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UPPER LIMB

PROF : EZZ ELDIN USIM

Clavipectoral Fascia

Definition: Is continuation of the deep fascia from the neck to front of chest. Character: a) The fascia descends and split (divide) to surround the clavicle and the subclavius muscle. b) Then join (fuse) to form single layer again and descend to the Upper border of the pectoralis minor muscle. c) Then split again to enclose (surround) pectoralis minor muscle. d) Below pectoralis minor the fascia fuses again and descends as one layer (suspensory ligament of axilla) attach to floor of axilla

Clavipectoral fascia 2
Structures

pierce clavipectoral fascia: VERY 1) V: Vein (cephalic vein). Lazy 2) L: Lymph vessels and lymph nodes).

And

3) A: Artery (thoracoacromial artery.

Naughty 4) N: Nerve (lateral pectoral nerves) .

Deltopectoral Groove
Site:

Between pectoralis major muscle and deltoid muscle. Contents: 1) Artery: deltoid branch of thoracoacromial artery. Ahmed 2) Vein : Cephalic vein. Very 3) Lymph: Deltpectoral lymph nodes. Lazy

MAMMARY GLAND (BREAST)

@) Is a type of subcutaneous exocrine gland (has no capsule). @) Site: At superficial fascia function: secrets milk @) Structure: 1) formed of 12-15 lobes that formed of smaller lobules. 2) Fibrous tissue septa that separated the lobes and lobules. 3) Fatty tissue between the lobules. @) Shape: Is conical shape on its top present dark brown area called areola On the top of the areola present the nipple at level of 4th space. Part of the breast extends in front of the axilla called axillary tail.

Breast 2
Surface

marking: from above downward: It extends from 2 to 6 costal Cartilage . Laterally: from midaxillary line to Sternal margin medial. Muscles deep to breast: 70% of the breast lies on pectoralis major m. 30% on Serratus anterior m. and external oblique abdominis m.

Breast 3

Nerve supply: Intercostal nerves. Blood supply: a) Intercostal arteries. b) Lateral thoracic artery

c) Internal mammary (thoracic) artery: perforating branches. Lymph drainage: a) Medial part to parasternal lymph nodes of both sides b) Lateral part to axillary lymph nodes (apical and Pectoral groups)

Applied: cancer breast spread to axillary lymph nodes.

Pectoral muscles

They are three Pectoralis major ,pectoralis minor and Serratus anterior A) : PECTORALIS MAJOR =================== . Origin: clavicular head :from the front of the medial 1/3 of the clavicle

Sternocostal head: from anterior surface sternum And upper six costal cartilages.
Insertion: At lateral lip of the bicipital groove Nerve supply: medial and lateral pectoral nerves. Action: Adduction and medial rotation of the arm And Clavicular head is main flexor of The shoulder.

Pectoral muscle

Pectoralis minor
Insertion

Origin: from the 3rd -4th and fifth costal cartilage near the ribs. :At the upper surface of the coracoid process of The scapula.

Action:

depress and protract the shoulder. Nerve supply: medial and lateral pectoral nerves

Pectoralis minor and Serratus

SERRATUS ANTERIOR:

Origin: from the outer surface of upper eight ribs. Insertion: At deltoid tuberosity of the humerus.

Action: protract the scapula and rotate it laterally during Abduction above 90degree (as trapezius).

Nerve supply: long thoracic nerve (its injury results In winging of the scapula).

PECTORAL GIRDLE
FORMED

OF THREE BONES: Sternum, clavicle and scapula. and THREE JOINTS: a)sternoclavicular joint b) Acromioclavicular c) Shoulder joint.

SHOULDER JOINT
Type:

Ball and socket synovial Bones: Glenoid cavity of the scapula and the head of the humerus. Capsule: Attach around the Glenoid include the supraglenoid tubercle at the humerus attach around the neck and medially descend to the level of surgical of the humerus Synovial membrane: lines the inner surface of the capsule.

