Upper Limb

Artist Of Anatomy MariaM

DR/ IBRAHIM AMR

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ARTIST OF ANATOMY DR/ IBRAHIM AMR

Clavicle
Identification of the side:(right or left)
1- Superior surface is smooth .. Inferior surface is rough
2- Medial end is rounded .. Lateral end is flat
3- Medial 2/3 is convex anteriorly .. Lateral 1/3 is concave anteriorly
Articulations of clavicle:
1- Medial end: articulates with sternum (Sterno-Clavicular joint)
2- Lateral end: articulates with acromion process of scapula
(Acromio-Clavicular joint)

Superior
surface

Inferior
Surface

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ARTIST OF ANATOMY DR/ IBRAHIM AMR

- Attachments of clavicle:
1/2 Anterior Pectoralis major
Medial 1/3 Superior Sternomastoid
Subclavian groove Subclavius
Rough area (inferior) Costo-clavicular ligament

Anterior Deltoid
Posterior Trapezius
Lateral 1/3 Rough area (inferior) Coraco-clavicular ligament
- Conoid part: in conoid tubercle
- Trapezoid part: in trapezoid line

- Ossification of clavicle:
- it is the first bone in body to ossify (membranous ossification)
- Clinical notes:
- the weakest point of clavicle is junction between medial 2/3 and lateral 1/3
- fracture at this point due to falling on outstretched upper limb will lead to:
1- lateral segment: - is depressed by weight of arm and gravity
2- medial segment: - is pulled up by sternomastoid muscle

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ARTIST OF ANATOMY DR/ IBRAHIM AMR

Scapula
- it is a triangular flat bone

Identification of side of scapula:

1- Glenoid cavity is directed upwards and laterally
2- Spine is directed posteriorly

Surfaces of scapula:
(1) anterior Subscapular fossa Subscapularis muscle
surface:
(costal) Medial border Serratus anterior

Supraspinous fossa Supraspinatus muscle

Infraspinous fossa Infraspinatus muscle
(2) posterior
surface: Medial border Above spine: Levator scapulae
Opposite spine: Rhomboidus minor
Below spine: Rhomboidus major
Lateral border Upper 2/3: Teres minor
Lower 1/3: Teres major

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ARTIST OF ANATOMY DR/ IBRAHIM AMR

- Borders of scapula:

(1) superior border:

- presents a suprascapular notch
- it is transformed into a foramen by suprascapular ligament
- suprascapular nerve pass below the suprascapular ligament
- suprascapular vessels pass above the suprascapular ligament
(2) medial border(vertebral):
(3) lateral border(axillary):

- Angles of scapula:
(1) superior angle:
- opposite the 2nd rib
(2) inferior angle:
- opposite the 7th rib
(3) lateral angle:
- it carries glenoid cavity
- articulates with head of humerus (shoulder joint)
- supraglenoid tubercle: Long head of biceps
- infra-glenoid tubercle: Long head of triceps

- Processes of scapula:
1- spine of scapula:
- Upper border: Trapezius
- Lower border: Deltoid
2- acromion process:
- it is the lateral extension of spine of scapula
- it articulates with the clavicle (acromioclavicular joint)
3- coracoid process:
Coracobrachialis muscle
Tip
Coracoid Short head of biceps
process Pectoralis minor
+ Coraco-clavicular ligament

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ARTIST OF ANATOMY DR/ IBRAHIM AMR

Humerus
- It is a long bone that has a shaft, upper end and a lower end

Upper end:
- it has a head and two necks (anatomical and surgical)

Attached:
Lesser tuberosity Subscapularis

Greater tuberosity - Supraspinatus

- Infraspinatus
- Teres minor
Bicipital groove Floor: Latissimus dorsi
Medial lip: Teres major
Lateral lip: Pectoralis major
Related:
Bicipital groove: - long head of biceps
Surgical neck: - axillary nerve
- anterior and posterior circumflex humeral arteries

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ARTIST OF ANATOMY DR/ IBRAHIM AMR

Shaft of humerus:

Attached: Middle of shaft Medial Coracobrachialis

Lateral Deltoid
At the middle Spiral groove
Posterior aspect Above spiral groove Lateral head of triceps
Below spiral groove Medial heal of triceps
Anterior aspect Lower 1/2 Brachialis

Related: Spiral groove: Radial nerve

Profunda brachii artery

- Identification of side of humerus:

- Head is above and medially
- bicipital groove is anteriorly
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ARTIST OF ANATOMY DR/ IBRAHIM AMR

