Chapter 8

The Upper Limb

Introduction
For descriptive purpose, the upper limb in each side is usually divided into five parts: the shoulder, the arm, the elbow, the forearm and the hand. The shoulder region includes the axilla, the scapular region and the deltoid region. The arm and the forearm can be divided into anterior and posterior regions. The hand can be divided into the palm, the dorsum and the fingers.

Introduction

Divisions

The Shoulder The Arm The Elbow The Forearm The Hand

The pectoral region & axillary region 1. Boundaries of the axillary cavity
The axillary is a pyramidal region. So it has an apex, a base and four walls. The apex The apex of the cavity is directed upwards to the root of the neck, and is formed by the first rib, the superior border of the scapula, the posterior surface of clavicle. The base The base of the cavity is is directed downwards, formed by the skin, the superficial fascia and the axillary fascia.

Main contents
I. Boundaries of the axillary cavity

1. The apex Formed by: the first rib the superior border of the scapula the posterior surface of clavicle

2. The base Formed by: the skin the superficial fascia the axillary fascia.
The anterior wall The anterior wall of the cavity is formed by the pectoralis major, the pectoralis minor and the clavipectoral fascia. The clavipectoral fascia is a strong fibrous sheet posterior to the pectoralis major and between the pectoralis minor and the clavicle, pierced by the cephalic vein, thoracoacromial vessels and lateral pectoral nerve.

3. The anterior wall Formed by: the pectoralis major () the pectoralis minor () the clavipectoral fascia ---- a strong fibrous sheet posterior to the pectoralis major clavipectoral fascia and between the pectoralis minor and the clavicle, pierced by the cephalic vein() , thoracoacromial vessels and lateral pectoral nerve.
The posterior wall The posterior wall is formed by the subscapularis, the teres major, the

latissimus dorsi, the scapula.

In the posterior wall, there two important structures: the trangular space and the quadrangular space. The trangular space is the triangular space between the teres minor, the teres major, and the long head of the triceps brachii. It is pierced by the circumflex scapular vessels. The quadrangular space is the quadrangular space between the teres minor, the teres major, the long head of the brachii and the surgical neck of the humerus. It is pierced by the axillary nerve and the posterior humeral circumflex vessels.

Teres minor/ Subscapularis(/) Teres major () Long head of triceps brachii () Surgical neck of the humerus ()

Triangular space ()

the circumcircum-flex scapular vessels ().

Quadrangular space ()

the axillary nerve the posterior humeral circumflex vessels ().

The medial wall The medial wall is formed by first four ribs and their intercostal muscles, and the upper part of the serratus anterior.

The lateral wall The lateral wall is formed by the long head and the short head of the biceps brachii, the coracobrachialis, and the intertubercular sulcus of the humerus.

5. The medial wall Formed by: 1st---4th ribs and the intercostal muscles the upper part of the serratus anterior () 6. The lateral wall Formed by: the intertubercular sulcus of the humerus () the two heads of the biceps brachii() the coracobrachialis
()

2. Contents of the axillary cavity

The main contents in the cavity include the axillary artery and its branches, the axillary vein and its tributaries, the brachial plexus and its branches, the axillary lymph nodes. And at same time there are many fat and loose connective tissue in it. The axillary artery The axillary artery were divided into three parts by the pectoralis minor. In the first part, there is only one branch, the superior thoracic artery., it supplies the anterior part of the first and the second intercostal spaces. There are two branches coming from the trunk, the throracoacromial artery and the lateral thoracic artery. The throracoacromial artery pierces the clavipectoral fascia and divides into three branches immediately, one to the deltoid, one to the acromion, and the other goes to the pectorals. The lateral thoracic artery goes along the lower border of the pectoralis minor, mainly supplies the structures of the thoracic wall. In women, this artery is lager and gives the branch to breast. There are three branches in the third part. The first is the subscapular artery. Usually this artery is the largest branch of the trunk. It has two branches: the circumflex scapular artery and the thoracodorsal artery. The circumflex artery pierces the triangular space to the back of the shoulder. The thoracodorsal artery goes to the latissimus dorsi. In the third part there are two arteries go around humerus, the anterior humeral circumflex artery and the posterior humeral circumflex artery. The posterior humeral circumflex artery pierces the quadrangular space with the axillary nerve.

