is rough medially (for origin of may present a small tubercle pectoralis major m.) called the deltoid tubercle Upper surface it's upper surface: is smooth. It's upper surface is smooth It's lower surface is rough & It's lower surface is rough & shows: shows: (a) a rough depressed impression near the med-end for (a) Conoid tubercle: a prominent the attachment of the costo-clavicular ligament. tubercle close to the post border (b) a groove for insertion of the subclavius m. In the (at the junction of the lat.1/3 intermediate 1/3 of the lower surface. Lower &med.2/3 of the shaft). it gives (c) a nutrient foramen (commonly directed laterally) lies surface attachment to the conoid part of in the subclavius groove. the coraco-clavicular lig. (b) trapezioid line: a rough line extending from the conoid tubercle to the acromial end It gives attachment to the trapezoid part of the coraco-clavicular lig 12 ‫الصفحة‬ ‫مت التحويل بواسطة اللجنة العلمية للدفعة السادسة – طب بشري‬  UPPER LIMB BY DR.SAMEH DOSS (PH.D) PARTICULAR FEATURES OF THE CLAVICLE 13 1-MUSCLES ATTACHED (A) 2 muscles arise from the ant-aspect of the clavicle: 1-pectoralis major m: From the med 1/2 of the ant. aspect 2- Deltoid m.: From the lat. 1/3 of the ant.aspect. (B) 2 muscles are attached to the post aspect of the clavicle: (1) Sternomastoid m. (origin): from the med. 1/3 of post.&upper surfaces. (2) trapezius m. (insertion): into the lat. 1/3 of post. aspect (C)one muscle (the subclavius) is inserted into the middle of the inf. surface. 1-LIGAMENTS ATTACHED (1) Coraco-clavicular ligament: 1-it is a very strong lig. connecting the lower surface of the lat 1/3 of the clavicle to the upper surface of the coracoid process of scapula. 2- it has 2 parts: (a) conoid part: attached to the conoid tubercle (b) trapezoid part: attached to the trapezoid line 3- importance: it transmits most of the weight of the upper limb to the clavicle 13 ‫الصفحة‬ ‫مت التحويل بواسطة اللجنة العلمية للدفعة السادسة – طب بشري‬  UPPER LIMB BY DR.SAMEH DOSS (PH.D) (2) Costo-Clavicular ligament:. a- it connects the inf. surface of the med. end of the clavicle to the 1st costo.chondral Junction. b-importance: Fixation of the med-end of the clavicle &prevention of excessive elevation of the clavicle. (3) Inter-clavicular ligament: 1-it connects the medial ends of the 2 clavicles, Crossing above the sternum. 2- it is the only connection between the bones of the Rt.&Lt-upper limbs Differences between the male & female Clavicle: Female clavicle Male Clavicle shorter,thinner,smoother & less curved longer, thicker, more curved has more prominent muscular impressions. has less prominent muscular impressions in the living, the acromial end is slightly the acromial end lies on the same level as below the level of the sternal end the Sternal end. OSSIFICATION OF THE CLAVICLE see page 137 SUBCUTANEOUS BONY LANDMARKS: the whole shaft & the 2 ends of the Clavicle are subcutaneous. CLINICAL IMPORTANCE OF THE CLAVICLE 1-it is one of the most commonly fractured bones in the body. 2- the most common site of fracture is the junction between the med. 2/3 & the lat.1/ 3 of the shaft (a weak point). 3- the cause of the fracture is commonly an indirect force eg. Falling on the outstretched hand. 4-the effect of the fracture depends. on its site: (a) if the fracture is med. to the attachment of the Coraco Clavicular lig drop of the shoulder occurs. (b) if the fracture is lat-to the ligament, no drop occurs. 14 ‫الصفحة‬ ‫مت التحويل بواسطة اللجنة العلمية للدفعة السادسة – طب بشري‬  UPPER LIMB BY DR.SAMEH DOSS (PH.D) Right Humerus 1-Type: it is a typical long bone. It develops by Cartilagenous ossification. 2-Position: it is the bone of the arm. 3-identification of the Side (Rt. or Lt.): 1-the upper end is identified by the hemispherical head 2- the lower end is identified by the trochlea & capitulum 3-the med side is identified by the head (directed medially). 4-the post-surface is identified by the deep olecranon fossa in the lower end 15 ‫الصفحة‬ ‫مت التحويل بواسطة اللجنة العلمية للدفعة السادسة – طب بشري‬  UPPER LIMB BY DR.SAMEH DOSS (PH.D) GENERAL FEATURES OF THE HUMERUS -the humerus is composed of a shaft & 2 expanded ends: upper & lower (1) THE UPPER END : Head 2 tuberosities (greater & lesser). 2 necks (anatomical & surgical). (A) the head of the humerus: 1-forms less than 1/2 sphere &covered with articular cartilage (in the living). 2-it is directed upwards, medially & backwards. 3-it articulates with the glenoid Cavity of the scapula at the shoulder joint. (B) the Anatomical neck: 1- it is the constriction close to the margins of the head separating it from the tuberosities. 2-it gives attachment to the Capsule of Shoulder Joint (except medially where the Capsule descends For 1cm. to reach the surgical neck). (C) the Surgical neck: 1-it is the junction between the upper end & the shaft 2- it lies about one finger breadth below the head & the 2 tuberosities. 3- it is related medially to the circumflex n. &post.circumflex humeral vessels. (D) Lesser tuberosity: 1-it projects forwards medial to the intertubercular sulcus. 2-it shows one facet on its upper part (for the subscapularis m.). 3-its lat-edge is continuous below with the med-lip-of the bicipital groove. (E) Greater tuberosity: 1-lies on the lat- part of the upper end of the humerus 2-its ant-margin is continuous below with the lat-lip of the bicipital groove. 3- it shows 3 facets for muscular attachments on its upper & post-aspects (F) the intertubercular sulcus (bicipital groove): 1-it lies between the 2 tuberosities &extends to the upper1/3 of the shaft. 2-it has a floor & 2 lips (med- &lat.) For muscular attachments. 3-it lodges the tendon of the long head of biceps m. 4-its upper part is bridged-over by the transverse humeral lig 16 ‫الصفحة‬ ‫مت التحويل بواسطة اللجنة العلمية للدفعة السادسة – طب بشري‬  UPPER LIMB BY DR.SAMEH DOSS (PH.D) (2) THE LOWER END (A) the articular parts: -include the trochlea & the Capitulum representing modified condyles of lower end. (1) the trochlea: 1-it is a pully-like process Covering the ant.,inf &post.parts of the medial articular part of lowerend. 2-it articulates with the trochlear notch of ulna. 3-its med lip projects more down than the lat.lip. (2) the Capitulum: 1-it is a small ball-like process lying lat.to the trochlea. 2-it covers the ant-&inf.surfaces only of the lat. part of the of the articular surface of the lower end. 3-it articulates with the upper surface of the head of radius. (B) The epicondyles: (1)Med.epicondyle: 1-it projects from the med side of the lower end 2-it is more prominent than the lat.epicondyle &, is subcutaneous. 3-its ant-surface shows a rough impression for muscular attachment 4- its post surface may show a shallow groove (for ulnar nerve). (2) Lat-epicondyle: 1-it projects from the lat.side of the lower end (less prominent than med.epicondyl). 2-its ant- & lat. surfaces show rough impressions for muscular attachments. (C) The 3 fossae: (1) Olecranon fossa: 1-it is a deep depression on the post.surface of the lower end above the trochlea 2-it lodges the tip of the olecranon process of ulna when the elbow is extended. (2) Radial Fossa: 1-it is a very shallow depression on the ant-surface of the lower end above capitulum. 2- it receives the margin of the head of radius in full flexion of elbow. (3)Coronoid fossa: 1-a shallow depression above the trochlea on the ant-surface of the lower end 2-it receives the tip of the coronoid process of ulna in Full Flexion of elbow. 17 ‫الصفحة‬ ‫مت التحويل بواسطة اللجنة العلمية للدفعة السادسة – طب بشري‬  UPPER LIMB BY DR.SAMEH DOSS (PH.D) (3) THE SHAFT OF THE HUMERUS 1- it has 3 borders &3 surfaces. 2- its upper1/2 is rounded in cross-section 3- its lower 1/2 is triangular in cross-section Borders of the humerus (1) Anterior border: 1-its upper part forms the lat.lip of the bicipital groove 2-its middle part forms the ant boundary of the deltoid tuberosity 3-its lower part is smooth & rounded. (2) Medial border: 1-it extends from the lesser tuberosity above to the med.epicondyle below. 