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OCCIPITAL
Supraclavicular nerve
Spinal Accessory Nerve (XI)
Superior end of the sympathetic trunk
(Superior, Middle, Inferior cervical
sympathetic ganglion)
Cervical plexus
Semispinalis capitis muscle
Levator scapula muscle
Scalenus posterior muscle
Scalenus medius muscle
rd
Insertion
Innervation
Splenius capitis
Ligamentum nuchae
Upper 4 thoracic spines
Levator Scapula
Posterior
2 rib
Medius
Anterior
Scalenus
nd
st
1 rib
C4-C6
Action
Bends neck laterally
Elevates medial border of the
scapula
Raises medial border of scapula
Bends neck laterally
nd
Elevates 2 rib, laterally flexes
and rotates cervical part of
vertebral column
Elevates 1st rib, laterally flexes
and rotates cervical part of
vertebral column
3.
Key muscle in understanding the root of the neck and its relation to many neurovascular structures identified in the posterior triangle
Important relations:
Anteriorly related to carotid arteries, vagus nerve, IJV, and deep cervical lymph nodes
nd
Posteriorly related to the pleura, origin of the brachial plexus, and 2 part of the subclavian artery
Medially related to the vertebral artery and vein, sympathetic trunk, and thoracic duct (on the left side)
rd
Laterally - related to the emerging branches of the cervical plexus, roots of the brachial plexus, and the 3 part of the subclavian artery
Divides the subclavian artery into 3 parts
Fibers
1.
2.
Course
3.
4.
Areas of distribution
Phrenic Nerve
Motor, Sensory
Motor
CRANIAL ROOT
1. Emerges from anterior surface of the medulla oblongata
2. Nerve runs laterally in the posterior cranial fossa and joins the spinal root
SPINAL ROOT
1. Emerges from nerve cells in the anterior gray horn of the upper 5 segments of the cervical part of
the spinal cord
2. Nerve ascends alongside the spinal cord and enters the skull through the foramen magnum
turns lateral to join cranial root
rd
th
Cranial and Spinal root leave the skull through the jugular foramen and eventually separate:
Cranial root joins vagus nerve; distributed to soft palate, pharynx, and larynx muscles
Spinal root runs downward and laterally and enters SCM and over to the trapezius
Soft palate, pharynx, larynx, sternocleidomastoid, trapezius muscles
Subclavian arteries
Origin
Commencement
Course
Termination
Left Subclavian
Right Subclavian
Arch of the aorta
Brachiocephalic artery
Behind manubrium sterni
Behind right sternoclavicular joint
Ascends to the root of the neck
Arches upward and laterally over the pleura between the scalenus
anterior and medius muscles
st
Outer border of the 1 rib
Vertebral artery
Basilar artery
Posterior
cerebral artery
1st
Thyrocervical
trunk
Superficial cervical
artery
Suprascapular artery
Internal thoracic
artery
Subclavian artery
Superior epigastric
artery
Musculophrenic artery
2nd
Costocervical
trunk
Superior intercostal
artery
Deep cervical artery
3rd
Vertebral artery - ascends in the neck through foramina in the transverse processes of the
upper 6 cervical vertebrae ,ascends into the skull through the foramen magnum;
Forms the basilar artery at the anterior surface of the medulla oblongata at the level of the
lower border of the pons
Basilar artery - gives branches to the pons, cerebellum, and internal ear; contributes
to the formation of the Circle of Willis
Posterior cerebral artery - curves laterally and backward around the midbrain
Thyrocervical trunk
Inferior thyroid artery - closely related to recurrent laryngeal nerve; gives branches
to thyroid and inferior parathyroid glands
Superficial cervical artery - crosses the brachial plexus
Suprascapular artery - follows the suprascapular nerve onto the back of the scapula
st
Internal thoracic artery descends into the thorax behind the 1 costal cartilage and in front
of the pleura
Superior epigastric artery - supplies anterior abdomen
th th
Musculophrenic artery - supplies 7 -9 intercostal spaces and diaphragm
Subclavian Vein
st
Lymph Drainage
CERVICAL PLEXUS
st
C2, 3
Supraclavicular nerve
C3, 4
Distribution
Back of the scalp and
auricle
Skin over the angle of the
mandible
Skin over the front of the
neck
Extends upward to the base of the skull below the neck of the 1 rib
