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AXILLA & UPPER LIMB. Kaan Yücel M.D, Ph.D . 31. March . 2014 Monday. AXILLA ( ARMPIT). 6. Gateway to the upper limb An area of transition between the neck and the arm. . BLOOD COMES ARTERIES BLOOD GOES VEINS MUSCLES,VESSELS, SWEAT GLANDS INNERVATED - PowerPoint PPT Presentation
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AXILLA & UPPER LIMB
Kaan Yücel M.D, Ph.D. 31. March. 2014 Monday
AXILLA (ARMPIT)
Gateway to the upper limb
An area of transition between the neck and the arm.
6
BLOOD COMESARTERIESBLOOD GOESVEINSMUSCLES,VESSELS, SWEAT GLANDS INNERVATEDNERVES
Contents of the axillaAxillary artery and its branchesAxillary vein and its tributariesLymph vessels and lymph nodesBrachial plexus
These structures are embedded in fat.
Axillary arterySupplies the walls of the axilla & related regions.
Before: Subclavian artery After: Brachial arteryFrom lateral border of 1st rib
to Inferior border of teres major
a somatic nerve plexus - upper limbformed by intercommunications among ventral rami of
lower 4 cervical nerves ( C 5 - C 8) & T 1responsible for motor innervation to all of muscles of upper limb exception trapezius.
BRACHIAL PLEXUS
supplies all of the cutaneous innervation
of the upper limb exception area of the axilla (armpit)
(intercostobrachial nerve)
an area just above the point of shoulder (supraclavicular nerves)
dorsal scapular area (cutaneous branches of dorsal rami)
BRACHIAL PLEXUS
communicates with the sympathetic nervous system..
begins in the neck and extends into the axilla.
Almost all branches of the brachial plexus arise in the axilla (after the plexus has crossed the 1st rib). "Randy Travis Drinks Cold Beer"RootsTrunksDivisionsCords
Branches· Alternatively: "Read The Damn Cadaver Book!"· Alternatively: "Real Texans Drink Coors Beer".
The parts of the brachial plexus, from medial to lateral, are roots, trunks, divisions, and cords.
All major nerves that innervate the upper limb originate from the brachial plexus, mostly from the cords.
C5
C6
C7
C8
T1
Superior trunk
Inferior trunk
Middle trunkLateral cord
Posterior cord
Medial cord
Lateral pectoral nerveMusculocutaneous nerveLateral root of median nerve
Sup. & Inf. Subscapular nervesThoracodorsal nerveAxillary nerveRadial nerve
Medial pectoral nerveMedial cutaneous nerve of armMedial cutanoues nerve of forearmUlnar nerveMedian nerve
Suprascapular nerveThe nerve to subclavius muscle
Dorsal scapular nerveLongThoracİcnerve
Red: Anterior divisionBlue: Posterior division "Randy Travis Drinks Cold Beer"Roots
TrunksDivisionsCords
Branches· Alternatively: "Read The Damn Cadaver Book!"· Alternatively: "Real Texans Drink Coors Beer".
Region of upper limb attachment to the trunk Proximal segment of limb overlaps parts of the trunk (thorax and back) and lower lateral neck.
includes Pectoral ScapularDeltoid regions of the upper limblateral part (greater supraclavicular fossa) of lateral cervical region. Overlies half of the pectoral girdle.
SHOULDER
The pectoral (shoulder) girdle formed by:Scapulae and clavicles completed anteriorly by the manubrium of the sternum (part of the axial skeleton).
SUPERFICIAL POSTERIOR AXIOAPPENDICULAR MUSCLES
EXTRINSIC SHOULDER MUSCLESTrapezius & latissimus dorsi
DEEP POSTERIOR AXIOAPPENDICULAR MUSCLESEXTRINSIC SHOULDER MUSCLESLevator scapulae & rhomboids
SCAPULOHUMERAL (INSTRINSIC SHOULDER) MUSCLES
6 scapulohumeral muscles Deltoid, teres major, supraspinatus, infraspinatus, subscapularis, and teres minorpass from scapula to humerus Act on the glenohumeral joint.
