Human Anatomy 1 Note

By Monica Hsu
Last updated, 2011 Axilla and Shoulder Joint -------------------------------------p 2 I. Bones II. Axilla III. Mammary Gland IV. Shoulder Joint (Glenohumeral Joint) V. Movements at the Shoulder Joint Arm, Forearm, and Hand: I ----------------------------------- p 5 I. Bones II. Fascia III. Joints IV. Muscles of the Forearm (Antebrachium) V. Vessels of the Upper Extremity VI. The Wrist Region VII. Cubital Fossa Arm, Forearm, and Hand II: Hand (Manus) ------------- p 8 I. Bones II. Arrangement of Structures in the Palm III. Muscles of the Palm IV. Arrangement of Structures in the Dorsum of the Hand V. Vessels of the Hand The Thorax and Lungs (Respiratory Apparatus) ----- p 9 I. Thorax II. The Bony Thorax III. Joints of the Thoracic Wall IV. Vertebrae V. Muscles of the Thoracic Wall VI. Vasculature of the Thoracic Wall VII. Nerves of the Thoracic Wall

Axilla and Shoulder Joint

The upper limb is divided into Shoulder: scapular region and a pectoral region (which includes the mammary gland) the anatomical space inferior to the shoulder joint is the axilla Arm (brachium) Forearm (antebrachium) Wrist and hand (manus)

Medial epicondyle Ulnar nerve: medial epicondyle = funny bone when ulnar nerve is injured Distal end of the humerus Median nerve runs along distal end of the humerus Joints formed by the humerus Glenohumeral joint (shoulder joint): superior to fascia of axilla Elbow joint

I. Bones
Pectoral Girdle Clavicle S shape Medial to clavicle: sternum Lateral to clavicle: acromium Connects the upper limb to the trunk Transmits shocks (traumatic impact) from upper limb into axial skeleton Provides protection for neurovascular bundles (axillary nerve, arteries, veins, lymphatic vessels) Permits more mobility of upper limb Joints formed by the clavicle Sternoclavicular joint: saddle type of synovial joint Acts like ball and socket joint Movement: rotation, circumduction Synovial membrane, capsule, fluid Extrinsic ligaments - Interclavicular ligament: between clavicles on anterior side of manubrium - Costoclavicular ligament: 1st rib up to clavicle prevents hyperelevation of pectoral girdle - Anterior and posterior sternoclavicular ligaments: thickening of joint capsule on the front and back It is uncommon for the clavicle to dislocate at this joint Acromioclavicular joint: plane type of synovial joint Movement: rotation Direct blow can dislocate joint Acromioclavicular ligament Coracoclavicular ligament (2 parts): from coracoid process to clavicle Scapula (shoulder blade) Location: overlaps ribs 2-7 Connects the clavicle to the humerus Point of shoulder: acromion, highest point Root of scapular spine: T3 (T3-T4) Humerus Bone of both the shoulder and arm Anatomical neck: separates head and tubercles Surgical neck: inferior to tubercles Site of anterior and posterior humeral circumflex arteries, axillary nerve Fractures of the surgical neck is common in elderly people with osteoporosis Radial groove: posterior aspect If the humerus is broken here, radial nerve and profunda brachii artery can be damaged

II. Axilla
Location: between the upper part of the arm and the side of the chest Shape: pyramidal Boundaries Base: skin, superficial fascia, axillary fascia Apex: a narrow triangular interval leading into the neck, through which the axillary vessels and brachial plexus proceed to the arm from the neck 4 walls Anterior wall: pectoralis major, pectoralis minor, subclavius muscles Posterior wall: subscapularis, teres major, latissimus dorsi muscles Medial wall: serratus anterior, intercostals muscles from ribs 1-4 Lateral wall: coracobrachialis, biceps brachii, upper end of humerus Contents Axillary artery and its branches Axillary vein Brachial plexus Axillary lymph nodes Axillary Artery and Its Branches Source: subclavian artery Termination: brachial artery Branches: pectoralis minor divides the axillary artery into 3 parts 1. Superior thoracic artery 2. Thoracoacromial artery Supplies the pectoral and deltoid regions 2. Lateral thoracic (external mammary) artery Supplies anterior and medial walls of axilla Supplies mammary gland 3. Subscapular artery Supplies posterior wall of axilla Branches Circumflex scapular a.: anastomosis of scapula Thoracodorsal a.: supplies latissimus dorsi 3. Anterior & posterior circumflex humeral arteries Anastomosis around head of the humerus Anastomosis around the scapula Axillary and subclavian arteries supply branches to anastomose around the scapula Axillary artery Posterior circumflex humeral artery Subscapular artery circumflex scapular artery Subclavian artery Suprascapular artery Dorsal scapular artery