2-its upper part is ill defined while its lower end (above the med. epicondyle) is prominent & called med.supra condylar ridge. (3) Lateral border: 1-it extends from the back of the greater tuberosity above to the lat.epicondyle below. 2-its lower part is prominent & called lat.supra condylar ridge Surfaces of the humerus 1-Anteromedial surface: 1-lies between the ant- & med-borders 2-its uppers presents the bicipital groove Shaving Floor & 2 lips lat & med.). 3-a little below its middle it shows a nutrient foramen (directed downwards) (2) Antero lateral surface: 1-lies between the ant.&.the lateral borders 2- its middle part shows a v-shaped rough area (deltoid tuberosity) (3) Posterior surface: 1-lies between the med.& lateral borders. 2- its upper 1/3show an oblique ridge passing downwards &laterally. 3- its middle1l3 is crossed by the spiral groove (for radial n.) passing downwards & laterally. 18 ‫الصفحة‬ ‫مت التحويل بواسطة اللجنة العلمية للدفعة السادسة – طب بشري‬  UPPER LIMB BY DR.SAMEH DOSS (PH.D) ANGLES OF THE HUMERUS (1) the carrying angle: it is the angle between the long axis of the arm & the long axis of the forearm &it is about 165° -Cause of this angle: the med.lip of the trochlea projects downwards Causing lateral deviation of the ulna. (2) Angle of torsion: it is the angle between the long axis of the upper end & the long axis of the lower end of humerus. It is also 165 NERVES RELATED TO THE HUMERUS (1) circumflex (axillary) : post-circumflex humeral vessels curve around the surgical neck. (2) radial nerve (accompanied by the profunda brachii vessels) pass in the spiral groove of the humerus. (3) ulnar nerve (accompanied by sup-ulnar collateral vessels). pass behind the med-epicondyle N.B: the above mentioned nerves are liable to be injured in Fractures of the humerus because they lie in contact with the bone. PARTICULAR FEATURES OF THE HUMERUS I-LIGAMENTS ATTACHED (1) Capsule of shoulder joint: attached to the anatomical neck except medially where it descends for 1cm. to reach the surgical neck. (2) Coracohumeral lig: attached to the greater tuberosity & the upper most part of the anatomical neck (3) glenohumeral ligaments: sup.,middle & inferior: 1-the sup. is attached just above the lesser tuberosity. 2-the middle is attached just below the lesser tuberosity. 3- inferior. is attached to the lower part of the anatomical neck (4) transverse humeral lig.: attached between the 2 tuberosities across the upper part of the inter tubercular sulcus. (5) the lat.intermuscular septum : attached to the lat. supracondylar ridge & lat. border of humerus. (6) the med. intermuscular septum : attached to the med.supra condylar ridge & med. border of humerus. (7) Capsule of the elbow joint: attached around the articular surfaces of the lower end above the 3 fossae. 19 ‫الصفحة‬ ‫مت التحويل بواسطة اللجنة العلمية للدفعة السادسة – طب بشري‬  UPPER LIMB BY DR.SAMEH DOSS (PH.D) I-MUSCLES ATTACHED (A)3 muscles are inserted into the greater tuberosity : S-I-T (1) Supra-spinatus m. : inserted into the uppermost facet of greater tuberosity. (2) Infra.spinatus m.: inserted into the middle facet of the greater tuberosity. (3) Teres minor m.:inserted into the lower facet of the greater tuberosity. (B)3 muscles are inserted into the bicipital groove: T-L-P (1) Teres major m. inserted into the Med lip of the bicipital groove. (2) Latissimus dorsi m. : inserted into the floor of the bicipital groove. (3) Pectoralis majorm :. inserted into the lat.lip of the bicipital groove. (C) Subscapularis m: is inserted into the Lesser tuberosity. (D) the B-C-D muscles (1) Brachialis m. : arises from the lower½ of ant aspect of the shaft. (2) Coraco brachialis: inserted into middle of the medial border of humerus. (3) Deltoid m. inserted into the deltoid tuberosity. (E) 3 muscles arise from the supracondylar ridges: (1) Brachio.radialism: arises from the uppers2/3 of the lat.supra condylar ridge. (2) Ext-Carpi radialis langus: arises from the lower 1/3 of the lat.supra condylar ridge (3) Pronator teres (humeral head): arises from the lower part of med. supracondylar ridge. (F)3 muscles arise from the back of the humerus : (1)lat head of triceps: arises from oblique ridge in the upper 1/3of post.surface. (2) med. head of triceps: arises from the whole post.surface below the spiral groove. (3) anconeus.: arises from the back of the lat.epicondyle. (G) muscles arising from the front of the epicondyles: (1) Common Flexor origin (c-f-o): From the front of the med. epicondyle. (2) Common extensor origin (ce-o) From the front of the lat. epicondyle. - OSSIFICATION OF THE HUMERUS: See page 137 -SUBCUTANEOUS BONY LANDMARKS: (1)the lateral epicondyle & lateral supracondylar ridge. (2) the medial epicondyle & medial supracondylar ridge. 21 ‫الصفحة‬ ‫مت التحويل بواسطة اللجنة العلمية للدفعة السادسة – طب بشري‬  ‫)‪UPPER LIMB BY DR.SAMEH DOSS (PH.D‬‬ ‫الصفحة ‪21‬‬ ‫مت التحويل بواسطة اللجنة العلمية للدفعة السادسة – طب بشري‬  UPPER LIMB BY DR.SAMEH DOSS (PH.D) THE RADIUS : Type: typical long bone, it develops by cartilagenous ossification. Site: it is the lat.bone of the forearm, it lies parallel to the ulna in supination but crosses it in pronatio Identification of the side (RT. OR LT.): The upper end carries a disc shaped head The lower end is expanded and carries a styloid process. The shaft is convex laterally and has a sharp interosseous border medially. The ant.surface of the lower end is smooth and concave. OSSIFICATION OF THE RADIUS: SEE PAGE 137. 22 ‫الصفحة‬ ‫مت التحويل بواسطة اللجنة العلمية للدفعة السادسة – طب بشري‬  UPPER LIMB BY DR.SAMEH DOSS (PH.D) GENERAL FEATURES: The radius is formed of a shaft and 2 ends (upper and lower) (a)THE UPEER END Formed of: head, neck and tuberosity. (1)The head (disc-shaped): Its concave upper surface articulates with the capitulum of humerus. Its circumference articulates partially with radial notch of ulna and partially with annular lig. Of the sup.radio.ulnar joint. (2)THE NECK: It is the constricted part just below the head. The lower part of the annular lig. is loosely attached to the neck. (3)THE RADIAL TUBEROSITY: It lies below the medial part of the neck. Its post.rough part receives the insertion of the biceps tendon. Its ant.smooth part is related to bursa separating it from the biceps tendon (B)THE LOWER END: It is the widest part of the radius, it has 5 surfaces and styloid process. (A)The ant.surface: is smooth and slightly concave. (B) The post.surface: is rough and convex, it shows: 1-A prominent ridge called dorsal tubercle of lister (it can be felt, in the living, in line with the cleft between the index and middle fingers). 2-Lat.to the dorsal tubercle there is a wide groove. 3-Med. to the dorsal tubercle there are 2 grooves. (C)The lateral surface: Projects downwards beyond the rest of the bone forming the styloid process, which can be felt subcutaneously in the anatomical snuff-box. -The styloid process of radius projects 1cm. below the styloid process of ulna. --It gives attachment to the lat.lig. of the wrist joint 23 ‫الصفحة‬ ‫مت التحويل بواسطة اللجنة العلمية للدفعة السادسة – طب بشري‬  UPPER LIMB BY DR.SAMEH DOSS (PH.D) (D)The inferior surface: It is smooth, concave and is divided by a faint ridge into. 1-Lat. Triangular area for articulation with scaphoid 2-Med. quadrangular area for articulation with lunate. (E)The medial surface: -It is concave, forming the ulnar notch of radius wich articulates with the head of ulna (inf.radia.ulnar joint) -The ridge at the lower margin of the notch gives attachment to the base of the triangular articular disc of the inf.radio.ulnar joint. The shaft of the radius: It has 3 borders and 3 surfaces: 1-The interosseous border: -It is the sharpest border and directed medially. – It is begins below the radial tuberosity and ends distally by dividing into 2 lines enclosing a narrow triangular area above the ulnar notch. -The upper 2/3 of this border gives attachment to the interosseous membrane. 