Musculoskeletal System

Appendicular System: Upper Limb

Lecture 3: Pectoral Region, Back &
Shoulder muscles & Axilla

Dr. Ashraf Ramzy

Professor of Anatomy & Embryology
ash-ramzy@hotmail.com
Dr Ashraf Ramzy
 Movements of shoulder joint
* Includes:
1. Abduction & adduction.
2. Flexion & extension.
3. Med. Rotation & lateral rotation.
* Produced by: muscles inserted
in humerus.

Dr Ashraf Ramzy
 Movements of shoulder girdle
* Includes:
1. Elevation & depression.
2. Protraction & retraction.
3. Rotation up & rotation down of scapula.
* Produced by: muscles inserted
in shoulder girdle (clavicle
or scapula).

Dr Ashraf Ramzy
Pectoral Region

Dr Ashraf Ramzy
 Pectoralis major
▪ Origin:
It takes origin by 2 heads;
1. Clavicular head:
 Anterior surface of the medial
Clav.
½ of the clavicle.
2. Sternocostal head: P. M.
 Front of the sternum, upper 7
costal cartilages &
aponeurosis of the external
abdominal oblique.
▪ Insertion: By a flat bilaminar
tendon into the lateral lip of
the bicipital groove of the
humerus.

Dr Ashraf Ramzy
▪ N. supply: Lateral pectoral N.
& Medial pectoral N.
▪ Action:
1. Adduction, flexion & medial
rotation of the arm.
2. The clavicular head brings
the extended arm to the
resting position.
3. The sternocostal head brings
the flexed arm to the resting
position.
4. With the insertion fixed &
the arm raised, the whole
muscle draws the trunk
upwards towards the arm as
in swimming, playing
gymnastics & climbing.
Dr Ashraf Ramzy
 Pectoralis minor
▪ Origin: From 3rd , 4th & 5th
ribs just lateral to their
costal cartilages.
▪ Insertion: Into upper
surface of the coracoid
process of the scapula.
▪ Nerve supply: Medial
pectoral nerve.
▪ Action: Protraction &
depression of the
shoulder.
Dr Ashraf Ramzy
 Subclavius
▪ Origin: From the junction
between the 1st rib & its
costal cartilage.
▪ Insertion: Into the groove
for subclavius muscle
(subclavian groove) on
the lower surface of the
middle 1/3 of the clavicle.
▪ Nerve supply: N. to
subclavius.
▪ Action: Stabilizes & fixes
the clavicle.

Dr Ashraf Ramzy
 Clavipectoral fascia
▪ This is a well defined membranous
fascia that extends between
subclavius & pectoralis minor
muscles deep to pectoralis major
muscle. Sub.
▪ Attachments:
- Above: It splits to enclose the Clavipect. F.
P. min.
subclavius muscle & gets attached
to the clavicle (margins of the
groove for subclavius).
- Below: It splits to enclose the
pectoralis minor muscle & then the
2 layers fuse together to form the
suspensory lig. of the axilla which
gets attached to axillary fascia. Dr Ashraf Ramzy
Clavipectoral fascia

Dr Ashraf Ramzy
- Medially: The clavipectoral
fascia is attached to 1st
costal cartilage.
- Laterally: It is attached to
the coracoid process of the
scapula.
- Therefore, it could be
called the costocoracoid
membrane.

Dr Ashraf Ramzy
 Serratus anterior

■ Origin: By 8 fleshy slips from the middle of the outer

surface of the upper 8 ribs, interdigitating with the
slips of the external abdominal oblique muscle.
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■ Insertion: Into the ventral
surface of the medial
border of the scapula;
- 1st digitation opposite the
superior angle.
- 2nd & 3rd digitations along
the whole length of the
medial border.
- Lower 5 digitations
opposite the inferior
angle.
■ Nerve supply: Long
thoracic nerve (N. to
serratus anterior).

Dr Ashraf Ramzy
■ Action:
1. Protraction & depression of the shoulder.
2. The lower 5 digitations help in the rotation up
(lateral rotation) of the scapula to raise the arm
above the head.
■ Applied anatomy:
1. Since the long thoracic nerve runs on outer surface
of serratus anterior, therefore it is liable to injury.
2. Injury of long thoracic nerve
 Paralysis of serratus anterior
muscle causing winging of the
scapula (prominence of medial
border & inferior angle of the
scapula).
Dr Ashraf Ramzy
Back Muscles

Dr Ashraf Ramzy
* 5 muscles connecting the upper limbs to the vertebral column.

