Professional Documents
Culture Documents
Ossification:
3. The posterior surface lies between the The shaft and most of the upper end ossify
posterior and interosseous borders. It is from a primary centre which appears during the
subdivided into three areas by two lines. 8th week of development.
An oblique line divides it into upper and The superior part of the olecranon ossifies from
lower parts. The lower part is further a secondary centre which appears during the
divided by a vertical line into a medial and 10th year. It forms a scale-like epiphysis which
a lateral area. The lateral part of the joins the rest of the bone by 16 years. The
posterior surface gives origin from above lower end ossifies from a secondary centre
downwards to the abductor pollicis longus. which appears during the 5th year, and joins
the extensor pollicis longus. and the with the shaft by 18 years. This is the growing
extensor indicis. end of the bone (Table 2.1).
4.
5. The pronator quadratus takes origin from CLINICAL ANATOMY
the oblique ridge on the lower part of the
anterior surface. 1. The ulna is the stabilising bone of the
forearm, with its trochlear notch
The Lower End gripping the lower end of the humerus.
On this foundation the radius: can
The lower end is made up of the head and the pronate and supinate for efficient
styloid process. The head articulates with the working of the upper limb.
ulnar notch of the radius to form the inferior 2. The shaft of the ulna may fracture
radioulnar joint. It is separated from the wrist either: alone or along with that of the
joint by the articular disc. Ulnar artery and radius. Cross-union : between the radius
nerve lie on the anterior aspect of head of ulna. and ulna must be prevented to :preserve
The styloid process projects downwards from pronation and supination of the hand.
the posteromedial side of the lower end of the 3. Dislocation of the elbow is produced by
ulna. a fall on the outstretched hand with the
Posteriorly. between the head and the styloid elbow slightly flexed. The olecranon
process there is groove for the tendon of the shifts posteriorly and the elbow is fIxed
extensor carpi ulnaris. in slight flexion.Normally in an
extended elbow, the tip of the olecranon
Side Determination lies in a horizontal line with the two
epicondyles of the humerus; and in the
1. The upper end is hook-like with its flexed : elbow the three bony points
concavity directed forwards. from an equilateral triangle. These
relations are disturbed in dislocation of ends; and each will, therefore, unite with their
the elbow. shaft at a later period than their corresponding
4. Fracture of the olecranon is common ends.
and is caused by a fall on the point of The direction of the nutrient foramen in these
the elbow. Fracture of the coronoid bones, as a rule, is opposite to the growing end.
process is uncommon, and usually The time of appearance and fusion (either of
accompanies dislocation of the elbow. various parts at one end, or with the shaft) are
5. Madelung's defonnity is dorsal given in the Table 2.1.
subluxation (displacement) of the lower
end of the ulna, due to retarded growth Importance of Capsular Attachments and
of the lower end of the radius. Epiphyseal Lines
Fracture through the middle of the shaft of the Metaphysis is the epiphyseal end of the
ulna may occur alone or in combination with a diaphysis. It is actively growing part of the
similar bone with rich blood supply. Infections in this
part of the bone are most common in the young
CLAVICLE
age. The epiphyseal line is the line of union of
metaphysis with the epiphysis. At the end of
Fracture through the upper one third of the the bone, besides the epiphyseal line is the
shaft is often accompanied with forward attachment of the capsule of the respective
dislocation of the head of the radius. This is joints.
called Monteggia fracture dislocation. So infection in the joint may affect the
metaphysis of the bone if it is partly or
Fracture of the olecranon can occur because of completely inside the joint capsule. As a
direct injury through a fall. The fracture usually corollary, the disease of the metaphysis if
involves the trochlear articular surface. inside a joint may affect the joint. So it is
Fracture of the coronoid process is rare, and is worthwhile to know the intimate relation of the
usually associated with posterior dislocation of capsular attachment and the epiphyseal line at
the elbow joint. the ends of humeral, radial and ulnar bones as
shown in Table 2.2.
Ossification of Humerus, Radius, and Ulna The carpus is made up of 8 carpal bones, which
are arranged in two rows. The proximal row is
Law of Ossification convex proximally, and concave distally. The
distal row is convex proximally and flat
In long bones possessing epiphyses at both of distally.
their ends, the epiphysis of that end which 1. The proximal row contains (from lateral to
appears fIrst is last to join with the shaft. As a medial side): (i) the scaphoid, (ii) the lunate,
corollary, epiphysis which appeared last is fIrst (iii) the triquetral, and (iv) the pisiform bones.
to join. 2. The distal row contains in the same order:
These ends of long bones which unite last with (i) the trapezium, (ii) the trapezoid, (iii) the
the shaft are designated as growing end of the capitate, and (iv) the hamate bones.
bone. In case of long bones of the upper limb,
growing ends are at shoulder and wrist joints. Identification:
This implies that, the upper end of humerus and 1. The scaphoid, is boat-shaped and has a
lower ends of both radius and ulna are growing tubercle on its lateral side.
2. The lunate is half-moon-shaped or medial side of the hook gives attachment to the
crescentic. flexor digiti minimi and the opponens digiti
3. The triquetral is pyramidal in shape and minimi.
has an isolated oval facet on the distal part
of the palmar surface. Articulations
4. The pisiform is pea-shaped and has only
one oval facet on the proximal part of its 1. The scaphoid articulates with the following
dorsal surface. bones: radius, lunate. capitate, trapezium and
5. The trapezium is quadrangular in shape, trapezoid.
and has a crest and a groove anteriorly. It
has a concavoconvex articular surface 2. The lunate articulates with the following
distally. bones: radius. scaphoid, capitate, hamate and
6. The trapezoid resembles the shoe of a triquetral.
baby.
7. The capitate is the largest carpal bone, with 3. The triquetral articulates with the following
a rounded head. bones: pisiform, lunate, hamate and articular
8. The hamate is wedge-shaped with a hook disc of the inferior radioulnar joint.
near its base.
4. The pisiform articulates with the triquetral.
ATTACHMENTS 5. The trapezium articulates with the following
bones: scaphoid, fIrst and second metacarpal
There are four bony pillars at the four comers and capitate.
of the carpus. All attachments are to these four
pillars. 6. The trapezoid articulates with the following
bones: scaphoid, trapezium, second metacarpal
1. The tubercle of the scaphoid gives and capitate.
attachment to: (i) the flexor retinaculum; and
(ii) a few fibres of the abductor pollicis brevis. 7. The capitate articulates with the following
2. The pisiform gives attachment to: (i) flexor bones:
carpi ulnaris, (ii) flexor retinaculum, (iii) scaphoid, lunate, hamate, 2nd, 3rd and 4th
abductor digiti minimi, and (iv) extensor metacarpals and trapezoid.
retinaculum. 8. The hamate articulates with the following
3. The trapezium has the following bones: lunate, triquetral, capitate, and 4th and
attachments: 5th metacarpals.
(i) The crest gives origin to the abductor
pollicis brevis, flexor pollicis brevis, and CLINICAL ANATOMY
opponens pollicis.
These constitute muscles of thenar eminence. 1. Fracture of the scaphoid is quite
Figure 2.31 shows the distribution of median common. The bone fractures through
and superficial branch of ulnar nerves in the the waist at right angles to its long axis.
palm. (ii) The edges 0: The fracture is caused by a fallon the
the groove give attachment to the two layers of outstretched hand, or on the tips of the
the flexor retinaculum. (iii) The lateral surface fingers. This causes tenderness and
gives attachment to the lateral ligament of the swelling in the anatomical snuffbox,
wrist joint. (iv) The groove lodges the tendon and pain on longitudinal percussion of
of the flexor carpi radialis. the thumb and index finger.
6. The residual disability is more marked
4. Hamate. (i) The tip of the hook gives in the midcarpal joint than in the wrist
attachment to the flexor retinaculum, (ii) the joint. The impor~ tance of the fracture
lies in its liability to nonunion, and except the third metacarpal (Fig. 2.36). Dorsal
avascular necrosis of the body of the interossei arise from adjacent sides of two
bone. Normally, the scaphoid has two metacarpals (Fig. 2.37). The other attachments
nutrient arteries, one entering the are listed below.
palmar surface of the tubercle and the
other the dorsal surface of the body. Metacarpal
Occasionally (13% of cases) both
vessels enter through the tubercle or I. (i) The opponens pollicis is inserted on the
through the distal half of the bone. In radial border and the anterolateral surface of
such cases, fracture may deprive the the shaft.
proximal half of the bone of its blood (ii) The abductor pollicis longus is inserted on
supply leading to avascular necrosis. the lateral side of the base.
2. Dislocation of the lunate may be (iii) The first palmar interosseous muscle arises
produced by a fall on the acutely from the ulnar side of the base.
dorsiflexed hand with the forearm II. (i) The flexor carpi radialis is inserted on a
flexed. This displaces the lunate tubercle on the palmar surface of the base.
anteriorly, causing carpal tunnel (ii) The extensor carpi radialis longus is
syndrome. inserted on the dorsal surface of the base.
(iii) The oblique head of the adductor pollicis
Ossiflcation: The year of appearance of centre arises from the palmar surface of the base.
of ossification in the carpal bones is shown in III. (i) A slip from the flexor carpi radialis is
Figure 2.35A. inserted on the palmar surface of the base.
(ii) The extensor carpi radialis brevis is inserted
THE METACARPAL BONES on the dorsal surface of the base, immediately
beyond the styloid process.
1. The metacarpal bones are 5 miniature (iti) The oblique head of the adductor pollicis
long bones, which are numbered from arises from the palmar surface of the base.
lateral to the medial side. (iv) The transverse head oftheadductorpollicis
2. Each bone has a head placed distally, a arises from the distal two-thirds of the palmar
shaft and a base at the proximal end. surface of the shaft.
(i) The head is round. It has an IV. Only the interossei arise from it.
articular surface. It extends V. (i) The extensor carpi ulnaris is inserted on
more on the palmar surface the tubercle at the base.
than on the dorsal surface. (ti) The opponens digiti minimi is inserted on
The heads of the metacarpal the medial surface of the shaft.
bones form the knuckles. Articulations at the Bases
(ii) The shaft is concave on the
palmar surface. Its dorsal I. With the trapezium.
surface bears a flat triangular II. With the trapezium. the trapezoid. the capit
area in its distal part. and the third metacarpal.
(iii) The base is irregularly III. With the capitate and the 2nd and 4th
expanded. metacarpals.
IV. With the capitate, the hamate and the 3rd
and 5th metacarpals.
Main Attachments V. With the hamate and the 4th metacarpal.
Ossification: The shafts ossifY from one
The main attachment from shaft of metacarpals primary centre each, which appears during the
is of palmar and dorsal interossei muscles. 9th week of development. A secondary centre
Palmar interossei arise from one bone each for the head appears in the 2nd to 5th
metacarpals, and for the base in the fIrst In the proximal phalanx, the base is marked by
metacarpal. It appears during the 2nd3rd year a concave oval facet for articulation with the
and fuses with the shaft at about 16-18 years head of the metacarpal bone. In the middle
(Fig. 2.35B). phalanx, or a distal phalanx, it is marked by
two small concave facets separated by a smooth
CLINICAL ANATOMY ridge.
There are 14 phalanges in each hand, 3 for each 3. The Proximal Phalanx
fmger and 2 for the thumb.
Each phalanx has a base, a shaft and a head. (i) The fIbrous flexor sheath is attached to the
sides of the shaft.
The Base (ii) On each side of the base, parts of the
lumbricals and interossei are inserted.
4. In the thumb, the base of the proximal metacarpophalangeal joint of the little
phalanx provides attachments to the following finger, in about 75% of subjects.
structures. 5. Less frequently, there is a sesamoid
bone on the lateral side of the
(i) The abductor pollicis brevis metacarpophalangeal joint of the index
and flexor pollicis brevis are finger.
inserted on the lateral side. 6. Sometimes sesamoid bone may be
(ii) The adductor pollicis and the found at other metacarpophalangeal
first palmar interosseous are joints.
inserted on the medial side.
(iii) The extensor pollicis brevis
is inserted on the dorsal The Pectoral Region
surface.
The pectoral region lies on the front of the
5. In the little fmger, the medial side of the base chest. It consists of structures which connect
of the proximal phalanx provides insertion to the upper limb to the anterolateral chest wall.
the abductor digiti minimi and the flexor digiti
minimi. SURFACE LANDMARKS
The structure of the breast may be conveniently Male Breast: The mammary glands are
studied by dividing it into the skin, the rudimentary in the male and in the female
parenchyma, and the stroma. before puberty. The areola and a poorly
A. The skin: developed nipple can be recognized. Deep to
them there are a few ducts only.There are no
• Over the centre of the breast the skin
acini.
shows a dark circular area called the
areola. This region is rich in modified Blood Supply
sebaceous glands. These glands become
enlarged during pregnancy and produce The mammary gland is extremely vascular. It is
surface elevations called tubercles of supplied by branches of the following arteries.
Montgomery. 1. Internal thoracic artery, a branch of the
• In the centre of the areola there is a subclavian artery, through its
conical projection called the nipple. The perforating branches.
nipple is pierced by 15 to 20 lactiferous 2. The lateral thoracic, superior thoracic
ducts. It contains circular and and acromiothoracic (thoracoacromial)
longitudinal smooth muscle fibres branches of the axillary artery.
which can make the nipple stiff or 3. Lateral branches of the posterior
flatten it, respectively. It has a few intercostal arteries.
modified sweat and sebaceous glands. It The arteries converge on the breast and are
is rich in its nerve supply. distributed from the anterior surface.
• The skin of the areola and nipple is
devoid of hair and there is no fat The veins
subjacent to it. The veins follow the arteries. They first
B. The parenchyma: It is made up of glandular converge towards the base of the nipple where
tissue which secretes milk. The glandular tissue they form an anastomotic venous circle, from
of the breast consists of acini that are where veins run in superficial and deep sets.
aggregated to form lobules. Several lobules 1. The superficial veins drain into the
collect to form a lobe. There are about fifteen internal thoracic vein and into the
to twenty such lobes in each breast. The acini superficial veins of the lower part of the
of each lobe are drained by small ducts which neck.
ultimately end in one lactiferous duct for each 2. The deep veins drain into the internal
lobe. The ducts open on the surface of the thoracic, axillary and posterior
nipple. A little proximal to the opening each intercostal veins.
duct shows a dilation called a lactiferous sinus.
Nerve Supply: The breast is supplied by the
C. The stroma: It forms the supporting anterior and lateral cutaneous branches of the
framework of the gland. It is partly fibrous and 4th to 6th intercostal nerves. The nerves convey
partly fatty. sensory fibres to the skin, and autonomic fibres
to smooth muscle and to blood vessels.
tail) and partly in the posterior and
Lymphatic Drainage: Lymphatic drainage of apical groups.
the breast assumes great importance to the • Lymph from the anterior and posterior
surgeon because, carcinoma of the breast groups passes to the central and lateral
spreads mostly along lymphatics to the regional groups and through them to the apical
lymph nodes. The subject can be described group. Finally it reaches the
under two heads, the lymph nodes, and the supraclavicular nodes.
lymphatics. • The internal mammary nodes drain the
lymph not only from the inner half of
Lymph Nodes: Lymph from the breast drains the breast, but from the outer half as
into the following lymph nodes. well.
1. The axillary lymph nodes, chiefly the • A plexus of lymph vessels is present
anterior (or pectoral) group. The deep to the areola. This is the subareolar
posterior, lateral, central and apical plexus (of Sappy). Subareolar plexus
groups of nodes also receive lymph and most of lymph from the breast
from the breast either directly or drains into the anterior or pectoral
indirectly. group of lymph nodes.
2. The internal mammary (parasternal) • The lymphatics from the deep surface
nodes which lie along the internal of the breast pass through the pectoralis
thoracic vessels. major muscle and the clavipectoral
3. Some lymph from the breast also fascia to reach the apical nodes, and
reaches the supraclavicular nodes, the also to the internal mammary nodes.
cephalic (deltopectoral) nodes, Posterior • Lymphatics from the lower and inner
intercostals nodes, the quadrants of the breast may
subdiaphragmatic and communicate with the
subperitoneallymph plexuses. subdiaphragmatic and subperitoneal
lymph plexuses after crossing the costal
Lymphatic Vessels: margin and then piercing the anterior
abdominal wall through the upper part
A. The superficial lymphatics drain of the linea alba.
the skin over the breast except
for the nipple and areola. The CLINICAL ANATOMY
lymphatics pass radially to the 1. Mastitis: Inflammation of the
surrounding lymph nodes breast is called mastitis. It may
(axillary, internal mammary, be acute or chronic. Mastitis can
supraclavicular and cephalic). lead to abscess
B. The deep lymphatics drain the formation.Traditionally, radial
parenchyma of the breast, the incisions have been advised for
nipple and areola. drainage of an abscess to avoid
• About 75% of the lymph from the injury to the ducts. However,
breast drains' into the axillary nodes; such incisions are disfiguring
20% into the internal mammary nodes; and incisions along the junction
and 5% into the posterior intercostal of the areola and nipple are now
nodes. preferred.
• Among the axillary nodes, the
lymphatics end mostly in the anterior 2. Cysts: The obstruction of ducts
group (closely related to the axillary may lead to formation of single
or multiple cysts. A milk
containing cyst is called a peritoneum, to the liver
galactocele. and to pelvic organs.
3. Carcinoma: The breast is a • Apart from the
common site of carcinoma.Some lymphatics cancer may
important points are given spread through the
below. veins. In this
connection, it is
• Cancer cells may
important to know that
infIltrate the
the veins draining the
suspensory ligaments.
breast communicate
The breast then
with the vertebral
becomes fixed.
venous plexus of veins.
• Contraction of the Through these
ligaments can cause communications
retraction or puckering cancer can spread to
(folding) of the skin. the vertebrae and to the
• Infiltration of brain.An operation for
lactiferous ducts and removal of the breast is
their consequent called mastectomy.
fibrosis can cause Removal of the breast
retraction of the nipple. alone is called simple
• Obstruction of mastectomy. In the
superficial lymph past an extensive
vessels by cancer cells operation involving
may produce oedema removal of axillary
of the skin giving rise lymph nodes, the
to an appearance like pectoralis major and
that of the skin of an minor used to be
orange (peau d' orange performed in an effort
appearance). to remove all cancer
• Because of cells. Such an
communications of the operation is called
superficial lymphatics radical mastectomy.
of the breast across the Most surgeons have
midline, cancer may now given up the
spread from one breast traditional radical
to the other. operation. tn most
• Some vessels from the cases only simple
inferomedial part of removal of the breast
the breast probably along with removal of
communicate with axillary lymph nodes is
lymphatics within the undertaken. Sometimes
abdominal cavity the pectoralis minor is
(subperitoneal plexus). removed. Surgery is
Cancer of the breast followed by
has been known to radiotherapy (exposure
spread to the to X-rays which kill
cancer cells).
1. The muscle is an adductor and medial
DEEP PECTORAL FASCIA rotator of the arm.
2. The clavicular fibres (acting with
The deep fascia covering the pectoralis major anterior fibres of the deltoid) can flex
muscle is called the pectoral fascia. It is thin the arm.
and closely attached to the muscle by numerous
septa passing between the fasciculi of the 3. The sternocostal fibres can extend the
muscle. It is attached superiorly to the clavicle, flexed arm against resistance (helped by
and anteriorly to the sternum. Superolaterally, the latissimus dorsi and the teres major).
it becomes continuous with the fascia covering 4. The muscles can also cause forward
the deltoid. movement of the extended arm, as in
Inferolaterally, the fascia becomes cotinuous giving a blow. When the arm is raised
with the axillary fascia. Inferiorly, it is above the head and is fixed the
continuous with the fascia over the thorax and pectoralis major can raise the thorax (as
the rectus sheath. in climbing up a rope). This action is
helped by the latissimus dorsi.
MUSCLES OF THE PECTORAL REGION 5. When the arm is fixed the pectoralis
major can pull on the ribs and thus help
The pectoralis major in forced inspiration.
Origin:
1. Medial half of the anterior surface of Important Relations:
the clavicle.
The muscle forms the anterior fold of the axilla.
2. The anterior surface of the sternum. Anteriorly, it is related to the mammary gland.
3. The medial parts of the upper seven Posterior to it there are the pectoralis minor and
costal cartilages. the clavipectoral fascia, which partially
separate the vessels and nerves of the axilla
4. The aponeurosis of the external oblique from it. More laterally the muscle covers the
muscle. upper parts of the biceps brachii, the
Insertion: The fibres of the muscle converge coracobrachialis, and the serratus anterior.
towards the anterior aspect of the upper end of Pectoralis Minor
the humerus. They are inserted into the lateral
lip of the intertubercular sulcus. The tendon of Origin: The pectoralis minor takes origin
insertion is bilaminar, and consists of an mainly by slips from the 3rd, 4th and 5th ribs
anterior and a posterior lamina. The anterior (near their junctions with the costal cartilages).
lamina receives the clavicular and upper Insertion: The muscle ends in a tendon which is
sternocostal fibres. The posterior lamina inserted into the coracoid process of the scapula
receives the fibres from the lower costal (on its medial border and upper surface).
cartilages and from the aponeurosis of the
external oblique muscle. Nerve Supply: Medial and lateral pectoral
nerves (C6,7,8).
Nerve Supply: Lateral and medial pectoral
nerves (C 5, 6, 7, 8 T1) branches. Actions:
The 3rd to 6th intercostal nerves follow the 1. Draws the scapula forward, (in
Pectoralis Major protracting the arm). (with serratus
anterior)
Actions: 2. Depresses the point of the shoulder.