By Monica Hsu

 Axillary Vein Source: basilic vein, brachial vein Receives venous tributaries which correspond to branches of the axillary artery, also receives cephalic vein Termination: subclavian vein Thoracoepigastric vein lateral thoracic vein axillary vein Forms a collateral pathway between tributaries of the inferior and superior venae cavae Enables venous return in the presence of obstruction of the inferior vena cava Brachial Plexus 5 Spinal roots: located in the neck Ventral primary rami of C5T1 3 Trunks: located in the neck Upper trunk: formed from C5 + C6 Middle trunk: formed from C7 Lower trunk: formed from C8 + T1 6 Divisions: located behind the clavicle 3 anterior divisions 3 posterior divisions 3 Cords: located in the axilla Lateral cord: formed from anterior divisions of upper and middle trunk Posterior cord: formed from 3 posterior divisions Medial cord: formed from anterior division of lower trunk 5 Terminal branches Lateral cord Musculocutaneous nerve Lateral root of median nerve Posterior cord Axillary nerve Radial nerve Medial cord Medial root of median nerve Ulnar nerve 4 Nerves arising from spinal roots Dorsal scapular nerve Long thoracic nerve: innervates serratus anterior Suprascapular nerve Subclavian nerve (nerve to subclavius) Nerves arising from the cords Lateral cord Lateral pectoral nerve Posterior cord Upper and lower subscapular nerves Thoracodorsal nerve: innervates latissimus dorsi Medial cord Medial pectoral nerve Medial cutaneous nerve of arm Medial cutaneous nerve of forearm Clinical Note Injuries to upper trunk or C5-6 roots of brachial plexus Motorcycle accident Waiters tip position: injury to upper trunk Limb hangs by the side in medial rotation Erb-Duchenne paralysis Birth type of paralysis due to excessive pulling or traction of the arm in delivery, resulting in stretching or tearing of the upper trunk Erbs point: where C5-6 unite to form the upper trunk and suprascapular and subclavian nerves arise Result in paralysis of muscles of the shoulder and arm supplied by C5-6 spinal nerves Adducted shoulder, medially rotated arm, extended elbow

Klumpkes paralysis Lower trunk (C8, T1) is affected: therefore ulnar nerve is affected Claw hand: short muscles of the hand are affected Cervical rib A rudimentary cervical rib (enlarged transverse process of C7 vertebra) may elevate the lower trunk (C8, T1), forcing its way between the nerve and the 1st rib, causing pressure symptoms Communication with phrenic nerve Subclavian nerve sometimes carries a large contribution (accessory phrenic root) to the phrenic nerve (arise from C3-4 and some C5): both innervate the diaphragm Phrenic crushing: may not immobilize the corresponding half of the diaphragm if have communication with C5 Axillary Lymph Nodes Pectoral group (anterior) Lie along the medial wall of axilla, edge of pectoralis major muscle Drain medial wall of axilla, most of mammary gland Subscapular group (posterior) Lie along the subscapular vessels Drain posterior wall of axilla Humeral group (lateral) Lie along the lower part of axillary vein Drain lateral wall of axilla, upper extremity Central group Lie near base of axilla in the fatty tissue Receive lymph from the above 3 groups Dont have to be enlarged to be palpated Apical group Lie at apex of axilla, upper border of pectoralis minor muscle, behind costocoracoid membrane Receive lymph from the above 4 groups, breast Efferent vessels from apical nodes unite to form the subclavian lymphatic trunk, which enters the right lymphatic duct or thoracic duct

III. Mammary Gland (p105-112)

A modified gland of cutaneous origin Location Lies in the superficial fascia Has no fibrous capsule or sheath Topography The breast extends vertically from the 2nd-6th ribs, and horizontally from the lateral border of the sternum to the mid-axillary line Has an axillary tail 2/3rd of the gland lies on the pectoralis major muscle and 1/3rd on the serratus anterior muscle A small portion of the lower quadrant of the breast lies on the aponeurosis of the external oblique muscle of the abdomen Structure The breast is made up of 15-20 lobules of glandular tissue (parenchyma of mammary gland), which radiate from the nipple into the surrounding fat Each lobule is drained by a lactiferous duct, which opens independently on the nipple The glandular tissue is connected with the overlying skin by the suspensory ligaments of Cooper (fibrous septa, retinacula cutis) By Monica Hsu