2-The anterior border: - -Begins anterolateral to the radial tuberosity -Its upper part is called the ant.oblique line. -Its lower part forms the sharp lat.margin of the lower end. 3-The posterior border: -Starts above postero-inferior to the radial tuberosity. -Its upper part is oblique (post-oblique line) -Its ends below at the dordsal tubercle of lister. 4-Anterior surface: (between the ant. and interosseous borders): -Its upper 1/3 presents a nutrient foramen(directed towards the elbow). 5-Posterior surface: is rather flat and lies between the post. and interosseous borders. 6-Lateral surface: is convex and lies between the ant. and post. borders. -It presents a rough impression(pronator tuberosity) at its middle. Subcutaneous bony landmarks of radius: 1-Back of the head : felt on the back of elbow just below the lat. Epicondyle. 2-Post. surface of the lower end. 3-The styloid process (felt in the anatomical snuff-box. 24 ‫الصفحة‬ ‫مت التحويل بواسطة اللجنة العلمية للدفعة السادسة – طب بشري‬  UPPER LIMB BY DR.SAMEH DOSS (PH.D) PARTICULAR FEATURES MUSCLES ATTACHED A) Biceps tendon : inserted in the post. part of the radial tuberosity (B) 3 muscles are atteched to the ant. aspect of radius (1) flexor digitorum superficialis ( radial head ) : arises from ant. oblique line. (2) flexor pollicis longus : arises from the upper 2/3 of ant. Surface ( below ant. obl. line ) (3) pronator qudratus : inserted into the lower 1/4 of ant. surface of radius. (C) 3 muscles are inserted into the lateral aspect of radius : (1) supinator m. : inserted into the upper 1/3 of the shaft ( between ant. & post. oblique lines ). (2) pronator teres : inserted into the pronator tuberosity ( in the middle of the lat. surface ). (3) brachioradialis : inserted into the lower end of the lat. Surface ( above the styloid process ). (D) 2 muscles arise from the post. surface : (1) abductor pollicis longus : arises from the middle 1/3 of post. Surface ( below post. oblique line ). (2) extensor pollicis brevis : arises from the lower 1/3 of post. surface.( below Abd. poll. longus ). 25 ‫الصفحة‬ ‫مت التحويل بواسطة اللجنة العلمية للدفعة السادسة – طب بشري‬  UPPER LIMB BY DR.SAMEH DOSS (PH.D) 5 - THE ULNA ▪Type : typical long bone. it develops by cartilagenous ossification. ▪ Site : it is the medial bone of the forearm. ▪Identification of the side ( Rt. or Lt. ) : (1) the upper end is large & hook like ( trochlear notch ) (2) the lower end is smaller & carries head & styloid process. (3) the concavity of the trochlear notch is directed forwards. (4) the lateral ( interosseous ) border is sharp. ▪Ossification : see page 137. 26 ‫الصفحة‬ ‫مت التحويل بواسطة اللجنة العلمية للدفعة السادسة – طب بشري‬  UPPER LIMB BY DR.SAMEH DOSS (PH.D) GENERAL FEATURES ▪it consists of a shaft & 2 ends : upper and lower. (A) THE UPPER END ▪it is hook-shaped having : 1- 2 process : coronoid & olecranon 2-2 notches : trochlear & radial 3-2 muscular impressions : ulnar tuberosity & supinator fossa. (1) olecranon process : ▪forms the uppermost part of ulna & upper part of the trochlear notch. ▪it is bent forwards to form a prominent beak. ▪it lodges into the olecranon fossa of humerus ( in full extension ). ▪its post. part is smooth & subcutaneous. (2) coronoid process : ▪it projects forwards like a broad beak. ▪its upper surface forms the lower part of trochlear notch. -its ant. surface shows a rough area called the ulnar tuberosity. - -its ant. border lodges into the coronoid fossa of humerus ( in full flexion ). (3) trochlear notch : -it is formed by the ant. surface of olecranon pr. & upper surface of coronoid pr. -it articulates with the trochlea of the humerus. (4) Radial notch : ▪lies on the lat. surface of the coronoid process. ▪it articulates with the circumference of head of radius in sup.radio.ulnar joint. (5) Ulnar tuberosity : ▪it is the rough area at the ant. surface of the coronoid process. ▪it receives the insertion of the brachialis muscle. (6) supinator fossa & crest : ▪ it is the depressed area lying below the radial notch ▪it is bounded posteriorly by a sharp ridge called the supinator crest. ▪the supinator fossa & crest give origin to the supinator muscle. 27 ‫الصفحة‬ ‫مت التحويل بواسطة اللجنة العلمية للدفعة السادسة – طب بشري‬  UPPER LIMB BY DR.SAMEH DOSS (PH.D) (B) THE LOWER END ▪it is smaller than the upper end & formed of head & styloid process. (1) the head of ulna : -it is rounded , directed laterally & can be felt subcutaneously ( in pronation ). -its lat. surface articulates with ulnar notch of radius (in the inf.radio-ulnar joint) -its lat. surface is separated from the carpal bones by triangular articular disc. -its post. surface is separated from the styloid process by a groove. (2) the styloid process : - it projects downwards from the posteromedial part of the head. -it can be felt subcutaneously ( in the supination position ). (C) THE SHAFT OF ULNA -it is thick above but tapers towards the lower end. -its upper 3/4 is triangular in cross section while its lower 1/4 is rounded. -it has 3 borders ( ant. , interosseous & post. ) & 3 surfaces ( ant. , med & post. ) (1) interosseous border : -it is sharp ,directed laterally & gives attachment to the interosseous membrane. -its upper end is continuous with the supinator crest. (2) Anterior border : -it is rounded & starts above at the lower end of med. border of coronoid process. -it ends below at the base of the styloid process. (3) posterior border : -is prominent & starts above at the apex of post. surface of olecranon process. it is subcutaneous & ends below at the base of the styloid process. (4) the anterior border ( between the ant. & interosseous borders ) : its upper 1/3 presents a nutrient foramen ( directed towards the elbow ). (5) the medial surface ( between the ant. & post. borders ) : -it is smooth & featureless. (6) the posterior surface ( between the interosseous & post. borders ) : it may present an oblique ridge in its upper 1/3 & a vertical ridge in its lower 2/3. 28 ‫الصفحة‬ ‫مت التحويل بواسطة اللجنة العلمية للدفعة السادسة – طب بشري‬  UPPER LIMB BY DR.SAMEH DOSS (PH.D) PARTICULAR FEATURES MUSCLES ATTACHED (A) 6 muscle are attached to the upper end : (1) Triceps m. : iserted into the post. part of upper surface of olecranon process. (2) Anconeus m. : inserted into the lat. sarface of olecranon pr. & upper 1/4 of post. surface. (3) Brachialis m. : inserted into the ulnar tuberosity. (4) Supinator m. : arises from the supinator fossa & crest. (5) flexor digitorum superficialis ( ulnar head ) : arise from med. border of the coronoid process. (6) pronator teres m. (ulnar head ) : arise from med. border of the coronoid process. (B) 2 muscles are attached to the ant. & medial surfaces : (1) flexor digitorum profundus : arises from the upper 3/4 of ant. & med. surfaces. (2) pronator quadratus : arises from the lower 1/4 of the ant. surface of ulna. 29 ‫الصفحة‬ ‫مت التحويل بواسطة اللجنة العلمية للدفعة السادسة – طب بشري‬  UPPER LIMB BY DR.SAMEH DOSS (PH.D) (C) 3 muscles arise from the posterior surface : (1) abductor pollicis longus (2) extensor pollicis longus (3) extensor indicis arise in that order ( from above downwards ) from the upper 2/3 of the post. surface. (D) 3 muscles arise from the post. border of ulna : (1) flexor carpi ulnaris ( ulnar head ) (2) extensor carpi ulnaris (3) flexor digitorum profundus arise by common aponeurosis called ulnar aponeurosis from the post. border. - SUBCUTANEOUS BONY LANDMARKS : (1) the olecranon process & the whole post. border of ulna. (2) the head of ulna : felt in the position of pronation (3) the styloid process : felt in the position of supination. STRUCTURES CONNECTING RADIUS AND ULNA structure attachment to radius attachment to ulna 1-annular lig. surrounds the head & attached to the ant. & loosely attached to the post. borders of the neck of radius radial notch 2-quadrate lig. its lat. end is attached its med. end is attached to the med. side of the just below the radial neck of radius notch 3-oblique cord attached just below the attached to the lat. side radial tuberosity of the ulnar tuberosity below quadrate lig. 4-interosseous attached to the to the interosseous membrane interosseous border of border of ulna radius 5- capsule of attached around the articular surfaces of the inf.radio.ulnar joint lower ends of radius & ulna 6-articular disc of inf. its base is attached to its apex is attached to radioulnar joint inf. border of the ulnar the depression at base notch of radius of the styloid process N.B : the supinator & pronator teres muscles also connect the radius & ulna together. 