3. Helps in forced inspiration
region to the apical group of
Subclavius axillary lymph nodes.
Origin: The subclavius arises (by a narrow
tendon) from the junction of the first rib with Serratus Anterior
its costal cartilage.
Insertion: The muscle is inserted into a groove
on middle one third of the inferior surface of Origin: The serratus anterior takes origin, by
the clavicle. several digitations from the outer surfaces of
the upper eight (or nine) ribs, and from the
Nerve Supply: The nerve to the subclavius (C5, fascia covering the intercostal muscles.
6) from the upper trunk of the brachial plexus.
Insertion: The fibres of the muscle run
Actions: backwards round the wall of the thorax. They
1. The subclavius depresses the clavicle pass deep to the scapula to reach its medial
and steadies it during movements at the border. The entire muscle is inserted into the
shoulder joint. costal surface of the scapula along its medial
border. The first digitation is inserted from the
2. It keeps the medial end of the clavicle
superior angle to the root of the spine
pressed against the articular disc of the
sterno-clavicular joint, and thus helps to 1. The next two or three digitations are
smoothen movements at this joint. inserted lower down on the medial
border
2. The lower four or five digitations are
Clavipectoral fascia.
inserted into a large triangular area over
Clavipectoral fascia is a fibrous sheet situated the inferior angle.
between the clavicle (above) and the medial
Nerve Supply: The nerve to the serratus
border of the pectoralis minor (below). Near its
anterior (C5. 6.)
upper end the fascia splits to enclose the
subclavius. At the medial edge of the pectoralis Actions:
minor its splits to enclose the pectoralis minor. (i) Helped by the pectoralis minor the
At the lower (lateral) edge of the pectoralis muscle pulls the scapula forwards
minor the fascia becomes continuous with the around the chest wall to protract the
axillary fascia (forming the dome shaped floor upper limb (as in pushing or giving
of the axilla). When traced medially, the fascia a blow).
reaches the first and second ribs and the upper
two intercostal spaces. Traced laterally, it (ii) The fibres inserted into the inferior
reaches the coracoid process. Between the angle of the scapula pull it forwards
coracoid process and the first rib it forms a and rotate the scapula so that the
thickened band called the costocorcicoid glenoid cavity is turned upwards. In
ligament. this action the serratus anterior acts
along with the trapezius which pulls
The clavipectoral fascia is pierced by the acromion upwards and
following structures: backwards.When the muscle is
(i) Lateral pectoral nerve; paralysed the medial 'margin of the
(ii) Cephalic vein; scapula gets raised specially when
(iii) Thoracoacromial vessels; 'pushing movements' are attempted.
(iv) Lymphatics passing from This is called 'winging of the
the breast and pectoral scapula'
(iii) The muscle steadies the scapula corresponds to a triangular interval
during weight carrying. bounded anteriorly by the clavicle,
posteriorly by the superior border of the
(iv) It helps in forced inspiration.
scapula, and medially by the outer
border of the first rib. This passage is
CLINICAL ANATOMY called the cervicoaxillary canal. The
axillary artery and the brachial plexus
1. Paralysis of the serratus anterior enter the axilla through this canal.
produces 'winging of scapula' in 2. Base or floor: It is directed downwards,
which the inferior angle and the and is formed by skin and fasciae.
medial border of the scapula are 3. Anterior wall: It is formed by the
unduly prominent. The patient is following:
unable to do any pushing action, (i) The pectoralis major in front
nor can he raise his arm above and
the head. Any attempt to do (ii) The clavipectoral fascia
these movements makes the enclosing the pectoralis
inferior angle of the scapula still minor and the subclavius; all
more prominent. deep to the pectoralis major.
2. Clinical testing: Forward 4. Posterior wall: It is formed by :
pressure with the hands against a (i) Subscapularis above.
wall, or against resistance (ii) Teres major and latissimus
offered by the examiner makes dorsi below.
the inferior angle of the scapula 5. Medial wall: It is formed by :
prominent (winging of scapula). (i) Upper four ribs with their
3. Electromyography has intercostal muscles.
disproved the popular view that (ii) Upper part of the serratus
the serratus anterior is an anterior muscle.
accessory muscle of respiration. 6. Lateral wall: It is very narrow because
the anterior and posterior walls
THE AXILLA converge on it. It is formed by:
The axilla or armpit is a pyramidal space (i) Upper part of the shaft of the
situated between the upper part of the arm and humerus in the region of the
the chest wall. It resembles a four-sided bicipital groove, and
pyramid, and has (ii) Coracobrachialis and short
(i) an apex, head of the biceps.
(ii) a base, and
(iii) 4 walls-anterior, posterior,
medial and lateral. CONTENTS OF THE AXILLA
The axilla is disposed obliquely in such a way
that the apex is directed upwards and medially 1. Axillary artery and its
towards the root of the neck, and the base is branches.
directed downwards. 2. Axillary vein and its
tributaries.
BOUNDARIES 3. Infraclavicular part of
the brachial plexus.
1. Apex: It is directed upwards and 4. Five groups of axillary
medially towards the root of the neck.It lymph nodes and the associated
is truncated (not pointed), and lymphatics.
5. The long thOracic and central group lies in the fat of the axilla.
intercostobrachial nerves. The apical group lies behind and above
6. Axillary fat and areolar the pectoralis minor, medial to the
tissue in which the other contents axillary vein.
are embedded.
THE BRACHIAL PLEXUS
Layout It is made up by the ventral primary rami of the
lower four cervical (C5-C8) and the first
• Axillary artery and the brachial plexus thoracic (T1) nerves.
of nerve run from the apex to the base The plexus consists of roots, trunks, divisions,
along the lateral wall of the axilla, cords and branches.
nearer to the anterior wall than the 1. Roots: These are constituted by the anterior
posterior wall. primary rami of spinal nerves C5, 6, 7, 8 and
• The thoracic branches of the axillary Tl, with contributions from the anterior primary
artery lie in contact with the pectoral rami of C4 and T2.
muscles, the lateral thoracic vessels Variations: The origin of the plexus may shift
running along the lower border of the by one segment either upward or downward,
pectoralis minor. resulting in a prefixed or postfixed plexus
• The subscapular vessels run along the respectively.
lower border of the subscapularis. The In a prefixed plexus, the contribution by C4 is
subscapular nen'e and the thoracodorsal large and that from T2 is often absent. In a
nerve (nerve to latissimus dorsi) cross postfixed plexus, the contribution by Tl is
the anterior surface of the muscle. The large, T2 is always present.
circumflex scapular vessels wind round C4 is absent, and C5 is reduced in size. The
the lateral border of the scapula. The roots join to form trunks:
axillary nerve and the posterior
circumflex humeral vessels pass 2. Trunks:
backward close to the surgical neck of • Roots C5 and C6 join to form the upper
the humerus. trunk.
• The medial wall ofthe axilla is • Root C7 forms the middle trunk.
avascular, except for a few small • Roots C8 and T1 join to form the lower
branches from the superior thoracic trunk.
artery. However, the long thoracic nerve
(or nerve to the serratus anterior) 3. Divisions of the trunks: Each trunk divides
descends on the surface of the muscle, into ventral and dorsal divisions (which
and the intercostobrachial nerve pierces ulimately supply the anterior and posterior
the anterosuperior part of the medial aspects of the limb). These divisions join to
wall and crosses the spaces to reach the form cords.
medial side of the arm.
• The axillary lymph nodes are 20 to 30 4. Cords:
in number, and are arranged in five sets. • The lateral cord is formed by the union
The anterior group lies along the lower of the ventral divisions of the upper and
border of the pectoralis minor, on the middle trunks.
lateral thoracic vessels. The posterior • The medial cord is formed by the
group lies alnng the lower margin of the ventral division of the lower trunk.
posterior wall along the subscapular • The posterior cord is formed by union
vessels. The lateral group lies of the dorsal divisions of all the three
posteromedial to the axillary vein. The trunks.
These arise only from the upper trunk which
The first and second parts of the axillary artery gives two branches.
are related to the cords; and third part is related 1. Suprascapular nerve (C5, 6) 2. Nerve to
to the branches of the plexus. Study the subclavius (C5, 6)
description of the brachial plexus before
proceeding further. C. Branches of the Cords
1. Sympathetic nerves for the upper limb are 1. Lateral pectoral (C5-C7) 2.
derived from spinal segments T2 to T6. Most of Musculocutaneous (C5-C7) 3. Lateral root of
the vasoconstrictor fibres supplying the arteries median (C5-C7)
emerge from segments T2 and T3. The
preganglionic fibres arise from lateral ham cells (b) Branches of Medial Cord
and emerge from the spinal cord through
ventral nerve roots. Passing through white rami 1. Medial pectoral (C8, T1) 2. Medial
communicans they reach the sympathetic chain. cutaneous nerve of arm (C8, T1) 3. Medial
They ascend within the chain and end in the cutaneous nerve of forearm (C8, T1) 4. Ulnar
middle cervical, inferior cervical and first (C7, C8, T1). C7 fibres reach by a
thoracic ganglia. communicating branch from lateral root of
2. Postganglionic fibres from middle cervical median nerve.
ganglion pass through grey rami communicans 5. Medial root of median (C8, T1)
to reach C5, C6 nerve roots. Postganglionic
fibres from inferior cervical ganglion pass (c) Branches of Posterior Cord
through grey rami communicans to reach C7,
C8 nerve roots. Fibres from first thoracic 1. Upper subscapular (C5, C6) 2. Nerve to
ganglion also follow above route to reach T1 latissimus dorsi (thoracodorsal) (C6, C7, C8) 3.
nerve root. These fibres pass through roots, Lower subscapular (C5, C6) 4. Axillary
trunks, divisions, cords and branches. (Circumflex) (C5, C6) 5. Radial (C5-C8, T1)
3. The arteries of skeletal muscles are dilated
by sympathetic activity. For the skin, however, In addition to the branches of the brachial
these nerves are vasomotor, sudomotor and plexus, the upper limb is also supplied, near the
pilomotor. trunk, by the supraclavicular branches of the
cervical plexus, and by the intercostobrachial
Branches of the Plexus for the Upper Limb branch of the second.
intercostal nerve. Sympathetic nerves are
The roots value of each branch is given in distr.buted through the brachial plexus. The
brackets. arrangement of the various nerves in the axilla
will be studied with the relations of the axillary
A. Branches of the Roots artery.
THE BACK
1. The extemal occipital protuberance, • The skin is thick and fixed to the
which is a median bony projection and underlying fasciae.
the superior nuchal lines mark the • The superficial fascia is thick and
junction of the back of the head with strong and contains variable amount of
that of the neck. fat.
2. The second cervical spine can be felt • The deep fascia is dense in texture.
about 5 cm below the extemal occipital
protuberance. Cutaneous Nerves
3. The seventh cervical spine is readily felt
at the root of the neck. The cutaneous nerves of the back are derived
4. The nuchal furrow extends to the from the posterior primary rami of the spinal
external occipital protuberance, above, nerves. Their distribution extends up to the
and to the spine of C7 below. posterior axillary lines.
5. The scapula extends from the second to
the seventh ribs on the posterolateral 1. The posterior primary rami of
aspect of the upper thorax. the spinal nerves C1, C7, C8, L4
i. The acromion lies at the and L5 do not give off any
top of the shoulder. cutaneous branches. All twelve
ii. The crest of the spine of thoracic and five sacral nerves,
the scapula runs from the however, give cutaneous
acromion to the medial branches.
border of the scapula. 2. Each posterior primary ramus
iii. The medial border and divides into medial and lateral
the inferior angle of the branches, both of which supply
scapula can also be the erector spinae muscles, but
palpated. only one of them, either medial
6. The eighth rib is just below the inferior or lateral, continues to become
angle of the scapula. The lower ribs can the cutaneous neryes. In the
be counted from the eighth rib. upper half of the body (up to
7. The iliac crest is a curved bony ridge T6), the medial branches, and in
lying below the waist. The anterior the lower half of the body
superior iliac spine is felt at anterior end (below T6) the lateral branches,
of the crest. The posterior superior iliac of the posterior primary rami
spine is felt in a shallow dimple above provide the cutaneous branches.
the buttock, about 5 cm from the Each cutaneous nerve divides
median plane. into a smaller medial and a
8. The sacrum lies between the right and larger lateral branch before
left dimples mentioned above. Usually supplying the skin.
3. The posterior primary rami 4. A tubercle near the medial end of the
supply the intrinsic muscles of spine.
the back and the skin covering
them. The cutaneous distribution
extends further laterally than the Nerve Supply: The muscle is supplied by the
extensor muscles. spinal part of the accessory nerve and by
4. No posterior primary ramus ever branches from the third and fourth cervical
supplies skin or muscles of a nerves.
limb. The cutaneous branches of Actions:
the posterior primary rami of
nerves Ll, L2, L3 (S1-S3) are The trapezius takes part in perfoiming the
exceptions in this respect: they following movements:
turn downwards unlike any 1. Forward rotation of the scapula, along
other nerve and supply the skin with the serratus anterior.
of the gluteal region.
2. Elevation of the scapula, along with the
MUSCLES CONNECTING THE UPPER levator scapulae.
LIMB WITH THE VERTEBRAL COLUMN 3. Retraction of the scapula, along with
rhomboids.
Muscles connecting the upper limb with the
4. The muscles of the two sides acting
vertebral column are the trapezius, the
together draw the head backwards.
latissimus dorsi, the levator scapulae, and the
rhomboideus 5. Each muscle acting alone draws the
minor and rhomboideus major. The head backwards and laterally to its own
attachments of these muscles are given in Table
5.1, and their nerve supply and actions in Table
5.2. Structures Under Cover of the Trapezius
Trapezius
A large number of structures lies immediately
Origin: The muscles has a long linear origin
under cover of the trapezius.
from the following structures.
1. Medial one-third of superior nuchal A. Muscles:
line. • Semispinalis capitis and Splenius
2. External occipital protuberance. capitis.
• Levator scapulae, Rhomboideus minor
3. Ligamentum nuchae. and Rhomboideus major.
4. Spine of 7th cervical vertebra. • Inferior belly of omohyoid.
5. Spines of all thoracic vertebrae and • Supraspinatus.Infraspinatus and
intervening supraspinous ligaments. Latissimus dorsi.
• Serratus posterior superior.
Insertion:
1. The posterior border of the lateral one- B. Vessels:
third of the clavicle.
• Suprascapular artery and vein
2. The medial margin of the acromion.
• Superficial branch of the transverse
3. The crest of the spine of the scapula. cervical artery (superficial cervical) and
accompanying veins.
• Deep branch of transverse cervical 3. Extension of the arm (specially when
artery (dorsal scapular) and the flexed arm is extended against
accompanying veins. resistance).
C. Nerves: 4. It can depress the raised arm against
• Spinal root of accessory nerve. resistance (along with the pectoralis
• Suprascapular nerve. major).
• C3, C4 nerves.
5. It can elevate the trunk if the arm is
• Posterior primary rami of C2-C6 and
raised and fixed (as in exercising on
T1-T12 pierce the muscle to become
parallel bars) (again along with the
cutaneous nerves.
pectoralis major).
D. Bursa: A bursa lies over the smooth
triangular area at the root of the spine of the
scapula.
The levator scapulae:
The main lymph nodes of the upper limb are The dense palmar plexus drains mostly into the
the axillary lymph nodes. These have been lymph vessels on to the dorsum of the hand.
described in Chapter 4: Other nodes are as where these continue with the vessels of the
follows. forearm.
1. The infraclavicular nodes lie in or on Lymph vessels of the back of forearm and arm
the clavipectoral fascia along the curve round their medial and lateral surfaces
cephalic vein. They drain the upper part ascend up to reach the floor of the axilla. Thus
of the breast, and the thumb with its there is a vertical area of 'lymphshed' in the
web. middle of back of forearm and arm.
Deep Lymphatics (iii) The greater tubercle of the humerus
forms the most lateral bony point of
Deep lymphatics are much less numerous than the shoulder.
the superficiat lymphatics. They drain
structures lying deep to the deep fascia. They
run along the main blood vessels of the limb.
and end in the axillary nodes. Some of the Cuttaneous nerves: The skin covering the
lymph may pass through the deep lymph nodes shoulder region is supplied by:
present along the axillary vein as mentioned a) The lateral supraclavicular nerve, over
above. the upper half of the deltoid;
b) the upper lateral cutaneous nerve of the
CUNICAL ANATOMY arm, over the lower half of the deltoid;
c) the dorsal rami of the upper thoracic
1. Inflammation of lymph vessels is nerves, over the back, i.e. over the
known as lymphangitis. In acute scapula.
lymphangitis. the vessels may be seen
through the skin as red, tender streaks. The superflcial fascia: The superflcial fascia
2. Inflammation of lymph nodes is called contains (in addition to moderate amounts of
lym- ' phadenitis. It may be acute or fat and cutaneous nerves) the inferolateral part
chronic. The nodes enlarge and become of the platysma arising from the deltoid fascia.
palpable and painful.
3. Obstruction to lymph vessels can result The deep fascia: The deep fascia covering the
in accumulation of tissue fluid in areas deltoid sends numerous septa between its
of drainage called lymphoedema. This fasciculi. The subscapularis, supraspinatus and
may be caused by carcinoma, infection infraspinatus fasciae provide origin to a part of
with some parasites like or because of the respective muscle.
surgical removal of lymph nodes.
MUSCLES OF THE SCAPULAR REGION
The shoulder or scapular region
These are the deltoid, the supraspinatus, the
The shoulder or scapular region comprises infraspinatus, the teres minor, the
stnIc~ tures which are closely related to and subscapularis, and the teres major.
surround the shoulder joint. For a proper
understanding of the region revise some The Deltoid
features of the scapula and the upper end of the
humerus. Origin:
1. The anterior border of the lateral one-
SURFACE LANDMARKS third of the clavicle.
2. The lateral border of the acromion.
(i) The acromion, crest of the spine, its 3. Lower lip ofthe crest of the spine of the
medial and lateral borders, and scapula.
inferior angle of the scapula are all Insertion: The deltoid tuberosity of the
palpable. humerus.
(ii) The upper half of the humerus is Nerve Supply: Axillary nerve (C5. C6).
covered on its anterior, lateral and Actions:
posterior aspects by the deltoid 1. The acromial fibres are powerful
muscle. This muscle is triangular in abductors of the arm at the shoulder
shape and forms the rounded joint from 15°-90°.
contour of the shoulder.
2. The anterior fibres are flexors and (i) The supraspinatus initiates
medial rotators of the arm. abduction of the arm and
3. The posterior fibres are extensors and carries it up to 15°
lateral rotators of the arm. (ii) Along with other short
Structures Under Cover of the Deltoid Bones scapular muscles it steadies
Bones: The upper end of the humerus and the head of the humerus
coracoid processof scapula. during movements of the
Insertians of Muscles: arm, so that the latter does
not slip out of the glenoid
(i) Pectoralis minor on coracoid cavity
process.
(ii) Supraspinatus, infraspinatus and Infraspinatus
teres minor (on the greater tubercle
of the humerus). Origin: Medial two-thirds of the infraspinous
(iii) Subscapularis on lesser tubercle of fossa of the scapula
humerus Insertion: Middle impression on the greater
(iv) Pectoralis major, teres major and tubercle of the humerus
latissimus dorsi on the Nerve supply: Suprascapular nerve (C5. C6)
intertubercular sulcus of the Actions:
humerus. (i) Lateral rotator of arm
(ii) Along with other short scapular muscles it
Origin of Muscles: steadies the head of the humerus during
1. Coracobrachialis and short head of movements of the arm
biceps from the coracoid process.
2. Long head of the biceps from the Teres minor
supraglenoid tubercle.
3. Long head of the triceps from the Origin: Upper two-thirds of the dorsal surface
infraglenoid tubercle. of the lateral border of the scapula
4. The lateral head of the triceps from the Insertion: Lowest Impression on the greater
upper end of the humerus. tubercle of the humerus
Vessels: Anterior and Posterior circumflex Nerve supply: Axillary nerve (C5. C6)
humeral. Actions:
Nerve: Axillary Nerve. (i) Lateral rotator of arm
Joints and Ligaments: Musculotendinous cuff (ii) Along with other short scapular muscles it
of the shoulderand Coracoacromial ligament. steadies the head of the humerus during
Bursae: All bursae around the shoulder joint, movements of the arm
including the subacromial or subdeltoid bursa.
Subscapularis
Origin: Medial two-thirds of the subscapular
Supraspinatus fossa
Insertion: Lesser tubercle of the humerus
Origin: Medial two-thirds of the Supraspinatus Nerve supply: Upper and lower subscapular
fossa of the scapula. nerves
Insertion: Upper impression of the greater Actions: Medial rotator and adductor of arm
tubercle of the humerus
Nerve supply: Suprascapular nerve (C5. C6) Teres major
Actions: Origin: Lower one-third of the dorsal surface
of lateral border and inferior angle of the
scapula
Insertion: Medial lip of the bicipital groove of feeling for the contracting muscle with
the humerus the other hand.