Directly behind the internal and common carotid arteries, embedded in deep fascia
Superior: 2 rib
th
Inferior: 6 rib
Medial: Lateral margin of the sternum
Anterior: Skin
Posterior: Deep pectoral fascia
th
Nipples (at level of 4 intercostal space) are small and surrounded by a colored area of
the skin areola
Areolar glands produces tiny tubercles in the areola
Darkening of areola increased deposits of melanin in the epidermis
Axillary tail of Spence
Extension upward and laterally piercing the deep fascia at lower border of
pectoralis major
Enters the axilla
Each breast consist of 15-20 lobes radiate out from the nipple
Main duct of each lobe opens separately on the summit of the nipple each
possess a dilated ampulla (before termination)
Lobes are separated by fibrous septa serves as
suspensory ligaments of Cooper
Retromammary space - space behind the breast filled by loose connective tissue
Perforating branches of internal thoracic artery,
intercostal arteries
Axillary artery via
Lateral
lateral thoracic and thoracoacromial arteries
(correspond to arteries)
Medial
Into the internal thoracic group of nodes
Lateral
Into the anterior axillary or pectoral group of nodes
Posterior Into the posterior intercostal nodes
th th
4 -6 intercostal nerves
Medial
Arterial supply
Venous supply
Lymph
drainage
Innervation
Insertion
Pectoralis major
Clavicle
Sternum
Upper 6 costal cartilages
Pectoralis minor
3 , 4 , and 5 ribs
Subclavius
1 costal cartilage
Clavicle
Serratus anterior
Upper 8 ribs
rd
th
st
th
Innervation
Medial and lateral pectoral
nerves from brachial
plexus
Medial pectoral nerve
from brachial plexus
Nerve to subclavius from
upper trunk of brachial
plexus
Long thoracic nerve
Nerve Roots
C5, 6, 7, 8, T1
C6, 7, 8
C5, 6
C5, 6, 7
Action
Adducts arm and rotates it medially
Clavicular fibers also flex arm
Depresses point of shoulder
if fixed scapula elevates ribs of origin
Depresses clavicle and steadies this
bone during movements of the
shoulder girdle
Draws the forward anterior around the
thoracic wall
Rotates the scapula
The Axilla
Axilla (armpit)
Pyramid-shaped space between the upper part of the arm and side of the
chest
Forms an important passage for nerves, blood, and lymph vessels as they
travel from root of the neck to the upper limb
BRACHIAL PLEXUS
Complicated plexus allowing nerve fibers from different segments of the spinal cord to be arranged and distributed
efficiently in nerve trunks to the various parts of the upper limbs
th
th
st
Formed in the posterior triangle of the neck union of anterior rami of the 5 to 8 cervical and 1 thoracic spinal nerves
Important functions:
1. Sensory innervation to the skin and deep structures
2. Motor innervation to the muscles
3. Influence over the diameters of the blood vessels by the sympathetic vasomotor nerves
4. Sympathetic secretomotor supply to the sweat glands
Divided into roots, trunks, divisions, and cords
Roots, trunks, divisions reside in lower part of posterior triangle of the neck
Cords and its branches arranged around the axillary artery in the axilla; enclosed in axillary sheath
Lateral cord Upper (C5, 6) + middle (C7)
Posterior cord Upper (C5, 6) + middle (C7) + lower (C8, T1)
Medial cord Lower (C8, T1)
Roots
C5
C5, 6, 7
C5, 6
C5, 6, 7
C5,6
C6, 7, 8
C5, 6, 7,
8, T1
C8, T1
Distribution
Rhomboid minor, Rhomboid major,
Levator scapulae muscles
Serratus anterior
Supraspinatus and infraspinatus
Subclavius
*Gives contribution to phrenic nerve
Pectoralis major
Coracobrachialis, biceps brachii, brachialis
Subscapularis
Subscapularis and teres major
Deltoid and teres mainor
Latissimus dorsi
Triceps, anconeus, part of brachialis,
forearm and hand and finger muscles
Pectoralis major and minor
Skin of medial side of arm
Skin of medial side of forearm
Hand and finger muscles
C5, 6, 7
C5, 6, 7,
8, T1
Axillary artery
st
1 part
Branch
Highest thoracic
artery
Thoracoacromial
artery
nd
2 part
Lateral thoracic
artery
Subscapular artery
rd
3 part
Anterior circumflex
humeral artery
Posterior circumflex
humeral artery
Relation
Anterior: Pectoralis major and skin
Posterior: Long thoracic nerve
Lateral: 3 cords of the brachial plexus