31 ‫الصفحة‬ ‫مت التحويل بواسطة اللجنة العلمية للدفعة السادسة – طب بشري‬  UPPER LIMB BY DR.SAMEH DOSS (PH.D) 6- SKELETON OF THE HAND -the skeleton of the hand is divided into 3 segment consist of 8 short bones arranged in 2 rows : (A) proximal row : formed of 4 bones (bones of the wrist) 1-scaphoid 2-lunate 3-triquetral carpal bones 4-pisiform ( from lat. to med. ) (B) distal row : formed of the following 4 bones : 1-trapezium 2-trapezoid 3-capitate 4-hamate (from lat. to med. ) consist of 5 short long bones which are numberd from Metacarpals the palm ) ( bones of lat. to med. i.e the 1st belongs to the thumb while the 5th belongs to the little finger consist of 14 miniature long bones ( bones of the fingers ) which are arranged as follows : phalanges (A) the thumb has only 2 phalanges : proximal & distal (B) each of the med. : 4 fingers has 3 : proximal , middle & distal 1.CARPAL BONES (1) scaphoid bone : ( scaphoid = boat shape ): - it has a prominent tubercle which projects anterolaterally from its palmar surface. - it articulates with : 1) the radius ( proximally ), 2) with trapezium & trapezoid bones ( distally) & 3) with the lunate bone ( medially ). (2) lunate bone : ( cresntic in shape ) : - it has a large ant. surface & narrow post. surface -it articulates with the radius proximally & with capitate bone distally (3) Triquetral bone : ( pyramidal in shape ): -it articulates : (a) proximally wih the articular disc of ulna , (b) distally with tha hamate bone & (c) anteriorly with the pisiform bone )4) pisiform bone : (pea-shaped ) - it articulates with the palmar surface of the triquetral bone only -it is considered as a sesamoid bone within the tendon of flexor carpi ulnaris m. 31 ‫الصفحة‬ ‫مت التحويل بواسطة اللجنة العلمية للدفعة السادسة – طب بشري‬  UPPER LIMB BY DR.SAMEH DOSS (PH.D) (5 ) Trapezium : (quadrangular in shape ) -its palmar surface is grooved (by fl. carpi radialis tendon ) & has a crest lat. to the groove - it articulates : proximally with scaphoid , distally with the 1st metacarpal bone & medially with trapezoid bone. (6) Trapezoid : ( irregular in shape ): it articulates with : scaphoid (proximally ) , 2nd metacarpal bone ( distally ) & trapezium ( laterally ). (7) capitate : (bone with a head ) : it is the largest carpal bone -proximally , its head articulates with the scaphoid & lunate bone -distally , it articulates with the 3rd metacarpal bone (8) Hamate :( bone with a hook ): - it has a hook anteriorly ( its distal aspect is related to the deep br. of the ulnar n. ) -it articulates : proximally with triquetral , distally with the 4th & 5th metacarpal bone & laterally with the capitate bone. 2- METACARPAL BONES -they are 5 short long bones forming the skeleton of the hand -each metacarpal bone has a shaft & 2 ends: a- base (proximal end ) which articulates with the distal row of carpal bone b- head (distal end) which articulates with the proximal phalanx of a finger N.B : - the 1st metacarbal bone is the shortest & thickest while the 2nd is the longest bone when the metacarpophalangeal joints are flexed, the heads of the metacarpal bones become prominent to form the knuckles 3- THE PHALANGES -they constitute the bones of the fingers each of the med. 4 fingers has 3 phalanges (proximal, middle & distal ) while the thumb has only 2 ( proximal & distal ). -each phalanx is a miniature long bone having a shaft & 2 ends : (a) base ( proximal end ) : the base of the proximal phalanx carries an oval concave facet. for articulation with the head of a metacarpal bone , while the base of the middle or the terminal phalanx carries 2 small concave facets separated by a smooth ridge (b) head (distal end ) : the head of the middle & proximal phalanx has a pully-shaped articular surface while the head of the terminal phalanx is tapering & non articular -ossification of the bones of the hand : see page 138 32 ‫الصفحة‬ ‫مت التحويل بواسطة اللجنة العلمية للدفعة السادسة – طب بشري‬  UPPER LIMB BY DR.SAMEH DOSS (PH.D) THE SKIN , FASCIA & MUSCLES OF THE U.L (1) THE PECTORAL REGION -definition : it is the region infront of the upper part of the chest : (1) THE SKIN OF THE PECTORAL REGION : cutaneous nerve supply : 1- the skin above the level of the sternal angle is supplied by supraclavicular nerves which are branches of the cervical plexus (C3, C4). 2- the skin below the level of the sternal angle is supplied by the ant. & lat. cutaneous branches of the 2nd, 3rd, 4th ,5th ,6th intercostal (thoracic ) nerves 3- the floor of the axilla is supplied by the intercostobrachial n. which is the lat. cutaneous branch of the 2nd intercostal n. (T2) 2) THE SUPERFICIAL FASCIA OF THE PECTORAL REGION : a) it is continuous with the superficial fascia of the neck, U.L & ant. abdominal wall. (b) it contains the following structures : (1) the mammary gland : see the breast ( page 133) (2) platysma muscle which is a thin sheet of muscle arising from the deep fascia covering the deltoid m. & upper part of pectoralis major & extending upwards to the neck 3) THE DEEP FASCIA : there are 2 types of deep fascia : (A) pectoral fascia : - it is a thin membrane which closely invests the pectoralis major - attachment : (1) above : it us attached to the clavicle (2) medially : it is attached to the front of the sternum (3) below : it is continuous with the deep fascia covering the abdominal m. &it is continuous with the axillary fascia at the lower border of pectoralis major m. (4) laterally : it is continuous with the deep fascia covering the deltoid m. B) Clavipectoral fascia : see page 36 (4) MUSCLES OF THE PECTORAL REGION : (1) pectoralis major (p.34) (2) pectoralis minor (p.35) (3) subclavius m. (p.35) (5) BLOOD SUPPLY OF THE PECTORAL REGION : (a) branches oh axillary a. : the sup. thoracic , acromiothoracic & lat. thoracic branches (b) perforating branches of internal thoracic a. : pierce the intercostal spaces to supply the front of the chest & the breast. (c) perforating branches of intercostal arteries : pierce the intercostal spaces to supply the front of the chest & the breast 33 ‫الصفحة‬ ‫مت التحويل بواسطة اللجنة العلمية للدفعة السادسة – طب بشري‬  UPPER LIMB BY DR.SAMEH DOSS (PH.D) PECTORALIS MAJOR MUSCLE - it is a huge & powerful muscle lying infront of the chest & axilla - origin : by 2 heads : (1) clavicular head : from the medial 1/2 of the ant. surface of the clavicle (2) sternocostal head : from : (a) ant. surface of the sternum (b) upper 6 costal cartilages (c) external abdominal oblique aponeurosis -insertion : by a flat bilaminar tendon into the lat. lip of bicipital groove -N. SUPPLY : medial & lateral pectoral nerves which enter the deep surface of the muscle in a reversed manner to their names -ACTION : (1)adduction & med. rotation of the arm (2) the (2)clavicular head : flexes the arm (3) the sternocostal head : extends the flexed arm (4) the muscle : can elevate the ribs ( in deep inspiration ) -RELATIONS: (A) deep relations: 1- sternum , upper 6 ribs & their costal cartilages 2- pect. minor , subclavius & serratus ant. muscle 3- clavipectoral fascia 4- axilla and its contents (B) superficial relations : 1- skin & superficial fascia containing platysma muscle & supraclavicular nerves 2- the breast 3- deep ( pectoral fascia ) (C) it's upper border : is separated from deltoid by the delto-pectoral