All the intrinsic muscles but the deltoid and the subscapularis are muscles of the posterior scapular
region.
4 musclespass between the scapula and proximal end of humerus:SupraspinatusInfraspinatusTeres minorTeres major
POSTERIOR SCAPULAR REGION
+ part of long head of the triceps brachii, passes between the scapula and the proximal end of the forearm.
Originate from 2 large fossae, 1 above and 1 below the spine, on the posterior surface of the scapula.
Supraspinatus initiates abduction of the arm. Infraspinatus laterally rotates the humerus.
Supraspinatus & Infraspinatus
A cord-like muscle
Laterally rotates the humerus
Component of the rotator cuff.
Teres minor
4 intrinsic shoulder muscles1) Supraspinatus2) Infraspinatus3) Teres minor4) Subscapularis
ROTATOR CUFF MUSCLES
(SITS muscles)
Form a musculotendinous rotator cuff around the glenohumeral joint.
ROTATOR CUFF MUSCLESFunctional exception:
All except supraspinatus are rotators of the humerus
Supraspinatus, besides being part of the rotator cuff, initiates and assists the deltoid in the first 15° of abduction of the arm.
The two major nerves of the posterior scapular region: Suprascapular & Axillary nerves
originate from the brachial plexus in the axilla.
Nerves
medial & lateral intermuscular septaAnterior compartment – flex the elbow jointPosterior compartment- extend the elbow joint
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ARM FlexionExtensionPronationSupination
Anterior compartment of the arm coracobrachialis, brachialis, and biceps brachii musclesinnervated predominantly by musculocutaneous nerve.
Posterior compartmenttriceps brachii muscle innervated by radial nerve.
24
Deep artery of the arm (L. arteria profunda brachii)
Largest branch & most superior origin
Accompanies radial nerve along the radial groove
Terminates by dividing into middle & radial collateral arteries
25
Brachial artery
2 main superficial veins of the armcephalic and basilic veins.
Cephalic vein – lateral sideinto axillary vein
Basilic vein- medial sideBasilic vein+ Brachial veins
Axillary vein
26
4 main nerves pass through the arm: Median Ulnar Musculocutaneous Radial
27
1. Which structures pass between the arm & forearm?
Most major structures (nerves,veins,arteries)via cubital fossa, anterior to elbow joint Exception ulnar nerveposterior to the medial epicondyle of humerus
2. How is forearm divided?
pronation
supination
3. Movements of the forearm muscles?
Muscles in the anterior compartment Flex the wrist & digits Pronate the handMuscles in the posterior compartment Extend the wrist & digitsSupinate the hand
31
Muscles of the anterior compartment Mainly by median nerveThe one and a half exceptions by ulnar nerve Muscles of the posterior compartment All by radial nerve (directly or by its deep branch)
Watch out, Median nerve @median plane of the forearmUlnar nerve @ medial side
4. Innervation of the forearm muscles?
1. Layers of anterior compartment forearm muscles?Superficial Intermediate Deep
4 muscles 3 muscles
2. Muscles of the superficial layer?
1. flexor carpi radialis2. flexor carpi ulnaris3. palmaris longus4. pronator teres
two headsUlnar headHumeral head
Medial epicondyle
2. Muscles of the superficial layer?
1. flexor carpi radialis
Medial epicondyle of humerus Base of metacarpals II & III
2. flexor carpi ulnarisHumeral head: Medial epicondyle of humerusUlnar head: Olecranon & Posterior border of ulna•Pisiform & hamate •5th metacarpal3. palmaris longusMedial epicondyle of humerus Flexor retinaculum & palmar aponeurosis
4. pronator teresHumeral head: Medial epicondyle & adjacent supraepicondylar ridgeUlnar head: Coronoid processLateral surface of radius
35
3. ..the muscles of the intermediate and deep layers?