* Arranged in 2 layers•

1st layer Trapezius

Trapezius Latissimus
dorsi
2nd layer

Levator scapulae Rhomboideus minor Rhomboideus major

Dr Ashraf Ramzy
 1. Trapezius
* Origin (3):
1. External occipital
protuberance + medial ⅓
of the superior nuchal
line.
2. Ligamentum nuchae +
C7 spine.
3. All thoracic vertebral
spines (T1 – T12) +
Supraspinous ligaments. Dr Ashraf Ramzy
 Lig. nuchae

7th

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Insertion (3):
1. Posterior border of the
lateral ⅓ of clavicle.
(Upper fibers).
2. Medial border of the
acromion + upper lip of
crest of spine of scapula
(Middle fibers).
3. Tubercle at the medial
end of the scapular spine.
(Lower fibers).
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Dr Ashraf Ramzy
* Nerve supply:
1. Motor: spinal accessory nerve (11th cranial N.).
2. Sensory (Proprioceptive): C3 & C4.
* Action (3):
1. Upper fibers → elevate the scapula.
2. Middle fibers → retract the scapula.
3. Upper and lower fibers (with lower (5)
digitations of serratus anterior) → upward
rotation of the scapula from (90° - 180°).

Dr Ashraf Ramzy
 2. Latissimus dorsi
* The only muscle of the upper limb
which has pelvic attachment.
* Origin:
1. Pelvic: Posterior ⅓ of the outer lip
of the iliac crest of the hip bone.
2. Vertebrel: Lumbar fascia + spine
of lower 6 thoracic vertebrae.
3. Costal: back of the lower 3 or 4
ribs.
4. Scapular: back of the inferior
angle of the scapula.
Dr Ashraf Ramzy
 * Insertion:
* The floor of the bicipital groove of the
humerus.

* Nerve supply:
* Nerve to latissimus dorsi (C 6,7,8).

* Action:
* Adduction, medial rotation and extension of the arm.

Dr Ashraf Ramzy
 3. Levator scapulae
* Origin: the transverse
processes of the upper (4)
cervical vertebrae.
* Insertion: Back of the
medial border of the scapula
between the superior angle
and the scapular spine.
* Nerve supply: Nerve to
rhomboides (Dorsal scapular
nerve).
* Action: Elevation &
rotation down of scapula.
Dr Ashraf Ramzy
Dr Ashraf Ramzy
 4. Rhomboideus Minor
* Origin: Lower part of
ligamemtum nuchae, 7th
cervical & 1st thoracic spines.
* Insertion: root of the
scapular spine.
* Nerve supply: Nerve to
rhomboides (Dorsal scapular
nerve).
* Action: Retraction &
rotation down of scapula.

Dr Ashraf Ramzy
 5. Rhomboideus Major
* Origin: Spines of T 2, 3, 4, 5
and their supraspinous
ligaments.
* Insertion: Back of the medial
border of the scapula between
the root of the scapular spine
and the inferior angle of the
scapula.
* Nerve supply: Nerve to
rhomboides (Dorsal scapular
nerve).
* Action: Retraction & rotation
down of scapula. Dr Ashraf Ramzy
 Levator scapulae

Rhomboideus minor
Rhomboideus major

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* Triangle of auscultation:  Bounded by Trapezius, latissimus
dorsi & medial border of scapula. (Rhomboideus major in floor).
* Used to hear breath
sounds.

Ausc.

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Shoulder Muscles

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 6 Muscles
* 2 teres: Major & Minor.
* 2 Spinatus: Supra & infra.

* 2 large: Deltoid & Subscapularis.

* General rules:
1. All originate from the scapula.
2. All are inserted into the humerus.
3. All supplied by nerves with root value C5,6.
4. All act on the shoulder joint.

Dr Ashraf Ramzy
* Origin:-
Medial ⅔ of supraspinous
fossa of scapula.
* Insertion:
Upper impression of greater
tuberosity of the humerus.
* Nerve supply:
Suprascapular nerve.
* Action: Initiation of
abduction of shoulder (0-
18 Dr Ashraf Ramzy
* Origin:-
Medial ⅔ of infraspinous
fossa of scapula.
* Insertion:
Middle impression of greater
tuberosity of the humerus.
* Nerve supply:
Suprascapular nerve.
* Action: Adduction & lateral
rotation of shoulder joint.
Dr Ashraf Ramzy
* Origin:-
Upper ⅔ of the dorsal
aspect of the lateral
border of the scapula.
* Insertion:
Lowest impression of greater
tuberosity of the humerus.
* Nerve supply: Axillary N.
* Action: Adduction & lateral
rotation of shoulder joint.
Dr Ashraf Ramzy
* Origin:-
Lower 1/3 of the dorsal
aspect of the lateral
border of the scapula.
* Insertion:
Medial lip of bicipital groove
of the humerus.
* Nerve supply:
Lower subscapular nerve.
* Action: Adduction,
extension & medial rotation
of shoulder joint. Dr Ashraf Ramzy
* Origin:-
Medial ⅔ of subscapular
fossa.
* Insertion:
Lesser tuberosity of the
humerus.
* Nerve supply:
Upper & Lower
subscapular nerves.
* Action: Adduction &
medial rotation of
shoulder joint. Dr Ashraf Ramzy
* Origin:-
1. Anterior fibers: from
anterior & upper surface of
lateral ⅓ of clavicle.
2. Middle fibers: from lateral
border of the acromion
process.
3. Posterior fibers: from
inferior lip of the crest of the
scapular spine.
* Insertion:
Deltoid tuberosity of the Deltoid is a
humerus. Multipennate muscle
Dr Ashraf Ramzy
* Nerve supply:
Axillary nerve.
* Action:
1. Anterior fibers: Flexion
& medial rotation of
shoulder joint.
2. Middle fibers:
Abduction of shoulder
joint (18-90
3. Posterior fibers:
Extension & lateral
rotation of shoulder joint.
Dr Ashraf Ramzy
 Rotator Cuff
* Is formed by:
1- Subscapularis.
2- Supraspinatus.
3- Infraspinatus.
4- Teres Minor.
* These muscles are
inserted partially in
capsule of shoulder
joint.
* They help in stability
of shoulder joint.
Dr Ashraf Ramzy
 Abduction at Shoulder
* 0-90º take place at shoulder joint:
1- 0-18º → by supraspinatus.
2- 18-90º → by middle fibers of deltoid.