Shoulder 2
Ligaments:

1) Glenohumeral Ligament: to lesser tubercle of the humerus. 2) Coracohumeral ligament: to greater tuberosity of humerus. 3) Transverse humeral ligament: between two tubercles of the Humerus.

Shoulder 3

Movement of the shoulder : a) Flexion : Clavicular head of pectoralis major and coracobrachialis. b) Extension: Latissmus dorsi, teres major. c) Adduction: pectoralis major, Latissmus dorsi. d) Abduction: from 0 - 15 by Supraspinatus m. 15- 90 by deltoid m. 90 -180 by Trapezius and serattus anterior m.

e) Medial rotation: Pectoralis major, latissmus dorsi and teres major. f) Lateral rotation: Teres minor and infraspinatus m.

Shoulder stability

5) Coracoacromial arch: formed by: coracoid process, acromion and Coracoacromial ligament. 6) Labrum glenoidale: A cartilage around the glenoid to increase its depth it is intracapsular structure and also extrasynovial. Nerve supply: Medial and lateral pectoral nerves, axillary nerve. . (According to Hiltons law: the muscle acts on the joint its nerve supply Will supply that joint).

FACTORS STABILIZE (SUPPORT) SHOULDER JOINT


1) The capsule of the joint 2) The ligaments of the joints (coracohumeral ,glenohumeral ligaments) 3) Tendon of the biceps muscle inside the capsule prevent upward Dislocation of the head of the humerus (intracapsular, extrasynovial). 4) Rotator cuff muscles: surround the capsule they are: a)subscapularis m. b) Supraspinatus m. c) Infraspinatus m. d)teres minor m.

AXILLA
Definition

and site: is a conical space at the arm pit between the upper arm and the trunk. Boundaries: a) Anterior wall: skin, superficial fascia and Platysma muscle. 1) Pectoralis major muscle. 2) clavipectoral fascia at the upper part. 3) Pectoralis minor at middle part.

Axilla

N.B: Pectoralis major only forming anterior axillary fold at the lower part. b) Posterior wall: from above downward 1) Subscapularis muscle. 2) Teres major muscle. 3) Latissmus dorsi muscle. N.b: teres major and Latissmus dorsi form the posterior Axillary fold.

Axilla 3
c)

Lateral wall: mainly formed by intertubercular groove (bicipital groove). d) Medial wall: formed by 1) Serratus anterior muscle. 2) Nerve supply of Serratus (long thoracic nerve )on the Serratus anterior. 3) Upper five ribs and intercostal muscles in Between the ribs.

Axilla 4

e) Apex of axilla: behind the clavicle forming passage Called cervico axillary canal that bounded by : 1) Clavicle anterior 2) posterior by upper border Of the scapula 3) medial by outer border of First rib. f) Base of the axilla: formed of skin, superficial fascia And deep axillary fascia

Contents of the axilla


1)

Axillary artery: enter through the apex and descend To leave the axilla at lower border of teres major Where it continue as brachial artery.

At the axilla it Is divided by pectoralis minor muscle into three parts. Braches of the axillary artery at axiila.

2)

Contents of axilla 2
3)

Axillary vein medial to the artery. 4) Axillary lymph nodes. 5) Cords of the brachial plexus and its branches. 6) Intercostbrachial nerve (th.2) cross the floor of the Axilla and supply skin of the floor of axilla. 7) Fatty areolar connective tissue that support the Contents of axilla.

Spaces of the axilla


Quadrangular

space Upper triangular Lower triangular

Spaces of axilla 2
1)

quadrangular space : Boundaries : a) inferior :teres major m. b) superior :subscapularis m. c)Medially:long head of triceps. d) lateral: surgical neck. :axillary nerve and posterior circumflex humeral artery.

Content

Spaces of axilla 3
2)Uppr

triangular space: a) above :teres minor . b) below :teres major. c) lateral: long head of triceps. Contents : CICUMFLEX SCAPULAR ARTERY.