Nerve supply: Lower subscapular nerve 3. In subacromial bursitis, pressure over
Actions: Medial rotator and adductor of arm the deltoid below the acromion with the
arm by the side causes pain. However,
Musculotendinous Cuff of the Shoulder or when the arm is abducted pressure over
Rotator Cuff the same point causes no pain, because
the bursa disappears under the i
Musculotendinous cuff of the shoulder is a acromion (Dawbarn's sign).
fibrous sheath formed by the four flattened Subacromial or subi deltoid bursitis is
tendons which bend with the capsule of the usually secondary to inflam: mation of
shoulder joint and strengthen it. The muscles the supraspinatus tendon. In this con- , :
which form the cuff arise from the scapula and dition there is pain in the shoulder on
are inserted into the lesser and greater tubercles abduction and medial rotation of the
of the humerus. They are the subscapularis, the arm.
supraspinatus, the infraspinatus and the teres 4. The tendon of the supraspinatus may
minor. Their tendons become flattened and undergo degeneration. This can give
blend with each other and with the capsule of rise to calcification l i and even
the joint, before insertion. spontaneous rupture of the tendon.
The cuff gives strength to the capsule of the
shoulder joint all around except inferiorly. Intermuscular Spaces
Therefore dislocations of the humerus occur
most commonly in a downward direction. Three intermuscular spaces are to be seen in the
scapular region. These are:
Subacromial Bursa
Quadrangular Space
Subacrominal bursa is the largest bursa of the
body, situated below the coracoacromial arch Boundaries:
and the deltoid muscle. Below the bursa there
are the tendon of the supraspinatus and the Superior.
greater tuberosity of the humerus. (iii) Subscapularis in front.
The subacromial bursa is of great value in the (iv) Capsule of the shoulder
abduction of the arm at the shoulder joint. (i) It joint.
protects the supraspinatus tendon against (v) Teres minor behind.
friction with the acromion. (ii) During overhead Inferior. Teres major.
abduction the greater tuberosity of the humerus
passes under the acromion: this is facilitated by
the presence of this bursa. Medial. Long head of the triceps.
Lateral. Surgical neck of the humerus.
CLINICAL ANATOMY Contents:
(i) Axillary nerve.
1. Intramuscular injections are often given (ii) Posterior circumflex
into the deltoid. They should be given humeral vessels.
in the lower half of the muscle to avoid
injury to the axillary nerve. Upper Triangular Space
2. The deltoid muscle is tested by asking
the ; patient to abduct the arm against Boundaries:
resistance applied with one hand, and
Medial. Teres minor.
Lateral. Long head of the triceps. nerve, and laterally to the
Inferior. Teres major. coracobrachialis.
• The nerve winds around the
lower border of the
Contents: Circumflex scapular artery. It subscapularis, close to the
interrupts the origin of the teres minor and lowest part of the capsule of
reaches the infraspinous fossa for anastomosis the shoulder joint, and enters
with the suprascapular artery. the quadrangular space.
(B) In the quadrangular space: The
Lower Triangular Space nerve then passes backwards through
the quadrangular space. Here it is
Boundaries: accompanied by the posterior
Medial. Long head of the triceps. circumflex humeral vessels and has the
Lateral. Medial border of humerus. following relations.
Superior. Teres major. • Superiorly:
Contents: Subscapularis, Lowest
(i) Radial nerve. part of the capsule of the
(ii) Profunda brachil vessels. shoulder joint and
Surgical neck of
AXILLARY OR CIRCUMFLEX NERVE humerus.
• Inferiorly: Teres major.
Axillary or circumflex nerve is an important • Medially: Long head of
nerve because it supplies the deltoid muscle the triceps.
which is the main abductor of the arm. Branches:
Surgically it is important, because it is In the quadrangular space, the nerve divides
commonly involved in dislocations of the into anterior and posterior branches in relation
shoulder and in fractures of the surgical neck of to the deltoid muscle.
the humerus. 1. The anterior branch is accompanied
The axillary nerve is a branch of the posterior by the posterior circumflex humeral
cord of the brachial plexus (C5, C6). vessels. It winds round the surgical neck
of the humerus, deep to the deltoid,
Surface Marking: reaching almost up to the anterior
Axillary or circumflex nerve is marked as a border of the muscle. It supplies the
horizontal line on the deltoid muscle, 2 cm deltoid and the skin over its
above the midpoint between the tip of the anteroinferior part.
acromion process and the insertion of the 2. The posterior branch supplies the
deltoid. teres minor and the posterior part of the
deltoid. The posterior __ ~ -.... - en
Root Value: Its root value is ventral rami of pierces the deep fascia at the lower part
cervical 5, 6 segments of spinal cord. l.erior border of the deltoid and
continues as --e ppeT lateral cutaneous
Course and Relations nerve of the arm.
(i) Musculocutaneous nerve is motor (Ii) Radial (iv) The nutrient artery of the humerus enters
nerve is proprioceptive the bone.
Flexes forearm at the elbow joint 5. Veins (i) The basilic vein pierces the deep
fascia.
Actions Flexes the forearm at the elbow joint
(ii) Two venae comitants of the brachial artery
(i) It is strong supinator when the forearm is may unite to form one brachial vein.
flexed. All screwing movements are done with
it (ii) It is a flexor of the elbow (iii) The short 6. Nerves (i) The median nerve crosses the
head is a flexor of the arm. brachial artery from the lateral to the medial
(iv) The long head prevents upwards side.
displacement of the head of the humerus (v) It
can be tested against resistance as shown in (ii) The ulnar nerve pierces the medial
Fig. 8:6 intermuscular septum with the superior ulnar
Additional Points about the Coracobrachialis collateral artery and goes to the posterior
compartment.
1. The muscle is pierced by the
musculocutaneous nerve. (iii) The radial nerve pierces the lateral
2. Morphologically it represents the medial intermuscular septum with the anterior
compartment of the arm. descending (radial collateral) branch of the
3. Its insertion is an important landmark; many profunda brachii artery and passes from the
transitions occur at this level. posterior to the anterior compartment.
Changes at the level of Insertion of (iv) The medial cutaneous nerve of the arm
Coracobrachialis pierces the deep fascia.
1. Bone: The circular shaft becomes triangular (v) The medial cutaneous nerve of the forearm
below this level. pierces the deep fascia.
2. Fascial septa: The medial and lateral
intermuscular septa become better defmed from
this level down. Additional Points about Biceps Brachii
3. Muscles (i) Deltoid is inserted at this level.
(ii) Upper end of origin of brachialis. 1. Additional heads of biceps
(a) When present, the third head of the biceps The Arm 87
arises from the upper and medial part of the
brachialis, passes behind the brachial artery, MUSCULOCUTANEOUS NERVE
and is inserted on the bicipital aponeurosis and
the medial side of the bicipital tendon. At times The musculocutaneous nerve is the main nerve
the third head consists of two slips which pass of the front of the arm, and continues below the
in front and behind the brachial artery. elbow as the lateral cutaneous nerve of the
forearm (Fig. 6.1). It is a branch of the lateral
(b) A fourth head may arise from the lateral cord of the brachial plexus, arising at the lower
side of the humerus, or from the intertubercular border of the pectoralis minor.
sulcus.
Surface Marking
(c) Other additional heads may occur.
Musculocutaneous nerve is marked by joining
2. The tendon of the long head of the biceps the following two points.
may be dislocated from the intertubercular (i) A point lateral to the axillary artery 3 cm
sulcus. In such cases, the arm is fIxed in above its termination.
abduction, but the head of the humerus is in (ii) A point lateral to the tendon of the biceps
normal position. The tendon is easily replaced brachii muscle 2 cm above the bend of the
by flexing the elbow and then rotating the limb. elbow. (Here it pierces the deep fascia and
continues as the lateral cutaneous nerve of the
3. Bicipital aponeurosis: This is a broad forearm.)
tendinous expansion from the medial side of
the tendon of the biceps given off at the level of Root Value
the bend of the elbow. It passes obliquely
downwards and medially, crosses the brachial The root value of musculocutaneous nerve is
artery and fuses with the deep fascia covering ventral rami of C5-C7 segments of spinal cord.
the origin of flexors of the forearm. It separates
the median cubital vein from the brachial Course and Relations
artery, and may be pierced by the perforating
vein of this region. The sharp concave upper In the lower part of the axilla: It accompanies
border of the aponeurosis is easily felt when the the third part of the axillary artery and has the
supinated forearm is flexed against resistance. following relations.
Anteriorly: Pectoralis major.
4. The tendon of insertion of the biceps is Posteriorly: Subscapularis.
twisted in such a way that its anterior part is Medially: Axillary artery and lateral root of the
formed by the short head, and the posterior part median nerve.
by the long head. Laterally: Coracobrachialis.
Musculocutaneous nerve leaves the axilla, and
Additional Points about the Brachialis enters the front of the arm by piercing the
coracobrachialis.
Variations (a) The muscle may be divided into In the arm: It runs downward and laterally
two or more ?arts. ')etween the biceps and brachialis to reach the
lateral side of the tendon of the biceps. It ends
:b) It may fuse with the brachioradialis. by piercing the fascia 2 cm above the bend of
the forearm.
c It may send a tendinous slip to the radius, or -
- :...'-le bicipital aponeurosis. Branches and Distribution
At its termination it bifurcates into the radial
Muscular: It supplies the following muscles of and ulnar arteries.
the front of the arm: Course and Relation
Action: Actions:
1. It is the main pronator of the forearm. 1. Flexion of the wrist (along with the
2. It also flexes the elbow. flexor carpi radialis and the palmaris
longus).
Flexor Carpi Radialis 2. Adduction of the wrist (along with the
extensor carpi ulnaris).
Origin: From the medial epicondyle of the 3. Fixes the pisiform bone during
humerus (common flexor origin). contraction of the hypothenar muscles.
Insertion: Into palmar surface of the bases of Flexor Digitorum Superficialis (Sublimus)
the second and third metacarpal bones.
The Flexor digitorum superficialis is a large
Nerve Supply: Median nerve. muscle forming a middle stratum between the
other four superficial flexors and the deep
flexors in front of the forearm.
Palmaris Longus
Origin:
Origin: Medial epicondyle of the humerus 1. Humeroulnar head from the medial
(common flexor origin). epicondyle of the humerus, the ulnar
Insertion: Distal half of flexor retinaculum and collateral ligament, and a tubercle on
the apex of the palmar aponeurosis. the medial border of the coronoid
Nerve Supply: Median nerve. process of ulna.
Action: Palmaris longus flexes the wrist and 2. The radial head arises from the anterior
makes the palmar aponeurosis tense. border of the radius up to the insertion
of the pronator teres.
Flexor Carpi Ulnaris 3. Some fibres arise from fibrous arch
passing from the ulna to the radius and
Origin: connecting the two heads. The median
1. Humeral head from the medial nerve and the ulnar artery pass deep to
epicondyle of the humerus (common this arch.
flexor origin).
2. Ulnar head from the medial margin of Insertion: The muscle ends in four tendons, one
the olecranon and by an aponeurosis each for the medial four digits. Opposite the
from the posterior border of the ulna. proximal phalanx the tendon for each digit
The ulnar nerve passes between the splits into medial and lateral slips which are
humeral and ulnar heads. inserted on the corresponding sides of the
middle phalanx. At the wrist the four tendons
Insertion: The insertion is primarily into the are arranged in two pairs, the superficial pair
pisiform bone, but the pull of the muscle is for the middle and ring fingers, and the deep
pair for the index and little fingers. The tendons the oblique head of the adductor pollicis. to
lie medial to the palmaris longus and lateral to enter the fibrous flexor sheath of the thumb.
the ulnar vessels and nerve. 3. The muscle may be connected by slips with
The tendons enter the hand by passing deep to the flexor digitorum superficialis, the flexor
the flexor retinaculum, enclosed within a digitorum
common synovial sheath, the ulnar bursa. Table 9.1: Attachments of the deep muscles of
Nerve Supply: Median nerve. the front of the forearm Muscle Origin from
Actions: The flexor digitorum superficialis is Insertion 1. Flexor digitorum (i) Upper three-
the main flexor of the proximal interphalangeal fourths of the anterior (i) The muscle forms 4
joints. Secondarily it may also flex the tendons for the medial profundus and medial
metacarpophalangeal and wrist joints. surface of the shaft of ulna 4 digits which enter
the palm by passing (composite or deep to the
DEEP MUSCLES OF THE FRONT OF THE flexor retinaculum hybrid muscle) (ii) Upper
FOREARM three-fourths of the posterior border (ii)
Opposite the proximal phalanx of the of ulna
Deep muscles of the front of the forearm are corresponding digit the tendon perforates the
the flexor digitorum profundus. the flexor tendon of the flexor digitorum superficial is
pollicis longus and the pronator quadratus and (iii) Medial surface of the olecranon and (iii)
are described in Tables 9.1 and 9.2. Following Each tendon is inserted on the palmar coronoid
are some other points of importance about these processes of ulna surface of the base of the
muscles. distal phalanx (iv) Adjoining part of the
anterior surface of the interosseous membrane
Additional Points about the Flexor Digitorum 2. Flexor pollicis (i) Upper three-fourths of the
Profundus anterior surface (i) The tendon enters the palm
by passing longus of the shaft of radius deep to
1. It is the most powerful. and most bulky. the flexor retinaculum (ii) Adjoining part of the
muscle of the forearm. It forms the muscular anterior surface of the interosseous membrane
elevation seen and felt on the posterior surface (ii) It is inserted into the palmar surface of the
of the forearm medial to the subcutaneous distal phalanx of the thumb 3. Pronator
posterior border of the ulna. quadratus Oblique ridge on the lower one-
2. The main gripping power of the hand is fourth of (i) Superficial fibres into the lower
provided by the flexor digitorum profundus. one-fourth anterior surface of the shaft of ulna,
3. The muscle may be joined by accessory slips of the anterior surface and the anterior and the
from the radius (action on the index finger), area medial to it border of the radius (ii) Deep
from the flexor digitorum superficialis. or from fibres into the triangular area above the ulnar
the flexor pollicis longus. or from the coronoid notch
process of the ulna.
Table 9.2: Nerve supply and actions of the deep
Additional Points about the Flexor Pollicis muscles of the front of the forearm
Longus
Muscle
1. The anterior interosseous nerve and vessels
descend on the anterior surface of the 1 . Flexor digitorum profundus (Figs 9.6, 9.7)
interosseous membrane between the flexor
digitorum profundus and the flexor pollicis Nerve Supply
longus.
2. The tendon passes deep to the flexor (i) Medial half by ulnar nerve (ii) Lateral half
retinaculum between the opponens pollicis and by anterior interosseous nerve (C8, T1)
2. Flexor pollicis longus (Fig. 9.8) metacarpal bones. It is important to note that
the lower medial end is continuous with the
Anterior interosseous nerve digital synovial sheath of the little fmger.
Infection of the ulnar bursa is usually
3. Pronator quadratus secondary to infection of the little finger. In
tum this may spread to the forearm space of
Anterior interosseous nerve Parona. It results in an hour-glass swelling
called a compound palmar ganglion.
(i) Superficial fibres pronate the forearm (ii) (2) The synovial sheath of the tendon of flexor
Deep fibres bind the lower ends of radius and pollicis longus (radial6ursa). This sheath is
ulna usually separate but may communicate with the
common sheath behind the retinaculum.
profundus. or the pronator teres. The Superiorly, it is coextensive with the common
interosseous portion, or the whole muscle, may sheath and inferiorly it extends up to the distal
be absent. phalanx of the thumb.
(3) The digital synovial sheaths. The sheaths
Synovial Sheaths of Flexor Tendons enclose the flexor tendons in the fmgers and
line the fibrous flexor sheaths. The digital
(1) Common flexor synovial sheath (ulnar sheath of the little finger is continuous with the
bursa). ulnar bursa, and that of the thumb with the
The long flexor tendons of the fingers (flexor radial bursa. However, the
digitorum superficialis and profundus), are rliO"it::ll !':.np::Itn!':. of tnp ;nnpv mirl"':l1p
enclosed in a common synovial sheath while ",nrl rinri f:nri.o~~
passing deep to the flexor retinaculum (carpal
tunnel). The sheath has a parietal layer lining Vincula Longa and Brevia
the walls of the carpal tunnel, and a visceral
layer closely applied to the tendons The vincula longa and brevia are synovial
folds, similar to the mesentery, which connect
Actions the tendons to the phalanges. They transmit
vessels to the tendons.
(i) Flexor of distal phalanges after the flexor
digitorum superficial is has flexed the middle Arteries on the Front of the Forearm
phalanges
supply the hand through the deep and
(ii) Secondarily it flexes the other joints of the superficial palmar arches. The arterial supply of
digits and fingers, and the wrist the forearm is chiefly derived from the
(iii) It is the chief gripping muscle. It acts best common interosseous branch of the ulnar
when the wrist is extended artery, which divides into anterior and posterior
interosseous arteries. The posterior interosseous
(i) Flexes the distal phalanx of the thumb. artery is reinforced in the upper part and
Continued action may also flex the proximal replaced in the lower part by the anterior
joints crossed by the tendon interosseous artery.
Median nerve is the main nerve of the front of Branches and Distribution in the Forearm
the forearm. It also supplies the muscles of
thenar eminence. 1. Muscular branches are given off in the
cubital fossa to flexor carpi radialis,
Surface Marking palmaris longus and flexor digitorum
superficialis.
In the Arm: Mark the brachial artery. The nerve 2. The anterior interosseous branch is
is then marked lateral to the artery in the upper given off in the upper part of the
half and medial to the artery in the lower half forearm. It supplies the flexor pollicis
of the arm. longus, the lateral half of the flexor
The nerve crosses the artery anteriorly in the digitorum profundus (giving rise to
middle of the arm. tendons for the index and middle
In the Foreann: It is marked by joining the fingers) and the pronator quadratus. The
following two points: nerve also supplies the distal radioulnar
(i) A point medial to the brachial and wrist joints.
artery at the bend of the elbow. 3. The palmar cutaneous branch arises a
(ii) A point in front of the wrist, short distance above the flexor
over the tendon of the palmaris retinaculum and supplies the skin over
longus (or 1 cm medial to the the thenar eminence and the central part
tendon of the flexor carpi of the palm.
radialis). 4. Articular branches are given to the
elbow joint and to the proximal
Course and Relations radioulnar joint.
5. Vascular branches supply the radial and half digits is warm, dry and
ulnar arteries. scaly. The nails get cracked
6. A communicating branch is given to the easily.
ulnar nerve. 3. Injury to the median nerve at the wrist
is much more common than at the
CLINICAL ANATOMY elbow. This is due to the superficial
position of the nerve at this site.
1. The median nerve controls coarse 4. It produces:
movements of the hand, as it supplies (a) Ape thumb deformity where the
most of the long muscles of the front of thenar muscles are wasted, and
the forearm. It is, therefore, called the the thumb is adducted and
labourer's nerve'. laterally rotated.
2. When the median nerve is injured above (b) Opposition of the thumb is
the level of the elbow, as might happen totally lost.
in supracondylar fracture of the (c) Paralysis of the fIrst and second
humerus, the following features are lumbricals makes the index and
seen. middle fIngers lag behind in
(a) The flexor. pollicis longus is slowly making a fIst. The
paralyzed. The patient is unable sensory loss, vasomotor and
to bend the terminal phalanx of trophic changes are similar to
the thumb when the proximal that seen in lesions of the nerve
phalanx is held fIrmly by the at the elbow.
clinician (to eliminate the action 5. The distribution of the median nerve in
of the short flexors). Similarly, the hand, is discribed later in this
the terminal phalanges of the chapter.
index and middle fmgers can be
tested. Ulnar Nerve
(b) The forearm is kept in a supine
position due to paralysis of the Surface Marking
pronators.
Ulnar nerve is marked in the arm by joining the
(c) The hand is adducted due to following points.
paralysis of the flexor carpi
radialis, and flexion at the wrist (a) A point at the junction of the
is weak. anterior onethird and posterior
(a) Flexion at the interphalangeal two-thirds of the lateral wall of
joints of the index and middle the axilla at its lower limit, i.e.
fIngers is lost so that the index the lower border of the teres
(and to a lesser extent) the major muscle.
middle fIngers tend to remain (b) The second point at the middle
straight while making a fIst. of the medial border of the arm.
(b) Ape thumb deformity is present (c) The third point behind the base
due to paralysis of the thenar of the medial epicondyle of the
muscles. humerus.
(c) The area of sensory loss in the
hand is much less than the area Ulnar nerve is marked in the forearm by
of distribution. joining the following two points.
(d) Vasomotor and trophic changes:
The skin on lateral three and a
(a) A point on the back of the base 1. The ulnar nerve is also known as
of the medial epicondyle of the the 'musician's nerve' because it
humerous. controls fine movements of the
(b) The second point lateral to the fingers. Its details will be
pisiform bone. considered in the later part of
this chapter.
In the lower two-thirds of the forearm, the ulnar 2. The ulnar nerve is commonly
nerve lies medial to the ulnar artery. injured at the elbow, ,behind the
medial epicondyle; and at the
Course and Relations wrist in front of the flexor
retinaculum. When the neIVe is
1. At the elbow, the ulnar nerve lies behind the injured at the elbowthe flexor
medial epicondyle of the humerus. It enters the carpi ulnaris and the medial half
forearm by passing between the two heads of of the flexor digitorum
the flexor carpi ulnaris. profundus are paralyzed. Due to
2. In the forearm, the ulnar nerve runs between this paralysis the medial border
the flexor digitorum profundus and the flexor of the forearm becomes
digitorum superficialis laterally. It enters the flattened.
palm by passing superficial to the flexor 3. An attempt to produce flexion at
retinaculum lateral to the pisiform bone. the wrist result in abduction of
3. At the wrist, the ulnar neurovascular bundle the hand. The tendon of the
lies between the flexor carpi ulnaris and the flexor carpi ulnaris does not
flexor digitorum superficialis. The bundle tighten on making a fist. Flexion
enters the palm by passing superficial to the of the terminal phalanges of the
flexor retinaculum, lateral to the pisiform bone. ring and little fmgers is lost.
