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Dr. Jitendra P Patel Smt. NHL Municipal Medical College, Ahmedabad.
All Human dissection video available on

YouTube channel.
Chapter.1
Pectoral Region
BREAST (MAMMILARY GLAND)
Introduction:
Breast is a modified sweat gland, which is capable of secreting milk.
It is devoid of any distinct fibrous capsule.
Rudimentary in males and is well developed in females after puberty.
It also forms an important accessory organ of the female reproductive system.
Axillary tail of Spence:

Sometimes a tail like projection from upper and outer quadrant of the breast enters
the axilla through an opening in deep fascia.
The opening is known as foramen of langer.
Applied: it may be mistaken for lipoma when it is enlarge.

It is variable. It may be Hemispherical, conical or pendulous.
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Dr. Jitendra P Patel Smt. NHL Municipal Medical College, Ahmedabad. All Human dissection video available on
YouTube channel.
Structure on which base of the breast rests

1. Retro mammary space of loose areolar tissue intervenes between the base of the
gland & the deep fascia covering the deeper structures.
As a result of these, breast is freely movable over the pectoralis major muscle.
Applied: In CA breast, the breast is fixed to the pectoralis major muscle.
2. Deep fascia (pectoral fascia) covering the pectoralis major muscle.
3. Muscles:
Pectoralis major – in medial two thirds
Serratus anterior – in lateral one thirds
External Oblique – in infero-medial quadrant
Structure of the Breast
Skin
1. Nipple:
Conical projection from just below the center of the breast, at the level of 4th
intercostal space.
It is pierced by 15-20 lactiferous ducts.
It contains circularly disposed smooth muscles – erect the nipple
Longitudinally disposed smooth muscles – flatten the nipple
It has very reach nerve supply – useful for suckling reflex.
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2. Areola:
It is a pigmented circular area of skin around the base of the nipple.
It is irreversibly darken after first pregnancy.
Outer margin contains numerous modified sebaceous glands, which are enlarge
during pregnancy and lactation to form raised tubercles known as tubercles of
Montgomery.
Oily secretion of these glands prevents cracking of nipples during lactation.
It also contains sweat glands and some accessory mammary glands.
Both nipple and areola are devoid of subcutaneous fat and hair.
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Parenchyma
1. Glandular tissue:
It consists of 15-20 pyramidal lobes.
Lobes are arranged in radiating manner and converge toward the areola.
Each lobe is a cluster of alveoli, and is drain by a separate lactiferous duct.
On reaching areola, each duct presents a dilatation beneath it to form lactiferous
sinus.
Ultra-structure of Glands
Each large duct drains a segmental system of smaller ducts.
Each segmental duct divides into number of terminal ducts, from which numerous
secretary glands pouch out to form clusters of alveoli.
Lobule of Gland: It is the area of breast parenchyma drained by a single terminal
duct is known as lobule. So each lactiferous duct drains many lobules.
The ducts possess myoepithelial cells resting on basement membrane.
Applied:
- CA Breast: usually from larger duct system
- Fibro-adenoma: from distal smaller ducts
Stroma
It forms supporting framework of the gland:
Two types:
1. Fatty stroma: (adipose tissue)
• Main bulk of gland but devoid beneath nipple & areola.
2. Fibrous stroma:
• It forms septa, known as Suspensory Ligaments of Cooper, which anchor the skin
and gland to pectoral fascia.
• They are arranged like spoke of a wheel
Applied:
- Infiltration of these ligaments by cancer cells causes fixation of gland and
produce dimples in overlying skin (puckering of skin).
- Incision is always given radially to avoid injury to duct system.
In male
- Ducts are present but without alveoli
- Supported by fibro-fatty tissue.
Applied:
- As they are richly drain by lymphatics, so prognosis of CA breast of male is
worse than that of female.
- Gynecomastia:
- Abnormal and bilateral hypertrophy of male breasts.
E.g.- Klinefelter’s syndrome (47, XXY)
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- Endocrine disorders
- Impaired liver function
Hormones acting on glandular tissue

• Estrogen:
– stimulates growth and branching of ducts
• Progesterone:
– Stimulates the alveolar formation at the ends of the branching ducts.
• Placental Oestrogen & Progesterone:

– For the formation of true secretary alveoli during pregnancy.
• Prolactin and Growth hormone:

– Maintain lactation.
• Oxytocin:
– Helps in milk ejection, initiated by suckling reflex.
Witch’s Milk: Maternal estrogen circulating in neonates stimulates the ductal

epithelium of breast to secrete a fat-free fluid in the first one or two weeks after birth.
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Arterial supply of the Breast:

1. Lateral thoracic: branch of axillary artery: gives lateral mammary
branches supplying the lateral part of the gland.
2. Superior thoracic: branch of axillary artery, supplies upper part of gland.
3. Perforating branches: branches of the internal thoracic artery to
2nd, 3rd, and 4th intercostal space forms the medial mammary branches. Supply the
medial part of gland.
4. Lateral branches: branches of 2nd, 3rd, and 4th intercostal arteries supply the deep
surface of the gland.
Venous Drainage of the Breast:

The veins first converge toward the base of the nipple where they form an anastomosis
venous circle from where they run in superficial and deep sets.
1. Superficial veins: drain in the internal thoracic and superficial veins of the lower neck
(external and anterior jugular veins)
2. Deep veins: drain into internal thoracic, axillary and posterior intercostal veins.
Importance of Veins:
• They also indicate lymphatic pathways
• Carcinoma can spread through veins
• The connection of posterior intercostal veins with vertebral venous plexus
provides route for the carcinomatous spread to bones and CNS.
Nerve Supply:
Anterior and lateral cutaneous branches of 4th to6th intercostal nerves.
- They convey sensory fibres to skin and autonomic fibres to smooth muscle and
blood vessels.
Nerves do not control secretion of milk because it is regulated by
hormone Prolactin secreted by Anterior Pitutary Gland.
Lymphatic Drainage of Breast

- There two division in lymphatic drainage
1. Lymph node
2. Lymphatics
Lymph nodes draining the breast:
1. Principal nodes
Axillary nodes, mainly, anterior group.
• Anterior group – receive lymph from upper half of the trunk anteriorly and
from major part of breast.
• Posterior group – receive lymph from upper half of trunk posteriorly and
from axillary tail of breast.
• Lateral group – drain lymph from upper limb
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• Central group – receive lymph from other groups of axillary lymph node and
drain into apical group.
• Apical group – receive lymph directly from upper part of breast and
indirectly from rest of breast via central group.
Internal mammary (para-sternal) on the internal mammary vessels

2. Other nodes
Supraclavicular nodes
Deltopectoral (Cephalic) node
Posterior Intercostal node, in front of heads of ribs
Subdiaphragmatic and subperitoneal lymph plexuses
Lymphatics: arranged in two sets

1. Superficial lymphatics:
Drain the skin over the breast except nipple and areola.
They pass radially to axillary, internal mammary, supraclavicular and cephalic lymph
nodes.
Superficial lymphatics of one side communicate with those of the other side.
Some communicate with those of rectus sheath and form a sub-peritoneal plexus
drain into sub-diphragmatic nodes some may reach hepatic nodes.
2. Deep Lymphatics:
Drain parenchyma of breast and also nipple and areola.
The lymph vessels form plexuses in the interlobular connective tissue and walls of
lactiferous ducts.
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Theyjoin with the subareolar plexus of Sappy which collects the lymph from areola
and nipple.
Some of the lymphatics from the deep surface of the gland join with those on the
underlying deep fascia.
They provide alternate route when normal channels are obstructed by the spread
of cancer cells.
Drainage of deep set:

1. About 75% of lymphatics drain into axillary nodes, mainly the anterior group and few
of them follow axillary tail and reach the posterior group.
Efferent from these nodes pass to the central group and thence to apical group.
2. About 20% accompany the perforating branches of internal thoracic artery and drain
into internal mammary nodes from both medial and lateral parts of breast.
3. About 5% lymphatics from lateral and posterior part of gland follow posterior
intercostal vessels and drain into posterior intercostal nodes.
Applied Anatomy of Breast