Medial: axillary vein
Anterior: Pectoralis minor, pectoralis major and the
skin
Posterior: Posterior cord of the brachial plexus,
subscapularis, shoulder joint
Lateral: Lateral cord of the brachial plexus
Medial: Medial cord of the brachial plexus and
axillary vein
Anterior: Pectoralis major, crossed by medial root
of median nerve
Posterior: Subscapularis, latissimus dorsi, teres
major, axillary and radial nerves
Lateral: Coracobrachialis, biceps, humerus, lateral
root of median and musculocutaneous nerve
Medial: Ulnar nerve, axillary vein, medial
cutaneous nerve of the arm
AXILLARY VEIN
Commencement: Lower border of the teres major
st
Termination: Lateral border of the 1 rib
Drains into subclavian vein
Formed from union of:
venae comitantes of the brachial artery and basilic vein
Vein receives tributaries corresponding to branches of the axillary artery
Cephalic vein
Termination
Drainage
Axillary vein
Commencement
Basilic vein
Medial border of the wrist
Lower border of teres major
Joins venae comitantes of brachial artery
into the axillary vein
Medial cubital vein and Median vein of the forearm - Communicating veins (links cephalic and basilica veins)
Insertion
Innervation
Nerve Roots
Action
ANTERIOR COMPARTMENT
Biceps
brachii
Long head
Short head
Coracobrachialis
Brachialis
Supraglenoid tubercle of
scapula
Coracoid process of
scapula
Front of lower half of
humerus
POSTERIOR COMPARTMENT
Long head
Infraglenoid tubercle of
scapula
Lateral head
Upper half of posterior
Triceps
surface of humerus shaft
Medial head
Lower half of posterior
surface of humerus shaft
Lateral epicondyle of the
Anconeus
humerus
Tuberosity of radius
bicipital aponeurosis
Medial shaft of humerus
C5, 6
Musculocutaneous nerve
C5, 6, 7
C5, 6
Supinator of forearm
flexor of elbow
Weak flexor of shoulder joint
Flexes arm, weak adductor
Flexor of elbow joint
Radial nerve
C6, 7, 8
Median Nerve
Ulnar Nerve
Radial Nerve
Radial Nerve
Ulnar Nerve
Branches
In axilla -Posterior cutaneous nerve of the arm; branches given to
the long and medial heads of triceps
In spiral groove branches given lateral and medial heads of
triceps and anconeus
Lower lateral cutaneous nerve of the arm
Posterior cutaneous nerve of the forearm
In anterior compartment of the arm gives branches to brachialis,
brachioradialis, extensor carpo radialis longus muscles
Articular branches to elbow joint
Descends behind the septum, covered posteriorly by the medial head
Accompanied by superior ulnar collateral vessels
At elbow lies behind medial epicondyle of the humerus on the medial
ligament of the elbow joint
Enters the forearm between 2 heads of origin of flexor carpi ulnaris
No articular branch to elbow joint
Origin: Brachial artery
Accompanies radial nerve through the spiral groove
Supplies triceps muscle, takes part in anastomosis around elbow joint
Origin: brachial artery
Take part in anastomosis around elbow joint
Cubital Fossa
Triangle depression in front of the elbow
Roof: skin and fascia reinforced by the bicipital aponeurosis
Floor: Brachialis
Base of the triangle: Imaginary line between the humeral
Lateral: brachioradialis
Medial: Pronator teres
Contents (medial to lateral):
Median nerve
Bifurcation of the brachial artery
Tendon of the biceps
Radial nerve and its deep branch
ELBOW JOINT
Articulation: between trochlea and capitulum of the humerus and the trochlear notch of the ulna and head of the radius
articular surfaces covered with hyaline cartilage
Type: Synovial hinge joint
Capsule: Anterior: attached above to the humerus along upper margins of coronoid and radial fossae
to the front of the medial and lateral epicondyles and below to the margin of the coronoid process of the ulna and to the annular ligament
Posterior: attached above to margins of olecranon fossa of the humerus and below to the upper margin and sides of the olecranon process
Ligaments: Lateral ligament triangular; attached by its apex to lateral epicondyle of humerus
Medial ligament triangile; with 3 strong bands: anterior band, posterior band, transverse band
Synovial membrane : lines the capsule and covers fatty pads in the floors of the coronoid, radial, and olecranon fossae