Effects of paralysis on the hand
Branches (claw hand) will be considered
(a) Muscular, to the flexor carpi later.
ulnaris and the medial half of
the flexor digitorum profundus. Radial Nerve
(b) Palmar and dorsal cutaneous
branches. The palmar cutaneous Surface Marking
nerve arises in the middle of the
forearm and supplies the skin Radial nerve is marked by joining the following
over the hypothenar eminence. three points.
(i) The dorsal branch (a) A point 1 cm lateral to the
arises 7.5 em above the biceps tendon at the level of the
wrist, winds backwards lateral epicondyle.
and supplies the proximal (b) The second point at the junction
part of the ulnar 21/2 fingers of the upper two-thirds and
and the adjoining area of lower one-third of the lateral
the dorsum of the hand. border of the forearm just lateral
(ii) Articular branches to the radial artery.
are given off to the elbow (c) The third point at the anatomical
joint. snuff box.
The nerve is vertical in its course between
CLINICAL ANATOMY points one and two. At the second point it
inclines backwards to reach the snuff box.
The nerve is closely related to the lateral side of subcutaneous fat into small tight compartments
the radial artery only in the middle one-third of which serve as water-cushions during firm
the forearm. gripping. The fascia contains a subcutaneous
muscle, the palmaris brevis, which helps in
Course and Relations improving the grip by steadying the skin on the
ulnar side of the hand. The superficial
1. The radial nerve divides into its two terminal metacarpal ligament which stretches across the
branches in the cubital fossa at the level of the roots of the fIngers over the digital vessels and
lateral epicondyle. Thee deep terminal branch nerves, is a part of this fascia.
(posterior interosseous) soon enters the back of
the forearm by passing through the supinator The deep fascia is specialized to form: (i) the
muscle. The superficial terminal branch (the flexor retinaculum at the wrist, (ii) the palmar
main continuation of the nerve) runs down in aponeurosis in the palm, and (ill) the fIbrous
front of the forearm. flexor sheaths in the fmgers. All three form a
2. The superficial terminal branch of the radial continuous structure which holds the tendons in
nerve is closely related to the radial artery only position and thus increases the effIciency of the
in the middle one-third of the forearm. In the grip.
upper one third, it is widely separated from the
artery, and in the lower one-third it passes Flexor Retinaculum
backwards under the tendon of the
brachioradialis. The superficial terminal branch Flexor retinaculum is a strong fIbrous band
is purely cutaneous and is distributed to the which bridges the anterior concavity of the
lateral half of the dorsum of the hand, and to carpus and converts it into a tunnel, the carpal
the proximal parts of the dorsal surfaces of the tunnel.
thumb, the index finger, and lateral half of the
middle fmger. Surface Marking
Injury to this branch results in small area of
sensory loss over the root of the thumb. Flexor retinaculum is marked by joining the
following four points:
THE PALMAR ASPECT OF THE WRIST (i) Pisiform bone (ii) Tubercle of the scaphoid
AND HAND bone
(iii) Hook of the hamate bone (iv) Crest of the
trapezium The upper border is obtained by
The human hand is designed: (i) for grasping, joining the first and second points, and the
(ii) for precise movements, and (ill) for serving lower border by joining the third and fourth
as a tactile organ. points (Fig. 9.18). The upper border is concave
upwards, and the lower border is concave
The skin of the palm is: (i) thick for protection downwards.
of underlying tissues, (ii) immobile because of
its fIrm attachment to the underlying palmar Attachments
aponeurosis, and (ill) creased. All of these
characters increase the efficiency of the grip. Medially, to (i) the pisiform bone, and (ii) to
the hook of the hamate. Laterally, to (i) the
The skin is supplied by spinal nerves C6, C7, tubercle of the scaphoid, and (ii) the crest of the
C8 through the median and ulnar nerve. trapezium.
On either side the retinaculum has a slip: (1)
The superficial fascia of the palm is made up of the lateral deep slip is attached to the medial lip
dense fIbrous bands which bind the skin to the of the groove on the trapezium which is thus
deep fascia (palmar aponeurosis) and divide the converted into a tunnel for the tendon of the
flexor carpi radialis; (2) the medial superficial Trophic changes: Long-standing cases of
slip (volar carpalligamentJ is attached to the paralysis lead to dry and scaly skin. The nails
pisiform bone. The ulnar vessels and nerves crack easily with atrophy of the pulp of fingers.
pass deep to this slip. It usually occurs in females between the age of
40 and 70. They complain of intermittent
Relations 'attacks of pain in the distribution of the median
The structures passing superficial to the flexor nerve on one or both sides. The attacks
retinaculum are: (i) the tendon of the palmaris frequently occur at night. Pain may be referred
longus, (ii) the palmar cutaneous branch of the proximally to the forearm and arm.
median nerve, (iii) the palmar cutaneous branch
of the ulnar nerve, (iv) the ulnar vessels, and Palmar Aponeurosis
(v) the ulnar nerve.
The flexor carpi ulnaris is partly inserted on the This term is often used for the entire deep
retinaculum, and the thenar and hypothenar fascia of the palm. However, it is better to
muscles arise from it. restrict this term to the central part of the deep
fascia of the palm which covers the superficial
The structures passing deep to the flexor palmar arch, the long flexor tendons, the
retinaculum are: (i) the median nerve, (ii) the terminal part of the median nerve, and the
tendons of the flexor digitorum superficialis, supeificial branch of the ulnar nerve.
(ill) the the flexor dogitorum profundus, (iv) Features
the tend flexor pollicis longus, (v) the ulnar
bursa, and _ --_ radial bursa. The tendon of the Palmar aponeurosis is triangular in shape. The
flexor carpi raci.icLs Iies between the apex which is proximal blends with the flexor
retinaculum and its deep sUp, in the groove on retinaculum and is continuous with the tendon
the trapezium. of the palmaris longus. The base is directed
distally. It divides into four slips opposite the
CLINICAL ANATOMY heads of the metacarpals of the medial four
digits. Each slip divides into two parts which
Carpal Tunnel Syndrome This syndrome are continuous with the fibrous flexor sheaths.
consists of motor, sensory, vasomotor and Extensions pass to the deep transverse
trophic symptoms in the hand caused by metacarpal ligament, the capsule of the
compression of the median nerve in the carpal metacarpophalangeal joints and the sides of the
tunnel. Examination reveals wasting of thenar base of the proximal phalanx. The digital
eminence (ape-like hand) hypoaesthesia to light vessels and nerves, and the tendons of the
touch on the palmar aspect of lateral 3V2 lumbricals emerge through the inter. vals
digits. between the slips. From the lateral and medial
However, the skin over the thenar eminence is margins of the palmar aponeurosis, the lateral
not affected as the branch of median nerve and medial palmar septa pass backwards and
supplying it arises in the forearm. divide the palm into compartments.
Motor changes: Ape-like thumb deformity, loss
of opposition of thumb, index and middle Morphology
fmgers lag behind while making the fist.
Sensory changes: Loss of sensations on lateral Phylogenetically, the palmar aponeurosis
3V2 digits including the nail beds and distal represents the degenerated tendon of the
phalanges on dorsum of hand. palmaris longus.
Vasomotor changes: The skin areas with
sensory loss is warmer due to arteriolar Functions
dilatation; it is also drier due to absence of
sweating due to loss of sympathetic supply. '
Palmar aponeurosis fixes the skin of the palm Muscles (ii)-(iv) are muscles of hypothenar
and thus improves the grip. It also protects the eminence.
underlying tendons, vessels and nerves. 3. Four lumbricals.
4. Four palmar interossei.
CLINICAL ANATOMY 5. Four dorsal interossei.
Dupuytren's Contracture: This condition is due These muscles are described below.
to inflammation involving the ulnar side of the
palmar aponeurosis. There is thickening and
contraction of the aponeurosis. As a result the
proximal phalanx and later the middle phalanx Abductor Pollicis Brevis
become flexed and cannot be straightened. The
terminal phalanx remains unaffected. The ring Origin
finger is most commonly involved.
1. Tubercle of the scaphoid.
Fibrous Flexor Sheaths of the Fingers 2. Crest of the trapezium.
3. Flexor retinaculum.
The fibrous flexor sheaths are made up of the
deep fascia of the fingers. The fascia is thick Insertion 1. Lateral side of the base of the
and arched. proximal phalan of the thumb.
It is attached to the sides of the phalanges and Nerve supply: Median nerve (C8,T1),
across the base of the distal phalanx. Action: Abduction of the thumb at the
Proximally, it is continuous with a slip of the metacarpophalangeal and carpometacarpal
palmar aponeurosis. In this way, a blind joints. Abduction is associated with medial-
osseofascial tunnel is formed which contains rotation.
the long flexor tendons enclosed in the digital Flexor Pollicis Brevis
synovial sheath (Fig. 9.19). The fibrous sheath
is thick opposite the phalanges and thin Origin: The superficial head takes origin from
opposite the joints to permit flexion. 1. The crest of the trapezium.
The sheath holds the tendons in position during 2. The flexor retinaculum.
flexion of the digits. The deep head arises from the trapezoid and
capitate bones.
INTRINSIC MUSCLES OF THE HAND Insertion: Lateral side of the base of the
proximal phalanx.
The intrinsic muscles of the hand serve the NeIVe Supply: It is supplied by the median
function of adjusting the hand during gripping nerve.
and also for carrying out fine skilled The deep head may be supplied by the deep
movements. The origin and insertion of these branch of the ulnar nerve.
muscles is within the territory of the hand. Action: Flexion of the thumb.
There are 20 muscles in the hand, as follows.
1. (a) Three muscles of thenar eminence (i) Opponens Pollicis
Abductor pollicis brevis.
(ii) Flexor pollicis brevis. Origin
(iii) Opponens pollicis.
(b) One adductor of thumb (i) Adductor 1. Crest of trapezium. 2. Flexor retinaculum.
pollicis.
2. Four hypothenar muscles (i) Palmaris brevis. Insertion: Lateral half of the palmar surface of
(ii) Abductor digiti minimi.(iii) Flexor digiti the fIrst metacarpal bone.
minimi. (iv) Opponens digiti minimi. NeIVe Supply: Median nerve (C8.Tl).
Action: Opposition of the thumb. This is a , Action: Abduction of little fmger at the
combination of flexion and medial rotation. metacarpophalangeal joint.
Origin The muscle has two heads-oblique and Origin 1. Hook of the hamate bone.
transverse. 2. Flexor retinaculum.
The oblique head arises from: Insertion: Ulnar side of the base of the
1. The capitate bone. proximal phalanx of the little fmger.
2. The base of the 2nd and 3rd metacarpal NeIVe Supply: Deep branch of the ulnar nerve
bones. (C8.
The transverse head arises from the palmar Tl).
aspect of the third metacarpal bone. Action: Flexion of the little fmger at the
Insertion: Medial side of the base of the metacarpophalangeal joint.
proximal phalanx of the thumb.
Nerve Supply: Deep branch of ulnar nerve (C8. Opponens Digiti Minimi
Tl).
Action: The muscle adducts the thumb from the Origin 1. Hook of the hamate.
flexed or abducted position. The movement is 2. Flexor retinaculum.
forceful in gripping. Insertion: Medial surface of the shaft of the
fifth metacarpal bone.
NeIVe Supply: Deep branch of ulnar nerve
Palmaris Brevis (C8. Tl).
Action: Flexor of the fIfth metacarpal and
This muscle is superfIcial and lies just under rotates it laterally (as making the palm hollow).
the skin.
Origin: From flexor retinaculum and palmar Lumbrical Muscles
aponeurosis.
Insertion: Skin along medial border of the Lumbrical muscles are four small muscles that
hand. take origin from the tendons of the flexor
Nerve Supply: Ulnar nerve. superfIcial branch digitorum profundus. They are numbered from
(C8. lateral to medial side.
Tl). Origin: The first lumbrical arises from the
Action: Helps in gripping by making the radial side of the tendon for the index fmger.
hypothenar eminence more prominent. and by The second lumbrical arises from the radial
wrinkling the skin over it. side of the tendon for the middle fmger. The
third lumbrical arises from contiguous sides of
Abductor Digiti Minimi the tendons for the middle and ring fingers. The
fourth lumbrical arises from the contiguous
Origin: This muscle arises from the pisiform sides of the tendons for the ring and little
bone. fingers.
The origin extends on to the tendon of the
flexor carpi ulnaris (proximally) and on to the Insertion: The tendons of the first, second, third
pisohamate ligament (distally). and fourth lumbricals pass backwards on the
Insertion: Ulnar side of the base of the radial side of the second, third, fourth and fifth
proximal phalanx of the little fmger. metacarpophalangeal joints respectively. They
Nerve Supply: Deep branch of ulnar nerve (C8. are inserted into the dorsal digital expansions of
Tl). the corresponding digits.
Nerve Supply 2. Second palmar interosseous muscle from the
1. The first and second lumbricals medial half of the palmar aspect of the shaft of
by the median nerve (C8, Tl). the second metacarpal bone.
2. The third and fourth lumbricals 3. Third palmar interosseous muscle from the
by the deep branch of the ulnar lateral part of the palmar aspect of the shaft of
nerve (C8, Tl). the fourth metacarpal bone.
Actions: The lumbrical muscles flex the 4. Fourth palmar interosseous from the lateral
metacarpophalangeal joints, and extend the part of the palmar aspect of the shaft of the
interphalangeal joints of the digit into which fIfth metacarpal bone.
they are inserted. Insertion
1. The ulnar nerve enters the palm by passing 1. The ulnar nerve is often called the
superficial to the flexor retinaculum where it 'musician's nerve' because it controls fm~
lies between the pisiform bone and the ulnar movements of the fmgers through its extensive
vessels. motor distribution to the short muscles of the
Here the nerve divides into its superficial and hand.
deep terminal branches. 2. The ulnar nerve is most commonly injured at
2. The superficial terminal branch supplies the two sites: behind the medial epicondyle of the
palmaris brevis and divides into two digital humerus, and at the wrist. At both sites, it is
branches for the medial 1 ½ fingers. quite superficial and vulnerable to injury. An
3. The deep terminal branch accompanies the ulnar nerve lesion at the wrist produces 'ulnar
deep branch of the ulnar artery. It passes clawhand', involving mainly the ring and little
backwards between the abductor and flexor fIngers.
digiti minimi, and then between the opponens True claw-hand, involving all the fIngers is
digiti minimi and the fIfth metacarpal bone, produced by a combined lesion of the ulnar and
lying on the hook of the hamate. median nerve.
Finally, it turns laterally within the concavity of Ulnar claw-hand is characterized by the
the deep palmar arch. It ends by supplying the following signs., (a) Hyperextension at the
adductor pollicis muscle. metacarpophalangeal joints and flexion at the
interphalangeal joints, involving the ring and
little fIngers-more than the index and middle
Branches fmgers. The little fmger is held in abduction by
extensor muscles.
From Superficial Tenninal Branch
The intermetacarpal spaces are hollowed out
due to wasting of the interosseous muscles.
Clawhand deformity is more obvious in wrist
lesions as the profundus muscle is spared: this
causes marked flexion of the terminal
phalanges (action of paradox).
(b) Sensory loss is confIned to the medial
onethird of the palm and the medial one and a
half fIngers including their nail beds.
(c) Vasomotor changes: The skin areas with
sensory loss is warmer due to arteriolar
dilatation;
it is also drier due to absence of sweating due
to loss of sympathetic supply.
(d) Trophic changes: Long-standing cases of
paralysis lead to dry and scaly skin. The nails
crack easily with atrophy of the pulp of fIngers.
(e) The patient is unable to spread out the
fIngers due to paralysis of the dorsal interossei.
The power of adduction of the thumb, and
flexion of the ring and little fingers are lost. It
should be noted that median nerve lesions are
more disabling. In contrast, ulnar nerve lesions
leave a relatively efficient hand.
Claw-hand can be produced by a number of
lesions, including Klumpke's paralysis, lesion
of the medial cord of the brachial plexus, lesion
of the ulnar nerve, a combined lesion of the
ulnar and median nerves. A similar deformity
can also result from a late and severe
Volkmann's ischaemic contracture, the end
result of a neglected suppurative tenosynovitis
of the ulnar bursa.
Ulnar nerve injury at the wrist can be excluded
by Froment's sign, or the book test which tests
the adductor pollicis muscle. When the patient
is asked to grasp a book fIrmly between the
thumb and other fIngers of both the hands, the
terminal phalanx of the thumb on the paralysed
side becomes flexed at the interphalangeal joint
(by the flexor pollicis longus which is supplied
by the median nerve).
Median Nerve 1. Median nelVe injury at the wrist. This
is a common occurrence and is
The median nerve is important because of its characterized by the following signs.
role in controlling the movements of the thumb (a) The median nerve controls
which are crucial in the mechanism of gripping coarse movements of the hand
by the hand. and is the nerve of grasp. In all
injuries of this nerve, at
Course and Relations whatever level, the patient is
unable to pick up a pin with the
1. The median nerve enters the palm by thumb and index fmger. In fact,
passing deep to the flexor retinaculum, inability to oppose the thumb is
where it lies in front of the ulnar bursa the chief disability of median
enclosing the flexor tendons, in the nerve lesions at the wrist.
narrow space of the carpal tunnel. (b) Ape-likehand. Paralysis of the
Immediately below the retinaculum the short muscles of the thumb, and
nerve divides into lateral and medial the unopposed action of the
divisions. extensor pollicis longus
2. The lateral division gives off a muscular produces an ape-like hand.
branch to the thenar muscles, and three 1. The thenar eminence is wasted and
digital branches for the lateral one and flattened. The thumb is adducted and
half digits including the thumb.The laterally rotated so that the first
muscular branch curls upwards round metacarpal lies in the same plane as the
the distal border of the retinaculum and other metacarpals.
supplies the thenar muscles. Out of the (c) Pen test for abductor pollicis
three digital branches, two supply the brevis. Lay the hand flat on a
thumb and one the lateral side of the table with the palm directed
index finger. The digital branch to the upwards. The patient is unable
index finger also supplies the first to touch with his thumb a pen
lumbrical. held in front of the palm.
3. The medial division divides into two (d) Sensory loss corresponds to
common digital branches for the second distribution of the median nerve
and third interdigital clefts, supplying in the hand.
the adjoining sides of the index, middle 2. As already mentioned, median nerve
and ring fingers. The lateral common lesions are more disabling than ulnar
digital branch also supplies the second nerve lesions. This is largely due to the
lumbrical. inability to oppose the thumb, so that
the gripping action of the hand is totally
Distribution lost.
3. Carpal tunnel syndrome. Involvement
In the hand, the median nerve supplies: of the median nerve in carpal tunnel
(a) Five muscles, namely the abductor pollicis syndrome has been described earlier
brevis, the flexor pollicis brevis, the opponens with flexor retinaculum.
pollicis and the first and second lumbrical 4. If both median and ulnar nerves are
muscles. paralysed, the result is complete claw-
(b) Palmar skin over the lateral three and a half hand.
digits with their nail beds.
Radial Nerve
CLINICAL ANATOMY
The part of the radial nerve seen in the hand is
a continuation of the superficial terminal
branch. It reaches the dorsum of the hand (after
winding round the lateral side of the radius)
and divides into 4 or 5 dorsal digital branches
which supply the skin of the digits as follows.
1. 1st: Lateral side of thumb
2. 2nd: medial side of thumb
due to occlusion of the vessels by the tension.
3. 3rd: lateral side of index finger The proximal one-fifth (epiphysis) escapes
4. 4th: contiguous sides of index and because its artery does not traverse the fibrous
middle fingers septa.
5. 5th: when present it supplies the
contiguous sides of the middle and ring Midpalmar Space
fingers.
Note that skin over the dorsum of the distal Midpalmar space is triangular space situated
phalanges, and part of the middle phalanges, is under the inner half of the hollow of the palm.
supplied by the median nerve (not radial). Proximally, it extends up to the distal margin of
Sensory loss corresponds to the distribution of the flexor retinaculum and communicates with
the nerve. the forearm space (Table 9.3). Distally, it
extends up to the distal palmar crease and
THE SPACES OF THE HAND communicates with the fascial sheaths of the
3rd and 4th (occasionally 2nd) lumbrical
Spaces of the Hand muscles (lumbrical canals).
Having learnt the anatomy of the whole hand, The space is bounded:
the clinically significant spaces of the hand (a) Anteriorly by the palmar
need to be understood and their boundaries to aponeurosis and the flexor
be identified from the following text. tendons of the 3rd, 4th and 5th
fingers:
The arrangement of fasciae and the fascial (e) the 2nd, 3rd and 4th lumbrical
septa in the hand is such that many spaces are muscles;
formed. These spaces are of surgical (iii) the superficial
importance because they may become infected palmar arch; and
and distended with pus. The important spaces (ill) the digital
are as follows: nerves and vessels
A. Palmar Spaces 1. Pulp space of the fmgers of the medial three
2. Midpalmar space 3. Thenar sp'ace B. Dorsal and a half fIDgers.
Spaces 1. Dorsal subcutaneous space 2. Dorsal (b) Posteriorly, by the 3rd, 4th and
subaponeurotic space C. The Forearm Space of 5th metacarpals. The fascia,
Parana. covering the interossei of the
3rd and 4th spaces.