Carcinoma of Breast
Breast become fixed and immobile due to infiltration of suspensory ligament
Infiltration of cancer cells along the suspensory ligaments of Cooper causes retraction
and puckering of skin.
Extension of growth along the lactiferous ducts and their subsequent fibrosis leads to
retraction of nipple.
PeauD’orange or oedema with pitting
- oedema - obstruction of the cutaneous lymhatics by cancer cells
- pitting - fixation of the hair follicles to the subcutaneous tissue (Skin of an orange).
Axillary lymph nodes of both the sides should be examined. If involved, they are stony
hard and fixed.
Carcinoma may spread to distant places like liver, lung, bones and ovary.
Cancer cells migrate transcoelomically and deposit on the ovary producing a secondary
tumor in ovary called Krukenberg’s tumor.
Metastasis of carcinoma of breast can reach to brain via venous route.
-
Intracranial
Mammography and Self-examination of the breast are very helpful in early detection
of the breast cancer.
In male breasts are richly drained by lymphatics so prognosis of CA breast of male is
worse than that of female
Surgery of breast:
- In surgery of breast, the skin is incised along skin creases to avoid ugly scar.
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- The dissection during surgery is done radially to avoid injury to lactiferous ducts.
- The mammography is useful for early detection of breast cancer.
- Radical mastectomy is done in Carcinoma breast.
- Total removal of breast with all axillary nodes, pectoralis major and most of pectoralis
minor muscles.
- Medical management of CA breast includes chemotherapy and radiotherapy.
Congenital Anomalies:
- Amastia: Bilateral agenesis of mammary gland is a rare anomaly.
- Polymastia: Accessory breasts may occur along the milk ridge, and or rare occasion are
functional.
- Macromastia: large breast
- Micromastia: small breast
- Athelia: Absence of nipple
- Polythelia: Supernumerary nipples may be found irregularly over the breast and not along
the milk ridges.
Gynecomastia: Abnormal and bilateral hypertrophy of male breasts.
E.g.- Klinefelter’s syndrome (47, XXY)
- Endocrine disorders
- Impaired liver function
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CLAVIPECTORAL FASCIA
It is a strong sheet of fascia which stretches from pectoralis minor to the clavicle
Extension of clavipectoral fascia
Medially : it fuses with anterior intercostal membrane of upper 2 spaces.
Laterally : it is attached to coracoid process and blends with coraco-clavicular ligament.
Above : the fascia splits to enclose the subclavius muscle and is attached to two lips of
subclavius groove of clavicle.
Below : it splits to enclose pectoralis minor, reunites below and extends downwards as
suspensory ligament of axilla, which blends with axillary fascia.
Suspensory ligament of axilla is attached to the axillary fascia, and helps to keep
it pulled up.
Structure piercing to clavipectoral fascia or costocoracoid membrane
Thoracoacromial vessels
Cephalic vein
Lateral pectoral nerve
Lymphatics
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Chapter.2
Axilla
Introduction:
Axilla or Arm pit is pyramidal shaped space between the upper part of arm and the
lateral thoracic wall.
It presents apex, base and four walls – anterior, posterior medial and lateral.
Apex is directed upwards and medially towards the root of neck and base is directed
downwards.
Boundaries of Axilla
Apex:
Also known as cervico-axillary canal.
In front by clavicle.
Behind by superior border of scapula.
Medially by outer border of 1st rib.
- Structures passing are:
- Axillary vessels
- Cords of brachial plexus
- Long thoracic nerve
- Efferent subclavian lymph trunk from apical axillary L.N.
Base (Floor):
It is directed below and presents a concavity which is bounded :
In front by the anterior axillary fold
Behind by the posterior Axillary fold, and
Medially by the chest wall.
It is formed by,
- skin,
- superficial fascia
- Axillary fascia which extends from anterior to posterior axillary folds and is
supported from above by the suspensory ligament of axilla.
Anterior axillary fold
- Formed by the spirally arranged lower border of pectoralis major.
Posterior axillary fold
- Formed by latissimus dorsi in the medial part and teres major in the lateral
part.
Anterior wall: is formed by

pectoralis major – in front
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pectoralis minor, subclavius, clavipectoral fascia and suspensory ligament of axilla –

in deep plane.
Posterior wall:is formed by
subscapularis above
Teres major and latissimus dorsi below.
Medial wall: is formed by

upper four or five ribs with their intercostal muscles
upper part of the serratus anterior muscle
Lateral wall:
it is narrow because anterior & posterior Walls converge on it and is formed by.
Upper part of shaft of humerus in region of the bicipital groove.
Coracobrachialis and short head of the biceps muscles.
Contents of Axilla:
Axillary artery and its branches
Axillary vein and its tributaries
Cords of brachial plexus and their branches
Long thoracic and Intercosto-brachial nerve
Axillary lymph nodes and their lymphatics
Axillary fat and occasionally axillary tail of the breast.
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AXILLARY ARTERY
Origin:
- It is the continuation of the subclavian artery.
Extent:
- It extends from the outer border of the 1strib to the lower border of the teres major
muscle where it continues as brachial artery.
Parts: Pectoralis minor muscle crosses it and divides it into three parts.
- First part: proximal to the muscle.
- Second part: posterior to the muscle.
- Third part: distal to the muscle.
Branches of Axillary artery

One from 1st part
1. Superior thoracic artery:
• It runs along the upper border of pectoralis minor & supplies the pectoral
muscles.
Two from 2nd part
2. Thoraco-acromial artery:
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• It emerges at the upper border of pectoralis minor, pierces clvipectoral fascia

and divides into four terminal branches i.e. deltoid, clavicular, acromial and
pectoral).
3. Lateral thoracic artery:
• It runs along the lower border of pectoralis minor and is related to anterior
axillary L.N. It supplies pectoral muscles and in female also the breast.
Three from 3rd part:
4. Subscapular artery:
• Largest branch of axillary artery.
• Runs along the posterior wall of axilla.
• Supplies lattissimusdorsi and serratus anterior and ends at inferior angle of
scapula.
• Gives a large branch, circumflex scapular aretery, which passes throught the
triangular space and takes part in anastomosis around the scapula.
5. Anterior Circumflex humeral artery:
• Passes anteriorly and anastomosis with posterior Circumflex Humeral artery.
• Gives an ascending branch which passes through the bicipital groove and
supplies the shoulder joint.
6. Posterior circumflex humeral artery
• It accompanies axillary nerve and passes through the quadrangular space.
• It supplies deltoid, triceps and shoulder joint.
• Gives a descending branch which anastomosis with profundabrachii artery.
Applied Anatomy:
Atherosclerosis, Arteriosclerosis, Thrombosis, Blockage, Embolism, Hemorrhage,
Aneurysm of axillary artery
Palpation of Axillary artery – in lateral wall of axilla
When second part of axillary artery blocks it lead to collateral circulation start. Arterial
anastomosis around the scapula more prominent and pulsation feel over the scapula.
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BRACHIAL PLEXUS
Brachial plexus supplies the upper limb and is formed by ventral rami of lower four
cervical nerves and the first thoracic nerve (C5,6,7,8,T1).
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It consists of roots, trunks, divisions and cords.

Run To Drink Cold Beer (Beverages)
Roots, Trunks, Divisions, Cords, Branches
Roots:
- Roots are five in number (C5- T1) with some contribution from C4 and T2.
- Roots emerge downwards and laterally between the scalenus anterior and medius
muscles.
- It may shift by one segment upwards or downwards making the plexus prefixed or
postfixed respectively.
- In a prefixedplexuscontribution by C4 is large and T2 is often absent.
- In a postfixed plexus contribution by T1 is large, T2 is always present, C4 is absent and
C5 is reduced in size.
- C5 and C6 roots receive grey rami from the middle cervical ganglion of the sympathetic
trunk.
- C7 and C8 roots receive grey rami from the inferior cervical ganglion and T1 root from
the first thoracic ganglion.
- Sympathetic grey rami convey post-ganglionic vasomotor fibres to the blood vessels of
upper limb (preganglionic fibres are derived from lateral horn cells of T2 – T7
segments).
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Trunks:
- C5 and C6 join to form the upper trunk.
- C7 forms the middle trunk.
- C8 and T1 join to form the lower trunk.
- Upper and middle trunks lie above and lateral to subclavian artery
- Lower trunk lies behind subclavian artery in the groove on the superior surface of 1st
rib.
Divisions:
- Each trunks on approaching clavicle divides in to ventral and dorsal division behind
clavicle
Cords:
Lateral cord
- formed by union of ventral divisions of upper and middle cord.
- It contains fibres from C5,6,7.
Medial cord
- formed by continuation of ventral division of lower cord.
- It contains fibres of C8 and T1
Posterior cord
- formed by union of dorsal divisions of all three trunks.
- It contains fibres of C5-T1.
- The cords enter the axilla and are arranged according to their names around the
second and third part of axillary artery.
Branches of Brachial Plexus

Supraclavicular branches:
From the roots:
• Dorsal Scapular nerve (Nerve to rhomboids) (C5)
• A branch to join with phrenic nerve – C5
• Long thoracic nerve (Nerve to serratus anterior) (C5-7)
• Muscular branches to longus colli and scalene
From the trunks: from the upper trunk only

Nerve to Subclavius
Suprascapular nerve
Infra-clavicualar branches:
Branches of lateral cord (C5,6,7)
– Lateral pectoral nerve
– Musculo-cutaneous nerve
– lateral root of median nerve
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Branches of medial cord

– Medial pectoral nerve (C8,T1)
– Medial cutaneous nerve of arm (C8,T1)
– Medial cutaneous nerve of forearm (C8,T1)
– Ulnar nerve (C7,8,T1)
– Medial root of median nerve (C8,T1)
Branches of posterior cord

– Upper subscapular nerve (C5,6)
– Thoraco-dorsal nerve (C6,7,8)
– Lower subscapular nerve (C5,6)
– Axillary nerve (C5,6)
– Radial nerve (C5 –T1)
Sympathetic nerves are distributed with the branches of brachial plexus.
Applied Anatomy
Erb’s Paralysis:
Site of injury:
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– Erb’s point. Upper trunk of the brachial plexus where six nerves meet is called Erb’s
point.
Cause of injury:
– Undue separation of head of humerus from the shoulder, occurs commonly during
– birth injury
– fall on the shoulder
– during anaesthesis
Nerve roots involved:
– Mainly C5 and partly C6
Muscle paralyzed:
– Mainly biceps, deltoid, brachialis and brachioradialis
– Partly supraspinatus, infraspinatus and supinator
Deformity: known as ‘policeman’s tip hand’ or ‘porter’s tip hand’.
– Arm: hangs by side; it is adducted and medially rotated
– Forearm: extended and pronated
Disability:
– abduction and lateral rotation of the arm (shoulder)
– flexion and supination of the forearm
– biceps and supinator jerks are lost
– sensations are lost over a small area over the lower deltoid.
Klumpke’s paralysis
Site of injury:
– Lower trunk of the brachial plexus
Cause of injury:
– Undue abduction of the arm as while clutching something with the hands after a fall
from the height
– Birth injury
Nerve roots involved:
– Mainly T1 and partly C8
Muscles paralyzed:
– Intrinsic muscles of the hand (T1)
– Ulnar flexors of the wrist and fingers (C8)
Deformity:
– Claw hand due to unopposed action of the long flexors and extensors of the fingers.
– There is hyperextension at the MP joints and flexion at the IP joint.
Disability:
– Claw hand
– Cutaneous anesthesia and analgesia in a narrow zone along the ulnar border of the
forearm and hand
– Horner’s syndrome – ptosis, meiosis, anhydrosis, enophthalmos, and loss of ciliospinal
reflex.
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Injury to nerve to the serratus anterior (Nerve of Bell):