groove which contains : 1- upper part of the cephalic v. 2- deltoid br. of thoraco-acromial a. 3- delto.pectoral L.Ns (D) it's lower border : forms the ant. Axillary fold. 34 ‫الصفحة‬ ‫مت التحويل بواسطة اللجنة العلمية للدفعة السادسة – طب بشري‬  UPPER LIMB BY DR.SAMEH DOSS (PH.D) PECTORALIS MINOR MUSCLE -it is a small triangular m. lying behind the middle 1/3 of pectoralis major -origin : from the 3rd , 4th, 5th ribs just lat. to their cartilages -insertion : into the med. border & upper surface of coracoid process of scapula - N. supply : med. pectoral n. ( from the med. cord of the brachial plexus ) which pierces the m. N.B: the muscle also receives few fibres from the lat. pectoral n. through its communication with med. pectoral n. Action : ( 1) pulls the scapula forwards ( protraction ) , thus stretching the arm to reach a far object (2) depresses the scapula ( depresses the shoulder ) (3) acting from its insertion ( when the scapula is fixed ) it can raise the ribs as in forced inspiration -important relation : a -deep relations : 2nd part of axillary a. , axillary v. & cords of the brachial.plexus. b-it is upper border : is attached to the clavipectoral fascia & related to the structures piercing it c- its lower border : is related to the lat. thoracic vessels & ant. group of axillary L.Ns SUBCLAVIUS MUSCLE -it is a small muscle lying immediately below the clavicle 1-origin : from the upper surface of the 1st rib at its junction with its costal cartilage 2-insertion : into the subclavius groove on the inf. surface of the middle 1/3 of the clavicle 3- N.supply : n. to subclavius ( C5,6) from the upper trunk of the brachial plexus 4- Action : (1) it steadies the clavicle at the sterno-clavicular joint (2) it acts as a soft pad protecting the axillary vessels & nerves from the hard clavicle 35 ‫الصفحة‬ ‫مت التحويل بواسطة اللجنة العلمية للدفعة السادسة – طب بشري‬  UPPER LIMB BY DR.SAMEH DOSS (PH.D) CLAVI-PECTORAL FASCIA Definition : it is a strong fibrous membrane of deep fascia filling the gap between pectoralis minor & the clavicle. it lies behind the clavicular head of pectoralis major it covers the axillary vessels & cords of brachial plexus -attachments : (1) above : the fascia splits to enclose the subclavius m. & then becomes attached to the lips of the subclavius groove of the clavicle (2) below : it splits to enclose the pectoralis minor m. then proceeds downwards ( as the suspensory lig. of axilla), to be attached to the deep fascia of the floor of axilla ( it is responsible for the hollow of the armpit ) (3) medially : it is attached to the 1st & 2nd costal cartilages & the ant. interosseous membrane inbetween (4) laterally : it is attached to the coracoid process & the coraco-clavicular lig. N.B : the part of the clavipectoral fascia which lies just below the subclavius m. is thickened band extending along the lower border of the muscle from the 1st rib medially to coracoid process laterally & is called the costocoracoid ligament -structures piercing the clavi-pectoral fascia : 1- the terminal part of cephalic v. ( passing deeply to join the axillary v. ) 2- the lateral pectoral n. ( passing superficially to enter pectoralis major m. ) 3- the thoraco-acromial a. ( passing superficially then divides into 4 terminal brs.) 4- efferent lymphatic vessels from the infra-clavicular L.Ns ( passing deeply to end in the apical group of axillary L.Ns ) 36 ‫الصفحة‬ ‫مت التحويل بواسطة اللجنة العلمية للدفعة السادسة – طب بشري‬  UPPER LIMB BY DR.SAMEH DOSS (PH.D) SERRATUS ANTERIOR MUSCLE -it is a fan-shaped muscle covering the upper part of the side of the chest -origin : arises by 8 digitations from the outer surfaces of the upper 8 ribs midway between their angles & their costal cartilages N.B : (1) the 1st digitation arises from the 1st & 2nd ribs (2) the lower 4 digitations interdigitate with the external abdominal oblique muscle -insertion : into the ventral lip of the med. border of the scapula as follows : (1) the 1st digitation : inserted into the ventral aspect of the sup. angle (2) the 2nd & 3rd digitations : inserted into the whole length of ventral aspect of med. border (3) the lower 5 digitations : ( the largest & most important part ) converge to be inserted into the ventral aspect of inf. angle -NERVE SUPPLY : n. to serratus ant. ( long thoracic n. or nerve of Bell ) from the roots C5,6,7 of the brachial plexus -Action : (1) it pulls the scapula forwards ( it is the most powerfull protractor ) (2) fixation of the scapula on the chest wall ( its paralysis leads to winging of the scapula ) (3) the lower 5 digitations pull the inf. angle of the scapula so that the glenoid cavity faces upwards ( as in raising the arm above the head ) (4) acting from its insertion , the muscle can elevate the ribs ( as in forced inspiration ) - important relations : 1- it enters in the formation of the medial wall of the axilla 2- its 1st digitation lies behind the 1st part of axillary a. & the med. cord of br. plexus 3- the n. to serratus ant. descends vertically on its outer surface in the midaxillary line 4- the lat. cut. branches of the intercostal nerves emerge between the digitations of the muscle - Clinical importance : paralysis of serratus ant. leads to " winging of scapula " ( the med. border projects backwards like a wing ) 37 ‫الصفحة‬ ‫مت التحويل بواسطة اللجنة العلمية للدفعة السادسة – طب بشري‬  UPPER LIMB BY DR.SAMEH DOSS (PH.D) DELTOID MUSCLE -it is a thick muscle which covers the shoulder region giving it a rounded contour -origin : v-shaped ( corresponding to insertion of trap ) (1) ant. fibres ( parallel ) : arise from the ant. aspect of the lat. 1/3 of clavicle (2) middle fibres : ( multipennate ) : arise from the lat. border of acromion (3) post. fibres : ( parallel ) : arise from the lower lip of crest of spine of scapula -insertion : into deltoid tuberosity of humerus -N. supply : circumflex ( axillary ) n. C5, 6 from post. cord of brachial plexus -Action: 1- ant. fibres : flex the arm & rotates it medially 2- middle fibres : abduct the arm from 15° to 90° 3- post. fibres : extend the arm & rotates it laterally -structures deep to the deltoid m. : (1) coraco-acromial lig. , arch & subacromial bursa (2) coracoid process & muscles attached to it ( pect. minor , coracobrachialis & biceps ) (3) muscles inserted into the greater tuberosity ( supraspin. , infraspin. & teres minor ) (4) the subscapularis m. inserted into lesser tuberosity (5) tendons of pectoralis major & long head of biceps (6) capsule of shoulder joint TRAPEZIUS MUSCLE -it is a large triangular m. extending from the back of skull to the back of thorax -origin : extensive ; from 3 areas : (1) back of skull : from med. 1/3 of sup. nuchal line + the external occipital protuberance (2) back of neck : from the ligamentum nuchae + the spine of C7 (3) back of thorax : from all thoracic spines & supraspinous ligaments 38 ‫الصفحة‬ ‫مت التحويل بواسطة اللجنة العلمية للدفعة السادسة – طب بشري‬  UPPER LIMB BY DR.SAMEH DOSS (PH.D) -insertion : v-shaped ( opposite the origin of deltoid ) : (1) upper fibres ( occipital & upper cervical ): are inserted into the post. aspect of lat. 1/3 of clavicle (2) middle fibres ( lower cervical & upper thoracic ): are inserted into med. border of acromion & upper lip of the crest of spine of scapula (3) lower fibres : ascend to be inserted by q tendon into the tubercle of the crest of spine of scapula -N. supply : (1) motor : spinal accessory n. (2) sensory ( proprioceptive ): branches from C3, 4 N.B : trapezius is the only m. in U.L not supplied by brachial plexus -Deep relations : ( rest of muscles of the back + artery + nerve ): -levator scapulae , rhomboids , lat. dorsi , supra & infraspinatus m. -spinal accessory n. & superficial br. of transverse cervical a. -Action : (1) upper fibres : elevate the scapula & shoulder ( shrug the shoulder ) (2) middle fibres : retract the scapula ( position of standing at attention of soldiers ) (3) lower fibres : rotates the scapula so that the glenoid cavity faces upwards (4) acting from its insertion , trapezius pulls the head backwards & laterally LATISSIMUS DORSI MUSCLE -it is a wide flat muscle which covers the lower 1/2 of the back ( extending down to the iliac crest ) -origin : by an aponeurosis from : (1) the lower 6 thoracic spines & supraspinous ligaments ( under cover of trapezius m. ) (2) from the lumbar spines ( through thoracolumbar fascia ) (3) from the post. part of outer lip of the iliac crest (4) outer surfaces of lower 3 or 4 ribs (5) dorsal aspect of inf. angle of the scapula -insertion : by a flat tendon into the floor of the bicipital groove of the humerus -N.supply : nerve to latissimus dorsi ( thoracodorsal n. ) from the post. cord of brachial plexus N.B : it enters the muscle with the thoracodorsal artery. 