 Blood Supply Internal thoracic artery (internal mammary artery): main source of arterial supply through its perforating branches in the 2nd, 3rd, and 4th intercostal spaces Lateral thoracic artery (external mammary artery): supplies the lateral and caudal portions of the breast Thoracoacromial artery 2nd, 3rd, and 4th intercostal arteries Nerves of the breast 4th-6th intercostal nerves Lymph Drainage Cutaneous drainage: radiates from the circumareolar plexus of lymph vessels

Fixation of the breast to the underlying muscles Seen in advanced cancer when the cancer has invaded the deep fascia of pectoralis major muscle Normally, there is a bursa between the breast tissue and the deep fascia of pecotralis major muscle; but in cancer, the bursa is filled with cancer and the breast gland is fixed to the muscle

IV. Shoulder Joint (Glenohumeral Joint)

Joint Type: ball and socket type of synovial joint Articulating Parts Glenoid cavity of the scapula (shallow) Superior: to the medial nodes Head of humerus (large, round) Both are covered by articular cartilage Rotator Cuff Muscles Lateral: to the Medial: to the internal mammary Supraspinatus muscle Teres minor muscle pectoral (thoracic) nodes or parasternal Infraspinatus muscle Subscapularis muscle axillary nodes nodes and cutaneous lymphatics Hold head of humerus of the opposite breast All the rotator cuff muscles except the supraspinatus Inferior: to the cutaneous lymphatics of muscle are rotators of the humerus the upper abdominal wall and liver Inflammation can occur from repetitive use of these (subdiaphragmatic/phrenic lymph nodes) muscles by baseball players Parenchymal drainage Stability of the Joint Lymph passes from the skin of nipple, areola, and Most mobile of all joints unstable most the breast proper subareolar lymphatic plexus frequently dislocated (Sappey) pectoral axillary nodes Capsule The subareolar lymphatic plexus communicates A lax fibrous layer uniting the bony parts with the lymphatics of the deep fascia and Attached superiorly to the circumference of the constitutes the anatomical basis for the removal of glenoid cavity and below the anatomical neck of the a wide area in radical mastectomy humerus, except medially where it extends on the Clinical Note shaft for about 2 cm below the articular surface Prognosis in cancer of breast based on lymphatic drainage Capsular Ligaments 12 oclock Glenohumeral ligament Coracohumeral ligament ! Dangerous because Upper Upper Transverse humeral ligament: retains long head of Most favorable of its proximity to the inner outer beceps brachii muscle in the intertubercular sulcus mediastinum quadrant quadrant Glenoid labrum: fibrocartilage that deepens the 9 oclock 3 oclock glenoid cavity, affording a better receptive area for the head of humerus !! Most dangerous Lower Lower Synovial Membrane outer inner because of its proximity Less favorable quadrant quadrant Lines the inside of the capsular ligament to the peritoneal cavity Sends two extensions (2 holes of the capsule) Subscapular bursa 6 oclock Sheath for the long tendon of biceps brachii muscle Venous spread of cancer of breast Musculotendinous relations As the breast is drained by axillary, internal Anteriorly: **subscapularis muscle mammary and intercostals veins, cancer of the Superiorly: **supraspinatus muscle breast spreads frequently by venous channels to Posteriorly: **infraspinatus muscle, **teres minor muscle Lung via axillary and internal thoracic veins Superiorly & inferiorly: long head of biceps brachii muscle subclavian vein superior vena cava Other Relations heart lung Superiorly: coracoacromial arch protective structure Liver via the azygos system of veins Formed by coracoid process and acromion and Bones of axial skeleton via the intercostals the coracoacromial ligament connecting them veins which communicates with the vertebral Prevent superior dislocation of the shoulder joint venous plexus Anteriorly: axillary vessels, brachial plexus Anatomic basis of physical signs of cancer of breast Inferiorly: axillary nerve, posterior circumflex humeral vessels Lump WEAK area of the capsule (where dislocation occurs) Earliest sign of serious pathology in the breast Posteriorly and laterally: deltoid muscle Fixation or depression of overlying skin Blood Supply Due to the invasion of fibrous septa which Anterior and posterior circumflex humeral arteries extend from the skin to the lobules of the gland Branches of the suprascapular artery Cancer cells cause shortening of the septa, Innervation resulting in fixation or depression of skin Suprascapular and axillary nerves Fixation, retraction, or inversion of the nipple Due to neoplastic involvement of the By Monica Hsu lactiferous ducts (shortened or thickened)