The main branches of the brachial plexus There are many branches coming from the three cords of the brachial plexus, but the most important branches are the musculocutaneous nerve, the median nerve, the ulnar nerve, the radial nerve and the axillary nerve.

2. The main branches of the brachial plexus

the musculocutaneous nerve
()

the median nerve () the ulnar nerve () the radial nerve ()

the humeromuscular tunnel()

the axillary nerve ()

the quadrangular space

the thoracodorsal nerve (

the long thoracic nerve (

The axillary sheath The prevertebral layer of the deep cervical fascia extends from the neck and through the apex to the axillary cavity, in the cavity it enclose the axillary artery, the axillary vein and the brachial plexus, we call it axillary sheath.

Because the fascia of the sheath comes from the prevertebral layer, so if there is a prevertebral

abscess, the pus maybe spread to axilla through the axillary sheath. And when the surgical operation doing only on the lower part of the limb, we can inject the anesthetic into the axillary sheath to block the bracial plexus. But be careful not damage the artery. So the operator should first touch the axillary according to its pulsation. And then insert the needle superior or inferior to the palpating index finger. The axillary lymph nodes
There are many lymph nodes in the axillary cavity and were divided into five groups. The nodes arrange along lower border of the pectoralis minor called the pectoral lymph nodes. The pectoral lymph nodes receive the vessels from the anterior and lateral thoracic wall, the central and lateral parts of the breast. The nodes arrange near the distal part of the axillary vein called the lateral lymph nodes and they receive the vessels from the upper limb. The nodes arrange near subscapular vessels called the subscapular lymph nodes and they receive the vessels from the scapular region and the back. The efferent vessels of these three group drain into the center group. The center group lies in the fat of the axillary cavity. And its efferent vessels drain into the apical nodes. The apical nodes arrange near the upper part of the axillary cavity and receive the vessels from the center group and the upper part of the breast. And their efferent vessels form the subclavian trunk.

The lymphatic drainage of the breast The cancer of breast is a common tumour happening in wemen, and it can spread through the lymphatic vessels. So studying the lymphatic drainage of the breast is very important. Usually there are four pathways for lymphatic drainage: The lymphatic vessels of the lateral and upper parts drain into the pectoral lymph nodes, this is the main lymphatic drainage of the breast, and usually is invaded early by the beast cancer. The lymphatic vessels of the medial parts drain into the parasternal lymph nodes. These vessels can anastomose with the contralateral lymphatic vessels.

 The lymphatic vessels of the inferomedial parts anastomose with the lymphatic vessels of the anterior abdominal wall , the subdiaphragmatic and hepatic lymphatic vessels. The deep lymphatic vessels of the breast pierce the pectoralis major and minor directly and drain into the apical lymph nodes.

Axillary nodes receive more than 75% of lymph from the gland, and the remainder largely draining to parasternal nodes. So in the radical mastectomy, the pectoralis major and minor, the accessible lymph nodes must be removed thoroughly. When the operator working, he must be careful not to damage those important vessels and nerves going nearby. For example, when cutting the pectoralis major and minor, dealing with the clavipectoral dascia or removing the apical lymph nodes, he should protect the cephalic vein from damage. And when removing the pectoral lymph nodes, he should protect the long thoracic nerve; and when removing lateral and central lymph node, he should protect vessels and nerves in the axillary cavity especially the axillary vein; And when removing the subscapular lymph nodes you should protect the thoracodorsal nerve.

The anterior region of the arm, the elbow, the forearm, and the wrist.
The superficial vein There are two larger veins here. One is the cephalic vein, and the other is the basilic vein. The cephalic vein begins at the radial side of the dorsal venous rete of hand, and ascends to the elbow at the lateral side of the forearm, then goes into the cleft between the pectoralis major and deltoid, pierces the clavipectoral fascia and drains into the axillary vein.

Main Contents
1. Superficial veins 1) The cephalic vein ()

begins at the radial side of the dorsal venous rete of hand() ascends in the anterolateral part of the forearm to the elbow runs along the lateral bicipital groove runs along the interval between the deltoid and pectoralis major pierces the clavipectoral fascia ends in the axillary vein.