Cause of injury:
– sudden pressure on the shoulder from above
– carrying heavy loads on the shoulder
Deformity:
– Winging of scapula i.e. excessive prominence of the medial border of the scapula
Disability:
– loss of pushing and punching action. During attempts on pushing, winging of scapula
occurs.
– Arm cannot be raised beyond 90 degree.
Injury to the cord of brachial plexus:

Injury to the cords of brachial plexus
Lateral cord Medial cord

cause Dislocation of humerus Subcoracoid dislocation of
humerus
Nerves involved - Musculocutaneous - Ulnar nerve
- Lateral root of median - Medial root of median
nerve nerve
Muscles paralysed 1. Biceps and 1. Muscles supplied b ulnar
coracobrachialis nerve: 15 muscles of
2. All muscles supplied by hand and 1.5 muscles of
the median nerve except forearm
those of hand 2. Five muscles of hand
supplied by median nerve
Deformity and disability a. Midprone forearm 1. Claw hand
b. Loss of flexion of 2. Sensory loss on the ulnar
forearm side of the forearm and
c. Loss of flexion of wrist hand
d. Sensory loss on the radial
side of the forearm
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Chapter.3
Scapulo-Humeral Region
DELTOID
Origin:
Anterior fibres - Anterior border and upper surface of lateral 1/3 of the clavicle
Middle fibres - Lateral border of acromion process
Posterior fibres - Whole length of lower lip of the crest of the spine scapula
Insertion:
lateral surface of shaft of humerus.

Lateral border of acromion process presents 4 tubercles, from which 4 fibrous septa
descend into muscle
From the deltoid tuberosity, 3 fibrous septa arise in between the upper 4 septa.
Adjacent surface between septa gives origin to series of Multipennate muscle fibres.
Anterior and posterior fibres are arranged in parallel bundles: increase range of
movement but force of contraction is less.
Middle fibres are multipennate – increase force of contraction
Nerve Supply:
Axillary nerve (C5,C6) branch of posterior cord of brachial plexus.
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Actions:
Acromial fibres (Anterior fibres)
- Prime movers for Abduction of shoulder
- Abduction from 15 – 90 degrees
- Anterior and posterior fibres act as guy to steady the abducted arm
Clavicular fibres, together with pectoralis major
- flexion, adduction and medial rotation of shoulder joint.
Posterior fibres
- Assist in extension, adduction and lateral rotation of the arm
Structure under cover of the Deltoid

Bone:
- The upper end of humerus
- Coracoid process
Muscles:
Insertions:
- Pectoralis major (on lateral lip of bicipital groove of humerus)
- Latissimus dorsi (on the floor of bicipital groove of humerus)
- Teres major (on medial lip of bicipital groove of humerus)
- Pectoralis minor (on coracoid process)
- Subscapularis (on lesser tubercle of humerus)
- Supraspinatus, infraspinatus and teres minor (on greater tubercle of humerus)
- Origins:
- Coracobrachilis
- Both heads of biceps brachii
- Long and lateral heads of the triceps.
Vessels:
- Anterior circumflex humeral
- Posterior circumflex humeral
Nerves:
- Axillary nerve (C5,6) (insert scan from I B singh or BDC)
Joints and ligaments:
- Shoulder joint and its ligaments
- Coracoacromial ligament
Bursae:
- All bursae of shoulder joint
Applied anatomy
Intramuscular injections are given in the lower half of the deltoid nearer to its insertion
to avoid injury to the axillary nerve and posterior circumflex vessels.
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MUSCULOTENDINOUS CUFF OF SHOULDER (ROTATORS CUFF)

Definition:
- It is a fibrous sheath formed by the four flattened tendons which blend with the capsule
of the shoulder joint and strengthen it.
Formation:
It is formed by subscapularis, supraspinatus, infraspinatus and teres minor.
All muscles of rotator cuff originates from scapula and are inserted into the lesser and
greater tubercles of the humerus
These tendons become flattened and they blend with each other and also with the fibrous
capsule of the shoulder joint.
Function: cuff gives strength to the capsule of the shoulder joint all around except
inferiorly
Applied:
Dislocation of shoulder joint most commonly occur inferiorly where it is not strengthened
by the rotator cuff.
Musculo-tendinous cuff tendonitis
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SUBACROMIALBURSA
• It is the largest bursa of the body
• It is situated below the acromion process and deltoid muscle.
Relation:
1. Above the bursa 2. Below the bursa
- Coraco-acromial arch -Tendon of supraspinatus
- Deltoid muscle - Greater tuberosity of humerus
Significance:
- It protects the supraspinatus muscle during abduction of shoulder.
- The greater tubercle of humerus slips beneath the acromion during overhead
abduction of arm.
Applied Anatomy:
Subacromial bursitis:
- Pressure below the deltoid with arm by the side causes pain.
- However, pressure over the same point with arm abducted to right angle causes no
pain (Dawbarn’s sign).
- This is because the bursa disappears under the acromion when the arm is abducted to
right angle.
Supraspinatus tendonitis:
- Collagen degeneration of the tendon of supraspinatus can give rise to calcification and
even spontaneous rupture of the tendon.
- In acute condition, a paste like deposit in the tendon can enter the bursa and give rise
to acute severe pain in shoulder.
- In chronic condition, the paste is powder like and cause gradual increase in stiffness of
shoulder with pain on abduction.
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INTERMUSCULAR SPACES
Quadrangular Space
Boundaries:
Superior:
- Subscapularis in front
- Capsule of shoulder joint
- Teres minor behind
Inferior:
- Teres major
Medial:
- Long head of the triceps
Lateral:
- Surgical neck of the humerus
Contents:
Axillary nerve
Posterior circumflex humeral vessels
Upper triangular Space:

Boundaries:
Medial: Teres minor
Lateral: Long head of triceps
Inferior: Teres major
Contents:
Circumflex scapular artery
Lower triangular space:
Boundaries:
Medial: long head of triceps
Lateral: Medial border of humerus
Superior: Teres major
Contents:
Radial nerve
Profunda brachii vessels
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AXILLARY NERVE
Origin:
It is a branch of posterior cord of brachial plexus
Root Value:
C5,6
Course
Origins from posterior cord in axilla, it lied posterior to 3rd part of axillary artery.
It descends over Subscapularis muscles between median nerve and coracobrachialis
muscle.
The nerve leaves axilla through the quadrangular space.
It is accompanied by circumflex humeral vessels
Here, it lies close to surgical neck of humerus.
In the quadrangular space, the nerve divides into anterior and posterior
branches.
Anterior branch
- It is accompanied by the posterior circumflex humeral vessels.
- It winds round the surgical neck of humerus, under cover of deltoid upto its anterior
border and supplies:
Deltoid muscle
Skin over antero-inferior part of deltoid. (Regimental badge area)
- Posterior branch
It supplies posterior part of deltoid and gives a branch to teres minor where it forms a
pseudoganglion.
– It then pierces the deep fascia and supplies the skin along the posterior border of
deltoid as the upper lateral cutaneous nerve of arm.
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Branches
Muscular:
– Deltoid
– Teres minor
Cutaneous:
– Skin over lower half of deltoid and upper part of long head of triceps
Articular:
– to the shoulder joint
Vascular:
– to the posterior cirucumflex humeral artery.
Applied Anatomy
It is damaged during
- Dislocation of shoulder joint
- Fracture of surgical neck of humerus
i.Deltoid is paralyzed with loss of power of abduction
ii.Rounder contour of shoulder is lost and greater tubercle of humerus becomes
prominent
iii.Sensory loss over lower half of deltoid
Neuroma of axillary nerve
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ANASTOMOSIS AROUND SCAPULA

Around body of scapula:
Between 1st part of subclavian and 3rd part of axillary artery
Formed in supraspinatus, infraspinatus and subscapular fossa by,
– Suprascapular artery,
– Deep branch of transverse cervical artery (Thyrocervical trunk)
– Circumflex scapular artery, (branch of subscapular)
Over acromion process:

Between 1st part of subclavian and axillary artery
Formed by
– Acromial branch of thoraco-acromial artery
– Acromial branch of suprascapular artery
– Acromial branch of posterior circumflex humeral artery.
Importance:
Collateral circulation when proximal part of subclavian or distal part of axillary artery is
blocked.
Applied:
• Pulsating scapula:
- when blockage of second part of axillary artery occur it lead to collateral circulation
start between the subclavian artery and third part of axillary artery
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Chapter.4
Arm
BRACHIAL ARTERY
Introduction:
- Continuation of axillary artery as it leaves the axilla.
Extent:
- Lower border of teres major to neck of radius where it divides into ulnar and radial artery.
Course:
- Runs downwards and laterally from medial side of arm to front of elbow.
- The artery is superficial throughout lying successively over long head of triceps, medial of
triceps and brachialis.
- In the upper part of arm it is related to the medial cutaneous nerve of the forearm.
- It is accompanied by vena commitants.
- Median nerve crosses it anteriorly from lateral to medial side in the middle of arm.
- In cubital fossa it is crossed over by bicipital aponeurosis
- Tendon of biceps lies lateral to it in cubital fossa
- Median nerve lies medial to branchial artery in cubital fossa.
Branches:
- Profunda brachii artery
- Nutrient artery to humerus
- Superior ulnar collateral artery
- Inferior ulnar collateral artery
- Muscular branches to anterior compartment
- Radial artery
- Ulnar artery
Applied:
• Volkmann’s ischemic contracture:
- Supra Condylar fracture of humerus is common in children, and usually occurs due to a
fall on the outstretched hand.
- Lower fragment is often tilted backward, and the sharp edge of the anteriorly displaced
upper fragment may injure the brachial artery, which may undergo vasospasm.
- This results in ischemia affecting deep group of flexor muscles of forearm. This
culminates ischemic contracture.
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• Brachial artery palpated in cubital fossa just medial to biceps tendon.