 Bursae Associated with the Shoulder Joint Subscapular bursa Communicate with the articular (joint) cavity Subacromial (subdeltoid) bursa Facilitates movement of the supraspinatus tendon Does not communicate with the articular cavity (but with increase in age and use, a communication can be developed) Clinical Note Dislocation of glenohumeral joint Commonly dislocated due to its freedom of movement and instability Mostly in downward direction: clinically described as anterior or posterior dislocations Anterior dislocation: occurs most often in athletes caused by excessive extension and lateral rotation of the humerus Supraspinatus tendonitis Deposition of calcium in the supraspinatus tendon Causes increased local pressure that results in excruciating pain during abduction of the arm Subacromial bursitis The calcium deposit of the supraspinatus tendon may irritate the overlying subacromial bursa, producing an inflammatory reaction Pain occurs during abduction: supraspinatus tendon is in intimate contact with the inferior surface of the acromion

Arm, Forearm, and Hand: I

I. Bones
Humerus, radius, ulna, carpals, metacarpals, phalanges

II. Fascia
Superficial fascia: subcutaneous tissue contains fat Deep fascia: same continuous fascia throughout Pectoral fascia Antebrachial fascia Axillary fascia Extensor and flexor retinaculua Brachial fascia Palmar fascia

III. Joints
Elbow Joint (Cubital Joint) Type: hinge type of synovial joint Articulating parts Humeroulnar: trochlea of humerus, trochlear notch of ulna Humeroradial: capitulum of humerus, head of radius Fibrous capsule Thin/weak anteriorly and posteriorly: allow movements Complete all around the joint Encloses proximal radioulnar joint Intrinsic ligaments (thickening of fibrous capsule) of the elbow joint Radial (lateral) & ulnar (medial) collateral ligament: reinforce sides of fibrous capsule, radial collateral ligament fuses with annular ligament at head of radius Annular ligament: attached to ulna, encircle, support and allow movement of head of radius Synovial membrane Lines fibrous capsule Goes into fossae: protect annular ligament Sacciform recess: helps pronation and supination Bursae around the elbow joint Subcutaneous olecranon bursa: called students elbow if become inflamed Subtendinous olecranon bursa: deep to tendon of triceps brachii muscle Intratendinous olecranon bursa: between tendon of triceps brachii muscle, not always present Radioulnar bursa: called tennis elbow when become inflamed between extensor digitorum tendon, humeroradial articulation, and supinator muscle Bicipital bursa (bicipitoradial bursa): between biceps brachii tendon and radial tuberosity bicipital bursitis results in pain when the forearm is pronated (biceps brachii muscle supinates forearm) Fat pads: present in radial, coronoid and olecranon fossae Movements: flexion, extension Stability: very stable structure, complete fibrous capsule Clinical note: late fusion of epiphysis of radius and ulnar in children children can easily dislocate radius, ulnar, and even the humerus Blood supply Anastomosis around the elbow joint: branches of brachial and profunda brachii arteries anastomose with recurrent branches from forearm arteries Importance of anastomosis: form collateral circulation that serves as extra blood routes to distal parts of the limb to insure an adequate blood supply distally when there is acute angulation at the joint, also serves as alternate routes to supply blood distally if the main channel is cut or blocked

V. Movements at the Shoulder Joint

Humeral Movements
Movement Flexion Extension Abduction Adduction Medial rotation Lateral rotation Movement Prime movers Pectoralis major (clavicular head), deltoid (anterior part) Deltoid (posterior part) Deltoid (middle part) Pectoralis major, latissimus dorsi Subscapularis Infraspinatus Synergists Coracobrachialis (assisted by biceps) Teres major Supraspinatus Subscapularis, infraspinatus, teres minor Pectoralis major, deltoid (anterior part), latissimus dorsi Teres minor, deltoid (posterior part)