flexor digitorum superficialis
3. Muscles of the intermediate layer?
Humeroulnar head• Medial epicondyle of humerus • Adjacent margin of coronoid processRadial headSuperior half of anterior border
Shafts of middle phalanges of
medial four digits
3. ..the muscles of the intermediate and deep layers?flexor digitorum profundus
flexor pollicis longus
pronator quadratus
4. Muscles of the deep layer?
•Proximal ¾ of medial & anterior surfaces of ulna
•Interosseous membrane
Bases of distal phalanges of 4th & 5th digitsBases of distal phalanges of 2nd & 3rd digits
• Anterior surface of radius• Adjacent interosseous
membrane
Base of distal phalanx of thumb
Distal ¼ of anterior surface of ulna
Distal ¼ of anterior surface of radius
5. Fxns of the anterior compartment muscles
Flexion of forearm @ the elbow jointPronator teresFlexion of hand @ the wrist jointFlexor carpi radialis et ulnaris- Palmaris longus
Abduction (radial deviation) of hand @ the wrist jointFlexor carpi radialis
Adduction (ulnar deviation) of hand @ the wrist jointFlexor carpi ulnaris
Pronation of forearmPronator teres – Pronator quadratus
5. Fxns of the anterior compartment muscles
Flexor digitorum superficialis
Flexor digitorum profundus Flexes distal phalanges 4 & 5 at distal interphalangeal joints
Flexes distal phalanges 2 and 3 at distal interphalangeal joints
Flexes proximal interphalangeal joints of the index, middle, ring, & little fingers Flexes metacarpophalangeal joints of the same fingers and the wrist joint
Flexor pollicis longusFlexes phalanges of thumb
6. Innervation of the anterior compartment muscles
All the muscles by median nerve
Except 1.5 muscles by ulnar nerveFlexor carpi ulnaris full
Flexor digitorum profundus medial half part associated w/ring & little fingers
7. Arteries in the anterior compartment of the forearm
Brachial artery
8. Veins in the anterior compartment of the forearm
deep venous palmar arch in
the hand
9. Median nerve
principal nerveno branches in the arm other than small twigs to the brachial artery. Its major branch in the forearm anterior interosseous nerve
Leaves cubital fossa by passing between 2 heads of pronator teres &humero-ulnar &radial heads of flexor digitorum superficialis
10. Ulnar nerve
Enters the anterior compartment by passing posteriorlyaround medial epicondyle of humerus &between humeral & ulnar heads of flexor carpi ulnaris muscle
Two small cutaneous branches palmar branch & dorsal branch
11. Radial nerve
motor and sensory functions in both arm & forearm but only sensory functions in the hand
Superficial (sensory)deep to brachioradialis
Deep (motor)between two heads of supinator
12. Lateral & medial cutaneous nerves of forearm
Lateral cutaneous nerve of forearmContinuation of musculocutaneous nerve
Medial cutaneous nerve of forearmBranch of medial cord of brachial plexus
Posterior cutaneous nerve of forearmBranch of radial nerve
46
An important area of transition between the arm and the forearm. seen superficially as a depression on the anterior aspect of the elbow.
Deeply, it is a space filled with a variable amount of fat anterior to the most distal part of the humerus and the elbow joint.
1. What is the cubital fossa?
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Superiorly imaginary line connecting medial &lateral epicondyles.Medially pronator teres.Laterally brachioradialis.
2. What are the boundaries of the cubital fossa?
48
1) Terminal part of the brachial artery,radial and ulnar arteries 2) Biceps brachii tendon
3) Median nerve
4) Radial nerve
5) (Deep) accompanying veins of the arteries
3. What are the contents of the cubital fossa?
49
1. Which muscles are in the superficial layer?
Common origin lateral epicondyle of the humerus Except for the brachioradialis and anconeus, extend as tendons into the hand.