• Atherosclerosis, Arteriosclerosis, Thrombosis, Blockage, Embolism, Hemorrhage, Aneurysm
of brachial artery
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PROFUNDABRACHII ARTERY
Introduction:
• It is the chief artery for the back of arm.
Origin:
• It arises just below teres major and runs primarily in posterior compartment of arm.
Course:
• From its origin, it passes backwards accompanying the radial nerve and enters the radial
groove on posterior surface of humerus.
• Here, it runs downwards and laterally
• It gives various branches that join with collateral branches of branchial artery and
recurrent branches of ulnar and radial arteries to form an anastomosis around elbow joint.
Branches:
• Nutrient artery to humerus
• Ascending branch to anastomosis with anterior and posterior circumflex humoral
• Anterior descending branch or radial collateral artery
• Posterior descending branch
Applied Anatomy
of profunda brachii artery
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RADIAL NERVE
• Radial nerve is the main continuation of the posterior cord of the brachial plexus.
Consequently it receives branches from each nerve root from C5/T1.
• After leaving the axilla the nerve gives three sensory branches and one motor innervates
the three heads of the triceps muscle and the small anconeus muscle.
• This motor nerve which is very close to ulnar nerve hence is also called ulnar collateral
nerve which supplies to medial head of triceps.
Sensory Branches of the Radial Nerve

• In Arm
- Posterior Cutaneous Nerve of the Arm
- Lower Lateral Cutaneous Nerve of the Arm
- Posterior Cutaneous Nerve of the Forearm
• In Forearm
- Superficial Radial Nerve
- The nerve then snakes its way down the humerus in the spiral groove, after which it
gives muscular branches to brachioradialis, long head of the extensor carpi radialis
supinator and then bifurcates into a sensory and motor branch.
- Sensory branch, the superficial radial nerve travels in the forearm over the radial bone
and over the extensor tendons to the thumb where it can easily be palpated and
supplies most of the dorsal surface of the hand.
• At the elbow the motor branch of the radial nerve becomes the posterior interosseous
nerve and enters the extensor compartment through the supinator muscle under the
arcade of Frohse . There it supplies the remaining extensors of the wrist, thumb and fingers
Motor Branches of the Radial Nerve

In Arm
- Triceps (Three Heads)
- Anconeus
In Elbow
- Brachioradialus
- Long head of extensor carpi radialus
- Supinator
Posterior Interosseus Nerve
- Extensor Carpi Radialis (Short head)
- Extensor Digitorum
- Abductor Pollicis Longus
- Extensor Indicis
- Extensor Pollicis Longus
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- Extensor Pollicis Brevis
Applied Anatomy
Injury to radial nerve in axilla
• Causes
- Pressure of upper end of crutch (Crutch palsy)
- Drunken falling asleep with his/her one arm over the back of chair (Saturday night
palsy)
• Motor loss
- Loss of extension of elbow – due to paralysis of triceps
- Loss of extension of wrist – due to paralysis of extensors of wrist (Back of forearm)
- Loss of extension of digit – due to paralysis of extensors of digit (Back of forearm)
- Wrist drop – due to unopposed action of flexors of wrist (front of forearm)
- Loss of supination in extended elbow – due to paralysis of supinator muscle
(supination in flexed elbow is normal because if biceps brachii)
• Sensory loss
- On skin over posterior surface of lower part of arm
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- Along back of forearm

- Lateral part of dorsum of hand and dorsal surface of lateral 3½ digits.
Injury to radial nerve in spiral groove
• Causes
- Midshaft fracture of humerus
- Pressure on back of arm on edge of table
• Motor loss
- Loss of extension of wrist and digits (paralysis of muscles ofback of forearm)
- Wrist drop
- Loss of supination
• Sensory loss
- Small area over dorsum of hand between 1st and 2nd metacarpals.
Extension of elbow is normal – triceps receive nerve supply when radial nerve is in
axilla.
Injury to radial nerve at elbow
• Radial tunnel sundrome – entrapment of radial nerve at elbow by
- Fibrous band
- Tendinous margin of extensor carpi radialis brevis
- Radial recurrent artery
- Arcade of Frohse – free aponeurotic proximal edge of superficial part of supinator
muscle
- Clinical feature – Pain over extensor aspect of forearm
Injury to deep branch of radial nerve (posterior interosseous nerve)
• Causes
- Fracture of proximal end of radius
- Dislocation of head of radius
• Clinical feature
- No wrist drop (extensor carpi radialis longus and brachioradialis muscles spared)
- No sensory loss (posterior interosseous nerve is pure motor)
Neuroma of Radian nerve
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MUSCULO CUTANEOUS NERVE

Introduction:
It is a branch of lateral cord of brachial plexus
Root Value
entral rami of C5, C6, C7 spinal nerves
Course
It arises behind the lower border of Pectoralis minor and lies lateral to 3rd part of axillary
artery.
Then it passes laterally and pierces coracobrachialis to enter front of arm.
In the arm it passes downwards and laterally between biceps anteriorly and brachialis
posteriorly.
It ends by piercing the deep fascia lateral to lower part of biceps tendon, 2 cm above bend
of elbow. It forms the lateral cutaneous nerve of forearm.
Branches:
Muscular
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- Coracobrachialis muscle
- Biceps brachii muscle
- Brachialis muscle
Cutaneous
- Lateral cutaneous nerve of forearm
Articular
- Elbow joint
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ULNAR NERVE (Musicians nerve)

Introduction:
Ulnar nerve is the direct continuation of medial cord of brachial plexus in axilla.
Root values
fibres supply flexor carpi ulnaris

Course
It enters the arm on the medial side of the brachial artery in anterior compartment of arm
Near middle of arm it pierces the medial Intermuscular septum and enters the posterior
compartment of arm along with superior ulnar collateral artery
It lies immediately posterior to medial epicondyle in a groove
Nerve enters the forearm between two heads of flexor carpi ulnaris.
It descends along the medial side of front of forearm.
It lies on flexor digitorum Profundus and is covered by flexor carpi ulnaris. However in
lower 2/3, it lies lateral to the tendon and is covered by skin and fascia only.
It enters the palm superficial to flexor retinaculum lying medial to ulnar artery and divides
into superficial & deep branches below palmaris brevis
Branches:
Muscular
In forearm
- Flexor carpi ulnaris
- Medial half of flexor digitorum Profundus
In hand
- Palmaris brevis
- Abductor digit minimi
- Flexor digiti minimi
- Opponents digiti minimi
- 3rd and 4th lumbricals
- 4 palmar interossei
- 4 dorsal interossei
- Adductor pollicis
- Flexor pollicis brevis
Cutaneous
- Dorsal branch to dorsum of hand – given out 5 cm above wrist.
- Palmar cutaneous branch to palmar aspect of hand passes superficial to flexor
retinaculum.
Articular branches
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- Elbow joint
- Inter carpal joints
- Carpo-metacarpal joints.
Vascular
-
Applied Anatomy
Injury to ulnar nerve at elbow
• Causes
- Fracture of medial epicondyle
- Thickening of the fibrous roof of the cubital tunnel (Cubital Tunnel Syndrome)
- Compression between two head of flexor carpi ulnaris muscle
- Tardy or Late Ulnar Nerve Palsy)
- Atrophy and flattening of hypothenar muscle
- Claw hand – affecting ring and little finger. Hyperextension of meta-
carpophalyngeal joint and flexion of proximal & distal interphalangeal joint.
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- Loss of abduction and adduction of fingers – due to paralysis of palmar and dorsal
interosseous muscle.
- Loss of sensation over palmar and dorsal surface of medial ½ of hand and medial
1½ fingers.
- Foment’s sign is positive (Book test) – person hold book between thumb and index
finger by flexion of distal phalanx of thumb.
Injury to ulnar nerve at wrist
• Causes
- Superficial position of ulnar nerve – cut during injury
- Compression in guyon’s canal
- Claw hand – more pronounced (Ulnar Paradox – flexor digitorum profundus is not
paralyzed lead to marked flexion of distal interphalangeal joint)
- Atrophy and flattening of hypothenar eminence
- Loss of abduction and adduction of fingers
- Foment’s sign is positive (Book test)
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MEDIAN NERVE (Laborer’s Nerve)

Introduction:
• It is formed in axilla by medial and lateral roots. Medial root comes from medial cord and
lateral root comes from lateral cord of brachial plexus.
Root value
•
Course
• It descends along the lateral side of axillary artery
• Lies lateral to proximal part of brachial artery in arm
• In the middle of arm it becomes medial to the brachial artery
• Lies beneath superficial and deep heads of pronator teres and crosses over to the lateral
side of ulnar artery
• It lies between flexor digitorum superficialis and Profundus in forearm
• Enters hand deep to flexor retinaculum in carpal tunnel
• At the distal end of flexor retinaculum it ends by dividing into lateral and medial branches.
Branches
Muscular In arm
- Nerve to pronator teres muscle
In the forearm
- Pronator teres muscle
- Flexor carpi radialis muscle
- Palmaris longus muscle
- Flexor digitorum superficialis muscle
- Lateral part of flexor carpi ulnaris
- Anterior interosseous nerve
Anterior Interosseous Nerve:
Introduction:
- Anterior interosseous nerve (branch of median nerve) in forearm supplies the deep
muscles of the front of forearm.
- Passes between 2 heads of pronator teres muscle, may be impinged upon.
Branches:
Muscular
- Flexor digitorum profundus
- Pronator qudratus
- Flexor pollicis longus
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Nutrient branches to radius and ulna