Pulp Space of the Fingers (c) Medially, by the medial palmar
septum; and (d) Laterally, by the
The tips of the fIDgers and thumb contain intermediate palmar septum.
subcutaneous fat arranged in tight Mter the advent of antibiotics and advanced
compartments formed by fibrous septa which surgical techniques, the incidence of infection
pass from the skin to the perios· teum of the of the midpalmar space has been markedly
terminal phalanx. Infection of this spacf is reduced. Sometimes, however, infection of the
known as whitlow. The rising tension in the space may result from tenosyhovitis of the
spacf gives rise to severe throbbing pain. middle and ring fingers, or Features 1. Shape
Infections in the pulp space (whitlow) can be 2. Situation 3. Extent:
drained by a lateral incision which opens all Proximal Distal 4. Communications:
compartments and avoids damage to the tactile Proximal Distal 5. Boundaries:
tissue in front of the finger. Anterior
If neglected, a whitlow may lead to necrosis of
the distal four-fifths of the terminal phalanx Midpalmar space Triangular
Thenar space Triangular Thenar Space
Under the inner half of the hollow of the palm Thenar space is a triangular space situated
under the outer half of the hollow of the palm.
(i) Flexor tendons of 3rd, 4th and 5th fingers Proximally, it extends up to the distal margin of
(ii) 2nd, 3rd and 4th lumbricals (iii) Palmar the flexor retinaculum, and communicates with
aponeurosis Fascia covering interossei and the forearm
metacarpals Intermediate palmar septum Digital Synovial Sheaths
Distal margin of the flexor retinaculum Distal The synovial sheaths of the 2nd, 3rd and 4th
palmar crease digits are independent and terminate proximally
at the levels of the heads of the metacarpals.
Forearm space Fascial sheaths of the 3rd and The synovial (c) Medially, by the intermediate
4th lumbricals; occasionally 2nd palmar septum; sheath of the little fmger is
continuous proximally and with the ulnar bursa,
Posterior Lateral and that of the thumb with the (d) Laterally. by
the lateral palmar septum. radialhI.JJ::'b.~-
Medial ~<>o.."-<>o..'-"""--~~~~~enttle fi Th th
\o,~"""~<:~",,,,--~-,>-~ --=~~~=-=""--~~
Medial palmar septum -==.<:;;. "\:uUIDn are more dan er, .... U:~er.
_____~~___~~!:.59~~-~..,,-~ --=~~~~o=
Incision in either the 3rd or 4th web space .......>1).:5 results in spre~d' i~ ...~ "'---",,-~~_.
~...<\..~ ~~~ause th ....%'\:1
Incision in the first web, posteriorly ----:~~~ ~~~').-:nng of the web of the thumb
",--=d.. ~'e"<'..=--,<- ~ ~~ '-'-0. '-"'.....'- ya.u:n ~
6. Drainage 13ec regIon. The th'U~'b ~- ~~~"'- ~ ~ ~"c>"'-
~""-~O POSI·ti i:ne wrist I and eVen u t ey can
Under the outer half of the hollow of the palm ·~~""-PQ;5teiTOrlY:~o;;;;~a by an inCiSion in
th fi on. bursae c~;:;:bo~t 50% cases, th: r:d~5
Distal margin of the flexor retinaculum cm abOve ere the pus Points. e Irst fleXor
Proximal transverse palmar crease retinacu~~~te With each othe: b:~dulnar Dorsal
Spaces Infecti the Th H o~~Oftb!
Fascial sheath of the first lumbrical; lD;&'''~'''ynoVIa1sneathsaredrained ,_.:
occasionally 2nd <!..9.~al .<:1;'( through two transverse
inJj,.sjn.7')F ~...#-~
(i) Short muscles of thumb (ii) Flexor tendons ...,f ~~~~~-7~.c"
of the index finger (iii) First lumbrical (iv) 'TI- . ~~~~~z/~o-.z./J"7.dIC ana t6....E!... <>-
Palmar aponeurosis Transverse head of ~'-=-. ·--~~--'~~~~~~d-"-A?L.fi2'ea1aCe(\l...
adductor pollicis (i) Tendon of flexor pollicis ate aYsr.aL~~~~"",,~---u""''''U':l.'t suea'tn at
longus with radial bursa (ii) Lateral palmar ~~&?C"d7C75c.s~~~~m~enand. The €1'tner
septum Intermediate palmar septum end.
from a web infection which has spread '-aorsal subtendinous space lies between the
proximally through the lumbrical canals. When metacarpal bones and the extensor tendons
this happens the normal concavity of the palm which are united to one ~other by a thin
is obliterated, and the swelling extends to the C:l.l2Qnt\1t.~~\~,
dorsum of the hand. The space can be drained
by an incision in either the 3rd or 4th web \W:ecllon of the dorsal sp~ces is uncommon.
depending on where the pus points. However, swelling of the dorsum is very
common and can be produced by almost every possibly also with the thenar space. The
infection of the hand, especially in midpalmar proximal part of the flexor synovial sheaths
space infections. Some- protrudes into the forearm space.
The forearm space may be infected through
ppet' Umb infections in the related synovial sheaths,
especially of the ulnar bursa. Pus points at the
space. Distally, it extends up to the proximal margins of the distal part of the forearm where
trans,-erse palmar crease and communicates it may be drained.
with the subcutaneous web of the thumb.
through the fascial sheath of the first lumbrical SYNOVIAL SHEATHS
muscle. It may also communicate with the
second lumbrical canal. Many of the tendons entering the hand are
surrounded by synovial sheaths. The extent of
It is bounded these sheaths is of surgical importance as they
can be infected (Fig. 9.9).
(a) Anteriorly by the palmar aponeurosis
covering: (i) the tendon of the flexor pollicis Ulnar Bursa
longus with its synovial sheath; (ii) the flexor
tendons of the index finger; (ill) the first lmection of this bursa is usually secondary to
lumbrical muscle; and (iv) the palmar digital the infection of the little fmger, and this in turn
vessels and nerves of the thumb and lateral side may spread to the forearm space of the Parona.
of the index finger. It results in an hour-glass swelling (so called
(b) Posteriorly, by the fascia covering the because there is one swelling in the palm and
transverse head of the adductor pollicis and the another in the distal
first dorsal interosseous muscle; space. Distally, it extends up to the proximal
transverse palmar crease and communicates
Septum with the subcutaneous web of the thumb.
through the fascial sheath of the fIrst lumbrical
muscle. It may also communicate with the
times the dorsal spaces are infected after injury second lumbrical canal.
over the knuckles. In subcutaneous infections.
the pus points through the skin. and can be It is bounded
drained at the pointing site. In subtendinous
infections, the pus points either at the webs or (a) Anteriorly by the
at the borders of the hand, and can be drained palmar aponeurosis covering: (i) the tendon
accordingly. of the flexor pollicis longus with its
synovial sheath; (ii) the flexor tendons of
Forearm Space of Parona the index fInger; (iii) the fIrst lumbrical
muscle; and (iv) the palmar digital vessels
Foream space of Parona is a rectangular space and nerves of the thumb and lateral side of
situated deep in the lower part of the forearm the index fInger.
just above the wrist. It lies in front of the (b) Posteriorly, by
pronator quadratus, and deep to the long flexor the fascia covering the transverse head of
tendons. the adductor pollicis and the fIrst dorsal
Superiorly, the space extends up to the oblique interosseous muscle;
origin ofthe flexor digitorum superficialis. (c) Medially, by the intermediate palmar
Inferiorly. septum;
it extends up to the flexor retinaculum, and and (d) Laterally, by the lateral palmar septum.
communicates with the midpalmar space; and
The thenar space may be infected by spread of margins of the distal part of the forearm where
any infection in the thumb or index fmger. This it may be drained.
results in marked swelling of the web of the
thumb and thenar region. The thumb is held in SYNOVIAL SHEATHS
an abducted position.
The space can be drained by an incision in the Many of the tendons entering the hand are
fIrst web posteriorly. or where the pus points. surrounded by synovial sheaths. The extent of
these sheaths is of surgical importance as they
Dorsal Spaces can be infected.
Foream space of Parona is a rectangular space Infection of this bursa is usually secondary to
situated deep in the lower part of the forearm the infection of the little fmger. and this in tum
just above the wrist. It lies in front of the may spread to the forearm space of the Parona.
pronator quadratus, and deep to the long flexor It results in an hour-glass swelling (so called
tendons. because there is one swelling in the palm and
Superiorly, the space extends up to the oblique another in the distal part of the forearm, the two
origin of the flexor digitorum superfIcialis. beingj oined by a constriction in the region of
Inferiorly. the flexor retinaculum).
it extends up to the flexor retinaculum. and The ulnar bursa is approached by an incision
communicates with the midpalmar space; and along the lateral margin of. the hypothenar
possibly also with the thenar space. The eminence.
proximal part of the flexor synovial sheaths
protrudes into the forearm space. Radial Bursa
The forearm space may be infected through
infections in the related synovial sheaths. Infection of the thumb may spread to the radial
especially of the ulnar bursa. Pus points at the bursa and then to the ulnar bursa if these two
communicate. It can be drained by an incision
along the I~·edial margin of the thenar SURFACE LANDMARKS
eminence.
The incision should be restricted proximally to 1. The olecranon process of the ulna is the most
avoid injury to the branch of the median nerve prominent bony point on the back of a flexed
to the thenar muscles. elbow. Normally, it forms a straight horizontal
line with the two epicondyles of the humerus
CLINICAL ANATOMY when the elbow is extended, and an equilateral
triangle when the elbow is flexed to a right
Surgical Incisions of the Hand angle. The relative position of the three bony
points is disturbed when the elbow is
Incisions in the hand should be planned dislocated.
carefully to avoid contractures. In general, the 2. The head of the radius can be palpated in a
incision should be transverse, parallel with the depression on the posterolateral aspect of an
creases of the wrist, hand or fingers. They extended elbow just below the lateral
should never be at right angles to the creases. epicondyle of the humerus. Its rotation can be
When necessary the transverse incision can be felt during pronation and supination of the
enlarged by a longitudinal extension at each forearm.
end in opposite directions (Figs 9.41, 9.42). 3. The posterior border of the ulna is
A longitudinal incision in the fingers, palm, or subcutaneous in its entire length. It can be felt
wrist must be at the sides where the skin is least in a longitudinal
subjected to movements. Here the skin is thin
and pliable and heals well in time.
There are seven superficial muscles on the back Actions: Flexor of forearm. especially in the
of the forearm: midprone position. It supinates the fully
pronated forearm; and pronates the fully
1. Anconeus 2. Brachioradialis 3. Extensor supinated forearm to bring it to the mid prone
carpi radialis longus 4. Extensor carpi radialis position.
brevis 5. Extensor digitorum 6. Extensor digiti
rninirni 7. Extensor carpi ulnaris. Some Important Relations
All the seven muscles cross the elbow joint. 1. The upper fleshy part of the muscle
Most of them take origin (entirely or in part) forms the lateral boundary of the cubital
from the tip of the lateral epicondyle of the fossa. Here the radial nerve is deep. to
humerus. the muscle (between it and the
brachialis) .
This is the common extensor origin. 2. Near its insertion its tendon is crossed
by the tendons of the abductor pollicis
Common Extensor Origin longus and the extensor pollicis brevis.
3. At the wrist the radial artery is medial
Anconeus to the tendon (between it and the tendon
of the flexor carpi radialis).
Origin: Posterior aspect of lateral epicondyle of
the humerus. Extensor Carpi Radialis Longus
Origin:
Insertion 1. Lower one-third of the lateral
supracondylar ridge of the humerus.
1. Lateral aspect of olecranon process of ulna. 2. Some fibres arises from the common
extensor origin.
2. Upper one-fourth of the posterior S1.C-2 ~ 3. Some fibres from the lateral
ulna. intermuscular septum.
Insertion: Dorsum of base of the second
NeIVe Supply: Radial nerve (C7. C8. Tl). The metacarpal bone.
'-."" :: travels through the substance of the Nerve Supply: Radial nerve (C6, C7).
medial head c:the triceps. Actions
1. Extension of wrist (along with extensor retinaculum, and have a common
the extensor carpi ulnaris). synovial sheath.
2. Abduction of the wrist (along 2. The four tendons of the extensor digitorum
with the flexor carpi radialis). emerge from under cover of the extensor
3. Assists movements of the digits retinaculum and fan out over the dorsum of the
by fixing the wrist. hand. The tendon to the index finger is joined
on its medial side by the tendon of the extensor
Extensor Carpi Radialis Brevis indicis, and the tendon to the little fmger is
Origin: joined on its medial side by the two tendons of
1. Common extensor origin. the extensor digiti minimi.
2. Radial collateral ligament of elbow. 3. On the dorsum of the hand adjacent tendons
Insertion: Dorsal aspect of bases of second and are variably connected together by three
third metacarpal bones. intertendinous connections directed obliquely
Nerve Supply: Posterior interosseous nerve downwards and laterally. The medial
(C7, C8). connection is strong; the lateral connection is
Actions: Same as those of extensor carpi weakest and may be absent.
radialis longus described above. The four tendons and three intertendinous
The extensor carpi radialis longus and brevis connections are embedded in deep fascia, and
act as synergists with the flexors of the fmgers together form the roof of the subtendinous
when the fist is clenched, and stabilize the (subaponeurotic) space on the dorsum of the
wrist. They act more often as synergists than as hand.
prime movers. The brevis is a better prime
mover in pure wrist extension, and the longus is Dorsal Digital Expansion
a better synergist in grasping or clenching. The
tendons of these two muscles pass through the The dorsal digital expansion (or extensor
same compartment of the extensor retinaculum, expansion) is a small triangular aponeurosis
and have a common synovial sheath. (related to each tendon of the extensor
digitorum) covering the dorsum of the proximal
Extensor Digitorum phalanx. Its base, which is proximal, covers the
Origin: Common extensor origin. metacarpophalangeal joint. The main tendon of
Insertion: The muscle ends in a tendon which the extensor digitorum occupies the central part
splits into four parts, one for each digit other of the extension, and is separated from the MP
than the thumb. Over the proximal phalanx the joint by a bursa.
tendon for each digit divides into three slips- The posterolateral corners of the extensor
one intermediate and two collateral. The expansion are joined by tendons of the
intermediate slip is inserted into the dorsal interossei and of lumbrical muscles. The
aspect of the base of the middle phalanx. The comers are attached to the deep transverse
collateral slips reunite to be inserted into the metacarpal ligament. The points of attachment
dorsal aspect of the base of the distal phalanx. of the interossei (proximal) and lumbrical
Also see dorsal digital expansion. (distal) are often called 'wing tendons'.
Nerve Supply: Posterior interosseous nerve Near the proximal interphalangeal joint the
(C7, C8). extensor tendon divides into a central slip and
Actions: Extension of interphalangeal, twocollateral slips. The central slip is joined by
metacarpophalangeal and wrist joints. some fibres from the margins of the expansion,
crosses the proximal interphalangeal joint, and
Additional Points is inserted on the dorsum of the base of the
middle phalanx. The two collateral slips are
1. The extensor digitorum and extensor indicis joined by the remaining thick margin of the
pass through the same compartment of the extensor expansion. They then join each other
and are inserted on the dorsum of the base of Nerve supply: Posterior interosseous nerve (C7,
the distal phalanx. C8).
At the metacarpophalangeal and Actions:
interphalangeal joints the extensor expansion 1. Extension of wrist along with the
forms the dorsal part of the fibrous capsule of extensor carpi radialis longus and
the joints. brevis.
The retinacular ligaments (link ligaments) 2. Adduction of the hand along with the
extend from the side of the proximal phalanx, flexor carpi ulnaris.
and from its fibrous flexor sheath, to the 3. Fixes the wrist during forceful
margins of the extensor expansion to reach the movements of the hand.
base of the distal phalanx. The tendon passes through a separate
compartment of the extensor retinaculum, in
Extensor Digiti Minimi the groove between the head and styloid
process of the ulna.
Origin: Common extensor origin.
Insertion: The tendon joins the tendon of the Muscles Inserted into Dorsal Digital
extensor digitorum for the fifth digit. It is Expansions of
inserted through the dorsal digital expansion,
into the dorsal aspect of the base of the middle • Index Finger: First dorsal interosseous,
phalanx, and the base of the distal phalanx. second palmar interosseous, first
Nerve Supply: Posterior interosseous nerve lumbrical, extensor digitorum slip, and
(C7, C8). extensor indicis.
Action: Extension of the little fmger at the • Middle Finger: Second and third dorsal
interphalangeal and metacarpophalangeal interos ~ second lumbrical, extensor
joints. It can help in extending the wrist joint. digitorum slip.
• Ring Finger: Fourth dorsal interosseous,
Additional Points third palmar interosseous, third
lumbrical and extensor digitorum slip.
1. Extensor digiti minimi is usually fused with • Little Finger: Fourth palmar
the extensor digitorum. interQsseous, fourth lumbrical, extensor
2. The tendon passes through a separate digitorum slip and extensor digiti
compartment of the extensor retinaculum, minimi.
behind the radioulnar joint. On the dorsum of
the hand the tendon divides into two parts DEEP MUSCLES OF THE BACK OF THE
which (with the tendon of the extensor FOREARM
digitorum) join the extensor expansion of the
little fmger. These are as follows.
1. Supinator.
Extensor Carpi U1naris 2. Abductor pollicis longus.
3. Extensor pollicis brevis. 4. Extensor pollicis
Origin: longus.
1. Common extensor origin. 5. Extensor indicis.
2. Posterior border of the ulna (by an In contrast to the superficial muscles, none of
aponeurosis common to it and to the the deep muscles cross the elbow joint. They
flexor carpi ulnaris and the flexor arise from the radius, the ulna and the
digitorum profundus). interosseous membrane.
Insertion: Medial side of the base of the fUth
metacarpal bone. Supinator
The muscle may be absent, or completely fused
Origin: with the abductor pollicis longus.
1. Lateral epicondyle of humerus.
2. Radial collateral ligament of the elbow Extensor Pollicis Brevis:
joint. Origin: Posterior surface of the radius below
3. Annular ligament. the origin of the abductor pollicis longus; and
4. Supinator crest of the ulna, and the from the interosseous membrane.
posterior part of the triangular area in Insertion: Dorsal surface of the base of the
front of it. proximal phalanx of the thumb.
Insertion: Upper one-third of the lateral surface Nerve Supply: Posterior interosseous nerve
of the radius. . (C7, C8).
Nerve Supply: Posterior interosseous nerVe Action: Extends the proximal phalanx and
(C6, C7). metacarpal of the thumb.
Action: Supination of the forearm. Note: The abductor pollicis longus and the
Note: The muscles have two layers, superficial extensor pollicis brevis are deep to the
and deep. The posterior interosseous nerve runs superfIcial extensors in the upper part of the
downwards between these layers. forearm. They become superficial by emerging
between the extensor carpi radialis brevis and
Abductor Pollicis Longus the extensor digitorum. They then cross the
tendons of the extensor carpi radialis longus
Origin: Upper parts of the posterior surfaces of and brevis to reach their insertion.
the tllna and the radius, and from the
interosseous membrane. Extensor Indicis
Insertion: The tendon usually splits into two
parts: one part is attached to the lateral side of Origin: Posterior surface of the ulna below the
the base of the fIrst metacarpal, and the other origin of the extensor pollicis longus, and from
part is attached to the trapezium. Further the interosseous membrane.
fasciculi may become continuous with the Insertion: The tendon joins the ulnar side of the
opponens pollicis, or with the abductor pollicis tendon of the extensor digitorum for the index
brevis. finger.
Nerve Supply: Posterior interosseous nerve Nerve Supply: Posterior interosseous nerve
(C7, C8). (C7, C8).
Action: Abduction and extension of the thumb Action: Extension of the index finger. It helps
at the carpometacarpal joint. to extend the wrist.
Origin: Posterior surface of the ulna (below the The muscle may send slips to the extensor
origin of the abductor pollicis longus); and tendons of other digits. Rarely its tendon may
from the interosseous membrance. be interrupted, on the dorsum of th~ hand by an
Insertion: Base of distal phalanx of the thumb additional muscle belly called the extensor
(dorsal aspect). indicis brevis manus.
Nerve Supply: Posterior interosseous nerve
(C7, C8). CLINICAL ANATOMY
Action: Extension at all joints of the thumb.
Note: The tendon of the extensor pollicis Paralysis of the extensor muscles of the
longus crosses the tendons of the extensor carpi forearm produces wrist drop. This is usually
radialis longus and brevis to reach the thumb. due to injury to the radial nerve above the level
of the origin of the posterior interosseous
nerve, for example in the axilla and arm. Branches and Distribution
Wrist drop is quite disabling because the Posterior interosseous nerve gives muscular
patient cannot grip any object firmly in the and articular branches.
hand without the synergistic action of the Muscular Branches
extensors.
a. Before piercing the supinator,
DEEP TERMINAL BRANCH OF RADIAL branches are given to the
NERVE OR POSTERIOR INTEROSSEOUS extensor carpi radialis brevis
NERVE and to the supinator. .
b. While passing through the
It is the chief nerve of the back of the forearm. supinator another branch is
It is a branch of the radial nerve given off in the given to the supinator.
cubital fossa, at the level of the lateral c. After emerging from the
epicondyle of the humerus. supinator, the nerve gives three
short branches to: (i) the
Surface Marking: Posterior interosseous nerve extensor digitorum, (ii) the
is marked by joining the following three points. extensor digiti minimi, and (iii)
1. A point 1 cm lateral to the biceps the extensor carpi ulnaris.
tendon at the level of the lateral d. It also gives two long branches.
epicondyle. (i) a lateral branch supplies the
2. The second point; at the junction of the abductor pollicis longus and the
upper one-third and lower two-thirds of extensor pollicis brevis. (ii) a
a line joining the middle of the posterior medial branch supplies the
aspect of the head of the radius to the extensor pollicis longus and the
dorsal tubercle at the lower end of the extensor indicis.
radius (Lister's tubercle).