* 90-180º take place at shoulder girdle:

by the rotation up (lateral rotation) of
scapula → by action of lower 5
digitations of serratus anterior & upper &
lower fibers of trapezius.
Dr Ashraf Ramzy
 Intermuscular Axillary spaces

Quadrangular space

Lower triangular
space

Upper triangular space

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 Boundaries & Contents of
Intermuscular Spaces
Upper triangular Quadrangular Lower triangular
space space space

1. Superior Teres minor. Teres minor. Teres major.

boundary:
2. Inferior Teres major. Teres major.
boundary:
3. Medial Long head of Long head of
boundary: triceps. triceps.
4. Lateral Long head of Surgical head of Shaft of
boundary: triceps. humerus. humerus.
5. Contents: Circumflex 1. Axillary nerve. 1. Radial nerve.
scapular artery. 2. Posterior 2. Profunda
circumflex brachii artery.
humeral artery.
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Dr Ashraf Ramzy
Axilla

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 AXILLA
● It is a pyramidal space between the upper part
of the arm (laterally) and the side of the chest
wall (medially).

● Forms an important passage for nerves, blood

and lymphatic vessels from the root of the neck
to the upper limb.

● Has an apex directed upwards into the root of

the neck, lower end or base, and 4 walls
(anterior, posterior, medial and lateral).
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Dr Ashraf Ramzy
Dr Ashraf Ramzy
 Walls of the axilla
1. Anterior wall : formed of :
a.Pectoralis major (superficial layer).
b.Pectoralis minor, Subclavius & clavipectoral
fascia (deep layer).

● Anterior fold of axilla: This is the lower border of

the anterior wall of the axilla. It is formed by the
lower border of pectoralis major only.

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Dr Ashraf Ramzy
2. Posterior wall of axilla: formed by :
a. Subscapularis (above).
b. Latissimus dorsi & Teres major (below).

● Posterior fold of axilla: This is the lower

border of the posterior wall of the axilla. It
is formed by Latissimus dorsi &Teres
major. It is lower than the anterior fold of the
axilla.

Dr Ashraf Ramzy
Dr Ashraf Ramzy
Dr Ashraf Ramzy
3.Medial wall of axilla: formed of :
a. Upper 5 ribs & intercostal spaces in between.
b. Upper digitations of Serratus anterior which
arise from upper 5 ribs.

Dr Ashraf Ramzy
4.Lateral wall of axilla: formed of :
a. Bicipital groove of the humerus.
b. coracobrachialis & short head of biceps.

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5. Apex of axilla (upper end) :
 It is a triangular bony space which connects the
neck with the upper limb.
 It is called cervico-axillary canal.
 It gives passage to arteries & nerves to enter the
upper limb & veins & lymphatics to leave the upper
limb.
 It is bounded by:
* Front: Lateral half of clavicle.
* Behind: Upper border of scapula.
* Medial: Outer border of 1st rib.
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Dr Ashraf Ramzy
Dr Ashraf Ramzy
6.Base (lower end) of axilla:
 It is formed by axillary fascia & skin stretching
between anterior and posterior axillary walls.
 It is bounded by :
* Front: Anterior axillary fold (pectoralis major).
* Behind: Posterior axillary fold (tendon of
latissimus dorsi and teres major).
* Medial: Chest wall.

Dr Ashraf Ramzy
Dr Ashraf Ramzy
 CONTENTS OF AXILLA

1. Axillary artery and its branches.

2. Axillary vein and its tributaries.
3. Brachial plexus; the cords and its
branches.
4. Axillary lymph vessels and nodes.
5. Axillary fat.
6. Axillary tail of the breast.
7. Axillary sheath.
Dr Ashraf Ramzy
Dr Ashraf Ramzy
Dr Ashraf Ramzy
Dr Ashraf Ramzy