- Cutaneous branch
• Palmar cutaneous branch (supplying lateral ½ of palmar skin)
In the Palm
- Abductor pollicis brevis
- Flexor pollicis brevis
- Opponens pollicis
- 1st & 2nd lumbrical
- Palmar digital branch (supplying lateral 3½ digits)
Applied Anatomy
Injury to median nerve at elbow
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• Causes
- Supracondylar fracture of humerus
- Tight tourniquet
- Entrapment of nerve between two heads of pronator teres or fibrous arch
connecting two head of flexor digitorum superficialis
- Forearm in supine position (loss of pronation)
- Wrist flexion is weak – paralysis of flexor of wrist except flexor carpi ulnaris &
medial half of flexor digitorum profundus
- Adduction of wrist – paralysis of flexor carpi radialis lead to unopposed action of
flexor carpi ulnaris
- Loss of flexion of interphalangeal joint of fingers – paralysis of flexor digitorum
superficial and profundus.
- Benediction attitude – person try to make fist, index and middle finger remain
straight. Ring and little fingers can be flexed because of intact nerve supply of
medial half of flexor digitorum profundus.
- Loss of flexion of interphalangeal joint of thumb
- Ape thumb deformity – thumb is rotated laterally and adducted
- Loss of sensation in lateral ½ of palm and lateral 3½ digits.
Injury to median nerve at mid forearm
- Pointing index – paralysis of radial head of flexor digitorum superficialis
- Other feature is same as injury at wrist and palm
Injury to median nerve at wrist
- Ape thumb deformity
- Loss of sensation in lateral ½ of palm and lateral 3½ digits
Injury to median nerve in Carpal tunnel – see carpal tunnel syndrome in palm
Neuroma of median nerve
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Chapter.5
Forearm
CUBITAL FOSSA
• It is a triangular space in front of the elbow.

Boundaries:
• Medially - lateral border of pronator teres
• Laterally – medial border of brachioradialis
• Base - an imaginary line joining both epicondyles of humerus
• Apex - formed by convergence of brachioradialis and pronator teres
• Floor – brachialis in upper part, supinator in lower and lateral part
• Roof - deep fascia of forearm, bicipital aponeurosis, median cubital vein, medial and lateral
cutaneous nerve of forearm
Content:
Medial to lateral side
• Median nerve
• Brachial artery, ulnar and radial artery
• Biceps tendon
• Radial nerve
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RADIAL ARTERY
Introduction:
• It is the smaller terminal branch of brachial artery
Extent:
• It begins at the neck of radius and terminates by forming the deep palmar arch with the
help of deep branch of ulnar artery in palm.
Course:
• Radial artery is accompanied by vena cava commitants throughout the forearm
• It lays between tendon of brachioradialis and flexor carpi redialis.
• At wrist, it lies in anatomical snuffbox and leaves it by passing through two heads of 1st
dorsal interosseous muscle.
• It enters the palm between two heads of adductor pollicis and ends by forming the deep
palmar arch.
Branches:
• Radial recurrent artery
• Muscular branches
• Palmar carpal branch for palmar carpal arch
• Dorsal carpal branch for dorsal carpal arch
• Superficial palmar branch
• 1st dorsal metacarpal artery
• Arteria princeps pollicis
• Arteria redialis indicis
Applied
• Radial artery palpated in front of lower 1/3 radius.
of radial artery
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ULNAR ARTERY
• It is the larger terminal branch of brachial artery
Extent
• Begins at the neck of radius
• Terminates by forming the superficial palmar arch.
Course
• In forearm, it is deep in upper 1/3 and superficial in lower 2/3
• It enters the palm passing superficial to flexor retinaculum along with the ulnar nerve and
passes on radial side of pisiform bone
• Terminate as by forming the superficial palmar arch with the help of a branch of radial
artery in palm.
Branches
• Anterior ulnar recurrent artery
• Posterior ulnar recurrent artery
• Common introsseous artery
• Anterior introsseous artery
• Posterior introsseous artery It is the main artery for extensor compartment of the forearm.
• Palmar and dorsal carpal branches
• Muscular branches
Applied Anatomy
of Ulnar artery
ARTERIAL ANASTOMOSIS AROUND ELBOW

• During flexion of elbow joint branchial artery is likely to be linked. Therefore, to provide
enough blood supply to the distal part of the limb, there is liberal anastomosis around
elbow joint between branches of brachial artery and proximal part of radial and ulnar
arteries.
In front of medial epicondyle
- Inferior ulnar collateral artery and branch of superior ulnar collateral artery (branches
of brachial artery)
- Anterior ulnar recurrent artery (branch of ulnar artery)
Behind medial epicondyle
- Superior ulnar collateral artery and branch of inferior ulnar collateral artery (branches
of brachial artery)
- Posterior ulnar recurrent artery (branch of ulnar artery)
In front of lateral epicondyle
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- Radial collateral artery (branch of profunda brachii artery)

- Radial recurrent artery (branch of radial artery)
Behind lateral epicondyle
- Posterior descending artery (branch of proffunda brachii artery)
- Interosseous recurrent artery (branch of posterior interosseous artery, branch of ulnar
artery)
Above olecranon fossa
- Middle collateral artery (branch of profunda brachii artery)
- Transverse branch from posterior division of inferior ulnar collateral artery.
ANATOMICAL SNUFF BOX

Elongated triangular depression seen on lateral side of dorsum of hand when the thumb is
hyperextended.
Boundaries
Anterolaterally
- Tendon of abductor pollicis longus
- Tendon of extensor pollicis brevis
Posteromedially
- Tendon of extensor pollicis longus
Floor
- Scaphoid
- Trapezium
Roof
- Skin
- Superficial artery
Contents
Radial artery
Structure crossing the roof
Cephalic vein
Superficial radial nerve
Applied Anatomy
Tenderness in anatomical snuff box – fracture of scaphoid
Pulsation of radial artery can be felt
Cephalic vein at this used for giving intravenous fluid
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Chapter.6
Palm
FLEXOR RETINACULUM
• It is a strong fibrous band attached to following carpal bones.
Laterally
• Tubercle of scaphoid, Crest of trapezium
Medially
• Pisiform bone, Hook of hamates
• It forms tunnel over the concave surface of carpal bones known as carpal tunnel
• It continues above with deep fascia of forearm &below with palmar aponeurosis
Structures passing superficial to flexor retinaculum:

From medial to lateral side
• Ulnar nerve
• Ulnar artery
• Palmar cutaneous branch of median nerve
• Palmaris longus tendon
• Palmar cutaneous branch of ulnar nerve
• Superficial palmar branch of radial artery
Structures passing deep to flexor retinaculum
• Median nerve, lies just below it
• Tendons of flexor digitorum superficialis
• Tendons of flexor digitorum Profundus
• Tendons of flexor pollicis longus
• Flexor carpi radialis tendon lies between superficial & deep slips of the retinaculum on
lateral side.
Applied anatomy:
• Carpal tunnel syndrome:
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CARPAL TUNNEL SYNDROME
• Compression of median nerve in carpal tunnel

Causes
• Idiopathic:
- Related to Congenital smallness of carpal tunnel
• Hand activity:
- Repetitive; Amount More common in dominant hand
• Reduced space in carpal tunnel
• Bone:
- Fracture; Osteophyte; Dislocation; Exostosis
• Mass:
- Ganglion; Gout; Hematoma
• Susceptibility of nerve to pressure
• Hereditary Liability to Pressure Palsies
• Diabetic Neuropathy
• Renal failure
• Other polyneuropathies
• Systemic disorders
• Pregnancy: Often resolves after delivery
• Endocrine:
- Hypothyroidism; Acromegaly
• Multiple myeloma; Amyloidosis
• Osteochondritis dissecans
• Acute causes
- Wrist fractures, dislocations (lunate bone, hyperextension), hematomas
• Pyogenic infections: tenosynovitis
• Rhematoid arthritis: Acute exacerbation
• Excessive unaccustomed manual work
Clinical features
• Epidemiology
- Female: Male:: 3:1
- Age peak: 40 to 60 years
• Pain
• Episodic
• Worse at night initially; Later during day also
• Location: Arm, forearm, wrist, hand & fingers
• Paresthesias
- Palmar thumb, 2nd& 3rdfingers
- Finger tips
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• Weakness: After sensory

• Abductor pollicis brevis (APB): Most common
• Opponenspollicis
• Electrodiagnostic
- Slow sensory conduction across transverse carpal ligament
• Systemic work-up:
- Thyroid; Blood sugar; Sed rate; CBC
Treatment:
• Splinting
• Corticosteroid injections
• Surgical decompression
- Complete section of transverse carpal ligament
• Primary treatment in acute carpal tunnel syndrome
• Avoid in pregnancy
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PALMAR APONEUROSIS
Introduction:
• It is the condensation of deep fascia of palm.
• It is made up of 3 parts, namely
- Central
- Medial
- Lateral
Central part
• This the palmar aponeurosis proper
• It is thick & triangular in shape.
• Apex is directed proximally & fuses with flexor retinaculum.
• It continues with the tendon of palmaris longus proximally.
• Distally it divides into four digital slips for medial four fingers. Each slip divides into a set of
superficial & deep fibers.
• Superficial fibres are attached to the dermis & superficial transverse ligament of palm.
• Deep fibres are attached to deep transverse ligament of palm, palmar ligament of
metacarpo phalangeal joints, base of proximal phalanges & at last blends with the fibrous
flexor sheaths.
Medial part
• It is thin & covers the hypothenar muscles of palm.
Lateral part
• It is thin &covers thenar muscles of palm
• On each side the aponeurosis continues with deep fascia of dorsum of hand
• Medial & lateral palmar septae extend deep from the respective margins of the central
part of palmar aponeurosis.
• The medial septum is attached to palmar surface of shaft of 5th metacarpal bone & the
lateral septum is attached to 1st metacarpal bone.
Function of palmar aponeurosis
• Protects the palmar neurovascular bundle
• Prevents bow stringing of long tendons of flexor muscles
• Allows for a better grasp of an object.
• The free movement of thumb due to absence of digital slip from it leads to movements of
opposition & helps in better grip.
Morphology:
• Degenerated tendon of the palmaris longus
Applied:
• Dupuytren’s contracture
• Inflammation of ulnar side of palmar aponeurosis.
• It leads to thickening & contraction of the aponeurosis.
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• Proximal & middle phalanx become fixed & cannot straightened, the terminal phalanx
unaffected the ring finger most commonly attached.
SUPERFICIAL PALMAR ARCH