3. The third point on the back of the wrist Articular Branches: Articular branches are
1 cm medial to the dorsal tubercle. given to:
(i) the wrist joint,
Course and Relations (ii) the distal radioulnar joint,
1. Posterior interosseous nerve (iii) some intercarpal and
leaves the cubital fossa and enters the back intermetacarpal joints.
of the forearm by passing between the two
planes of fibres of the supinator. Sensory Branches: Sensory branches are given
2. Within the muscle it winds to the interosseous membrane, the radius and
backwards round the lateral side of the the ulna.
radius.
3. It emerges from the supinator on CLINICAL ANATOMY
the back of the forearm. Here it lies
between the superficial and deep muscles. The deep branch of the radial nerve may be
4. At the lower border of the damaged during an operation for exposure of
extensor pollicis brevis, it passes deep to the head of the radius. Since the extensor carpi
the extensor pollicis longus. radialis longus and brevis are spared wrtst drop
5. It then runs on the posterior does not occur.
surface of the interosseous membrane up to
the wrist where it enlarges into a THE POSTERIOR INTEROSSEOUS
pseudoganglion and ends by supplying the ARTERY
wrist and intercarpal joints.
1. It is the smaller terminal branch of the clavicle, the clavicular notch of the manubrium
common interosseous artery in the sterni, and the upp~r surface of the fIrst costal
cubital fossa. cartilage. It is a complex joint as its cavity is
2. It enters the back of the forearm by subdivided into two parts by an intra-articular
passing between the oblique cord and disc.
the upper margin of the interosseous The articular surface of the clavicle is covered
membrane. with fIbrocartilage (as the clavicle is a
3. It appears on the back of the forearm in membrane bone).
the interval between the supinator and The surface is convex from above downwards
the abductor pollicis longus and and slightly concave from front to back. The
thereafter accompanies the posterior stemal surface is smaller than the clavicular
interosseous nerve. At the lower border surface. It has a reciprocal convexity and
of the extensor indicis, the artery concavity. Because of the concavo-convex
becomes markedly reduced and ends by shape of the articular surfaces, the joint can be
anastomosing with the anterior classilled as a saddle joint.
interosseous artery which reaches the The capsular ligament is attached laterally to
posterior compartment by piercing the the margins of the clavicular articular surface;
interosseous membrane at the upper and medially to the margins of the articular
border of the pronator quadratus. Thus areas on the stemum and on the fIrst costal
in its lower one-fourth the back of the cartilage. It is strong anteriorly and posteriorly
forearm is supplied by the anterior where it constitutes the anterior and posterior
interosseous artery. stemoclavicular ligaments.
4. The posterior interosseous artery gives However, the main bond of union at this joint is
off an interosseous recurrent .branch the articular disc. The disc is attached laterally
which runs upwards and takes part in to the clavicle on a rough area above and
the anastomosis on the back of the posterior to the articular area for the stemum.
lateral epicondyle of the humerus. Inferiorly, the disc is attached to the stemum
and to the fIrst costal cartilage at their junction.
Anteriorly and posteriorly the disc fuses with
the capsule.
THE SHOULDER GIRDLE
There are two other ligaments associated with
The shoulder girdle connects the upper limb to this joint. The interclavicular ligament passes
the axial skeleton. It consists of the clavicle and between the sternal ends of the right and left
the scapula. Anteriorly, the clavicle reaches the clavicles. some of its fibres being attached to
stemum and articulates with it at the the upper border of the manubrium sterni. The
stemoclavicular joint. The clavicle and the costoclavicular ligament is attached above to
scapula are united to each other at the the rough area on the inferior aspect of the
acromioclavicular joint. The scapula is not medial end of the clavicle.
connected to the axial skeleton directly, but is Inferiorly, it is attached to the first costal
attached to it through muscles. The clavicle and cartilage and to the first rib. It consists of
the scapula have been studied. The joints of the anterior and posterior laminae.
shoulder girdle are described below. Blood Supply: Internal thoracic and
suprascapular arteries.
Sternoclavicular Joint Nerve Supply: Medial supraclavicular nerve.
Movements: See movements of shoulder girdle,
The stemoclavicular joint is a synovial joint. It below.
is a compound joint as there are three elements
taking part.in it; namely the medial end of the Acromioclavicular Joint
2. Depression of the scapula
The acromioclavicular joint is a plane synovial (drooping of the shoulder). It is brought
joint. about by gravity, and actively by the lower
It is formed by articulation of small facets fibres of the serratus anterior and by the
present: (i) at the lateral end of the clavicle, and pectoralis minor. It is associated with the
(ii) on the medial margin of the acromion depression of the lateral end, and elevation
process of the scapula. The facets are covered of the medial end of the clavicle.
with fibrocartilage. The cavity of the joint is 3. Protraction of the scapula (as
occasionally subdivided by an articular disc in pushing and punchrng movements). It is
which may have perforation in it. brought about by the serratus anterior and
by the pectoralis minor. It is associated with
The bones are held together by a fibrous forward movements of the lateral end, and
capsule and by the articular disc. However, the backward movement of the medial end, of
main bond of union between the scapula and the clavicle.
the clavicle is the coracoclavicular ligament 4. Retraction of the scapula
described below (Fig. 10.1). (squaring the shoulders). It is brought about
Blood Supply: Suprascapular and by the rhomboideus and by the middle
thoracoacromial arteries. fibres of the trapezius. It is associated with
Nerve Supply: Lateral supraclavicular nerve. backward movement of the lateral end and
Movements: See movements of shoulder girdle. forward movement of the medial end of the
clavicle.
Coracoclavicular Ligament 5. Forward rotation of the
scapula round the chest wall takes place
The ligament consists of two parts-conoid and during overhead abduction of the arm. The
trapezoid. The trapezoid part is attached, below scapula rotates round the coracoclavicular
to the upper surface of the coracoid process; ligaments. The movement is brought about
and above to the trapezoid line on the inferior by the upper fibres of the trapezius and the
surface of the lateral part of the clavicle. The lower fib the serratus anterior. This
conoid part is attached, below to the root of the movement is associa with rotation of the
coracoid process just lateral to the scapular clavicle around its long axis.
notch. It is attached above to the inferior 6. Backward rotation of the
surface of the clavicle on the conoid tubercle. scapula occurs under the i~uence of gravity,
although it can be brought about-actively
Movements of the Shoulder Girdle by the levator scapulae and the
Movements at the two joints of the girdle are rhomboideus.This is associated with
always associated with the movements of the rotation of the clavicle in a direction
scapula. The movements of the scapula mayor opposite to that during forward rotation.
may not be associated with the movements of
the shoulder joint. The various movements are CLINICAL ANATOMY
described below.
1. Elevation of the scapula (as in 1. The clavicle may be dislocated at either
shrugging the shoulders). The movement is of its ends. At the medial end, it is
brought about by the upper fibres of the usually dislocated forwards. Backward
trapezius and by the levator scapulae. It is dislocation is rare as it is prevented by
associated with the elevation of the lateral the costoclavicular ligament.
end, and depression of the medial end of the 2. The main bond of union between the
clavicle. The clavicle moves round an clavicle and the manubrium is the
anteroposterior axis formed by the articular disc. Apart from its attachment
costoclavicular ligament. to the joint capsule the disc is also
attached above to the medial end of the passes below the ligament, and the
clavicle, and below to the manubrium. suprascapular artery above the ligament.
This prevents the sternal end of the The inferior transverse scapular (spinoglenoid)
clavicle from tilting upwards when the ligament. It is a weak band which bridges the
weight of the arm depresses the spinoglenoid notch. The suprascapular nerve
acromial end. and vessels pass beneath the arch to enter the
3. The clavicle dislocates upwards at the infraspinous fossa.
acromioclavicular joint, because the
clavicle overrides the acromion. THE SHOULDER JOINT
4. The weight of the limb is transmitted
from the scapula to the clavicle through Surface Marking
the coracoclavicular ligament, and from
the clavicle to the sternum through the The anterior margin of the glenoid cavity
sternoclavicular joint. Some of the corresponds to the lower half of the shoulder
weight also passes to the first rib by the joint. It is marked by a line 3 cm long drawn
costoclavicular ligament. The clavicle downwards from a point just lateral to the tip of
usually fractures between these two the coracoid process. The line is slightly
ligaments. concave laterally.
Type: The shoulder joint is a synovial joint of
, of sternod iic joim the ball and socket variety.
Articular Surface: The joint is formed by
In this dislocation the medial end of the
articulation of the scapula and the head of the
clavicle is usually displaced forwards.
humerus. Therefore, it is also known as the
Backward dislocation is much more serious as
glenohumeral articulation.
the bone may press on the trachea or one of the
Structurally, it is a weakjoint because the
large vessels at the root of the neck.
glenoid cavity is too small and shallow to hold
Dislocation or subluxation of the the head of the humerus in place. (The head is
acromioclavicular joint is more common than four times the size of the glenoid cavity.)
dislocation at the sternoclavicular joint. as the However, this arrangement permits great
latter is a stronger joint. mobility. Stability of the joint is maintained by
the fpllowing factors.
1. The coracoacromial arch or secondary socket
for the head of the humerus.
Ligaments of the Scapula 2. The musculotendinous cuff of the shoulder.
3. The glenoidal labrum helps in deepening the
The coracoacromiaJ ligament. It is a triangular glenoid fossa. Stability is also provided by the
ligament, the apex of which is attached to the muscles attaching the humerus to the pectoral
tip of the acromion, and the base to the lateral girdle, the long head of the biceps, the long
border of the coracoid process. head of the triceps, and atmospheric pressure.
The acromion, the coracoacromial ligament and
the coracoid process, together form the Ligaments of the Joint
coracoacromial arch, which is known as the
secondary socket for the head of the humerus. As the articular capsule is opened, the three
It adds to the stability of the joint and protects glenohumeral ligaments are noticeable on the
the head of the humerus. anterior part of the capsule. Defme the articular
The superior transverse scapular or surfaces, ligaments, bursae related to this
suprascapular ligament. It converts the scapular important joint.
notch into a foramen. The suprascapular nerve 1. The capsular ligament: It is very loose
and permits free movements. It is least
supported inferiorly where dislocations triceps, latissimus dorsi, and the coracoid
are common. Such a dislocation may process are present.
damage the closely related axillary
nerve. Relations
2. Medially, the capsule is attached to the
scapula beyond the supraglenoid Superiorly: Coracoacromial arch, subacromial
tubercle and the margins of the labrum. bursa, supraspinatus and deltoid.
Laterally, it is attached to the Inferiorly: Long head of the triceps brachii.
anatomical neck of the humerus with Anteriorly: Subscapularis, coracobrachialis,
the following exceptions. Inferiorly, the short head of biceps and deltoid.
attachment extends down to the surgical Posteriorly: Infraspinatus, teres minor and
neck. Superiorly, it is deficient for deltoid.
passage of the tendon of the long head Within the joint: Tendon of the long head of the
of the biceps brachii. biceps brachii.
The joint cavity communicates with the
subscapular bursa, with the synovial sheath for Blood Supply
the tendon 0f long head of the biceps brachii,
and often with - infraspinatus bursa. Anteriorly, 1. Anterior circumflex humeral vessels,
the capsule is reinforced by supplemental bands 2. Posterior circumflex humeral vessels,
called the superior. 3. Suprascapular vessels, and 4.
middle and inferior glenohumeral ligaments. Subscapular vessels.
The capsule is lined with synovial membrane.
An extension of this membrane forms a tubular Nerve Supply
sheath for the tendon of the long head of the
biceps brachii. 1. Axillary nerve,
2. The coracohumeral ligament: It extends from 2. Musculocutaneous nerve, and
the root of the coracoid process to the neck of 3. Suprascapular nerve.
the humerus opposite the greater tubercle. It
gives strength to the capsule. MOVEMENTS AT THE SHOULDER JOINT
3. Transverse humeral ligament: It bridges the
upper part of the bicipital groove of the The shoulder joint enjoys great freedom of
humerus (between the greater and lesser mobility at the cost of stability. There is no
tubercles). The tendon of the long head of the other joint in the body which is more mobile
biceps brachii passes deep to the ligament. than the shoulder. This wide range of mobility
4. The glenoidal labrum : It is a is due to laxity of its fibrous capsule, and the
fibrocartilaginous rim which covers the large size of the head of the humerus as
margins of the glenoid cavity, thus increasing compared with the shallow glenoid cavity. The
the depth of the cavity. range of movements is further increased by
concurrent movements of the shoulder girdle.
Bursae Related to the Shoulder Joint
Movements of the shoulder joint are considered
1. The subacromial (subdeltoid) bursa. in relation to the scapula rather than in relation
2. The subscapularis bursa, communicates with to the sagittal and coronal planes. When the
the joint cavity. arm is by the side (in the resting position) the
3. The infraspinatus bursa, may communicate glenoid cavity faces almost equally forwards
with the joint cavity. and laterally; and the head of the humerus faces
4. Several other bursae related to the medially and backwards. Keeping these
coracobrachialis, teres major, long head of the directions in mind, the movements are analyzed
as follows.
1. Flexion and extension. During flexion the upward pull on the head of the humerus. This is
arm moves forwards and :rpedially, and during counteracted by a dO\NTIward pull produced
extension the arm moves backwards and by the subscapularis, the infraspinatus and the
laterally. Thus flexion and extension take place teres minor (thus avoiding upward
in a plane parallel to the surface of the glenoid displacement of the head of the humerus).
cavity. Thus the deltoid and these three muscles
2. Abduction and adduction take place at right constitute a 'couple' which permits true
angles to the plane of flexion and extension, i.e. abduction in the plane of the body of the
approximately midway between the sagittal and scapula. The serratus anterior and the trapezius
coronal planes. In abduction, the arm moves increase the range of the abduction
anteroIaterally away from the trunk. This considerably up to 180 degrees by rotating the
movement is in the same plane as that of the scapula so that the glenoid cavity faces
body of the scapula. upwards.
3. Medial and lateral rotation are best 4. Adduction is brought about: (a) mainly by
demonstrated with a midflexed elbow. In this the pectoralis major and the latissimus dorsi;
position, the hand is moved medially in medial and (b) is assisted by the teres major, the
rotation, and laterally in lateral rotation of the coracobrachialis, the short head of the biceps
shoulder joint. brachii, and the long head of the triceps brachii.
4. Circumduction is a combination of different 5. Medial rotation is produced by the pectoralis
movements as a result of which the hand moves major, the anterior fibres of the deltoid, the
along a circle. latissimus dorsi, and the teres major. When the
The range of any movement depends on the arm is by the side the movement is also assisted
availability of an area of free articular surface by the subscapularis.
on the head of the humerus. It may be noted 6. Lateral rotation is produced by the posterior
that the articular area on the head of the fibres of the deltoid, the infraspinatus, and the
humerus is four times larger than that on the teres minor.
glenoid cavity.
Muscles Producing Movements Analysis of Abduction at the Shoulder
The disc shows age changes. With advancing 1. It binds the radius and ulna to each other.
age the disc undergoes progressive
degeneration characterized by reduced 2. It provides attachments to many muscles.
cellularity, loss of elastic fibres, mucoid
degeneration of ground substance, exposure of 3. It transmits forces (including weight) applied
collagen fibres, fibrillation, thinning, and to the radius (through the hand) to the ulna.
ultimately perforation. Perforation occurs only This transmission is necessary as radius is the
after the second decade of life. main bone taking part in the wrist joint, while
the ulna is the main bone taking part in the
Interosseous Membrane elbow joint.
Pronation is brought about chiefly by the The joint line is obtained by joining the styloid
pronator quadratus. It is aided by the pronator processes of the radius and ulna. It is convex
teres when the movement is rapid and against upwards.
resistance. Gravity also helps. The joint neither communicates with the
inferior radioulnar joint nor with the intercarpal
Supination is brought about by the supinator joints.
muscle and the biceps brachii. Slow supination,
with elbow extended, is done by the supinator. Articular Surfaces
Rapid supination with the elbow flexed, and
when performed against resistance, is done Upper 1. Inferior surface of the lower end of
mainly by the biceps. the radius.
There are three joint cavities among the Anteriorly, the joint is covered by the muscles
intercarpal. of the thenar eminence. Posteriorly, there are
carpometacarpal and intermetacarpal joints, long and short extensors of the thumb.
which are: (1) pisotriquetral, (2) first Medially there is the first dorsal interosseous
carpometacarpal. and (3) a common cavity for muscle, and the radial artery (passing from the
the rest of the joints. The dorsal to the palmar aspect of the .
common cavity may be described as the hand through the interosseous space). Laterally,
midcarpal (transverse intercarpal) joint between there is the tendon of the abductor pollicis
the proximal and distal rows of the carpus, longus.
which communicates with intercarpal joints
superiorly, and with intercarpal, Blood Supply
carpometacarpal and intermetacarpal joints
inferiorly. Radial vessels supply blood to the synovial
The midcarpal joint permits movements membrane and capsule of the joint.
between the 1Fo rows of the carpus as already
described with the wrist joint. Nerve Supply
Ulnar artery is marked by joining the following Axillary Nerve with its Divisions
three points.
(i) A point in front of the elbow at the level of Axillary nerve with its divisions is marked as a
the neck of the radius medial to the tendon of horizontal line on the deltoid muscle, 2 cm
the biceps brachii. above the .
(ii) A second point at the junction of the upper midpoint between the tip of the acromion
1/3 and lower 2/3 ofthe medial border of the process and the insertion of the deltoid.
forearm (lateral to the ulnar nerve).
(iii) The third point lateral to the pisiform bone. Intramuscular injections in the deltoid are given
Thus the cQurse of the ulnar artery is oblique in in the lower part of the muscle nearer to its
its upper 1/3, and vertical in its lower 2/3. The insertion to avoid injury to the nerve and its
ulnar nerve lies just medial to the ulnar artery accompanying vessels.
in the lower 2/3 ofits course. The ulnar artery
continues in the palm as the superficial palmar Musculocutaneous Nerve
arch.
Musculocutaneous nerve is marked by joining
Superficial Palmar Arch the following two points.
(i) A point lateral to the axillary artery 3 cm
Superficial palmar arch is formed by the direct above its termination.
continuation of the ulnar artery, and is marked (ii) A point lateral to the tendon of the biceps
as a curved line by joining the following points. brachii muscle 2 cm above the bend of the
elbow. (Here it pierces the deep fascia and
(i) A point just lateral and distal to the pisiform continues as the lateral cutaneous nerve of the
bone. forearm).
(ii) The second point on the hook of the hamate
bone. Median Nerve
(iii) The third point on the distal border of the
thenar eminence in line with the cleft between In the Arm
the index and middle fingers.
The convexity of the arch is directed towards Mark the brachial artery. The nerve is then
the fingers, and its most distal point is situated marked lateral to the artery in the upper half,
at the level of the distal border of the fully and medial to the artery in the lower half of the
extended thumb. arm. The nerve crosses the artery anteriorly in
the middle of the arm.
Deep Palmar Arch Deep palmar arch is formed In the Forearm
as the direct continuation of the radial artery. It
has a slight convexity towards the fingers. It is Median nerve is marked by joining the
marked by a more or less horizontal line, 4 cm following two points.
(11/2'1 long, just distal to the hook of the (i) A point medial to the brachial artery at the
hamate bone. bend of the elbow.
(ii) A point in front of the wrist, over the upper 2/3 and lower 1/3 of the lateral border of
tendon of the palmaris longus or 1 cm medial to the forearm just lateral to the radial artery.
the tendon of the flexor carpi radialis. (iii) The third point at the anatomical snuff box.
The nerve is vertical in its course between
In the Hand points one and two. At the second point it
inclines backwards to reach the snuff box.
Median nerve enters the palm by passing deep
to flexor retinaculum, immediately below Miscellaneous Topic$
which it divides into lateral and medial
branches. Lateral bran~h supplies the three The nerve is closely related to the lateral side
muscles of thenar eminence and gives two ofradial artery only in the middle 1/3 of the
branches to the thumb, and one to lateral side forearm.
of index finger. Medial branch gives branches
for the adjacent sides of index, middle and ring Ulnar Nerve
fingers. The lateral three and a half nail beds
are also supplied. In the Arm
The anterior margin of the glenoid cavity Common Flexor Synovial Sheath (Ulnar Bursa)
corresponds to the lower half of the shoulder
joint. It is marked by a line 3 cm long drawn Above the flexor retinaculum (or lower
downwards from a point just transverse crease of the wrist) it extends into
lateral to the tip of the coracoid process. The the forearm for about 2.5 cm. Here its medial
line is slightly concave laterally. border corresponds to the lateral edge of the
tendon of the flexor carpi ulnaris, and its lateral
Elbow Joint border corresponds roughly to the tendon of the
palmaris longus.
The joint line is situated 2 cm below the line Ulnar bursa becomes narrower behind the
joining the two epicondyles, and slopes flexor retinaculum, and broadens out below it.
downwards and medially. This slope is Most of it terminates at the level of the upper
responsible for the carrying angle. transverse creases of the palm, but the medial
part is continued up to the distal transverse
Wrist Joint crease of the little finger.