Scapular Movements
Muscles Producing Movement Trapezius (superior part), Elevation levator scapulae, rhomboids Pectoralis major and minor, latissimus dorsi, Depression trapezius (interior part), serratus anterior (inferior part) Protraction Serratus anterior, pectoralis major and minor Retraction Trapezius (middle part) Upward Trapezius (superior part), rotation serratus anterior (inferior part) Downward Levator scapulae, rhomboids, latissimus rotation dorsi, pectoralis minor and major

When massaging these muscles, bear in mind the fiber directions of the muscles Muscles in the scapular and shoulder regions: connect the upper extremity to the vertebral column

Innervation: musculocutaneous, radial, and ulnar nerves Clinical note Dislocation of elbow joint: result from hyperextension or a blow that drives the ulna posteriorly Effusions into elbow joint: excess fluid accumulation, seen in the back because the skin is looser (anterior structure is tight) Radioulnar Joints Type: pivot type of synovial joint Movement: pronation, supination Proximal (superior) radioulnar joint Articulating parts: head of radius, radial notch of ulna Capsule: continuous with that of the elbow joint Synovial cavity communicates with elbow joint cavity Oblique cord from ulna to radius and interosseous membrane holds radius and ulna together Annular ligament Blood supply: radial portion of anastomosis of the elbow joint Innervation: musculocutaneous, median, and radial nerves Distal (inferior) radioulnar joint Articulating parts: head of ulna, ulnar notch of radius, fibrocartilaginous articular disc Fibrocartilaginous articular disc Separate the cavity of distal radioulnar joint from the cavity of wrist joint Exclude the ulna from the wrist joint Fibrous capsule Ligaments: anterior and posterior ligaments strengthen the fibrous capsule Synovial membrane: extends superiorly to form sacciform recess of distal radioulnar joint aid movement Blood supply: anterior & posterior interosseous arteries Innervation: anterior & posterior interosseous nerves Wrist Joint (Radiocarpal Joint) Type: condyloid type of synovial joint Articulating parts Radius, fibrocartilaginous articular disc 3 carpal bones: scaphoid, lunate, triquetrum Fibrous capsule Ligaments 2 radiocarpal ligaments: ventral (palmar) and dorsal 2 collateral ligaments: radial and ulnar Movements Flexion, extension Adduction (ulnar deviation), abduction (radial deviation) Circumduction: requires stabilization of elbow joint Movements are increased by the associated sliding of the carpal bones Blood supply: anastomosis around wrist, branches of dorsal and palmar carpal arches Innervation: median, radial and ulnar nerves Clinical note Colles fracture: radius fractured 2 cm proximal to wrist joint most common fracture in people over 40 Lunate displacement: compress the median nerve and lead to carpal tunnel syndrome Scaphoid fracture: tenderness in anatomical snuff box, often missed on clinical examination and in fist x-ray due to swelling (reduce swelling first then come back after 3 days) common in young people

Intercarpal Joints Type: plane type of synovial joint Articulating parts Joints between carpal bones of the proximal row Joints between carpal bones of the distal row Midcarpal joint: between the proximal and distal rows of carpal bones Pisotriquetral joint: between pisiform and palmar surface of the triquetrum Articular capsule, synovial membrane Joint cavity A continuous, common articular cavity is formed by the intercarpal and carpometacarpal joints, except carpometacarpal joint of the thumb and pisotriquetral joint Continuity of articular cavity: spread of infection Movements: small gliding movements that enhance wrist movements Clinical note: arthritis limits ability to grab/grip Blood supply: dorsal and palmar carpal arches Innervation: median and ulnar nerves Carpometacarpal Joints Carpometacarpal joint of thumb: saddle type Most important Articulating parts: trapezium, 1st metacarpal Has a separate joint cavity Movements Flexion, extension: in a plane parallel to palm Abduction, adduction: in a plane at right angles to palm Opposition: combination of abduction, flexion and medial rotation in which thumb may touch tip of other fingers Carpometacarpal joint of other fingers: plane type Movement: variable degree of gliding Fibrous capsule, synovial membrane Blood supply: periarticular arterial anastomoses of the wrist and hand (dorsal and palmar carpal arches, deep palmar arch, metacarpal arteries) Innervation: median, radial and ulnar nerves Metacarpalphalangeal Joints (MCP, knuckles) Type: condyloid type of synovial joint Ligaments: palmar and collateral ligaments Movements MCP joints of 2nd5th digits: flexion, extension, adduction, abduction, circumduction MCP of the thumb: flexion, extension Interphalangeal Joints (IP) Type: hinge type of synovial joint Proximal interphalangeal joints (PIP) Distal interphalangeal joints (DIP) Possess all structural characteristics of synovial joints Movements: flexion, extension Ligaments: palmar and collateral ligaments Extensor expansions: expansions of long extensor tendons on dorsum of hand, allow insertion of some small muscles of the hand, account for normal bulge at interphalangeal joints