Spaces of axilla 4
3)

Lower triangular space : Boundaries : a) above:teres major b) lateral : shaft of humerus . c) medial: long head of triceps . CONTENTS : RADIAL NERVE AND BROFUNDA BRACHII ARTERY.

ANATOMY OF AXILLARY ARTERY


Begin:

As a continuation of the subclavian artery at the Outer border of the first rib. End: continue as brachial artery at lower border of teres Major muscle.

Course:

the artery divided by the pectoralis minor into Three parts.

Axillary artery 2

Relation:1) First part: related a) medially : axillary vein b) Posteriorly: medial cord. c) Laterally: lateral and posterior cord. d) Anterior: pectoralis major and claviPectoral fascia. 2) Second part :a) medial: axillary vein and medial cord. b) Lateral: lateral cord of the brachial Plexus. c) Posterior: posterior cord. d) Anterior: pectoralis major and minor.

Axillary artery 3

3) Third part: related to the branches of the cords; a) Anterior: pectoralis major . b) Posterior: Radial and axillary nerve. c) Medial: ulnar nerve and axillary vein. d) Lateral: musculo-cutaneous nerve and Formation of median nerve (the medial Root of the median nerve cross in front Of the artery from medial to lateral to Join the lateral root).

Branches of axillary artery


1) First part gives one branch: 1) superior thoracic A. Supplies the upper part of chest wall and breast. 2) Second part: gives two branches 1) Thoracoacromial artery: divided into a) Acromial branch: b) Pectoral branch: supply pectoral m. and breast. c) Clavicular branch d) Deltoid branch:at Deltopectoral groove 2) Lateral thoracic artery: supply the lateral part of The breast and chest wall.

Branches of the artery 2

3) Third part: gives three branches 1) Subscapular artery: pass along lower of Subscapularis muscle and gives circumflex Scapular artery that share at anastmosis around The scapula. 2) Anterior circumflex humeral artery. And 3) Posterior circumflex humeral artery. Both share at the anastmosis around surgical neck Of the humerus.

BRACHIAL PLEXUS

Formation and root value: -------------------------------------------- Formed by the union of the ventral rami of cervical nerves 5-6-7-8 Th.1 (may receive from c.4 or th.2). Site: The plexus formed of four stages; the first two Stages present at the neck (inside the posterior Triangle) . called supraclavicular stages.

The third Stage at cervico-axillary canal. The fourth stage Of cords present at axilla

Brachial plexus 2

STAGES: ----------------1) First stage of roots: the ventral rami C.5, 6, 7,8th1 present at posterior triangle of the neck between scalenus anterior and scalenus medius m. 2) Second stage of trunks: where C.5, 6 form upper Trunk. C.7 only forms the middle trunk. C.8 and Th.1 Forms the lower trunk. This stage also present at Posterior triangle.

Brachial plexus 3
3)

Third stage (stage of division of the trunks): each Trunk divides into anterior and posterior division, at Cervico-axillary canal behind the clavicle.
4)

Stage of cord and its branches: present at the axilla a) The anterior division of the upper and middle trunk Join to form lateral cord C. 5, 6, and 7

Brachial plexus 4
b)

The anterior division of the lower trunk form the Medial cord C. 8 th.1

c) The posterior divisions of all the trunks join to Form the posterior cord has a root value of: C. 5, 6, 7, 8, Th.1

Brachial plexus

BRANCHES OF THE PLEXUS

A) Branches of the roots: 1) dorsal scapular nerve: that Supply rhomboids minor and major. 2) Long thoracic nerve (c.5, 6, 7) supply Serratus anterior muscle. B) Branches of the trunks (from upper trunk): 1) Nerve to subclavius muscle c.5, 6. 2) Suprascapular nerve c.5, 6 passes at the Suprascapular foramen to supply two muscles Supraspinatus and Infraspinatus

Branches of B.plexus 2
C)

Branches of lateral cords at axilla: 3 a) Lateral pectoral nerve: pierce clavipectoral Fascia to supply pectoralis major muscle

b) Lateral root of median nerve: join the medial Root of medial cord to form median nerve . c) Musculo-cutaneous nerve: supply flexors of At the front of the arm.