Pectoral Region
- Pectoral region is the front of the upper part of the trunk
- it includes:
(1) Pectoralis major muscle
(2) Pectoralis minor muscle
(3) Subclavius muscle
(4) Clavipectoral fascia

Pectoralis major Pectoralis minor

Origin - two heads:
(a) Clavicular head: Front of 3rd, 4th, 5th ribs
- front of medial ½ of clavicle
(b) Sternocostal head:
- front of sternum
- upper 6 costal cartilages
Insertion - Humerus, - Coracoid process,
(lateral lip of bicipital groove) (medial & upper aspect)
Nerve medial & lateral pectoral nerves medial pectoral nerve
supply
action - Adduction & Medial rotation of arm - Protraction of scapula
- Flexion of the arm (clavicular head) - Depression of shoulder
- In case of fixation of the humerus - Accessory inspiratory
it acts as an accessory inspiratory
& helps in climbing

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ARTIST OF ANATOMY DR/ IBRAHIM AMR

- Subclavius muscle:
Origin: first rib (1st costo-chondral junction)
Insertion: subclavian groove of clavicle
Nerve supply: Nerve to subclavius.
Action:
Stabilization of clavicle and fixes it to the 1st rib.

- Clavipectoral fascia:
- It is a membranous layer of deep fascia
- Superiorly, it splits to enclose the subclavius muscle
- Inferiorly it splits to enclose the pectoralis minor
then continues down as the suspensory ligament of axilla
- the fascia is continuous inferiorly with the axillary fascia.

- Costo-coracoid membrane:
- is the upper part of the fascia which extends between 1st costal cartilage
and the coracoid process

- Structures piercing the clavipectoral fascia:

(1) Thoraco-acromial artery
(2) Cephalic vein (terminal part)
(3) Lateral pectoral nerve.
(4) Lymphatic vessels.

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ARTIST OF ANATOMY
Muscles of the back
(A) Superficial layer:
Trapezius muscle
Origin - Back of the skull:
(1) External occipital protuberance
(2) Superior nuchal line (medial 1/3)
- Back of the neck:
(1) Nuchal ligament
(2) Spine of the 7th cervical vertebra
- Back of the thorax:
(1) Spines of all thoracic vertebrae
(2) Supraspinous ligament
Insertion Clavicle: Posterior border of lateral 1/3
Scapula: - Medial border of acromion
- Upper border of crest of spine
Nerve Motor: Spinal accessory nerve
supply Sensory: From C3,4 (proprioception)
action (1) Upper fibers:
Elevation of shoulder (shrug shoulder)
+ rotation of the scapula so that
the glenoid cavity faces upwards.
(2) Middle fibers: Retract the scapula
(3) lower fibers: depress the shoulder
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DR/ IBRAHIM AMR
Latissimus dorsi
- Spines of T7 -T12 vertebrae
and supraspinous ligament
- Thoracolumbar fascia.
- iliac crest.
- Inferior 3 or 4 ribs.
- inferior angle of scapula
- Floor of bicipital groove
of the humerus
- Nerve to latissimus dorsi
Thoracodorsal N (C6,C7,C8)
- Adduction, extension and
medial rotation of the arm
- Climbing
- Swimming
- strong muscle of expiration
ARTIST OF ANATOMY DR/ IBRAHIM AMR

(B) Deep layer:

Levator scapula Rhomboideus minor Rhomboideus major

Origin Transverse processes spines of Spines of
of C1-C4 vertebrae C7 to T1 vertebrae. T2 to T5 vertebrae

Insertion - Medial border of - Medial border of - Medial border of

dorsal surface of dorsal surface of dorsal surface of
scapula scapula scapula
above the spine. at level of spine below the spine.
Nerve Dorsal scapular nerve (C5).
supply
action - Elevates scapula - Retraction of the scapula
- Rotation of the scapula
so that the glenoid cavity faces downwards.

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ARTIST OF ANATOMY DR/ IBRAHIM AMR

Scapular region

Supraspinatus Infraspinatus Teres minor muscle

muscle muscle
Origin Supraspinous Infraspinous fossa upper 2/3 of Lateral border
fossa of scapula
Insertion Superior facet of Middle facet of Inferior facet of
greater tuberosity greater tuberosity greater tuberosity
of humerus. of the humerus. of the humerus.