By Monica Hsu

IV. Muscles of the Forearm (Antebrachium)

Muscles act on the elbow, wrist and fingers The anterior and posterior compartments are separated by the interosseous membrane Anterior Compartment: Flexor Superficial and deep layers Clinical note: flexor digitorum profundus muscle is clinically important because it is innervated by median and ulnar nerves and is the only muscle that can flex all the following joints (wrist, carpometacarpal, metacarpophalangeal, proximal and distal interphalangeal joints) Clinical note: flexor pollicis longus is the only muscle capable of flexing interphalangeal joint of thumb Posterior Compartment: Extensor Superficial and deep layers Brachioradialis muscle is a flexor

VI. The Wrist Region

Structures Crossing the Wrist Muscle tendons Nerves, arteries, veins Retinacula Localized thickenings of the deep fascia Hold muscle tendons in place Extensor retinacula: over the extensor tendons Flexor retinacula: over the flexor tendon and median nerve attached to 4 carpal bones Carpal Tunnel Syndrome Median nerve passes deep to the flexor retinaculum In certain conditions (e.x. arthritis) and many other unknown reasons, the median nerve in this region becomes compressed, causing numbness and tingling in the lateral part of the hand supplied by the median nerve and some motor symptoms Treatment: division of flexor retinaculum

V. Vessels of the Upper Extremity

Anterior Compartment of the Arm Brachial artery Accompanied by 2 brachial veins Clinical note: brachial artery may be injured in supracondylar fracture of humerus Posterior Compartment of the Arm Profunda brachii artery Runs with radial nerve Branches: radial and middle collateral arteries Anterior Compartment of the Forearm Radial artery Supplies radial side Source: brachial artery Termination: deep palmar arch Ulnar artery Supplies ulnar side Source: brachial artery Termination: superficial palmar arch Branch: common interosseous artery (very short) Anterior interosseous artery: supplies the flexor compartment, travel with anterior interosseous nerve Posterior Compartment of the Forearm Posterior interosseous artery: supplies the extensor compartment, travels with posterior interosseous nerve Superficial Veins Basilic vein Source: dorsal venous network Termination: become axillary vein Cephalic vein Source: dorsal venous network Termination: joins axillary vein at infraclavicular fossa Median cubital vein Unites basilic and cephalic veins at the elbow Lymphatic Drainage Deep: accompany deep veins Superficial: a network in the superficial fascia Lymph nodes: a few lymph nodes are found along some of the upper limb vessels but all the lymph from the upper extremity eventually drains into the very important axillary lymph nodes

VII. Cubital Fossa

A triangular depression on the anterior elbow Boundaries Superiorly: a line connecting medial and lateral epicondyles of humerus Medially: pronator teres muscle Laterally: brachioradialis muscle Roof: deep fascia of forearm reinforced by bicipital aponeurosis passing from biceps brachii medially to blend with fascia of arm Floor: brachialis muscle, supinator muscle Contents Median nerve Brachial artery, origins of radial and ulnar arteries Biceps brachii tendon Radial nerve Clinical Note Superficial to the bicipital aponeurosis is the median cubital vein in the superficial fascia Cubital vein is used extensively for intravenous transfusions and for the taking of blood samples Lymphatics: cubital lymph nodes

By Monica Hsu

Arm, Forearm, and Hand II: Hand (Manus)

I. Bones
Carpals: at the wrist wrist is between forearm and hand Proximal row: scaphoid, lunate, triquetrum, pisiform Distal row: trapezium, trapezoid, capitate, hamate Metacarpals Phalanges