B .plexus branches 3

2) Branches of the medial cord: are 5 branches a) Medial pectoral nerve: pierce the pectoralis Minor to end at the major supplying both musc le.

b) Medial root of median nerve: crosses in front of Third part axillary artery from medial to lateral To join the lateral root forming median nerve c) Medial cutaneous nerve of the arm: supply skin At medial side of the arm. d) Medial cutaneous nerve of the forearm: supply Medial side of the forearm cutaneous supply. e) Ulnar nerve.

B . Plexus branches 4

3) Branches of the posterior cord: are 5 branches a) upper subscapular nerve : supply Subscapularis m. b) Lower subscapular nerve: supply Subscapularis And teres major muscles. c) Thoracodorsal nerve: called nerve to Latissmus Dorsi muscle supplying that muscle d) Axillary (circumflex) nerve: passes through the Quadrangular space of axilla to the back of Surgical neck to supply the deltoid and teres Minor muscles, it gives upper lateral cutaneous Nerve of the arm supplying sensory to skin over Lower part of deltoid muscle e) Radial nerve c5, 6, 7, 8, th.1.

CUBITAL FOSSA

Definition: Triangular intramuscular space in front of the elbow. Shape: triangular with apex below, and the base above. Boundaries: a) Lateral: Brachioradialis m. b) Medial: Pronator teres muscle.

c) Apex: meeting of pronator teres and brachioradialis m. with brachioradialis overlie the pronator teres m .
d) Floor: Brachialis and supinator muscles from above down.

e) Roof: Skin, superficial fascia and bicipital aponeurosis.

FLEXOR OF FORE ARM and cubital fossa

SUPERFICIAL CONTENT

Cubital fossa 2

Contents of the fossa: --------------------------a) Superficial content: laterally cephalic vein and Lateral cutaneous nerve of the forearm .Medially basilic vein and medial cutaneous nerve of the forearm . The median cubital vein connects the basilic to cephalic vein. M b) Deep contents: 1) Tendon of biceps muscle A 2) Three arteries: the brachial artery and Its two terminal branches radial and ulnar

3) Median nerve: medial to the artery And radial nerve is most lateral ln the fossa. (The contents are 1 tendon, 2 nerves and 3 arteries).

DEEP CONTENTS

CARPAL BONE
Carpal

bones: S. Scaphoid L. Lunate T. Triquetrum P. Pisiform Tm. Trapezium Td. Trapezoid C. Capitate H. Hamate (*=hook)

FLEXORS OF THE FOREARM

THEY ARE TWO GROUPS OF MUSCLES:

1) Superficial group Formed of Pronator teres ,Flexor carpi radialis, Palmaris longus, Flexor carpi ulnaris and Flexor Digitorum superficialis.

2) Deep group: Flexor pollicis longus, Flexor digitorum profundus and Pronator quadratus muscles N.B.: For origin and insertion look at the tables.

MEDIAN NERVE AT FOREARM


Root value: C.5, 6, 7, 8 and Th. 1 Course: 1) Leave the cubital fossa by passing between the two heads OF Pronator teres muscle to enter the forearm. 2) Descend at the forearm on flexor digitorum Profundus covered by flexor digitorum superficialis

3) Above the wrist it comes from under the cover of F.D.SUP. and lies between F.C.Radialis and F.D.Superficialis tendons. 4) enter the hand deep to flexor retinaculum (through carpal tunnel). End: At the hand as medial and lateral terminal branches at the hand

Median nerve 2

Branches at forearm: 1) Muscular: to pronator teres, F.carpi.radialis, palmar Longus and flexor digitorum superficialis. 2) Anterior interosseous nerve: Supply deep flexors: Flexor pollicis longus , pronator quadratus and Lateral half of the F.D.Profundus .