39 ‫الصفحة‬ ‫مت التحويل بواسطة اللجنة العلمية للدفعة السادسة – طب بشري‬  UPPER LIMB BY DR.SAMEH DOSS (PH.D) Action: (1) Extention, addution & med.rotation of the arm (2) It pulls the whole shoulder girdle downwards& backwards( as in swimming). (3) It can pull the trunk upwards when the arms are fixed above the head ( as in climbing). (4) It is a strong m.of expiration as it cam compress thr lower part of the thoracic cage. Important relation: -The tendon of L. Dorsi has tripple relation with teres major m. : being 1st behind teres major, then below it & finally infront of teres major at its insertion. Latissimus dorsi enters in the formation of 2 triangles: (A)△ of auscultation: bounded by: 1-Lower fibers ot trapezius: …… above 2-Upper fibers of L.dorsi:…….below 3-Med.border of scapula:……. laterally 4-Floor is formed by rhomboideus major m. (B)lumber△: bounded by: 1-Iliac crest …… ….below 2-External abd.ablique m …..infront 3-Latissimus dorsi… …behind LEVATOR SCAPULAE MUSCLE Origin: from the upper 4 cervical transverse processes. Insertion: into dorsal aspect of med.border of scapula extending from sup.angle to the root of the spine. N.supply: 1-C3, C4 ( from the cervical plexus). 2-N.to rhomboids ( C5) from brachial plexus. Action: 1-Elevate the scapula & fixes it. 2-Rotate the scapula downwards. 3-Lat.flexor of the neck ( when scapula is fixed). 41 ‫الصفحة‬ ‫مت التحويل بواسطة اللجنة العلمية للدفعة السادسة – طب بشري‬  UPPER LIMB BY DR.SAMEH DOSS (PH.D) RHOMBOIDEUS MINOR M. -Origin:lower part of ligement nuchae & spines of C7&T1. -Insertion: into dorsal aspect of med.border of sxapula opposite the root of spine. RHOMBOIDEUS MAJOR M. -Origin: spines of the 2nd, 3rd, 4th &5th thoracic vertebrae & supraspinous ligament. -Insertion: into dorsal aspect of med.broder of scapula extending from the root of spine to the inf.angle. -N.supply of the 2 rhomboids: n.to torhomboid( dorsal scapular n) from C5. -Action of the 2 rhomboids: 1-Retraction of scapula 2-Downward rotation of the scapula. SUPRASPINATUS MUSCLE -Origin: med ⅔ of supraspinatus fossa of scapula. -Insertion: upper most facet of greater tuberosity of humerus. -N.B: its tendon passes deep to the coracoacromial arch & seprated from it by the subacromial bursa. -N.supply: suprascapular n. -Action: 1-Abduction of the arm ( from 0⁰ to 15⁰). 2-Helps to keep the head of humerus in the glenoid cavity during the action of other muscles. INFRASPINATUS MUSCLE -Origin: 1-Med.⅔ of infraspinatus fossa. 2-From the fascia covering the muscle. -Insertion: into the middle facet of the greater tuberosity of the humerus. -N.supply: suprascapular n.( from upper trunk of bracial plexus). -Action: 1-Addution of the arm. 2-Lateral rotation of the arm. 3-Helps to steady the shoulder joint. 41 ‫الصفحة‬ ‫مت التحويل بواسطة اللجنة العلمية للدفعة السادسة – طب بشري‬  UPPER LIMB BY DR.SAMEH DOSS (PH.D) TERES MINOR M. -Origin : upper ⅔ of dorsal aspect of lat.border of scapula -N.B: its origin is traversed by the circumflex scapular a. -Insertion: lower most facet on the back of greater tuberosity of humerus. -N. Supply: axillary ( circumflex) n. : from its post.division. -ACTION: 1- Lateral otation of the arm 2- Addution of the arm 3-Helps to steady the shoulder joint. TERES MAJOR M. -Origin: from an oval area on the lower ⅓ of dorsal aspect of lat.border of scapula. -Insertion: into med.lip bicipital groove of thr humerus. -N. Supply: lower subscapular n. ( from the post.cord of the brachial plexus). -Action: 1-Adduction of the arm. 2-Med.rotation of the arm 3-Extension of the arm. Relations: 1-Its tendon forms the lower boundary of the quadrangular, upper tiangular spaces & upper boundary of the lower △ space. 2-The tendon of latissimus dorsi m. has a triple relation w ith teres major ( see page 40). 3-The lower border of teres major is the lower limit of axilla. 4-Both teres major & L.dorsi form the post.axillary fold. See axilla (Page 45) 42 ‫الصفحة‬ ‫مت التحويل بواسطة اللجنة العلمية للدفعة السادسة – طب بشري‬  UPPER LIMB BY DR.SAMEH DOSS (PH.D) SUPRASCAPULARIS M. -( it is a thick triangular multipennate muscle) -Origin: med. ⅔ of subscapular fossa of scapula. -Insrrtion: into the lesser tuberosity of humeru s & extending for ½ aninch on the shaft. N. Supply: upper &lower subscapular nerves ( from the post. Cord of the brachial plexus) -Action: 1-Adduction of the arm. 2-Med.rotation of the arm. 3-Helps to steady the shoulder joint. Important ralation: 1-The muscle forms the upper part of the post.wall of axilla. 2-It is supported from the serratus ant. By the cavity of the axilla. 3-It's lat.part is supported from the capsule of the shoulder joint by the subscapular bursa &is crossed superficially by the axillary vessels & the cord of the brachial plexus. 4-Its tendon passes to its insertion behind an arch formed by the coracoid process & the common origin of coracobrachialis & short head of biceps. THE RATATOR CUFF Definition: it is the name given to the subscapularis, supraspinatus, infraspinatus & teres minor ( i-e muscle inserted in the greater & lesser tuberosities because their tendons surround the shoulder joint & blend with its fibrous capsule, like a cuff, from above, behind & infrot. -Importance: these muscles reinforce the capsule of the shoulder joint & provide an active support to it during movements by pulling the head of humerus medially towards the glenoid cavity. 43 ‫الصفحة‬ ‫مت التحويل بواسطة اللجنة العلمية للدفعة السادسة – طب بشري‬  UPPER LIMB BY DR.SAMEH DOSS (PH.D) INTERMUSCULAR SPACES IN THE SHOULDER REGIO THE QUADRANGULAR SPACR: Boundaries: subscapularis ( infront) 1-Superiorly: Teres minor ( behind). Capsule of shoulder joint( inbetween). 2-Inferiorly: teres major m. 3-Laterally: surgical neck of humerus. 4-Medially: long head of triceps. -CONTENT: 1-Circumflex (axillary) nerve. pass from before backwards 2-Post.circumflex humeral vessels. 3-Fold from the capsule of shoulder joint. IMPORTANCE: this space adds to the weakness of the shoulder joint & the liability of its dislocation & the injury of the axillary nerve. THE UPPER TRIANGULAR SPACE: -Boundaries: subscapularis m. ( infront) 1- Superiorly: Teres minor muscle ( behind) Lat.border of scapula ( inbetween). 2-Inferiorly: teres major m. 3-Laterally: long head of triceps. -Content: circumflex scapular a. (3)THE LOWER TRIANGULAR SPACE: -Boundaries: 1-superiorly: teres major. 2-Medially : long head of triceps. 3-Laterally : shaft of humerus ( spiral groove). -Content: radial n. & profunda vessels. 44 ‫الصفحة‬ ‫مت التحويل بواسطة اللجنة العلمية للدفعة السادسة – طب بشري‬  UPPER LIMB BY DR.SAMEH DOSS (PH.D) THE AXILLA -Definition: the axilla or armpit is a hollowed out pyramidal- shaped space at the junction betwwen the arm & the trunk. -Site: it lies obliquely between the upper part of the arm & the upper part of the side of the chest. It is situated just above the armpit. -Shape: It is pyramidal in shape, having apex, base.& 4 walls ( ant., post., med., & lateral). (A)Apex of the axilla: -It lies in the upper part & is directed upward & medially. -It connects the axilla with the post.triangle of the neck ( it is called the cervicoaxillary canal). -It is narrow & triangular in outline& it is bounded by: 1-The middle ⅓ of the clavical anteriorly. 