II. Arrangement of Structures in the Palm

Skin and Subcutaneous Tissue Numerous fibrous bands attach superficial fascia to the deep fascia (palmar aponeurosis) The thicker, hairless skin of the palm is therefore much less mobile than the skin on the dorsum of the hand Palmar Aponeurosis (volar aponeurosis) Tough central part of the deep palmar fascia, deep to skin and superficial fascia Palmaris longus tendon inserts here Septa extends into palm and to fingers Dupuytrens contracture Progressive shortening of medial part of the palmar aponeurosis due to hypertrophy and hyperplasia unknown cause Produces flexion of the ring and little fingers Superficial palmar arch and most nerves are deep to palmar aponeurosis Ulnar nerve and artery are superficial to flexor retinaculum but deep to transverse ligaments 4 Fascial Compartments: separated by palmar aponerosis Thenar compartment: opponens pollicis, abductor pollicis brevis, and flexor pollicis brevis muscles Adductor compartment: adductor pollicis muscle Hypothenar compartment: opponens digiti minimi, abductor digiti minimi, and flexor digiti minimi brevis muscles Central compartment: lumbricals Infections of the Hand Infections of the fingers and the hand are common Spontaneous drainage of pus is hampered by the palmar aponeurosis and thick skin of the palm Administration of antibiotics and prompt surgical treatment to evacuate pus, relieving pressure and tendency of infection to spread within the palm, are frequently necessary Common sites of infection Pulps of finger tips (felon, whitlow) Tendon sheaths Fascial compartments: palmar aponeurosis sends septa deep into the palm forming potential spaces within the palm there is disagreement about this

Common flexor sheath (ulnar bursa) The tendons of the flexor digitorum superficialis and profundus enter the common flexor sheath deep to the flexor retinaculum Fibrous digital sheaths (fibrous flexor sheaths) Ligamentous tubes that enclose the synovial sheaths and flexor tendons From the metacarpal heads to distal phalanges In the 2nd5th fingers, the sheaths are occupied by 2 tendons: flexor digitorum superficialis anterior flexor digitorum profundus Each superficialis tendon splits opposite the proximal phalanx and allows the profundus tendon to perforate it and continue to be inserted into the distal phalanx In the thumb, the sheath is occupied by 1 tendon: flexor pollicis longus Synovial digital sheaths (synovial flexor sheaths) In areas of friction, the tendons are enclosed within synovial sheaths They are within the fibrous flexor sheaths Intrinsic Muscles Control the fine movements of fingers and thumb Short muscles of the thumb and little finger: actions are indicated by their names, help to cup the palm and assist in the grip of a large object Short muscles of the thumb 3 thenar muscles that originate from the flexor retinaculum and insert into the thumb Innervated by median nerve Short muscles of the little finger 3 hypothenar muscles that originate from the flexor retinaculum and insert into the little finger Innervated by ulnar nerve Palmaris brevis muscle Originates from palmar aponerosis, inserts into skin Protects ulnar nerve and artery Deepens the cup of the palm and wrinkles the skin of the hypothenar eminence Adductor pollicis muscle A triangular muscle (has 2 heads, oblique and transverse) lying deeply in the palm just anterior to metacarpals and interossei Arises from 2nd and 3rd metacarpals and adjacent carpal bones Fibers run laterally to thumb Adducts thumb and aids in grip of thumb Lumbrical muscles From each of the 4 flexor digitorum profundus tendons, a lumbrical muscle arises on the radial (lateral) side; runs along the radial side of the metacarpophalangeal joint and reaches the extensor expansion on the dorsum Flex metacarpophalangeal joints, extend interphalangeal joints Interossei muscles Interossei fill spaces between the metacarpals Insert into extensor expansions on dorsal side Actions: assist lumbricals 3 Palmar interossei (PAD): adduct fingers 4 Dorsal interossei (DAB): abduct fingers

III. Muscles of the Palm

Extrinsic Muscles Muscle bellies in the forearm, tendons insert into the palm Concerned with grip, flex the wrist, fingers and thumb Long flexor tendons of the extrinsic muscles 4 flexor digitorum superficialis tendons fingers 4 flexor digitorum profundus tendons fingers 1 flexor pollicis longus tendon thumb 1 palmaris longus tendon palmar aponeurosis (doesnt go under flexor retinaculum)

By Monica Hsu

IV. Arrangement of Structures in the Dorsum of the Hand

Thin Skin and Loose Areolar Connective Tissue This subcutaneous space collects most of the lymph from the palmar aspect before it travels up the arm During an infection of the palm, this dorsal subcutaneous space frequently becomes swollen, not with pus but with lymph, and should NOT be incised Extensor Retinacula Extensor tendons and abductor pollicis longus tendon from forearm have synovial sheaths where they pass deep to the extensor retinaculum Extensor tendons are strong extensors of metacarpophalangeal joints and weak extensors of interphalangeal joints, also extend wrist (Dorsal) Extensor Expansions Inserted into the middle and distal phalanges by slips of tendons which divide and reunite The lumbricals and interossei are inserted into these dorsal extensor expansions Dorsal Interossei Muscles Can be felt between metacarpals Anatomical Snuff Box Boundaries Laterally: abductor pollicis longus tendon, extensor pollicis brevis tendon Medially: extensor pollicis longus tendon Content Radial artery Related structures Cephalic vein: in superficial fascia Radial nerve: cutaneous innervation Radial artery: deep to tendons Scaphoid bone: floor of anatomical snuff box