3) Palmar coetaneous: supply sensory for lateral 2/3 of the palm of the hand. N.B.: Branches of the median in the hand later on (at the hand lectures).

RADIAL ARTERY
Begin:

As one of the two terminal branches of the brachial artery at level of neck of radius ,inside cubital fossa (It leave the fossa above the two heads of pronator teres) .
End:

At the hand as large deep and small superficial palmar branches (share In the formation of pal mar arches at the hand).

Radial artery 2

Course: 1) At forearm it descend on the the muscle attach to front of covered by bracioradialis

So it descends on: Supinator, biceps, pronataor teres, F. digitorum Superficialis, flexor pollicis longus and pronator quadratus m.

Then descend on the lower end of the radius bone where the pulse can felt. 2) Then passes to the anatomical snuff box at back of wrist then 3) Enter the hand between the two heads of the first dorsal interosseous m.

Radial artery 3

End: At the palm it forms mainly the deep palmar arch. Branches: a) radial recurrent anastmose around the elbow.

b) Muscular to the muscles in front of the forearm.


c) Anterior and Posterior carpal branches share at anastmosis around wrist joint

. AT the hand it gives 1) first dorsal metacarpal at back of wrist . 2) Princips pollicis to thumb at the palm to thumb. 3) Radialis indices to index at the palm supply index finger. 4) Then ends as deep and superficial palmar branches.

Radial artery

ULNAR ARTERY

Begin :Similar to the radial artery. End: As large superficial and small deep palmar branches. Course: 1) At upper 1/3of its course it descend oblique downward medially To leave the cubital fossa deep to pranator teres muscle two heads. 2) At lower 2/3 descend it descend vertically downward on flexor Digitorum profundus covered by flexor carpi ulnaris muscle. The ulnar nerve descend medial to lower 2/3 of the artery .

3) Above the wrist it comes from under the cover of flexor carpi Ulnaris to lie between the tendons of flexor carpi ulnaris medially and flexor digitorum superficialis muscle lateral.

Ulnar artery 2

4) It enters the hand superficial to the flexor retinaculum. N.B: the ulnar artery descends at the lateral side of the lower 2/3 of the artery. Branches: 1) Ulnar recurrent artery (ant. and post.)anastmose around elbow. 2) Common interosseous A.: that divides into anterior and posterior Interosseous branches descend in front and back of interosseous membrane.

3) Anterior and posterior carpal branches share at the anastmosis around wrist joint. 4) Then terminates at the hand as deep and superficial palmar branches both share at the palmar arches at the hand (for the ulnar artery Share mainly at formation of superficial palmar arch).

Posterior interosseous artery to the back of fore arm

ULNAR NERNE

Root value and origin: C.7-8-th1 from the medial cord of the brachial Plexus.

Course in the forearm:

1) it comes from behind the medial Epicondile of The humerus to enter the forearm between the two heads of flexor Carpi ulnaris m .

. 2) At the forearm it descend on F.D.Profundus covered by flexor carpi ulnaris. (Medial to the lower 2/3 of the ulnar artery ). 3) Above the wrist it comes from under the cover of flexor carpi ulnaris enter the hand superficial to the flexor retinaculum.

Ulnar nerve 2

Branches at forearm: a) 2 muscular branches :to flexor carpi ulnaris and the medial half of the flexor digitorum profundus. b) 2 cutaneous branches :1) palmar cutaneous to medial 1/3 of the palm descend superficial to flexor retinaculum

2) Dorsal cutaneous: to the medial 1/3 of the back of the hand and dorsal digital branches to media 1 fingers.

Branches at the hand: here it ends as superficial and deep branches 1) Deep branch: Supply all the short muscles of the hand EXCEPT the first and second lumbricals and and three thenar muscles of the thumb .

2) Superficial branch: supply Palmaris brevis muscle and sensory to Medial 3 fingers by its palmar digital branches.

FLEXOR
Definition:

RETINACULUM

Thickening of the deep fascia in front of the wrist. Shape: quadrangular in shape. Function: 1) keep the tendons at their position . 2)Protect structures deep to it (nerves and vessels).