2)

1)

2) 1)

And the basilic vein begins at the unlar side of the dorsal venous rete of hand and ascends to the elbow at the medial side of the forearm, and then goes along the medial bicipital groove and pierces the deep fascia of the arm and drain into the axillary vein. Some times there is a superficial vein connecting the cephalic vein and the basilic vein at the elbow. We call it the median cubital vein. Usually it comes from the cephalic vein and drain into the basilic vein upward and medially. Vein punctures are often performed at upper limb with these superficial veins. Usually there is a large superficial vein at the anterior aspect of the elbow, sometimes maybe it is the median cubital vein, and this superficial vein is connected with the deep vein, so we often make the vein punctures at the elbow.

2) The basilic vein()

begins from the ulnar side of the dorsal venous rete of hand ascends on the posterior surface of the ulnar side of the forearm inclines forwards to the anterior surface below the elbow runs upwards along the medial bicipital groove perforates the deep fascia a little below the middle of the arm ends in the axillary vein at the lower border of teres major. 3) The median cubital vein () Often divided from the cephalic vein at the cubital fossa. Connects the cephalic vein with the basilic vein, slants upwards and medially superficially Vein punctures are often performed at the elbow, and the largest vein usually the median cubital vein, is selected.

2) 3)

2)

The cubital fossa. The cubital fossa is a triangular depression. If you remove the skin and the superficial fascia you will find that all the content are deep to the aponeurosis of the biceps brachii and the deep fascia, so we can say the roof of the fossa is formed by the aponuerosis and the deep fascia. Then if you remove the deep fascia and cut off the apoeurosis, you can find the upper boundary is formed by an imaginary line connecting the two humeral epicondyles. The pronator teres is the inferomedial boundary and the brachioradialis is the inferolateral boundary. And the brachialis and supinator form the base of the fossa, and deep to all the content.

The contents in the cubital fossa arrange in a regular order. From the lateral side to the medial side, is the tendon of the biceps brachii, the terminal part of the brachil artery, and then the median nerve. At the lower part of the fossa the brachil artery divides into two branches: the radial artery and the ulnar artery.

The carpal canal First lets learn something about the deep fascia of the wrist. The deep fascia here includes two layers. The superficial layer of the deep fascia we call it the palmar carpal ligament. It is thickened by some transverse fibers. And the deep layer extends distally, we call it the flexor retinaculum. It is very thick. Both the ulnar end and the radial end of it is attached to some carpal bones. So there is a canal between the flexor retinaculum and the groove of the carpal bones, we call it the carpal canal.

3. The carpal canal

(1) The deep fascia of the anterior carpal region The superficial layer ---- the palmar carpal ligament() The deep layer ---- extends distally as the flexor retinaculum() (2) The flexor retinaculum( retinaculum( transverse carpal ligament) the ulnar end is attached to the pisiform() and the hook of hamate( ), and the radial end is attached to the tubercles of scaphoid() and trapezium().
palmar carpal ligament carpal canal flexor retinaculum

The median nerve and nine tendons pass through the carpal canal to the palm. The nine tendons include the flexor digitorum superficialis, the tendons of the flexor digitorum profundus and the tendon of the pollicis longous. Because the flexor retinaculum is very thick, so it can protect the tendons and the median nerve from some damage. But at the same time, any disease in the canal may injure the median nerve. And the deep space of the forearm can communicates with the space of palm through the carpal canal. So the infection of the palm may extend to the forearm through this way.

(3) The carpal canal

Formed by : the flexor retinaculum the groove of the carpal bones. Contents: the tendons of the flexor digitorum superficialis() the tendons of the flexor digitorum profundus() the tendons of the flexor pollicis longous () the median nerve.
flexor retinaculum

palmar carpal ligament

carpal canal

The posterior region of the arm, the elbow, the forearm , and the wrist.

The humeromuscular tunnel. It is located at the middle part on the back of the arm. And it extends downwards from the superomedial side to the inferolateral side. It is formed by the three

heads of the triceps brachii and the sulcus for the radial nerve on the humerus. The radial nerve and deep brachial vessels pass through the humeromuscular tunnel. So if there is a fracture at the humeral shaft, the radial nerve may be injured. over the cadaver to the prone position, abduct the upper limb and then make the incisions. Here we have two transverse incisions, one at the arm and the other at the wrist. Both of them continue with the anterior incisions. At the dorsum of hand, you should make a longitudinal incision in the midline and a curve incision along all the metacarpophalangeal joints.