Nerve supply: Branches from median, ulnar, musculocutaneous, and radial nerves
oblique muscle
Medially, splits into 3 lamellae
1. Posterior lamella covers deep muscles of the back;
attached to lumbar spines
2. Middle lamella attached to tips of transverse processes of the lumbar
vertebrae; lies anterior to deep muscles of the back and posterior to
the quadratus lumborum
3. Anterior lamella attached to anterior surface of the transverse
process of the lumbar vertebrae; anterior to quadratus lumborum
Erector spinae
Spinalis
Longissimus
Iliocostalis
Transversospinalis
Rotatores
Multifidus
Semispinalis
Interspinales
Intertrasnversarii
Deltoid
Supraspinatus
Infraspinatus
Teres major
Teres minor
Subscapularis
Insertion
Innervation
Nerve Roots
Action
SUPERFICIAL MUSCLES
Trapezius
Latissimus dorsi
Occipital bone
Ligamentum nuchae
th
Spine of 7 cervical vertebra
Spines of all thoracic vertebra
Iliac crest
Lumbar fascia
Spines of lower 6 thoracic
vertebrae
Lower 3-4 ribs
Inferior angle of the scapula
Spinal part of
accessory nerve
(motor)
C3, C4 (sensory)
XI cranial nerve
(spinal part)
Thoracodorsal nerve
C6, 7, 8
C3 and C4
Dorsal scapular nerve
C3, 4, 5
C4, 5
INTERMEDIATE MUSCLES
st
Levator Scapula
Rhomboid Minor
Rhomboid major
Serratus Posterior
Superior
Serratus Posterior
Inferior
DEEP MUSCLES
Splenius capitis
Splenius cervicis
Upper ribs
Intercostal Nerves
Lower ribs
Supraspinatus
Infraspinatus
Teres minor
Teres major
Subscapularis
Insertion
Middle lateral surface of shaft
of humerus
Innervation
Axillary nerve
Suprascapular nerve
Axillary nerve
Lower subscapular
nerve
Upper and lower
subscapular nerves
Nerve Roots
C5, 6
C4,5, 6
(C4), 5, 6
C6, 7
C5, 6, 7
Action
Abducts the arm
Anterior fibers: flex and
medially rotate arm
Posterior fibers: extend
and laterally rotate arm
Abducts arm and stabilizes
shoulder joint
Laterally rotates arm and
stabilizes shoulder joint
Medially rotates arm
Adducts arm
Stabilizes shoulder joint
Triangle of Auscultation
Site on the back where breath sounds may be most easily heard with a microscope
Inferior: Superior border of the latissimus dorsi
Medial: Inferior fibers of the trapezius
Lateral: Medial border of the scapula
Lumbar Triangle
Site where pus may emerge from the abdominal wall (pus accumulation may
occur)
Inferior: Iliac crest
Medial: Inferior border of latissimus dorsi
Lateral: posterior border of the external oblique of the abdomen
Suboccipital Triangle
Medial: Rectus capitis posterior major
Lateral: Oblique capitis superior
Oblique capitis inferior
Triangular space
Superior: Teres minor
Inferior: Teres major
Lateral: Long head of triceps brachii
Contains circumflex scapular artery
Quadrangular space
Superior: Subscapularis
Inferior: Teres major
Medial: Long head of triceps brachii
Lateral: surgical neck of humerus
Contains Axillary nerve and Posterior circumflex humeral artery
Anastomosis between the branches of the subclavian artery and axillary artery
Ensures adequate blood flow in upper limb irrespective of arm positioning
SHOULDER JOINT
Articulation: between rounded head of the humerus and shallow, pear-shaped glenoid cavity of the scapula
articular surfaces covered by hyaline cartilage; glenoid cavity deepened by glenoid labrum (fibrocartilaginous rim)
Type: Synovial ball-and-socket joint
Capsule: surrounds the joint and attached medially to the margin of the glenoid cavity outside the labrum
Thin and lax allows movement; strengthened by fibrous slips from the tendons of the subscapularis, supraspinatus, infraspinatus, and teres minor
Ligaments: Glenohumeral ligaments 3 weak bands of fibrous tissue, strengthen front of the capsule
Transverse humeral ligament strengthens the capsule and bridges the gap between 2 tuberosities
Coracohumeral ligament strengthens capsule above and stretches from the root of the coracoid process to the greater tuberosity of the humerus
Synovial membrane : lines the capsule and attached to margins of the cartilage covering the articular surfaces
extends through anterior wall of the capsule forms subscapularis bursa beneath subscapularis
Nerve supply: Axillar and suprascapular nerves
TOPOGRAPHIC ANATOMY