F.retinaculum

F. Retinaculum 2
Attachment:

Medially: at pisiform and hook of hamate. Laterally: Scaphoid and crest of the trapezium. Proximally: Continue with deep fascia of the forearm. Distally: Gives attachment to the palmar aponeurosis

PALMAR and DORSAL

F. RETINACULUM 3
Relation

to the retinaculum: Superficial: 1) Ulnar nerve and ulnar artery . 2) 2 palmar cutaneous branches: of the median and ulnar nerves. 3) Two tendons (tendon of Palmaris longus and flexor carpi ulnaris most medial.

F. RETINACULUM 4

Structures deep to the retinaculum: (AT THE CARPAL ----------------------------------------TUNNEL) . 1)Tendons of the flexor digitorum superficialis and profundus They are surrounded by common synovial sheath (ulnar bursa). 2)Tendon of flexor pollicis longus surrounded by its own synovial sheath forming (radial bursa ).

3) Tendon of the flexor carpi radialis in front of the trapezium. 4) MEDIAN NERVE.

F .RETINACULUM 5

Applied (surgical anatomy): Compression on the median nerve deep to the Flexor retinaculum called Carpal tunnel syndrome results in (Ape hand).

1)Motor effect: weakness of three thenar muscles and 12nd lumbricals thumb become adducted by adductor pollicis muscle.

Results in: (Thumb adduction, loss of opposition and flat thenar eminence due to atrophy of thenar muscle). Weak sensation at lateral2/3 of the palm and lateral 31/2 Fingers .

PALMAR APONEUROSIS
Definition:

Thickening of the deep fascia at the palm of hand. Shape: Triangular shape with BASE distally at level head of metacarpal bone and the APEX: proximal attach to flexor retinaculum. Function: protection of the structures deep to it.

Palmar aponeurosis

PALMAR APONEUROSIS 2

Attachment: a) Apex: At flexor retinaculum and provide insertion For the tendon of Palmaris longus muscles. b) Distally: It gives 4 slips attach to the fibrous flexor sheath and head of metatarsal bone and base of the proximal phalanx . c) Medially: Gives attachment to Palmaris brevis muscle.

D) Laterally: Continue with deep fascia at lateral side of hand That covers the thenar muscles.

MUSCLES OF THE HAND


They are four groups: 1) THENAR MUSCLES: They are the short muscles of the thumb: a) Abductor pollicis brevis. b)Flexor pollicis brevis . c) Opponens pollicis. (These three muscles form thenar eminence). d) Adductor pollicis muscle.

2) HYPOTHENAR MUSCLES: Are 3 a) Abductor digiti minimi b) Flexor digiti minimi c) Opponens digiti minimi.

Muscles of the hand

Muscles of the hand 2


3)

Four lumbricals muscles arises from the tendon of the flexor digitorum Profundus (1st-2nd are unipennate the 3rd - 4th are biennale muscles). 4) Interossei they are two groups: four dorsal Interossei and three palmar Interossei sometimes four The palmer Interossei are Unipennate while the dorsal Interossei are bipennate. N.B.: For origin and insertion look at the diagrams.

Interossei
Dorsal

palmar

Muscles of the hand 3

Action: the lumbricals flex the metacarpophalangeal joints and extend The interphalangeal joints (writing position) helped by interossei . @The Interossei: are two groups palmar and dorsal 1)the palmar (pad) adduct the fingers while the from the axis at middle finger .

2)the dorsal (dab) abduct the fingers, and both assist the lumbricals. Nerve supply: All short muscles of the hand supplied by ULNAR nerve deep branch, EXCEPT three thenar and 1st - 2nd lumbricals muscle by the median nerve .

MEDIAN NERVE in the hand

Median nerve in the hand: It enter the hand deep to the flexor retinaculum Through the carpal tunnel at the hand it divides into two terminal branches:

a) Lateral branch: supply three thenar muscles and first lumbricals muscle. b) Medial branch: supply the second lumbricals. Sensory: For the lateral 2/3 of the palm (from the palmar cutaneous).