The joint line is concave downwards, and is Synovial Sheaths for the Tendon of Flexor
marked by joining the styloid processes of the Pollicis Longus (Radial Bursa)
radius and ulna.
Radial bursa is a narrow tube which is
RETINACULA coextensi\ with the ulnar bursa in the forearm
and wrist. Belo the flexor retinaculum it is
Flexor Retinaculum continued into the thu up to its distal crease.
General Remarks
Development and Ossification The vertebral column is also called the spine,
the spinal column, or back bone. It is the
The sternum develops by fusion of two sternal central axis of the body. It supports the body
plates formed on either side of the midline. The weight and transmits it to the ground through
fusion of the two plates takes place in a the lower limbs.
craniocaudal direction.
Nonfusion of the plates causes ectopia cordis, Number of vertebrae: The vertebral column is
where the heart lies uncovered on the surface. made up of 33 vertebrae; seven cervical, twelve
Partial fusion of the plates may lead to the thoracic, five lumbar, five sacral and four
formation of sternal foramina, bifid xiphoid coccygeal.
process, etc. Number of vertebrae and number of spinal
In the cartilaginous sternum, five double bony nerves: In the thoracic, lumbar and sacral
centres appear from above downwards during regions, the number of vertebrae corresponds to
the fifth, sixth, seventh, eighth and ninth fetal the number of spinal nerves, each nerve lying
months. below the corresponding vertebra. In the
The upper centre forms the manubrium. The cervical region, there are eight nerves, the
other centres form four sternebrae, which fuse upper seven lying above the corresponding
with each other from below upwards during vertebrae and the eighth below the seventh
puberty. Fusion is complete by 25 years of age. vertebra. In the coccygeal region, there is only
The manubriosternal joint which is a secondary one coccygeal nerve.
cartilaginous usually persists throughout life. In The length of The Vertebral Column: The
only about 10% of subjects, fusion may occur length of the spine is about 70 cm in males and
in old age. about 60 cm in females. The intervertebral
The centre for the xiphoid process appears discs contribute one-fifth of the length of the
during the third year or later. It fuses with the vertebral column.
body at about 40 years.
Curvatures of the Vertebral Column
CLINICAL ANATOMY
1. Primary curves are present at birth and
1. Bone marrow for examination is usually due to the shape of the vertebral bodies.
obtained by manubriosternal puncture. The primary curves are thoracic and
sacral, both of which are concave
forwards.
2. Secondary curves are postural and are from the junction of the two laminae
mainly due to the shape of the there is the spine or spinous process.
intervertebral disc. The Secondary or 6. Transverse process: Passing
compensatory curves are cervical and laterally and usually somewhat
lumbar, both of which are convex downwards from the junction of
forwards. The cervical curve appears each pedicle and the corresponding
during four to five months after birth lamina, there is a transverse process.
when the infant starts supporting its The spinous and transverse
head: the lumbar curve appears during processes serve as levers for
twelve to eighteen months when the muscles acting on the vertebral
child assumes the upright posture. column.
7. Superior and inferior articular
Parts of a Typical Vertebra processes: Projecting upwards from
the junction of the pedicle and the
A typical vertebra is made up of the following lamina there is on either side a
parts. superior articular process; and
1. The body: The body lies anteriorly. projecting downwards there is an
It is shaped like a short cylinder, inferior articular process. Each
being rounded from side to side and process bears a smooth articular
having flat upper and lower surfaces facet: the superior facet is directed
that are attached to those of posteriorly and somewhat laterally.
adjoining vertebrae by intervertebral and the inferior facet is directed
discs. forwards and somewhat medially.
2. The pedices: The right and left The superior facet of one vertebra
pedices are short rounded bars that articulates with the inferior facet of
project backwards, and somewhat the vertebra above it. Two adjoining
laterally from the posterior aspect of vertebrae, therefore articulate at
the body. three joints-two between the right
3. The laminae: Each pedicle is and left articular processes, and one
continuous, posteromedial with a between the bodies of the vertebrae
vertical plate of bone called the through the intervertebral disc.The
lamina. The laminae of the two pedicle is much narrower in vertical
sides pass backwards and medially diameter than the body and is
to meet in the midline. The pedicles attached nearer its upper border. As
and laminae together constitute the a result there is a large inferior
vertebral or neural arch. vertebral notch below the pedicle.
4. The vertebral foramen: There is a The notch is bounded in front by the
large vertebral foramen bounded posterior surface of the body of the
anteriorly by the posterior aspect of vertebra, and behind by the inferior
the body on the sides by the pedicles articular process. Above the pedicle
and behind by the lamina.Each there is a much shallower superior
vertebral foramen forms a short vertebral notch. The superior and
segment of the vertebral canal that inferior notches of adjoining
runs through the whole length of the vertebrae join to form the
vertebral column and lodges the intervertebral foramina which give
spinal cord. passage to the dorsal and ventral
5. Spine or spinous process: Passing rami of the spinal nerves emerging
backwards and usually downwards from the spinal cord.
6. The transverse processes are large, and
The Thoracic Vertebrae are directed laterally and backwards
from the junction of the pedicles and
The thoracic vertebrae are identified by the laminae. The anterior surface of each
presence of costal facets on the sides of the process bears a facet near its tip, for
vertebral bodies. The costal facets may be two articulation with the tubercle ofthe
or only one on each side. corresponding rib. In the upper six
There are 12 thoracic vertebrae, out of which vertebrae, the costal facets on the
the second to eighth are typical, and the transverse processes are concave, and
remaining five (first, ninth, tenth, eleventh and face forwards and laterally. In lower
twelfth) are atypical. six, the facets are flat and face upwards,
laterally and slightly forwards (see
Typical Thoracic Vertebra costotransverse joints below).
7. The spine is long, and is directed
1. The body is heart-shaped with roughly downwards and backwards. The fIfth to
the same measurements from side to ninth spines are the "'""'o-est, more
side and anteroposteriorly. On each side vertical and overlap each other. The r
it bears two costal demifacets. The and lower spines are less oblique in
superior costal demifacet is larger and direction.
placed on the upper border of the body
near the pedicle. It articulates with the Attachments on a Typical Thoracic Vertebra
head of the numerically corresponding
rib. The inferior costal demifacet is 1. The upper and lower borders of the
smaller and placed on the lower border body give atachment, in front and
in front of the inferior vertebral notch. It behind respectively to the anterior and
articulates with the next lower rib. posterior longitudinal ligaments.
2. The vertebral foramen is comparatively 2. The upper borders and lower parts of
small and circular. the anterior surfaces of the laminae
3. The vertebral arch: provide attachment to the ligamenta
a. The pedic1es are directed flava.
straight backwards. The superior 3. The transverse process gives attachment
vertebral notch is shallow, while to:
the inferior vertebral notch is a. the lateral costotransverse
deep and conspicuous. ligament at the tip.
b. The laminae overlap each other b. the superior costotransverse
from above. ligament along the lower border.
4. The superior articular processes project c. the inferior costotransverse
upwards from the junction of the ligament along the anterior
pedicles and laminae. The articular surface.
facets are flat and are directed d. the intertransverse muscles to
backwards and a little laterally and upper and lower borders.
upwards. This direction permits rotatory e. the levator costae on the
movements of the spine. posterior surface.
5. The inferior articular processes are 4. The spines give attachment to the
fused to the laminae. Their articular supraspinous and interspinous
facets are directed forwards and slightly ligaments. They also give attachment to
downwards and medially. several muscles including the trapezius,
the rhomboideus, the latissimus dorsi,
the errati posterior, superior and 5. The superior vertebral notches are well
inferior, and many deep muscles of the marked as in cervical vertebrae.
back.
The Ninth Thoracic Vertebra
Ossification of a Thoracic Vertebra
The ninth thoracic vertebra resembles a typical
The ossifIcation is similar to that of a typical thoracic vertebra except that the body has only
vertebra. the superior costal demifacets. The inferior
It ossilles in cartilage from three primary and costal facets are absent.
fIve econdary centres.
The three primary centres, one for the centrum The Tenth Thoracic Vertebra
and one for each half of the neural arch, appear The tenth thoracic vertebra resembles a typical
during eighth to ninth week of fetal life. At thoracic vertebra except that the body has a
birth the vertebra consists of three parts, the single complete superior costal facet on each
centrum and two halves of the neural arch. The side, extending on to the root of the pedicle.
two halves of the neural arch fuse posteriorly
during the first year of life. The neural arch is Tenth Thoracic Vertebrae
joined with the centrum by the neurocentral
synchondrosis. Bony fusion occurs here during 1. The body has a single large costal facet
the third to sixth years of life. on each -ide. extending on to the upper
Five secondary centres: one for the upper part of the pedicle.
surface and one for the lower surface of the 2. The transverse process is small, and has
body, one for each transverse process, and one no articular facet. .
for the spine appear at about the 15th year and 5. Sometimes it is difficult to differentiate
fuse with the rest of the vertebra at about the between thoracic tenth and eleventh
25th year. vertebrae.
Failure of fusion of the two halves of the neural
arch results in 'spina bifida'. Sometimes the The Twelfth Thoracic Vertebra
body ossilles from two primary centres, and if
one centre fails to develop, one half, right or 1. The shape of the body, pedicles,
left of the body is missing. This results in a transverse processes and spine are
hemivertebra and lateral bend in the vertebral similar to those of a lumbar vertebra.
column or scoliosis. However, the body bears a single costal
facet on each side, which lies more on
The First Thoracic Vertebra the lower part of the pedicle than on the
body.
1. The body of this vertebra resembles that 2. The transverse process is small and has
of a cervical vertebra. It is broad and no facet, but has superior, inferior and
not heart-shaped. lateral tubercles.
2. Its upper surface is lipped laterally and 3. The inferior articular facets are lumbar
bevelled anteriorly. in type.These are everted and are
3. The superior costal facet on the body is directed laterally, but the superior
complete. It articulates with the head of articular facets are thoracic in type.
the first rib. The inferior costal facet is a
demifacet for the second rib. JOINTS OF THE THORAX
4. The spine is thick, long and nearly
horizontal. Manubriosternal Joint
Manubriosternal joint is a secondary
cartilaginous joint. It permits slight movements
of the body of the sternum on the manubrium Chondrosternal Joints
during respiration.
The first chondrostemal joint is a primary
Costovertebral Joints cartilaginous joint, it does not permit any
movement. The second to seventh costal
The head of a typical rib articulates with its cartilages articulate with the stemum by
own vertebra, and also with the body of the synovial joints. This helps in the stability of the
next higher vertebra, to form two plane shoulder girdle and of the upper limb.
synovial joints separated by an intra-articular
ligament. Interchondral Joints
The Pulmonary Pleura: The pulmonary pleura There are two folds or recesses of parietal
covers the surfaces and fissures of the lung pleura, which act as 'reserve spaces' for the
except at the hilum and along the attachment of lung to expand during deep inspiration.
the pulmonary ligament where it is continuous 1. The costomediastinal recess lies
with the parietal pleura. It is "firmly adherent to anteriorly, behind the sternum and
the lung and cannot be separated from it. costal cartilages, between the costal and
mediastinal pleurae, particularly in
The Parietal Pleura: The parietal pleura is relation to the cardiac notch of the left
thicker than the pulmonary pleura, and is lung. This recess is filled up by the
subdivided into four parts: anterior margin of the lungs even during
1. The costal pleura lines the thoracic wall quiet breathing. It is only obvious in the
comprises ribs and intercostal spaces to region of the cardiac notch of the lung.
which it is loosely attached by a layer of 2. The costodiaphragmatic recess lies
areolar tissue called the endothoracic inferiorly between the costal and
fascia. diaphragmatic pleura.Vertically it
2. The mediastinal pleura line the measures about 5 em, and extends from
corresponding surface of the the eighth to tenth ribs along the
mediastinum. It is reflected over the midaxillary line.
root of the lung and becomes Surface Marking of the Pleura
continuous with the pulmonary pleura
around the hilum. • The cervical pleura is represented by a
3. Diaphragmatic pleura line the superior curved line forming a dome over the
aspect of diaphragm. It covers the base medial one-third of the clavicle with a
of the lung and gets continuous with height of about 2.5 cm above the bone.
mediastinal pleura medially and costal • The anterior margin, the
pleura laterally, costomediastinal line of pleural
reflection is as follows:
4. The cervical pleura extends into the o On the right side it extends from
neck, nearly 5 cm above the first costal the stemoclavicular joint
downwards and medlally to the the diaphragmatic pleurae by the
midpoint of the sternal angle. phrenic nerves. The parietal pleura is
From here it continues vertically pain sensitive.
downwards to the midpoint of • The pulmonary pleura is supplied by
the xiphistemal joint. autonomic nerves. The sympathetic
o On the left side, the line follows nerves are derived from second to fifth
the same course up to the level spinal segments while parasympathetic
of the fourth costal cartilage. It nerves are drawn from the vagus nerve.
then arches outwards and The nerves accompany the bronchial
descends along the stemal vessels. This part of the pleura is not
margin up to the sixth costal sensitive to pain.
cartilage.
• The inferior margin, or the Blood Supply and Lymphatic Drainage of the
costodiaphragmatic line of pleural Pleura
reflection passes laterally from the
lower limit of its anterior margin, so 1. The parietal pleura is supplied by
that it crosses the eighth rib in the intercostal, intemal thoracic and
midc1avicular line, the tenth rib in the musculophrenic arteries.The veins drain
midaxillary line, and the twelfth rib at mostly into the azygos and intemal
the lateral border of the sacrospinalis thoracic veins. The lymphatics drain
muscle. Further it passes horizontally to into intercostal, intemal thoracic,
the lower border of the twelfth thoracic posterior mediastinal and diaphragmatic
vertebra, 2 cm lateral to the upper nodes.
border of the twelfth thoracic spine. 2. The pulmonary pleura, like the lung is
• Thus the pleurae descend below the supplied by the bronchial arteries while
costal margin at three places, at the the veins drain into bronchial veins. It is
right xiphicostal angle, and at the right drained by the bronchopulmonary
and left costovertebral angles below the lymph nodes.
twelfth rib behind the upper poles of the
kidneys. The latter fact is of surgical CLINICAL ANATOMY
importance in exposure of the kidney.
The pleura may be damaged at this site. Aspiration of any fluid from the pleural cavity
• The posterior margins of the pleura pass is called paracentesis thoracis. It is usually
from a point 2 cm lateral to the twelfth done in the eighth intercostal space in the
thoracic spine to a point 2 cm lateral to midaxillary line.
the seventh cervical spine.The costal The needle is passed through the lower part of
pleura becomes the mediastinal along the space to avoid injury to the principal
this line. neurovascular bundle.
Some clinical conditions associated with the
Nerve Supply of the Pleura pleura are as follows :
1. Pleurisy: This is
• The parietal pleura is supplied by the inflammation of the pleura. It may be dry,
somatic nerves. These are the but often it is accompanied by collection of
intercostal and phrenic nerves. The fluid in the pleural cavity. The condition is
costal and peripheral parts of the called the pleural effusion.
diaphragmatic pleurae are supplied by 2. Pneumothorax.
the intercostal nerves and the Presence of air in the pleural cavity.
mediastinal pleura and central part of
3. Haemothorax. the anterior or costomediastinal line of pleural
Presence of blood in the pleural cavity. reflection. The anterior border of the left lung
4. Hydropneumotho shows a wide cardiac notch below the level of
rax. Presence of both fluid and air in the the fourth costal cartilage. The heart and
pleural cavity. pericardium are uncovered by the lung in the
5. Empyema. region of this notch.
Presence of pus in the pleural cavity. The posterior border: The posterior border is
thick and ill defined. It corresponds to the
The lungs medial margins of the heads of the ribs. It
extends from the level of the seventh cervical
The lungs are a pair of respiratory organs spine to the tenth thoracic spine. The inferior'
situated in the thoracic cavity. Each lung border separates the base from the costal and
invaginates the corresponding pleural cavity. medial surfaces.
The right and left lungs are separated by the The costal surface: The costal surface is large
mediastinum. and convex. It is in contact with the costal
Texture, colour and weight: The lungs are pleura and the overlying thoracic wall.
spongy in texture. In the young, the lungs are The medial surface: The medial surface is
brown or grey in colour. Gradually, they divided into a posterior or vertebral part and an
become mottled 'black because of the anterior or mediastinal part.
deposition of inhaled carbon particles. The The vertebral part is related to the vertebral
right lung weighs about 700 g ; it is about 50- bodies, intervertebral discs,ihe posterior
100 g heavier than the left lung. intercostal vessels and the splanchnic nerves.--
The mediastinal part is related to the
Features mediastiifal septum, and shows a cardiac
Each lung is conical in shape. It has: impression, the hilum and a number of other
1. an apex at the upper end; impressions which differ on the two sides.
2. a base resting on the diaphragm; Various relations ofthe mediastinal surfaces of
3. three borders, i.e. ariterior, posterior and the two lungs are listed in Table 16.1.
inferior; and
4. two surfaces, i.e. costal and medial. The Structures related to the mediastinal surfaces of
medial surface is divided into vertebral the right and left lungs
and mediastinal parts.
Right side: 1. Right atrium and auricle, 2. A
The apex: The apex is blunt and lie above the small part of the 3. Superior vena cava
level of the anerior end of the first rib. It 4. Lower part of the right 5. Azygos vein 6.
reaches nearly 2.5 cm of the the medial one- Oesophagus 7. Inferior vena cava 8.
third of the clavicle, just medial to the Trachea 9. Right vagus nerve10. Right phrenic
supraclavicular fossa. It is covered by the nerve
cervica1 pleura and by the suprapleural Left side: 1. Left ventricle, left auricle
membrane, and is grooved by the subclavian infundibulum and adjoining part of the right
artery on the medial de and in front. ventricle 2. Pulmonary trunk right ventricle 3.
The base: The base is semilunar and concave. Arch of aorta 4. Descending thoracic
It rests on the diaphragm which separates the brachiocephalic vein aorta 5. Left subclavian
right lung from the right lobe of the liver, and artery 6. Thoracic duct 7. Oesophagus 8. Left
the left lung from the left lobe of the liver, the brachiocephalic vein 9. Left vagus nerve
fundus of the stomach, and the spleen. 10. Left phrenic nerve 11. Left recurrent
The anterior border: The anterior border is laryngeal nerve
very thin. It is shorter than the posterior border
on theright side it is vertical and corresponds to
Fissures and Lobes of the Lungs: The right 6. Anterior and posterior pulmonary p!
lung is divided into 3 lobes (upper. middle and exuses of nerves.
lower) by two fissures. oblique and horizontal. 7. Lymphatics of the lung.
The left lung is divided into two lobes by the 8. Bronchopulmonary lymph nodes.
oblique fissure. 9. Areolar tissue.
1. The oblique fissure: The oblique
fissure cuts into the whole thickness of Arrangement of Structures in the Root
the lung. except at the hilum. It passes
obliquely downwards and forwards. A. From before backwards. It is similar on the
crossing the posterior border about 6 cm two sides:
below the apex and the inferior border 1. Superior pulmonary vein
about 5 cm from the median plane. Due 2. Pulmonary artery
to the oblique plane of the fissure the 3. Bronchus
lower lobe is more posterior and the B. From above downwards. It is different on
upper and middle lobe more anterior. the two sides.
2. The horizontal flssure: In the right 1. Right side:
lung. the horizontal flssure passes from (i) Eparterial bronchus
the anterior border up to the oblique (ii) Pulmonary artery
fissure and separates a wedge-shaped (iii) Hyparterial bronchus
middle lobe from the upper lobe. The (iv) Inferior pulmonary vein
fissure runs horizontally at the level of 2. Left side:
the fourth costal cartilage and meets the 3. Pulmonary artery
oblique fissure in the midaxillary line. 4. Bronchus
The tongue-shaped projection of the left 5. Inferior pulmonary vein
lung below the cardiac notch is called
the lingula. It corresponds to the middle Relations of the Root
lobe of the right lung. Anterior:
a. Common on the mio sides 1. Phrenic nerve
Root of the Lung: Root of the lung is a short 2. Pericardiophrenic vessels 3. Anterior
broad pedicle which connects the medial pulmonary plexus b. On the right side 1.
surface of the lung to the mediastinum. It is Superior vena cava 2. A part of the right
formed by structures which either enter or atrium.
come out of the lung at the hilum. The roots of Posterior a. Common on the two sides 1. Vagus
the lungs lie opposite the bodies of the fifth, nerve 2. Posterior pulmonary plexus b. On left
sixth and seventh thoracic vertebrae. side 1. Descending thoracic aorta Superior a.
On right side Terminal part of azygos vein b.
Contents: The root is made up of the following On left side Arch of the aorta
structures: D. Inferior Pulmonary ligament.
1. Principal bronchus on the left side and
eparterial and hyparterial bronchi on Surface Marking of the Lung
right side.