2-The upper border of scapula posteriorly. 3-The outer border of the 1st rib medially. It transmits the axillary vessels & cords of the brachial plexus from the root of the neck to the axilla. (B)Base ( floor) of the axilla: -It forms the lower wall of the axilla & is directed downwards & laterally. -It is formed by the skin & fascia of the armpit ( axillary fascia). -The axillary fascia is connected above to the lower border of pectoralis minor by the suspensory ligament of the axilla. (C)Anteroir wall: consist of 2 layer : 1-Superficial layer: formed by pertoralis major m. 2-Deep layer: formed by the following 3 structures: 1-Subclavius muscle 2-Clavipectoral fascia arranged from the above dowewards 3-Pertoralis minor m. 45 ‫الصفحة‬ ‫مت التحويل بواسطة اللجنة العلمية للدفعة السادسة – طب بشري‬  UPPER LIMB BY DR.SAMEH DOSS (PH.D) (D)Posterior wall: is longer &wider than the ant.wall. -Is fromed of the following 3 muscles: 1-Subscapularis m. ( filling the subscapular fossa) 2-Teres major m. 3-Latissimud dorsi laying along the lat.border of the scapula (E)Medial wall: -formed of the following bones & muscles: 1-The upper 4 or 5 ribs. 2-The intercostal muscle between the ribs. 3-The upper part of serratus ant. muscle. (F)Lateral wall: is the narrowest wall& is formed of the following bone& muscles: 1-Upper part of the humerus. 2-Short head of biceps m. 3-Coracobrachialis. N. B: the main vessels & nerves of the axilla are related to the lateral wall. -Axillary folds: (A)Ant. Axillary fold: is the lower border of the ant. Wall of axilla & is formed by the lower border of pectoralis major m. alone. -Its downward continuation is called the ant.axillary line. (B)Post. axillary fold:is the lower border of post.wall of axilla. -It is formed by both teres major & latissimus dorsi muscles& it extends lower down than ant.axillary fold. _ a line drawn as a downward continuation of the post.fold is called the post.axillary line. N. B: the midaxillary line lies midway between the ant.& post. axillary lines. Contents of the axilla: it is filled with axillary fat & contains the following structures: (1)Axillary a.& its branches: it enters the axilla through its apex then runs along its lat. wall to end at the lower border of teres major m.by becoming the brachial a. It gives 6 branches in the axilla ( it is described in detail on page 75). (2)Axillary v. & its tributaries: it enters the axilla from below ( at the lower border ot teres major) then runs upwards along the med.side of the axillary a. It leaves the axilla at its apex by becoming the subclavical v. ( it is described indetail on page 89). (3)Cords & branches of the br.plexus: are arranged ar ound the axillary a.as follows: 1-The med.cord lies behind the 1st part of the artery then med.to its 2nd part. Its brs.lies med.to 3rd pa 2-The lat.cord lies lateral to the 1st & 2nd parts of the artery &its branches lies lat.the 3rd part of the artery. 3-The post.lies lat.to the 1st part then post.to the 2nd part& its branches lies post.to the 3rd part of the artery. (4)Axillary lymph nodes: arranged in 5 groups in relation to the walls & apex of axilla( see p. 132). (5)Axillary tail of female breast: an upwards extension of the mammary gland into the axilla ( p. 133). (6)N.to serratus ant. : descends vertically on the med.wall of the axilla in the midaxillary line (7)Intercostobrachial n. : is the lat.cut.br. of T2 nerve which crosses the axilla to supply its floor. 46 ‫الصفحة‬ ‫مت التحويل بواسطة اللجنة العلمية للدفعة السادسة – طب بشري‬  UPPER LIMB BY DR.SAMEH DOSS (PH.D) THE ARM DEEP FASCIA OF ARM ( brachial fascia) : -Characters: it is thin infront & medially but thick behind & laterally. -Extension: it sends 2 fibers membranes called the med.& lat.inter - muscular septa which extend deeply among the musclea of the arm to Med.intermuscular septum Lat.intermuscular septum Extension Shorter& broader, extending from Longer & narrower, extending from med.epicondyle below to the insertion of the lat.epicondyle below to the lower coracobrachailis above. part of lat.lip of the bicipital groove above. Strenght Is stronger & thicker Weaker& thinner. Relation It seprates the brachialis anteriorly from It seprates the brachialis, med.head of triceps posteriorly. brachioradialis& ext.carpiradialis longus anteriorly from med.head of triceps posteriorly. Structures Ulnar n. & sup.ulnar collateral vessels Radial n. & ant.descending br.of plercing it pierce it before backwards at the level of profounda pierce it from behind insertion of coracobrachialis. forwards alittle below the insertion of deltoid m. Muscles arising Brachialis ( anteriorly) &med.head of Brachialis, brachioradialis, ext.carpi from it triceps ( posteriorly). radialis longus( anteriorly) &med.head of triceps ( posteriorly). be attached to the medial & lateral borders of the humerus. MUSCLES OF ARM: -The 2 intermuscular septa together with the humerus, divide the arm into 2 compartment ( ant. & post.): (A) The ant.compartment ( infront of the humerus& the 2 septa) : contains 3 muscles: (1)Biceps brachii m. : extends along the whole length of the arm. (2)Coraco.brachialis m. : lies in the upper ½ of the ant.compartment. (3)Brachialis m. : lies in the lower ½ of the ant.compartment. (B)The post.compatrment ( behind the humerus & the 2 septa) contains one m.:triceps. 47 ‫الصفحة‬ ‫مت التحويل بواسطة اللجنة العلمية للدفعة السادسة – طب بشري‬  UPPER LIMB BY DR.SAMEH DOSS (PH.D) 1.BICEPS BRACHII MUSCLE Origin: by 2 heads : long & short: (A)Long head: arises by long tendon from the supra- glenoid tubercle of scapula ( intracapsular& extrasynovial). The tendon leaves the shoulder joint br piercing the capsule between the 2 tuberosities beneath the transverse humeral lig. (B)Short head: arises from the tip of coracoid process of scapula ( by common tendon to it& coracobrachialis). Insertion: double: (1)Biceps tendon: short strong tendon inserted into the post.rough part of the radial tuberosity. N. B: 1- the tendon is seprated from the ant.smooth part of the tuberosity by a bursa. 2- the tendon may contain a sesamoid bone. (2)Bicipital aponeurosis: arises from the med.side of the biceps tendon & is inserted into the deep fascia of med.side of upper part of forearm. -N. B: the aponeurosis seprates the median cubital v. ( superficial to it) from the brachial a. & median n. ( deep to it) -N. Supply: from musculocutaneous n. ( each head is supplied separately). -Action: 1-Powerful flexor & supinator of the forearm. 2-Helps flexion of the arm. 3-The long head steadies the head of the humerus in the glenoid cavity during abduction of the shoulder joint. 4-The bicipital aponeurosis stretches the deep fascia of the forearm & protects the underlying structures( brachial a. & median n. ) Important relation: ⑴ long head of origin ⑵ the muscle belly ⑶ biceps tendon ⑷ bicipital oponeurosis -Its upper part: lies - deep to it: - medially: median n. - superficially: inside the shoulder joint musculocutaneous & brachial a. the median cubital. ( intracapsular& n.desends between it & - laterally: radial n. - deeply: extrasynovial) & is the brachialis m. the brachial artery & sorrounded by synovial - medially, the median median nerve. sheath. nerve & the brachial - its lower part: runs in artery. the bicipital groove - laterally: the cephalic undercover of the v.ascends along it's insertion of pectoralis lat.border. major & infront of the tendon o insertion of latissimus dorsi. 