Formation
• It is an arterial arcade formed by superficial terminal branch of ulnar artery and completed
on lateral side by one of the following arteries.
- Superficial palmar branch of radial artery
- Arteria princeps pollicis, branch of radial artery
- Arteria radialis indices, branch of radial artery
• Superficial palmar arch lies beneath palmar aponeurosis
Important relations
Superficial
- Palmar aponeurosis
- Palmaris brevis
Deep
- Long flexor tendons
- Lumbricals
- Flexor digiti minimi
- Palmar digital branches of median nerve
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Branches
• 3 common palmar digital arteries
• 1 proper palmar digital artery
• Cutaneous branches
Distribution
• Little, ring &middle finger and medial side of index finger.
Important
• lateral 3 digital branches are joined by corresponding palmar metacarpal arteries from the
deep palmar arch.
DEEP PALMAR ARCH

Formation:
It is formed by terminal end of radial artery & deep branch of ulnar artery.
Important relations:
Superficial
- Oblique head of adductor pollicis
- Long flexor tendon
- Lumbricals
Deep
- Base of metacarpals
- Palmar interosseus
- The deep branch of ulnar nerve lies along the concavity of deep palmar arch.
Branches:
3 palmar metacarpal arteries.
3 perforating arteries.
Recurrent branch
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Distribution:
• Supply medial four metacarpals, carpal bones, joints & end in palmar arterial arch.
Important:
Three perforating arteries pass though medial three interosseous spaces to anastomosis
with dorsal metacarpal arteries.
FASCIAL SPACES OF HAND
Midpalmar Space
Triangular midpalmar space is located under the medial half palm.
Boundaries
Anterior:
- Palmar aponeurosis.
- Superficial palmar arch.
- Digital nerve and vessels supplying medial 3½ fingers.
- Ulnar bursa enclosing flexor tendons of medial three fingers.
- Medial three (2nd, 3rd, and 4th) lumbricals.
Posterior:
- Fascia covering interossei and medial three metacarpals.
Lateral:
- Intermediate palmar septum extending obliquely from medial edge of the palmar
aponeurosis to the third metacarpal bone. (Separates the midpalmar space from the
thenar space)
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Medial:
- Medial palmar septum extending from medial edge of palmar aponeurosis to the fifth
metacarpal. (Separates the midpalmar space from hypothenar space occupied by the
hypothenar muscles)
Proximal:
- Continuous with the forearm space of Parona.
Distal:
- Continuous with the medial three web-spaces through medial three lumbrical canals.
Web spaces:
- Subcutaneous space in each interdigital cleft and is filled with loose areolar tissue.
- Contains lumbrical tendon, interosseous tendon, digital nerve, and vessels.
- Extends from the free margin of the web to transverse metacarpal ligaments.
Applied Anatomy
Infection of midpalmar space:
- Ulnar bursa is considered as the inlet for infection and lumbrical canals as the outlets of
infection in midpalmar space.
- Pus form in space is drained by incisions in the medial two web spaces.
Thenar Space
Triangular thenar space is located under the outer half of the hollow of the palm.
Boundaries
Anterior:
- Palmar aponeurosis (lateral part).
- Digital nerve and vessels of lateral 1½ digits.
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- Radial bursa enclosing tendon of flexor pollicis longus.

- Flexor tendons of the index finger.
- First lumbrical.
Lateral:
- Lateral palmar septum extending from lateral edge of palmar aponeurosis to the first
metacarpal.
Medial:
- Intermediate palmar septum.
Posterior:
- Fascia covering the transverse head of adductor pollicis.
Proximal:
- Space is limited by the fusion of anterior and posterior walls in the carpal tunnel.
Distal:
- Space communicates with the first web space through the first lumbrical canal.
Applied Anatomy
Infection of thenar space:
- Infection may reach the thenar space from infected radial bursa or synovial sheath of the
index finger.
- Pus from thenar space is drained by an incision in the first web space (web space of the
thumb).
Pulp Spaces of Digits

Pulp spaces of the digits are subcutaneous spaces on the palmar side of tips of the fingers
and thumb.
Pulp space is filled with subcutaneous fatty tissue.
Boundaries
Superficially:
- Skin and superficial fascia.
Deeply:
- Distal two-third of distal phalanx.
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Features
- Space is traversed by numerous fibrous septa extending from skin to the periosteum of the
terminal phalanx, dividing it into many loculi.
- Deep fascia of pulp of each finger fuses with the periosteum of terminal phalanx distal to
the insertion of long flexor tendon.
- Digital artery that supplies the diaphysis of phalanx runs through this space.
- Epiphysis of distal phalanx receives its blood supply proximal to the pulp space.
Applied Anatomy
Pulp space infection:
- Pulp space is most exposed parts of the digits so it is more prone to infection.
- Abscess in the pulp-space is called Whitlow or Felon.
- Tension increase because of collection of pus in the pulp space causes severe throbbing
pain.
- Pus from pulp space is drained by a lateral incision, opening all loculi and avoiding tactile
skin sensation on the front of the finger.
- If not treated whitlow may lead to avascular necrosis of distal four-fifth of the terminal
phalanx due to occlusion of digital artery as result of pressure.
- Proximal one-fifth phalanx is not affected because the branch of digital artery supplying it
does not traverse the pulp space.
Space of Parona (Forearm space)

Fascial interval underneath the flexor tendons on the front of distal part of the
forearm.
Boundaries
Anterior:
- Tendon of flexor digitorum profundus and flexor digitorum superficialis surrounded by
a synovial sheath (ulnar bursa).
- Tendon of flexor pollicis longus surrounded by a synovial bursa (radial bursa).
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Proximal:
- Proximally, it is continuous with the intermuscular spaces of the forearm.
Distal:
- Distally it reaches at level of wrist.
Lateral:
- Outer border of the forearm.
Medial:
- Inner border of the forearm.
Forearm space (Parona’s space) becomes infected from infected ulnar bursa. Pus collects
behind the long flexor tendons.
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Chapter.7
Venous Drainage of Upper Limb
CEPHALIC VEIN
Formation
Cephalic vein begins as the continuation of lateral end of the dorsal venous arch.
Course
Crosses the roof of anatomical box, ascends on the radial border of the forearm.
Continues upwards in front of elbow along the lateral border of biceps, pierces the deep
fascia at the lower border of the pectoralis major
Runs in cleft between the deltoid and pectoralis major (deltopectoral groove) up to the
infraclavicular fossa.
Termination
It pierces the clavipectoral fascia and drains into the axillary vein.
At elbow, greater amount of blood from the cephalic vein is shunted into the basilic vein
through median cubital vein.
Cephalic vein is accompanied by the lateral cutaneous nerve of the forearm.
Cephalic vein is the preaxial vein of the upper limb and corresponds to the great
saphenous vein of the lower limb.
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BASILIC VEIN
Formation
Basilic vein begins as the continuation of the medial end of the dorsal venous arch of the
hand.
Course & Termination
Runs upwards along the back of the medial border of the forearm.
Winds round this border near the elbow to reach the anterior aspect of the forearm.
Continues upwards in front of the elbow along the medial side of the biceps brachii up to
the middle of the arm
Pierces deep fascia, unites with the brachial veins and runs along the medial side of the
brachial artery to become continuous with the axillary vein at the lower border of the teres
major.
Basilic vein is the postaxial vein of the upper limb and corresponds to the short saphenous
vein of the lower limb.
About 2.5 cm above the medial epicondyle of humerus, it is joined by the median cubital
vein.
It is accompanied by the medial cutaneous nerve of the forearm.
MEDIAN CUBITAL VEIN

It is a communicating venous channel between the cephalic and basilic veins, which shunts
blood from the cephalic vein to the basilic vein.
It Begins from the cephalic vein, 2.5 cm below the elbow bend, runs obliquely upwards
and medially to end in the basilic vein, 2.5 cm above the bend of elbow.
It is separated from brachial artery by the bicipital aponeurosis.
It connected with the deep veins through a perforator vein, which pierces the bicipital
aponeurosis.
It receives median vein of the forearm.
Median vein of the forearm

Median vein of the forearm begins from palmar venous network
Runs upwards in the midline on the anterior aspect of forearm to end in any one of three
veins in front of elbow.
Sometimes the upper end of median vein of the forearm bifurcates into median cephalic
and median basilica veins, which join the cephalic and basilic veins.
- In this situation, the median cubital vein is absent.
Common Venous Patterns In Front of Elbow
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eins in front of the elbow commonly form two patterns,