Brachioradialis
Extensor carpi radialis longusExtensor carpi radialis brevisExtensor carpi ulnarisExtensor digitorum
Extensor digiti minimi
Base of 2nd metacarpal
Base of 3rd metacarpalBase of 5th metacarpal
Anconeus
Proximal part of supraepicondylar ridge of humerus
Lateral surface of distal end of radius proximal to styloid process
Distal part of supraepicondylar ridge of humerus
Base of 2nd metacarpal
Lateral epicondyle of humerus common extensor origin
Base of 3rd metacarpals
Lateral epicondyle of humerus common extensor origin
Base of the 5th metacarpal
Lateral epicondyle of humerus
dorsal aspects of the bases of the middle and distal phalanges of the medial four digits
Lateral epicondyle of humerus
Extensor expansion (hood) of the 5th digit
Lateral epicondyle of humerus
Olecranon and proximal posterior surface of ulna
50
2. Which muscles are in the deep layer?
Except for the supinator muscle, all these deep layer muscles originate from the posterior surfaces of the radius, ulna, and interosseous membrane and pass into the thumb and fingers.
Supinator
Abductor pollicis longus
Extensor pollicis brevisExtensor pollicis longus
Extensor indicis
Superficial (humeroulnar) head•lateral epicondyle of humerus•radial collateral and anular ligaments Deep (ulnar) head Supinator crest of the ulna
Lateral surface of radius superior to the anterior oblique line
Posterior surface of proximal halves of ulna, radius, and interosseous membrane
Base of 1st metacarpal
Posterior surface of middle third of ulna and interosseous membraneDorsal surface of base of distal phalanx of thumb
Posterior surface of distal third of radius and interosseous membraneDorsal surface of base of proximal phalanx of the thumb
Posterior surface of distal 1/3 of ulna and interosseous membrane
Extensor expansion (hood) of 2nd digit
51
What is palmar aponeurosis?A triangular condensation of deep fascia that covers the palm and is anchored to the skin in distal regions.
Continuous with the palmaris longus tendon, when present; otherwise, anchored to the flexor retinaculum.
52
functions the intrinsic muscles of the hand?
Palmar interosseiadduct the thumb, index, ring, and little fingers with respect to a long axis through the middle finger
Dorsal interosseimajor abductors of the index, middle, and ring fingers, at the metacarpophalangeal joints
53
functions the intrinsic muscles of the hand?
Lumbricals
flexing metacarpophalangeal joints
extending interphalangeal joints
medial two deep branch of the ulnar nerve lateral two median nerve
54
functions the intrinsic muscles of the hand?
Palmaris brevis
deepens cup of the palm by pulling on skin over the hypothenar eminence forming a distinct ridge.
This may improve grip.
55
How are the intrinsic muscles innervated?All of the intrinsic muscles of the hand by deep branch of the ulnar nerve
Exceptthree thenar & two lateral lumbrical musclesby median nerve
56
arteries of the hand?
Superficial palmar archDeep palmar arch
princeps pollicis artery
radialis indicis artery
• three palmar metacarpal arteries •three perforating branches
palmar digital artery
common palmar digital arteries
57
Before penetrating the back of the hand, the radial artery gives rise to two vessels:
dorsal carpal branch passes medially as the dorsal carpal arch, across the wrist dorsal metacarpal arteriesdorsal digital arteries
first dorsal metacarpal artery supplies adjacent sides of the index finger and thumb.
58
veins of the hand?Cephalic vein originates from lateral side of dorsal venous network. Basilic vein originates from medial side of dorsal venous network.
59
sensory innervation of the hand?
Ulnar nerve medial side of the palm, medial half of the dorsum of the hand, 5th finger, medial half of the 4th finger, anterior surfaces of medial ½ digitsMedian nerve palmar surfaces of the lateral 3 ½ digits and cutaneous regions over the dorsal aspects of the distal phalanges (nail beds) of the same digitsRadial nerve dorsolateral aspect of the palm, dorsal aspects of the lateral three,one-half digits distally to approximately the terminal interphalangeal joints
60
carpal tunnel?base of the carpal arch
formed medially by pisiform & hook of hamate
laterally by tubercles of scaphoid & trapezium
SLTP
TTCH