2. One pulmonary artery. 1. The apex of the lung coincides with the
3. Two pulmonary veins. superior and cervical pleura, and is represented by a
inferior. line convex upwa rising 2.5 cm above
4. Bronchial arteries. ope on the right side the medial one-third of clavicle.
and two on the left side. 2. The anterior border of the right lung
5. Bronchial veins. corresponds very closely to the anterior
margin or costomedstinal line of the
pleura and is obtained by joining (i) a 1. It has 2 fissures and 3 lobes
point at the stemoclavicular joint, (ii) 2. Anterior border is straight
another point in the median plane at the 3. Larger and heavier weighs about
stemal angle, (iii) a third point in the 700 g
median plane just above 4. Shorter and broader
xiphistemaljoint. Left lung:
3. The anterior border of the left lung
corresponds to the anterior margin of 1. It has only one fissure and 2 lobes
the pleura upto the level of the fourth 2. Anterior border is interrupted by the
costal cartilage. In lower part, it cardiac notch
presents a cardiac notch of variable size. 3. Smaller and lighter weighs about
From the level of the fourth cartilage it 600 g
pas laterally for 3.5 cm from the sternal 4. Longer and narrower
margin, and it curves downwards and
medially to reach the sixth costal Arterial Supply of the Lungs: The bronchial
cartilage 4 cm from the median plane. arteries supply nutritionJo the bronchial tree
In region of the cardiac notch, the and to the pulmonary tissue. These are small
pericardium covered only by a double arteries that vary in number, size and origin,
layer of pleura. The area of the cardiac but usually they are as follows.
notch is dull on percussion and is called 1. On the right side there is one bronchial
the area of superficial cardiac dullness. artery which arises either from the third
4. The lower border of each lung lies two posterior intercostal artery or from the
ribs hig than the pleural reflection. It upper left bronchial artery.
crosses the sixth ril the midclavicular 2. On the left side there are two bronchial
line, the eighth rib in the midaxill line, arteries both of which arise from the
the tenth rib at the lateral border of the descending thoracic aorta, the upper
erector spinae, and ends 2 cm lateral to opposite fIfth thoracic vertebra and the
the tenth thoracic spine. lower just below the, left bronchus.
5. The posterior border coincides with the
poste margin of the pleural reflection
except that its 10' end lies at the level of Venous Drainage of the Lungs: The venous
the tenth thoracic spine. blood from the first one or two divisions of the
6. The oblique fissure can be drawn by bronchi is carried by bronchial veins. Usually
joining: (i) a point 2 cm lateral to the there are two bronchial veins on each side. The
third thoracic spine, (ii) another point right bronchial veins drain into the azygos vein.
on the fIfth rib in the midaxillary line, The left bronchial veins drain either into the
and (iii) a third point on the sixth costal left superior intercostal vein or into the
cartilage 7.5 cm from the median plane. hemiazygos vein.
7. The horizontal fissure is represented by The greater part of the venous blood from the
a line joining: (i) a point on the anterior lungs is drained by the pulmonary veins.
border of the right lung at the level of
the fourth costal cartilage, and (ii) a Lymphatic Drainage of the Lungs: There are
second point on the fIfth rib in the two sets of lymphatics, both of which drain into
midaxillary line. the bronchopulmonary nodes.
1. Superficial vessels drain the peripheral
Differences between the left and right lungs lung tissue lying beneath the pulmonary
pleura. The vessels pass round the
Right lung:
borders of the lung and margins of the principal bronchus is 2.5 cm long. It is shorter,
fissures to reach the hilum. wider and more in line with the trachea than the
2. Deep lymphatics drain the bronchial left principal
tree, the pulmonary vessels and the bronchus. Inhaled particles, therefore, tend to
connective tissue septa.They run pa~ more frequently to the right lung, with the
towards the hilum where they drain into result the infections are more common on the
the bronchopulmonary nodes. right side tha on the left. The left principal
• The superficial vessels have numerous bronchus is 5 cm. It is longer, narrower and
valves: the deep vessels have only a few more oblique than the right bronchus.
valves or no valves at all. Each principal bronchus enters the lung throug
• Though there is no free anastomosis the hilum, and divides into secondary lobar
between the superficial and deep vessels branch one for each lobe of the lungs. Thus
some connections exist which can open there are three lobar bronchi on the right side,
up, so that lymph can flow from the and only two on the left side. Each lobar
deep to the superficial lymphatics when bronchus divides into tertiary segmental
the deep vessels are obstructed in bronchi, one for each bronchopulmonar
disease of the lungs or of the lymph segment; which are l0 on the right side and l0
nodes. on th left side. The segmental bronchi divide
repeatedly to form very small branches called
Nerve Supply: Lung are supplied by tenninal bronchioles. Still smaller branches are
Parasympathetic as well as Sympathetic called respiratory bron chioles.
nerves. Both parasympathetic and Each respiratory bronchiole aerates a small
sympathetic nerves first form anterior and proportion of the lung known as a pulmonary
posterior pulmonary plexuses situated in unit. The respiratory bronchiole ends in
front of and behind the lung roots: from the microscopic passages which are termed: (i)
plexuses nerves are distributed to the lungs alveolar ducts, (ii) atria, (iii) air sac cules, and
along the blood vessels and bronchi. (iv) pulmonary alveoli. Gaseous exchange take
1. Parasympathetic nerves are derived place in the alveoli.
from the vagus. These fibres are:
(a) motor to the bronchial Bronchopulmonary Segments: These are well-
muscles, and on stimulation defmed sectors of the lung each one of which is
cause bronchospasm; aerated by a tertiary or segmental bronchus.
(b) secretomotor to the Each segment is pyramidal in shape with its
mucous glands of the bronchial apex directed towards the root of the lung.
tree; and The most widely accepted classification of seg
(c) sensory. The sensory fibres are ments is given in Table 16.3. There are 10
responsible for the stretch reflex segments on the right side and 10 on the left.
of the lungs, and for the cough Intersegmental planes: Each segment is
reflex. surrounded by connective tissue which is
2. Sympathetic nerves are derived from continuous on the surface with pulmonary
second to fifth spinal segments. These pleura. Thus the bronchopulmonary segments
are inhibitory to the smooth muscle and are independent respiratory units. The
glands of the bronchial tree. connective tissue septa between adjoining
segments form intersegmental planes which are
Bronchial Tree crossed by the pulmonary veins and
The trachea divides at the level of lower border occasionally by the pulmonary arteries. During
of the fourth thoracic vertebra into two primary removal of a segment or segmental resection,
principal bronchi, one for each lung. The right the surgeon works along the pulmonary veins
to isolate a particular segment.
Relation to pulmonary artery. The branches of 3. Knowledge of the detailed anatomy of
the pulmonary artery accompany the bronchi. the bronchial tree helps considerably in:
The artery lies dorsolateral to the bronchus. a. Surgical removal of a segment
Thus each segment has its own separate artery. or segmental resection.
Relation to pulmonary vein. The pulmonary b. Drainage of lung abscess or
veins do not accompany the bronchi or bronchiectasis by making the
pulmonary arteries. They run in the patient adopt a particular posture
intersegmental planes. Thus each segment has called postural drainage.
more than one vein and each vein drains more c. Visualizing the interior of the
than one segment. Near the hilum the veins are bronchi through an instrument
ventromedial to the bronchus. passed through the mouth and
It should be noted that the bronchopulmonary trachea. The instrument is called
segment is not a bronchovascular segment a bronchoscope and the
because it does not have its own vein. procedure is called
There is considerable variation in the above bronchoscopy.
pattern of bronchi, arteries and veins: the veins d. In understanding why abscesses
being more variable than arteries, and the are more common in some
arteries more variable than the bronchi. segments like the posterior
The bronchopulmonary segments segment of the right upper lobe,
Right lung: and the apical segment of the
A. Upper Lobe: Three Segments: 1. Apical 2. right lower lobe.
Posterior 3. Anterior
B. Middle Lobe: Two Segments: 1. Lateral 2. Mediastinum
Medial Mediastinum is the middle space left in the
C. Lower Lobe: Five Segments: 1. Superior 2. thoracic cavity in between the lungs. Its most
Anterior basal 3. Medial basal important content is the heart enclosed in the
4. Lateral basal pericardium.
5. Posterior basal The mediastinum is the median septum of the
thorax between the two lungs. It includes the
Left lung: mediastinal pleurae.
A. Upper Lobe: Two divisions : Boundaries
I. Upper division: Three Segments: 1. 1. Anteriorly: Sternum
Apical 2. Posterior 3. Anterior 2. Posteriorly: Vertebral column
II. Lower division: Two segments: 4. 3. Superiorly: Thoracic inlet
Superior Iingular 5. Inferior lingular 4. Inferiorly: Diaphragm
B. Lower Lobe: Five Segments: 1. Superior 2. 5. On each side: Mediastinal pleura.
Anterior basal 3. Medial basal Divisions
4. Lateral basal
5. Posterior basal For descriptive purposes the mediastinum is
divided into the superior mediastinum and the
CLINICAL ANATOMY inferior mediastinum. The inferior mediastinum
is further divided into the anterior, middle and
1. Usually the infection of a segment posterior mediastinum.
remains restricted to it, although some The superior mediastinum is separated from the
infections like tuberculosis may spread inferior by an imaginary plane passing through
from one segment to another. the sternal angle (anteriorly) and the lower
2. Segments are no barriers to the spread border of the body of the fourth thoracic
of bronchogenic carcinoma. vertebra posteriorly. The inferior mediastinum
is subdivided into three parts by the can pass down into the superior
pericardium. The area in front of the mediastinum but not lower down.
pericardium is the anterior mediastinum. The 2. The pretracheal fascia of the neck also
area behind the pericardium is the posterior extends to the superior mediastinum,
mediastinum. The pericardium and its contents where it blends with the arch of the
form the middle mediastinum. aorta. Neck infections between the
pretracheal and prevertebral fasciae can
SUPERIOR MEDIASTINUM spread into the superior mediastinum,
Boundaries and through it into the posterior
1. Anteriorly: Manubrium sterni mediastinum. Thus mediastinitis can
2. Posteriorly; upper four thoracic result from infections in the neck.
vertebrae 3. There. is very little loose connective
3. Superiorly: Plane of the thoracic inlet tissue between the mobile organs of the
4. Inferiorly: An imaginary plane passing mediastinum. Therefore, the space can
through the sternal angle in front, and be readily dilated by inflammatory
the lower border of the body of the fluids, neoplasms, etc.
fourth thoracic vertebra behind. 4. In the superior mediastinum, all large
5. On each side: Mediastinal pleura. veins are on the right side and the
arteries on the left side. During
Contents: increased blood flow veins expand
1. Trachea and oesophagus. enormously, while the large arteries do
2. Muscles: Origins of: (i) sternohyoid not expand at all. Thus there is much
and (ii) sternothyroid, and (ill) 'dead space' on the right side and it is
lower ends of longus colli. into this space that tumours or fluids of
3. Arteries: (i) Arch of aorta, (ii) the mediastinum tend to project.
brachiocephalic artery, (ill) left
common carotid artery, and (iv) left INFERIOR MEDIASTINUM
subcla~an artery. The inferior mediastinum is divided into
4. Veins: (i) Right and left anterior, middle and posterior mediastina.
brachiocephalic veins, (ii) upper These are as under:
half of the superior vena cava, and Anterior Mediastinum
(ill) left superior intercostal vein. Anterior mediastinum is a very narrow space in
5. Nerves: (i) Vagus, (ii) phrenic, (iii). front of the pericardium, overlapped by the thin
cardiac nerves, of both sides, and anterior borders of both lungs. It is continuous
(iv) left recurrent laryngeal nerve. through the superior mediastinum with the
6. Thymus. pretracheal space of the neck.
7. Thoracic duct. Boundaries
8. Lymph nodes: Paratracheal. 1. Anteriorly: Body of stemum.
brachiocephalic, and 2. Posteriorly: Pericardium.
tracheobronchial. 3. Superiorly: Imaginary plane separating
the superior mediastinum from the
CUNICAL ANATOMY inferior mediastinum.
1. The prevenebral layer of the deep 4. Inferiorly: Superior surface of
cervical fascia extends to the superior diaphragm.
mediastinum, and is attached to the 5. On each sides : Mediastinal pleura.
fourth thoracic vertebra. An infection Contents
present in the neck behind this fascia (i) Sternopericardial ligaments, (ii) lymph
nodes with lymphatics, (iii) small mediastinal
branches of the internal thoracic artery, (iv) the 5. Lymph nodes and lymphatics: (i)
lowest part of the thymus, and (v) areolar Posterior mediastinal lymph nodes
tissue. lying alongside the aorta, and (ii)
Middle Mediastinum the thoracic duct.
Middle mediastinum is occupied by the
pericardium and its contents, along with the CLINICAL ANATOMY
phrenic nerves and the pericardiophrenic 1. The posteIior mediastinum is
vessels. continuous through the supeIior
Boundaries mediastinum with the neck between the
1. Anteriorly: Posterior surface of sternum pretracheal and prevertebral layers of
2. Posteriorly : Oesophagus, descending the cervical fascia. This region of the
thoracic aorta, azygos vein neck includes the retropharyngeal
3. On each side - Mediastinal pleura. space, spaces on each side of the
Contents trachea and oesophagus. the space
1. Heart enclosed in pericardium. between these tubes and the carotid
2. Arteries: (i) Ascending aorta, (ii) sheaths. Infections leading to fluid
pulmonary trunk, and (iii) two collections from these spaces can spread
pulmonary arteries. to the supeIior and posteIior mediastina.
3. Veins: (i) Lower half of the superior 2. Copmpression of mediastinal structures
vena cava, (ii) terminal part of the by any tumour gives rise to a group of
azygos vein, and (iii) right and left symptoms known as 'mediastinal
pulmonary veins. syndrome'. The common causes of
4. Nerves: (i) Phrenic, and (ii) deep mediastinal syndrome are bronchogenic
cardiac plexus. carcinoma, Hodgkin's disease causing
5. Lymph nodes: Tracheobronchial nodes. enlargement of the mediastinal lymph
6. Tubes: (i) Bifurcation of trachea. and nodes, anemysm or dilatation of the
(il) the right and left principal bronchi. aorta, etc. The common symptoms are
as follows.
Posterior Mediastinum (i) Obstruction of the supeIior
Boundaries vena cava gives Iise to
1. Anteriorly: (i) Pericardium, (ii) engorgement of veins in the
bifurcation of trachea, (iii) pulmonary upper half of the body.
vessels, and (iv) posterior part of the (ii) Pressure over the trachea
upper surface of the diaphragm. causes dyspnoea, and cough.
2. Posteriorly: Lower eight thoracic (iii) Pressure on the oesophagus
vertebrae and intervening discs. causes dysphagia.
3. On each side: Mediastinal pleura. (iv) Pressure or the left recurrent
Contents laryngeal nerve gives Iise to
1. Oesophagus. hoarseness of voice.
2. Arteries: Descending thoracic aorta (v) Pressure on the phrenic
and its branches. nerve causes paralysis of the
3. Veins: (i) Azygos vein, (ii) diaphragm on that side.
hemiazygos vein, and (iii) accessory (vi) Pressure on the intercostal
hemiazygos vein. nerves gives Iise to pain in
4. Nerves: (i) Vagi, and (ii) splanchnic the area supplied by them. It
nerves, greater, lesser and least, is called intercostal
arising from the lower eight thoracic neuralgia.
ganglia of the sympathetic chain.
(vii) Pressure on the vertebral 5. On each side it is related to the
column may cause erosion mediastinal pleura, the mediastinal
of the vertebral bodies. surface of the lung, the phrenic nerve,
and the pericardiophrenic vessels.
THE PERICARDIUM 6. It protects the heart against sudden
overfilling.
The pericardium is a fibroserous sac which
encloses the heart and the roots of the great SEROUS PERICARDIUM
vessels. It is situated in the middle Serous pericardium is thin, double-layered
mediastinum. It consists of the fibrous serous membrane lined by mesothelium. The
pericardium and the serous pericardium. outer layer of parietal pericardium is fused with
Fibrous pericardium encloses the heart and the fibrous pericardium. The inner layer or the
fuses with the vessels which enter jleave the visceral peri~ardium, or epicardium is fused to
heart. Heart is situated within the fibrous and the heart, except along the cardiac gooves,
serous pericardial sacs. As heart develops, it where it is separated from the heart by blood
invaginates itself into the serous sac, without vessels. The two layers are continuous with
causing any breach in its continuity, the last each other at the roots of the great vessels, i.e.
part to enter is the region of atria, from where ascending aorta, pulmonary trunk, two venae
the visceral pericardium is reflected as the cavae, and four pulmonary veins.
parietal pericardium. Thus parietal layer of The pericardial cavity is a potential space
serous pericardium gets adherent to the inner between the parietal pericardium and the
surface of fibrous pericardium, while the visceral pericardium. It contains only a thin
visceral layer of serous pericardium gets film of serous fluid which lubricates the
adherent to the outer layer of heart and forms apposed surfaces and allows the heart to move
its epicardium. smoothly.
Sound produced by closure of the valves of the Second right costal cartilage near the sternum
heart can be heard using a stethoscope. The
sound arising in relation to a particular valve 3. Mitral
are best heard not directly over the valve, but at
areas situated some distance away from the 3 cm
valve in the direction of blood flow through it.
These are called auscu1tatory areas. An oblique line, 3 cm long; behind the left half
The position of the valves in relation to the of the sternum opposite the left fourth costal
surface of the body, and of the auscultatory cartilage
areas is given in Table 18.1 and Fig. 18.18.
Cardiac apex
Conducting System
4. Tricuspid
The conducting system is made up of
myocardium that is specialized for initiation 4 cm
and conduction of the cardiac impulse. Its
fibres are finer than other myocardial fibres, Most oblique of all valves, being nearly
and are completely cross-striated. vertical, 4 cm long; behind the right half of the
The conducting system has the following sternum opposite the fourth and fifth spaces
parts: .
1. Sinuatrial Node or SA node. It is known as Lower end of the sternum
the 'pacemaker' of the heart. It generates an
impulse at the rate of about 70/ min and CLINICAL ANATOMY
initiates the heart beat. It is horseshoe-shaped
and is situated at the 1. The fIrst heart sound is produced by
Valve 1. Pulmonary closure of the atrioventricular valves.
The second heart sound is produced by pale fIbres striated only at their
closure of the semilunar valves. margins. They usually possess double
2. Narrowing of the valve orifIce due to nuclei.
fusion of the cusps is known as 9. Defects of or damage to this system
'stenosis', viz. mitral stenosis, aortic results in cardiac arrhythmias, i.e.
stenosis, .etc. defects in the normal rhythm of
3. Dilatation of the valve orifIce, or contraction. Except for a part of the left
stiffening of the cusps causes imperfect branch of the AV bundle supplied by
closure of the valve leading to back- the left coronary artery the whole of the
flow of blood. This is known as conducting system is usually supplied
incompetence or regurgitation, e.g. by the right coronary artery. Vascular
aortic incompetence or aortic lesions of the heart can cause a variety
regurgitation. of arrhythmias.
4. atriocaval junction in the upper part of
the sulcus terminals. The impulse ARTERIES SUPPLYING THE HEART
travels through the atrial wall to reach
the AV node. The heart is supplied by two coronary arteries,
5. Atrioventricular node or AV node. It is arising from the ascending aorta. Both arteries
smaller than the SA node and is situated run in the coronary sulcus.
in the lower and dorsal part of the atrial
septum just above the opening of the Right Coronary Artery
coronary sinus. It is capable of
generating impulses at a rate of about Right coronary artery is smaller than the left
60/ min. coronary artery. It arises from the anterior
6. Atrioventricular bundle or AV bundle aortic sinus.
or bundle of His. It is the only muscular
connection between the atrial and Course
ventricular musculatures. It begins as
the atrioventricular (A V) node crosses 1. It first passes forwards and to the right
A V ring and descends along the to emerge on the surface of the heart
posteroinferior border of the between the root of the pulmonary trunk
membranous part of the ventricular and the right auricle.
septum. 2. It then runs downwards on the
7. At the upper border of the muscular part sternocostal surface of heart, in the right
of the septum it divides into right and anterior coronary sulcus to the junction
left branches. of the right and inferior borders of the
8. The right branch of the AV bundle heart.
passes down the right side of the 3. It winds round the inferior border to
interventricular septum. A large part reach the diaphragmatic surface of the
enters the moderator band to reach the heart. Here it runs backwards and to the
anterior wall of the right ventricle left in the right coronary sulcus to reach
where it divides into Purkinje fIbres. the posterior atrioventricular groove.
4. The left branch of the AV bundle 4. It terminates by anastomosing with
descends on the left side of the coronary artery.
interventricular septum and is
distributed to the left ventricle after Branches
dividing into Purkinje fibres.
5. The Purkinje fibres form a
subendocardial plexus. They are large
1. Right conus Artery: to 6. Near the posterior interventrtcular
infundibulum and lower part of pulmonary groove it terminates by anastomosing
trunk. with the right coronary artery.
2. Artery of the sinuatrial Branches
node: in 60% cases.
3. Small branches to the A. Large branches: (1) Anterior
right atrium and ventricle interventrtcular. (2) branches to the
4. Right Marginal Artery: diaphragmatic surface of the left ventrtc1e,
5. Posterior including a large diagonal branch.
interventrtcular Artery: B. Small branches: (1) Left atrial. (2)
pulmonary and (3) terminal.
Area of Distribution
Area of Distribution
1. Right atrium
2. Greater part of the right ventricle, 1. Left artium
except an area adjoining the anterior 2. Greater part of the left ventricle, except
interventrtcu1ar groove. the area adjoining the posterior
3. A small part of the left ventrtcle interventricular groove.
adjoining posterior interventrtcular 3. A small part of the right ventricle
groove. adjoining the anterior interventrtcular
4. Posterior part of the interventricular groove.
septum 4. Anterior part of the interventrtcular
5. Whole of the conducting system of the septum.
heart except a part of the left branch of 5. A part of the left branch of the AV
the A V bundle. The SA node is bundle. The SA node is supplied by the
supplied by the right coronary artery left coronary artery about 40% of cases.
about 60% of cases.
Tributaries