Palmar digital branches from its two terminal branches supply the lateral 3 fingers palmar surface and the dorsal surface of The terminal phalanx.

FLEXOR SYNOVIAL SHEATH


Definition: a serous membrane surround flexor tendons formed of inner Visceral and outer parietal layers.

There are two synovial sheathes:


1) Radial bursa or synovial sheath for the tendon of flexor pollicis Longus extend from above the wrist to thumb

2) Ulnar bursa or common synovial sheath for the tendons of flexor Digitorum superficialis and profundus. it starts above the wrist Down to the middle of the palm except that for little finger extend to the insertion at little finger. 3) tendon of index, middle and ring fingers have separate sheath

Applied anatomy : infection of the common synovial results in spread of infection to the thumb due to connection between the two synovial burse

Superficial extensor of fore arm


They are : 1)brachoiradialis 2)extensor carpi radialis longus 3) extensor carpi radialis brevis . 4) extensor digitorum 5) extensor digiti minimi . 6) extensor carpi ulnaris . 7) anconeus muscle :at back of elbow From back of lateral epiconyle of humerus to back of olecranon and upper part of ulna .

Deep extensor of forearm


They

are : 1)abductor pollicis longus 2) extensor pollicis brevis . 3) extensor pollicis longus . 4) extensor indicis . 5) supinator

RADIAL NERVE

Root value: c.5-6-7-8-th1

Origin: is a branch of posterior cord.

Course: 1) In the axilla it descend on subscapularis m. posterior to 3rd part Of the axillary artery to pass through the lower triangular space with Profunda brachii artery.

2) At upper arm descend at the back of the humerus at the radial or (Spiral) groove also with profunda brachii artery. 3) Then at front of the arm at cubital fossa (at level of lateral Epicondile of the humerus ) it ends as deep and superficial branch. (posterior interosseous nerves and radial)

Radial nerve 2

Branches of radial nerve: 1) At the axilla: nerve to long head of triceps Sensory: posterior cutaneous of the arm 2) At spiral (radial) groove: supply medial and lateral heads of triceps and nerve to ancoeus muscle . Sensory: posterior cutaneous nerve of the forearm and lower lateral cutaneous nerve of the arm. 3) At cubital fossa: muscular branches to brachioradialis, also nerve to extensor carpi radialis longus m. and lateral part of Brachialis.

Radial nerve 3

4) Superficial branch: Supply sensory to lateral 2/3 of the back (dorsum) Of the hand and lateral 3 fingers proximal phalanges (dorsal digital). 5) Deep branch (posterior interosseous nerve): pierce the supinator muscle And reach back of forearm to supply: supinator, ext. Capri. radialis brevis, ext.digitorum, ext. digiti minimi , ext. Carpi ulnaris. in addition to all the deep extensors (abductor Pollicis longus, extensor pollicis brevis, extensor pollicis longus and extensor indicis ) .

EXTENSOR RETINACULIUM

Definition: thickening of the deep fascia at the back of wrist. Attachment: Laterally: at lower part of the anterior border of radius Medially : at pisiform and trequetrum bone From the deep :surface of the retinaculum Descend 5 septa forming 6 extensor compartments deep to the retinaculum.

Extensor retinaculum

Extensor retinaculum 2

From lateral: 1st compartment contain: Abductor pollicis longus and extensor pollicis brevis. 2nd comp: Extensor carpi radialis longus and brevis. 3rd comp: extensor pollicis longus. 4th comp: Extensor digitorum and extensor indicis. 5th comp: Extensor digiti minimi. 6th comp: related to ulna for extensor carpi ulnaris.

BLOOD SUPPLY OF THE HAND


Superficial

palmar arch: Site: deep to palmar aponeurosis. Surface marking: At the level of distal border of abducted thumb Formation: superficial palmar branch of the ulnar artery mainly With the small superficial palmar branch of the radial artery Branches: three common palmar digital that divides into palmar branches that supply adjacent sides of digits.