48 ‫الصفحة‬ ‫مت التحويل بواسطة اللجنة العلمية للدفعة السادسة – طب بشري‬  UPPER LIMB BY DR.SAMEH DOSS (PH.D) 2.CORACOBRACJIALIS MUSCLE -Origin: from the tip of coracoid process ( by a tendon commen to it & the short head of biceps) & descends along the med.side of biceps m. -Insertion: into the middle of the medial border of humerus -N. Supply: br.from the musculocutaneous n. ( before it pierces the muscle). -Action: it is a weak flexor & adductor of the arm. -N. B: the coracobrachialis represents the adductor muscle mass of U. L. Relations: the following anatomical events occur at the level of insertion of coracobrachialis: (1)The insertion of deltoid m.on the anterolateral surface of humerus. (2)Ulnar n. ( with the sup.ulnar collateral a. ) pierces the medial intermuscular septum to reach the post.compartment of arm. (3)Median n.corsses the brachial.from lat.to medial. (4)Radial n.pierces the lat.intermuscular septum. (5)Med.cut.n.of forearm pierces the deep fascia. (6)Basilic v.pierces the deep fascia. (7)The nutrient a.of humerus enters the nutrient.foramen. 3. BRACHIALIS MUSCLE -Origin: (1)from the lower ½ of the front of the humerus. (2)From med.& lat.intermuscular septa of the arm. Insertion: by short thick tendon into the ulnar tuberosity ( on the ant.surface of coronoid process of ulna). -N. Supply: (1) its med.part is supplied by musculocutaneous n. (2) its lat.part is supplied by the radial n. ( this part is considered as a part of triceps m.which has migrated forwards & fused with brachialis n.but retaining its nerve supply from the radial n. ). -Action: it is the main flexor of the elbow joint. -Important relations : (1)anteriorly: musculocutaneous n. & biceps muscle. (2)medially: median n. & brachial artery. (3)laterlly:the radial n. & descending br.of profunda artery. 49 ‫الصفحة‬ ‫مت التحويل بواسطة اللجنة العلمية للدفعة السادسة – طب بشري‬  UPPER LIMB BY DR.SAMEH DOSS (PH.D) 4-TRICEPS MUSCLE -It is the muscle occuping the post.compartment of the arm. -It is formed of three heads:long, lat. & medial. -The superficial part of the muscle is formed by the long & lat.heads while the deep part is formed by the med.head. -Origin: by three heads: 1-Long head: from the infraglenoid tubercle of scapula. 2-Lat.head: from oblique ridge on the post surface of humerus above the spiral groove. 3-Med.head:from the whole post.surface of humerus below the spiral groove + from the med.& lat.intermuscular septa of the arm. -Insertion: the 3 heads unite together about the middle of the arm forming a common tendon which is inserted into the post.part of the upper surface of the olecranon process of ulna. -N. B: few deep fibers are inserted into the capsule of the elbow joint forming the articularis cubiti m. -N. Supply: Radial n. ; supplying each head separately: -The med.head: supplied by 2 branches : one arising in the axilla & the other arising in the spiral groove. -The long head: by one branch arising in the axilla. -The lat.head: by one branch arising in the spiral groove. -Action: (1)The muscle as a whole is the main extensor of the elbow joint. (2)The long head is a weak extensor of the shoulder. It also supports the inf.aspect of the capsule of the shoulder joint when the arm is abducted above the head. (3)The articularis cubiti m. pulls up the capsule of the elbow joint during its extension. THE FOREARM DEEP FASCIA OF FOREARM (antebrachial fascia) -It has the following characters: 1-It is well developed posteriorly than anteriorly & more thickened distally than proximally. 2-It is particularly thickened infront & behind the wrist forming flexor & extensor retinacula. 3-It gives partial origin to the superficial muscles of the front & back of the forearm. 4-It is thickened along the post.border of the ulna forming ulnar aponeurosis which gives origin to 3 muscles:1- flexor carpi ulnaris. 2- extensor carpi ulnaris. 3- flexor digitorum profoundas. 51 ‫الصفحة‬ ‫مت التحويل بواسطة اللجنة العلمية للدفعة السادسة – طب بشري‬  UPPER LIMB BY DR.SAMEH DOSS (PH.D) Muscles of forearm A- The superficial group of the muscles of the front of forearm -They include 5 muscles arranged as follows (from lat. To med.): 1- pronator teres 2- flexor carpi radialis. 3- palmaris longus (may be absent) 4- flexor digitorum superficialis (lies in deeper plane) 5- flexor carpi ulnaris -General rules about these muscles: 1- Origin: -all of them arise from the front of med. Epicondyle -some of them have additional origin from other bones 2-insertion: - the pronator terse is inserted in the radius -the remaining 4 muscles are inserted in the hand 3- N. supply: -all of them are supplied by the median n. Except flexor carpi ulnaris (supplied by ulnar n.) 4- action: -all of them help in flexion of elbow joint -each m. has a specific action which is indicated by the name of the m. e.g: pronator teres: involved in pronation 51 ‫الصفحة‬ ‫مت التحويل بواسطة اللجنة العلمية للدفعة السادسة – طب بشري‬  UPPER LIMB BY DR.SAMEH DOSS (PH.D) 1. Pronator teres muscle -Origin: by 2 heads: 1-humeral head: from the lower part of the med. Supra- condylar ridge + the front of med. Epicondyle (common fl. Origin) 2-ulnar head: from the med. Border of coronoid process of ulna -Insertion: into pronator tuberosity on the middle of lat. Surface of radius at the most curved part of the bone (to give maximal range of pronation) -N. supply: median n. (it gives a branch to the m. in the cubital fossa before piercing it) -Action: 1-pronation of the forearm 2-helps flexion of the forearm -Relations: 1-its lat. Border forms the med. Boundary of the cubital fossa 2-the median n. passes between the 2 heads of the m. 3-ulnar a. passes deep to the ulnar head of the m. which separates it from the median n. 2. Flexor carpi radialis muscle -Origin: from the front of med. Epicondyle of humerus (common flexor origin) -Insertion: into palmar aspect of the bases of the 2nd & 3rd metacarpal bones -N. supply: median n. (in the cubital fossa) - action: 1-helps flexion of the elbow 2-flexion of wrist 3-abduction radial deviation of wrist Relations: 1-the m. develops a strong tendon which descends vertically in the forearm 2-at the wrist, the tendon pierces the flexor retinaculum & occupies the groove on the front of trapezium having a special synovial sheath 3-the tendon is an important land mark at the wrist: -The radial a. lies lat. To it while median n. lies med. To it 52 ‫الصفحة‬ ‫مت التحويل بواسطة اللجنة العلمية للدفعة السادسة – طب بشري‬  UPPER LIMB BY DR.SAMEH DOSS (PH.D) 3. Palmaris longus -it is a small m. with a long tendon which may be present or absent -Origin: form the common flexor origin -Insertion: 1-the superficial part of the tendon is inserted into the apex of the palmar aponurosis of the palm 2-the deep part of the tendon blends with the ant. Surface of the fl. Retinaculum of the wrist -N. supply: median n. (by a br. Arising in the cubital fossa) -Action: 1-a weak fl. Of the elbow & wrist joints 2-protects the palm by putting the palmar aponeurosis tense 4. Flexor digitorum superficialis -Origin: by 2 heads: 1-humero-ulnar head arising from: a-common fl. Origin b-med. Border of coronoid process of ulna + ulnar collateral lig. 2-radial head arising from the ant. Oblique line of radius -Course & insertion: 1-the m. develops 4 tendons about the middle of the forearm (the tendons for the ring & middle fingers are superficial to those of the index & little fingers) 2-the tendons pass through the carpal tunnel to enter the palm then diverge to enter the fibrous fl. Sheaths of the med. 4 fingers 3-on the palmar surface of the proximal phalanx, each tendon is divided by the tendon of flexor digit. Profundus into 2 slips which are inserted into the side of the front of the shaft of the middle phalanx -N. supply: median n. (by a br. Arising in the cubital fossa) -Action: 1-flexes the middle & proximal phalanges 2-flexes the wrist joint & helps flexion of the elbow -Importance relations: A-in the forearm: 1. the median n. is adherent to its deep surface 2. radial a. & superficial radial n. descend superficial to its radial head B-in the carpal tunnel: 1. its tendons lie superficial to the tendons of fl. Digit. Profundus 2. the median n. lies lat. To its tendons C-in the hand: its tendons run in the midpalmar space deep to: 1. palmar aponurosis 2. Digital brs. Of median & ulnar n. 3. the superficial palmar arch & its brs. 53 ‫الصفحة‬ ‫مت التحويل بواسطة اللجنة العلمية للدفعة السادسة – طب بشري‬