Nerve
Suprascapular nerve (C5, C6) Axillary nerve (C5,C6)
supply
action - Abduction of arm Lateral rotation of Lateral rotation
from 0˚-18˚ arm + adduction of arm

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ARTIST OF ANATOMY DR/ IBRAHIM AMR

Teres major muscle Subscapularis muscle

Origin Posterior aspect of lower 1/3 Subscapular fossa

of lateral border of scapula
(above inferior angle)

Insertion Medial lip of bicipital groove Lesser tuberosity of humerus

of the humerus

Nerve Lower subscapular nerve Upper + lower subscapular nerves

supply (C5, C6) (C5, C6)

Action: Medial rotation of arm Medial rotation of arm

Adduction of arm Adduction of arm
extension of arm

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ARTIST OF ANATOMY DR/ IBRAHIM AMR

- Deltoid muscle:
- The deltoid muscle is the muscle forming rounded contour of the shoulder.
- The middle fibers are multipennate.

Anterior fibers: from the anterior border of lateral 1/3 of clavicle.

Origin Middle fibers: from the lateral margin of the acromion.
Posterior fibers: from lower lip of the crest of spine of the scapula.

Into the V-shaped deltoid tuberosity

Insertion on the middle of the lateral aspect of the shaft of the humerus.

Nerve
supply Axillary nerve (C5,C6)

Action: Anterior fibers:

- flexion + medial rotation of humerus.

Middle fibers:
- abduction from 18˚ -90˚

Posterior fibers:
- extension + lateral rotation of humerus

ROTATOR CUFF MUSCLES

- Rotator cuff muscles surround

the shoulder joint, they include:
(1) Subscapularis.
(2) Supraspinatus.
(3) Infraspinatus.
(4) Teres minor.

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ARTIST OF ANATOMY DR/ IBRAHIM AMR

- Delto-pectoral groove:
- it lies between deltoid muscle and pectorals major muscle
- it contains:
- deltoid branch of thoraco-acromial artery
- cephalic vein
- lymphatics (deltopectoral lymph nodes)

- Subdeltoid bursa (Subacromial bursa):

- it lies deep to coraco-acromial arch and deltoid muscle.
- It facilitates the movements between deltoid and supraspinatus.

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ARTIST OF ANATOMY DR/ IBRAHIM AMR

Intermuscular spaces

Boundaries Contents
Quadrangular Superiorly: Teres minor - axillary nerve
space: Inferiorly: Teres major. - posterior circumflex
Medially: long head of Triceps humeral artery
Laterally: surgical neck of humerus

Medial Superiorly: Teres minor circumflex scapular vessels

triangular Inferiorly: Teres major
space: Laterally: Long head of Triceps

Lateral Superiorly: Teres major - Radial nerve

triangular Medially: Long head of the Triceps - profunda brachii artery.
space: Laterally: Humerus

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ARTIST OF ANATOMY DR/ IBRAHIM AMR

- Serratus anterior muscle:

Origin - Outer surfaces of the upper 8 ribs by means of 8 digitations

Insertion into the scapula
- 1st digitations: into the ventral aspect of superior angle
- 2nd & 3rd digitations: into the ventral aspect of medial border.
- Lower five digitations: into ventral aspect of inferior angle
Nerve long thoracic nerve (nerve to serratus anterior)
supply
action (1) Protraction of the scapula (pulling of the scapula forwards).
(2) Keeping the scapula in contact with the chest wall
(3) Rotation of scapula during raising the arm above the head
(its lower fibers & upper fibers of trapzuis)

- Clinical notes:
- long thoracic nerve descends over
the serratus anterior muscle
and deep to the mammary gland.

- This explains why the nerve is liable to

be injured during mastectomy leading to
projection of medial border of the scapula
(Winging of the scapula)

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ARTIST OF ANATOMY DR/ IBRAHIM AMR

The Axilla

- The axilla is a four-sided pyramidal space between root of arm and chest wall.
- it allows passage of the nerves and blood vessels from neck to upper limb.

- it has a base, apex and 4 walls

- The base: is directed downwards and is formed by the axillary fascia between
lower border of pectoralis major (anteriorly)
and latissimus dorsi (posteriorly)

- The apex: is directed upwards posterior to the clavicle.

Boundaries of apex of axilla:

- Anteriorly: the clavicle.
- Posteriorly: superior border of scapula
- Medially: outer border of 1st rib.

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ARTIST OF ANATOMY DR/ IBRAHIM AMR

- The walls of the axilla:

Anterior wall - it is formed by:

- pectoralis major (superficial layer)
- pectoralis minor, subclavius muscle and clavipectoral fascia
(deep layer)
- lower border of anterior wall is called anterior fold of axilla
and is formed only by the pectoralis major muscle.