Blood supply of the hand 2

Deep palmar arch: Site: deep to the flexor tendons on the base of the metacarpal bones. Formation: mainly deep palmar branch of the radial artery and small deep palmar branch of the ulnar artery.

Level: 1 finger breadth proximal to superficial arch. Branches: 3 palmar metacarpal arteries supply the digits.

ANATOICAL SNUFF BOX

CONTENTS OF ANATOMICAL SNUFF BOX


1)

CEPHALIC VEIN . 2) RADIAL ARTERY . 3) SUPERFICIAL BRANCH OF RADIAL NERVE . 4) TENDON OF EXTENSOR CARPI RADIALIS LONGUS AND BREVIS.

Vein of upper limb


Superficial

veins : 1) DORSAL VENOUS ARCH:PRESENT AT DORSUM OF THE HAND , IT RECEIVES DORSAL DIGITAL VEIN FROM THE FINGERS FROM ITS MEDIAL END BEGIN THE BASILIC VEIN ,AND FROM THE LATERAL END BEGINS THE CEPHALIC VEIN.

Dorsal Arch

venous

VEINS 2
2)

CEPHALIC VEIN : ASCEND FROM THE LATERAL END OF DORSAL VENOUS ARCH AT SUPERFICIAL FASCIA AT ANATOMICAL SNUFF BOX THEN LATERAL SIDE OF FOREARM AND ARM TO REACH THE DELTOPECTORAL GROOVE WHERE IT PIERCE CLAVIPECTORAL FASCIA END AT AXILLARY VEIN .

VEINS

OF UPPERLIMB

VEINS 3
3)

BASILIC VEIN ; BEGINS AT THE MEDIAL END OF THE DORSAL VENOUS ARCH ASCEND ALONG THE MEDIAL SIDE OF THE UPPER LIMB AND JOINED BY BRACHIAL VEIN (DEEP VEIN) THEN AT LOWER BORDER OF TERES MAJOR IT CONTINUE AS AXILLARY VEIN

VEINS

BASILIC VEIN CONTINUE AS AXILLARY

Nerve injury 1) injury of the brachial plexus


All

the injuries of the plexus are common during the delivary of the baby the includes : two types A) upper trunk (C.5-6)lesion : known as Erbs Duschan paralysis (police man tip position) 1)the arm adducted and rotated medial 2) elbow extended . 3)hand pronated with flexed fingers .

Lower trunk lesion C.8 th1


Known

as klumpeks paralysis ; result in case of complete claw hand with flexed fingers and abducted thumb . This is due to paralysis of all short muscles of the hand . N.B: ALL SHORT MUSCLES OF THE HAND SUPPLIED BY C.8 AND Th .1

Axillary nerve injury


commonly due to fracture of the surgical neck of the humerus . Results : paralysis of deltoid and teres minor muscles results in failure of abduction of shoulder and flat shoulder. sensory loss over the lower part of shoulder.

Long thoracic nerve


Paralysis

of nerve to Serratus anterior C.5-6-7 results in winged scapula (The scapula retracted and rotated ).

Ulnar nerve injury

commonly due to fracture of medial Epicondile results in partial claw hand: motor effect : paralysis of short muscles of the hand except thenar and 1st and 2nd lumbricals muscles . sensory effect : sensory loss at medial 1/3 and medial 11/2 fingers .

Median nerve injury


Results in paralysis most of the flexor of forearm , thenar muscles and1st and 2nd lumbricals . PICTURE OF APE HAND with adducted thumb and flat thenar eminence. Sensory loss at lateral 2/3 of the palm And lateral 31/2 fingers .

Radial nerve injury

commonly due to fracture of the shaft Of the humerus of the spiral groove Results in paralysis of extensors of wrist and fingers . PICTURE OF DROP HAND

NERVE INURIES
1)PARTIAL Claw hand 2)Drop wrist

3)APE HAND