1. H-shaped pattern.
2. M-shaped pattern.
APPLIED ANATOMY OF VEINS

Venepuncture in the cubital fossa
eins in front of the elbow, median cubital vein, cephalic vein, and basilic vein are used for
giving intravenous injections and for withdrawing blood from the donors.
Median cubital vein is most preferred because of:
- Superficial vein, hence easy accessible.
- Supported by the underlying bicipital aponeurosis.
- Connected with the deep vein by a perforating vein, hence it does not slip during
procedure.
Hemodialysis
Cephalic vein is preferred for hemodialysis in the patients with chronic renal failure (CRF),
to remove waste products from blood.
Cut-down of cephalic vein in the deltopectoral groove is preferred when the superior vena
cava infusion is necessary.
Basilic vein is preferred for cardiac catheterization because of
Diameter of basilic vein increases as it ascends from cubital fossa to the axillary vein.
It is in direct line with the axillary vein.
Catheter passes in succession as follows:
-
of the heart.
Cephalic vein is not preferred for cardiac catheterization because of
Diameter does not increase as it ascends.
It joins the axillary vein at a right angle hence it is difficult to pass catheter
In deltopectoral groove, it frequently divides into small branches. One of these branches
ascends over the clavicle and joins the external jugular vein.
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Chapter.8
Joints of Upper Limb
SHOULDER JOINT
This is also known as Glenohumeral Joint
Type of Joint
It is multiaxial ball and socket type of synovial joint or multiaxial spherodial joint.
Bones forming joint

Head of humerus – It forms 1/3 of a sphere, forms the lateral articular surface.
Glenoid cavity of scapula – It is pear shaped, only 1/3 of the head of humerus is
accommodated in Glenoid cavity, Apex of the pear lies upward. It forms medial articular
surface.
Ligaments:
1. Fibrous Capsule:
Attachments:
Medial – Periphery of Glenoid cavity
Lateral – Anatomical neck of humerous. It is deficient at the intertubercular sulcus from
where it extends 1 cm inferomedially to surgical neck of humerous Capsule is lax and
twice the size of articular surface.
2. Glenohumeral ligaments – These are 3 in number
They are thickenings of anterior part of fibrous capsule and are named as superior,
middle and inferior.
Subcapsular bursa communicates with the joint cavity between superior and middle
glenohumeral ligaments.
3. Coraco-humeral ligament
It extends from lateral part of coracoid process to anatomical neck of humerus
between greater and lesser tubercles.
4. Transverse ligament
It connects the two lips of inter-tubercular sulcus.
5. Rotator cuff:
Tendons of following four muscles form an expansion and attach to the fibrous capsule.
This is known as the rotator cuff of shoulder joint.
Supraspinatus – Above
Subscapularis – Anteriorly
Infraspinatus – Posteriorly
Teres minor – Posteriorly
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Function
- Rotator cuff is in constant tonic contraction and keeps the head of humerus in
Glenoid cavity in static and kinetic state.
6. Coraco-acrominal arch:
It acts as a secondary socket for head of humerus when the arm is raised above the
head.
It is formed by the coracoid process, acromion process and coraco-acromial ligament.
Coraco-acromial ligament extends from the tip of acromion process to lateral border of
coracoid process.
Subacromial bursa lies below the arch and separates the Supraspinatus from arch.
Movements of shoulder joint:

Flexion
- Axis is perpendicular to axis of abduction and adduction
Muscles involved:
- Clavicular head of pectoralis major
- Deltoid (Anterior fibres)
- Coracobrachialis & assisted by biceps brachii
Extension:
- Axis is same as flexion
Muscles involved:
- From pendent position
- Posterior fibres of deltoid
- Teres major
- From flexed position
- Latissimus dorsi
- Pectoralis major
Abduction:
- Axis is antero-posterior axis passing through center of head of humerus
Muscles involve:
- Supraspinatus
- Middle fibres of deltoid
-
- Subscapularis, infraspinatus, teres minor
Adduction:
- Axis is same as abduction
Muscles involved:
- Anterior and posterior fibres of deltoid
- Pectoralis major
- Teres major
- Latissimus dorsi
- Coracobrachialis
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-
Medial rotation:
- Axis is vertical, passes from centre of humeral head to capitulum
Muscles involved:
- Pectoralis major,
- anterior fibres of deltoid,
- teres major,
- latissimus dorsi,
- subscapularis
Lateral rotation:
- Axis is same as medial rotation
Muscles involved:
- Infraspinatus,
- teres minor,
- posterior fibres of deltoid
Main Bursae in relation to joint

Subscapular bursa – present between tendon of Subscapularis and fibrous capsule.
Subacrominal bursa intervenes between coraco-aromial arch and supraspinatus. Does not
communicate with joint.
Arterial supply –
Anterior circumflex humeral artery
Posterior circumflex humeral artery
Suprascapular artery
Nerve supply –
Axillary nerve
Suprascapular nerve
Lateral pectoral nerve
Stability of shoulder joint is maintained by following factors

Glenoid labrum – deepens the Glenoid cavity
Rotator cuff, by its tonic contraction
Long head of biceps – passes through the joint cavity and keeps the head in position in
overhead abductor.
Supraspinatus tendon and coraco humeral ligament – Keep the head of humerus in
Glenoid cavity in pendant position of arm.
Important relations
Anterior - Subscapularis, coracobrachialis and short head of biceps
Posterior - Infraspinatus and teres minor
Superior - Supraspinatus, subacrominal bursa, coracoacrominal arch
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Inferior - Quadrangular space transmitting axillary nerve posterior circumflex humeral

vessels and long head of triceps.
Spinal cord segments
C5,C6,C7,C8 are involved in movements of shoulders joint
Flexion, Abduction, Lateral rotation – C5,C6
Extension, Adduction, Medial rotation – C6,C7,C8
Applied anatomy
Dislocation of Shoulder joint
- Inferior dislocation of shoulder joint is common. This is because this part is not
strengthened by rotator cuff.
- Anterior dislocation is also not uncommon. This dislocation of head of humerus is
subcorocoid.
Frozen shoulder (Adhesive capsulitis)
- Pain and uniform limitation of all movement.
- No radiological changes
- Due to shrinkage of capsule
- Seen in between 40 to 60 years of age
- Physiotherapy is the only treatment
Painful arch syndrome
- Chronic thickening of tendon Supraspinatus results in pain during abduction between
60 to 120 when the tendon rubs against coraco-acrominal arch. The condition is
known as.
- This is because of deposition of calcium in supraspinatus tendon, which leads to
irritation of subacromian bursa causing subacromian bursitis.
- Dawbarn’s sign – pain can be eliciated in subacromian bursitis when deltoid pressed
below acromion, when arm is adducted. But in abducted arm there is no pain because
of bursa slip under acromion process.
Supraspinatus is the most commonly affected tendon in rotator cuff injury.
The optimum position of shoulder in arthrodesis of shoulder joint is 45 abduction and 20
flexion.
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ACROMIOCLAVICULAR JOINT
Type of Joint:
It is Plane variety of synovial joint.
Bones forming joint:

Facet present on lateral end of clavicle
Medial margin of acromion process of scapula
Joint cavity is divided by incomplete wedge shape articular disc.
Ligaments:
Fibrous capsule
- Acromioclavicular ligament
- Coracoclavicular ligament – conoid and trapezoid part
Movements:
Rotation of acromion of scapula at acromion end of clavicle during over head abduction
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STERNOCLAVICULAR JOINT
Type of Joint:
It is Saddle variety of synovial joint.

Sterna end of clavicle
Superlateral angle of manubrium sterni and adjacent part of 1st costal cartilage
Articular surfaces are covered by fibrocartilage.
Joint cavity is divided by articular disc.
Ligaments:
Fibrous capsule
Anterior sternoclavicular ligament
Posterior sternoclavicular ligament
Interclavicular ligament
Costoclavicular ligament
Movements:
Allow movement of pectoral girdle during overhead abduction
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ELBOW JOINT
Type of Joint
Hinge Variety Of Synovial Joint.
It also a compound joint as formed by three bones.
It consists of humero-ulnar and humero-radial parts.
The elbow joint and superior radio-ulnar joint shares a common joint cavity hence
collectively called cubital articulation.
From above:
- Capitulum and Trochlea of the humerus
From below:
- Upper surface of the head of radius articulates with capitulum of humerus
- Trochlear notch of the ulna articulates with trochlea of humerus.
Axis of the joint

Directed medially and downwards.
Medial end of trochlea projects about 6 mm more than the lateral end. So the articulation
of radius and ulna with humerus is slightly oblique.
Hence the long axis of arm makes an angle of about 170° with the long axis of the forearm
when forearm is extended and supinated.
This angle is called Carrying Angle which helps in weight carrying action as the upper limb
remains away from the pelvis.
Angle disappears in full flexion of elbow and pronation.
Long axis of arm comes in line with that of forearm in mid prone position in which the hand
is mostly used.
Ligaments of Joint
Fibrous capsule:
- Proximally it is attached to lower end of humerus in such a way that the capitulum,
trochlea, radial fossa, coronoid fossa and olecranon fossa are intracapsular.
- Distally, it is attached to margins of trochlear notch of ulna except at the margins of
radial fossa. Laterally it is attached to annular ligament and not the radius.
Synovial membrane
- lines the inner surface of fibrous capsule and bones with in the capsule but it ceases at
the periphery of the articular cartilage.
Ulnar collateral ligament: triangular in shape

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- It extends from the medial epicondyle of humerus to medial margin of trochlear notch.
- It consists of three bands.
1. Anterior band – attached to medial margin of coronoid process
2. Posteror band – attached to medial margin of olecranon process
3. Oblique band – extends between olecranon and coronoid processes
- Also gives origin to flexor digitorum Superficialis
Radial collateral ligament: fan -shaped

- It extends from the lateral epicondyle of the humerus to the annular ligament. it also
gives origin to supinator and extensor carpi radialis brevis.
Relations of Elbow joint:

Anterior – Radial nerve, Brachialis, median nerve, brachial artery and tendon of Biceps
Posterior – Triceps and anconeus
Medial – Ulnar nerve, flexor carpi ulnaris and common flexors
Lateral – Supinator, ECRB, Common extensors
Blood supply
from anastomosis around the elbow joint
Nerve supply
Ulnar nerve, median nerve, radial nerve, musculocutaneous through its branch to
brachialis
Movements:
Flexion:
- done by brachialis, biceps and brachioradialis
Extension:
- done by triceps and anconeus
Applied Anatomy:
Distension of the elbow joint by effusion occurs posteriorly because the capsule is weak
here. Aspiration is also done from posterior aspect.
Dislocation of elbow is usually posterior and is often associated with fracture of the
coronoid process.
Pulled elbow:
- Subluxation of the head of radius is common in children when forearm is suddenly
pulled in pronation.
Tennis elbow:
- Abrupt pronation may lead to pain and tenderness over lateral epicondyle. It may due
to
- Tearing of fibres of extensor carpi radialis brevis
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- Sprain to radial collateral ligament

- Inflammation of the bursa of the ECRB
-
Golfer’s elbow:
- It is characterized by pain and tenderness at medial epicondyle due to inflammation of
common flexor tendon.
- It is caused due to repetitive flexion and pronation of forearm at elbow
Students elbow (Miner’s elbow):
- Painful swelling over olecranon
- Due to inflammation of subcutaneous olecranon bursa
An injury to the epiphysis of lateral epicondyle produces an increase in lateral deviation of
the forearm. This decreases the carrying angle which is known as cubitus valgus.
Ulnar nerve is gradually stretched producing ulnar neuropathy.
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SUPERIOR RADIO ULNAR JOINT

Type of Joint:
It is Pivot variety of synovial joint.

Circumference of radial head.
Fibro osseous ring made by radial notch and annular ligament
Ligaments:
Fibrous capsule
Annular ligament
- Encircle head of radius and hold it against radial notch of ulna
-
- Attached to margin of radial notch of ulna
Quadrate ligament
Movements:
Supination
Pronation
INFERIOR RADIO ULNAR JOINT

Type of Joint:
It is Pivot variety of synovial joint.

Head of ulna
Ulnar notch of radius
Ligaments:
Fibrous capsule
Articular disc
- Triangular fibro cartilageous disc
- Apex attached to base of styloid process
- Base attached to lower margin of ulnar notch of radius.
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Movements:
Supination
Pronation
SUPERIOR RADIO ULNAR JOINT

Supination - when in semi flexed elbow palm is turned upward
Pronation - when in semi flexed elbow palm is turned downward
Axis of movement
- Oblique and passes from center of head of radius to base of styloid process of ulna.
Supination
- In flexed elbow done by biceps brachii
- In extended elbow done by supinator
- Brachioradialis supinates the pronated forearm to mid prone position
Pronation
- Done by pronator teres and pronator qudratus
- Brachioradialis pronates the supinated forearm to mid prone position
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FIRST CARPO-METACARPAL JOINT

Type of Joint:
It is saddle variety of synovial joint because the articular surfaces are convexo-concave.
It has a separate joint cavity.

Distal surface of the trapezium
Proximal surface of the base of first metacarpal bone
Ligaments:
Fibrous capsule envelopes the joint cavity and is thickened dorsally and laterally
Lateral ligament strengthens the joint laterally
Anterior ligament
Posterior ligament
Blood supply:
Radial artery
Nerve supply:
Median nerve
Movements:
Flexion and extension take place in the plane of palm around an antero-posterior axis.
Abduction and adduction take place at tight angles to the plane of palm.
Flexion is produce by flexor pollicis brevis and opponens pollicis. During flexion there is
medial rotation of metacarpal which is called conjunct rotation
Extension is produced by abductor pollicis longus, extensor pollicis brevis and extensor
pollicis longus. During extension there is lateral rotation of metacarpal.
Abduction is produced by abductor pollicis longus and brevis
Adduction is produced by adductor pollicis
Opposition is initiated by abductor pollicis longus and brevis and is maintained by flexor
pollicis brevis and Opponens pollicis.
Applied Anatomy:
Bennett’s fracture is the fracture of the base of first metacarpal bone. The anterior part of
the base is shorn off due to a force along its long axis.
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WRIST JOINT
Type of Joint:
It is ellipsoid variety of synovial joint.
It joint between lower end of radius and proximal raw of carpal bones.
No contribution from ulna.

Inferior surface of lower end of radius
Inferior surface of triangular articular disc of inferior radio-ulnar joint
Proximal surface of scaphoid, triquetral and lunate.
Ligaments:
Fibrous capsule
Radial collateral ligament
Ulnar collateral ligament
Palmar radio carpal ligament
Palmar ulno carpal ligament
Dorsal radio carpal ligament
Movements:
Flexion is produced by flexor carpi radialis, flexor carpi ulnaris and plamaris longus.
Extension is produced by extensor carpi radialis longus, extensor carpi radialis brevis,
extensor carpi ulnaris.
Abduction is produced by flexor carpi radialis, extensor carpi radialis longus, extensor carpi
radialis brevis, abductor pollicis longus.
Adduction is produced by flexor carpi ulnaris, extensor carpi ulnaris.
Circumduction
Applied Anatomy:
Ganglion – nontender cystic swelling sometime appears on wrist commonly on dorsal
aspect. It is occurs due to mucoid degeneration of synovial sheath around tendon.
Aspiration of wrist joint – needle inserted posteriorly below styloid process of ulna
between extensor pollicis longus and extensor indicis.
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PRONATION AND SUPINATION

Pronation and supination occurs at the radio-ulnar joints.
In the anatomical position the palm is directed forwards and the forearm is supinated so
that radius and ulna lie side by side and almost parallel to each other.
During pronation, the head of radius spins with in the annular ligament around a more or
less a vertical axis and retains its position lateral to the ulna. But the lower end of the
radius rotates forwards and medially across the lower part of ulna. During this process the
interosseous membrane is spiralised.
In supination, the rotation is reversed and the lower end of the radius regains its original
position lateral to the ulna and the interosseous membrane is despiralised.
It usually appears that in pronation and supination, the radius rotates but ulna remains
stationary. But in practice the distal end of ulna moves backwards and laterally in
pronation and forward and medially in supination.
Axis of pronation and supination – from the center of the head of radius to ulnar
attachment of the articular disc. When this line is prolonged distally, it passes along the
little finger. This is when the lower end of ulna is fixed. But this line moves from little finger
towards the index finger when the lower end of ulna moves laterally during pronation. This
increases the range of supination and pronation of ulna even when the elbow is flexed.
Range of pronation and supination with flexed elbow is about 140-150 degree but with
extended elbow the range is increased to about 360 degree due to associated rotation of
humeral head at the shoulder joint and scapular movement.
Power of supination is stronger than the power of pronation. So all the screwing devices
are made to use supination for mechanical advantages.
Muscles Producing movements
1. Pronation: Pronator quadratus assisted by pronator teres, flexor carpi radialis and
gravity. Anconeus assists lateral displacement of ulna in full pronation.
2. Supination: Supinator in extension and biceps brachii in flexion.
Spinal Segments controlling movements
1. Supination: C6
2. Pronation: C7, C8
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Dr. Jitendra P Patel Smt. NHL Municipal Medical College, Ahmedabad.

All Human dissection video available on

Axillary tail of Spence:

Applied: it may be mistaken for lipoma when it is enlarge.

DR. JP PATEL, 22/10/2022 1

Structure on which base of the breast rests

Structure of the Breast

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DR. JP PATEL, 22/10/2022 3

DR. JP PATEL, 22/10/2022 4

Hormones acting on glandular tissue

• Placental Oestrogen & Progesterone:

• Prolactin and Growth hormone:

Witch’s Milk: Maternal estrogen circulating in neonates stimulates the ductal

DR. JP PATEL, 22/10/2022 5

Arterial supply of the Breast:

Venous Drainage of the Breast:

Lymphatic Drainage of Breast

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Internal mammary (para-sternal) on the internal mammary vessels

Lymphatics: arranged in two sets

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Drainage of deep set:

Applied Anatomy of Breast

DR. JP PATEL, 22/10/2022 8

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Anterior wall: is formed by

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pectoralis minor, subclavius, clavipectoral fascia and suspensory ligament of axilla –

Medial wall: is formed by

DR. JP PATEL, 22/10/2022 12

Branches of Axillary artery

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• It emerges at the upper border of pectoralis minor, pierces clvipectoral fascia

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It consists of roots, trunks, divisions and cords.

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Branches of Brachial Plexus

From the trunks: from the upper trunk only

Branches of medial cord

Branches of posterior cord

Sympathetic nerves are distributed with the branches of brachial plexus.

DR. JP PATEL, 22/10/2022 18

DR. JP PATEL, 22/10/2022 19

Injury to nerve to the serratus anterior (Nerve of Bell):

Injury to the cord of brachial plexus:

Lateral cord Medial cord

DR. JP PATEL, 22/10/2022 20

lateral surface of shaft of humerus.

DR. JP PATEL, 22/10/2022 21

Structure under cover of the Deltoid

DR. JP PATEL, 22/10/2022 22

MUSCULOTENDINOUS CUFF OF SHOULDER (ROTATORS CUFF)

DR. JP PATEL, 22/10/2022 23

DR. JP PATEL, 22/10/2022 24

Upper triangular Space:

DR. JP PATEL, 22/10/2022 25

DR. JP PATEL, 22/10/2022 26

DR. JP PATEL, 22/10/2022 27

ANASTOMOSIS AROUND SCAPULA