Posterior wall - it is formed by the subscapularis muscle above

and the latissimus dorsi and teres major muscles below.
- lower border of posterior wall is called posterior fold of axilla
and is formed by the latissimus dorsi and teres major muscles

Medial wall - it is formed of the thoracic wall (upper 4 ribs)

and serratus anterior muscle

Lateral wall - it is formed by upper part of shaft of the humerus,

Coracobrachialis muscle and short head of biceps

- Applied anatomy:
- Incisions in the axilla should be vertical
and nearer to the medial wall to avoid injury to the vessels and nerves

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ARTIST OF ANATOMY DR/ IBRAHIM AMR

- Contents of axilla:
(1) Brachial plexus (cords and branches).
(2) Axillary artery and branches.
(3) Axillary vein and tributaries.
(4) Axillary lymph nodes.
(5) Axillary fat.
(6) Axillary tail of female breast.

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ARTIST OF ANATOMY DR/ IBRAHIM AMR

Axillary Artery

Beginning: - it begins as a continuation of the subclavian artery

at outer border of 1st rib
Termination: - it ends at the lower border of teres major
and continues as brachial artery
Parts: - The artery is divided into 3 parts by pectoralis minor muscle.
- 1st part: from lateral border of 1st rib
to upper border of pectoralis minor
- 2nd part: - behind pectoralis minor
- 3rd part: - from lower border of pectoralis minor
to lower border of teres major
Branches: From the 1st Part:
(1) Superior thoracic artery.
From the 2nd Part:
(1) Thoraco-acromial artery.
(2) Lateral thoracic artery.
From the 3rd Part:
(1) Subscapular artery
(2) Anterior circumflex humeral artery.
(3) Posterior circumflex humeral artery

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ARTIST OF ANATOMY DR/ IBRAHIM AMR

- Surface anatomy of axillary artery:

- we put the arm in abduction (90 degree) and lateral rotation position.
- Then, we draw an imaginary line between midclavicular to mid-elbow points.
- The posterior axillary fold divides the imaginary line into:
(1) proximal part: corresponds to the axillary
(2) distal part: corresponds to the brachial artery.

- Applied anatomy:
- in case of severe bleeding from the distal part of the axillary artery,
we compress it against the outer border of the 1st rib to stop the bleeding.

Axillary lymph nodes:

- they are arranged in the following groups:
(1) Anterior (pectoral) axillary lymph nodes: - related to lateral thoracic artery
(2) Posterior (subscapular) axillary lymph nodes: - related to subscapular artery
(3) Lateral (brachial) lymph nodes: along lateral wall of axilla
(4) Central lymph nodes: in adipose tissue at base of the axilla
(5) Apical lymph nodes: - they are present at the apex of the axilla
- they receive lymph from all other groups

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ARTIST OF ANATOMY DR/ IBRAHIM AMR

Brachial plexus
- it is a network of nerves supplying the upper limb.

- Formation of the brachial plexus:

- it is formed from the ventral rami of the lower 4 cervical spinal nerves
and the 1st thoracic nerve (C5,6,7,8 and T1)

- Stages of the plexus:

(1) Roots: - Ventral rami of the lower 4 cervical nerves (C5,6,7,8).
- Ventral ramus of first thoracic nerve (T1).
(2) Trunks:
- Upper trunk: formed by the union of the C5 and C6.
- Middle trunk: formed by the C7.
- Lower trunk: formed by the union of the C8 and T1.
(3) Divisions:
- Each trunk divides into 2 divisions: anterior and posterior division.
(4) Cords:
- Lateral cord: (anterior divisions of the upper and middle trunks; C5,6,7).
- Medial cord: (anterior division of the lower trunk only; C8, T1).
- Posterior cord: (posterior divisions of the 3 trunks; C5,6,7,8,T1).

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ARTIST OF ANATOMY DR/ IBRAHIM AMR

- Position of the stages of the plexus:

(1) Roots & trunks: are present in the posterior triangle of the neck.
(2) Divisions: are present behind the clavicle.
(3) Cords: are present in the axilla.

- Branches of the plexus:

Stage Branches
The roots (1) Dorsal scapular nerve
(2) Long thoracic nerve.

The trunk: (1) Suprascapular nerve.

(2) Nerve to subclavius.

The cords:
- Medial cord:
(1) Medial Cutaneous nerve of the arm.
(2) Medial Cutaneous nerve of the forearm.
(3) Medial pectoral nerve.
(4) Medial root of median nerve.
(5) Ulnar nerve.

- Lateral cord:
(1) Lateral pectoral nerve
(2) Lateral root of median nerve.
(3) Musculocutaneous nerve.

- Posterior cord:
(1) Upper subscapular nerve.
(2) Lower subscapular nerve.
(3) Nerve to latissmus dorsi.
(4) Axillary nerve
(5) Radial nerve

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