The Thorax and Lungs (Respiratory Apparatus)

I. Thorax
Surface Anatomy: Vertebral Levels T1 Highest point of apex of lungs T2 Jugular notch of manubrium T3 Base of spine of scapula T4 Sternal angle (manubriosternal joint), aortic arch begins and ends, 2nd costal cartilage, trachea ends and bronchi begin, right and left pleurae meet retrosternally T5-7 Thoracic duct crosses from inferior right to superior left, posterior to the esophagus T8 Inferior vena cava passes through the diaphragm, inferior sternal angle T9 Xiphisternal junction T10 Esophageal hiatus of the diaphragm T11 T12 Abdominal aorta, aortic hiatus of the diaphragm Fascia of the Thoracic Wall Superficial fascia Deep fascia: pectoral fascia, clavipectoral fascia Endothroacic fascia: a thin layer of areolar tissue (loose connective tissue) that lines the inner thoracic cage

II. The Bony Thorax

The skeleton of the thorax (chest) is an osseocartilaginous cage which contains and protects the principal organs of respiration and circulation. The shape is conical, flattened from anterior to posterior and varies with sex and age Thoracic Inlet (superior thoracic aperture) Boundaries: 1st thoracic vertebra, 1st rib, upper border of the manubrium sterni Slopes down because of the oblique course of the 1st rib Trachea, esophagus, great blood and lymph vessels, and nerves pass through this entrance of thoracic cage Thoracic outlet syndrome Clinicians refer to the superior thoracic aperture as the thoracic outlet to emphasize the arteries and T1 spinal nerves that emerge from the thorax through this aperture to enter the lower neck and upper limbs Merging structures are affected by obstructions of the superior thoracic aperture Manifestations of the syndrome involve the upper limb Ex. costoclavicular syndrome: the subclavian artery and vein and the brachial plexus were compressed between the clavicle and normal first rib by cervical rib Thoracic Outlet (inferior thoracic aperture) Boundaries: 12th thoracic vertebra, 12th rib, inferior costal margin It is closed by the diaphragm Thoracic Cage Formed by thoracic vertebrae 1-12, intervertebral discs, ribs 1-12, sternum There are 11 intercostal spaces Sternum Forms the median portion of the anterior thoracic wall Its upper end supports the clavicles Its lateral margins articulate with cartilages of the ribs It consists of 3 parts: manubrium, body, xiphoid processes By Monica Hsu

V. Vessels of the Hand

Radial and Ulnar Arteries Supply the hand by means of 2 arterial arches (both in the palm), from which arise arteries for the digits Superficial Palmar Arch Largest and most important Deep to palmar aponeurosis Source: ulnar artery, a branch from radial artery Arch digital branches to fingers Deep Palmar Arch Lies on metacarpals and interossei, deep to long flexor tendons Source: radial artery, a branch from ulnar artery Arch digital branches to thumb and index finger Princeps pollicis artery: a branch of radial artery main arterial supply of the thumb Radial Artery at the Wrist Just above the wrist, the radial artery lies lateral to flexor carpi radialis tendon on the anterior aspect of the wrist Then the artery passes to dorsum of hand by passing deep to the tendons of the anatomical snuffbox to plunge through the first dorsal interosseous muscle between metacarpals of thumb and index finger In this way it reaches the deep region of the palm where it forms the deep palmar arch Clinical note: radial pulse is commonly taken at the wrist Veins of the Hand Superficial and deep venous palmar arches Dorsal venous network cephalic and basilic veins

 Ribs IV. Vertebrae Elastic arches of bone and cartilages connected posteriorly to the vertebral column Thoracic Vertebrae Usually there are 12 on each side Spinous processes: long, overlap each other as The ribs vary in their direction, shape, and size they point inferiorly True ribs (1-7) Costal facets (demifacets) on bodies and The costal cartilages articulate directly with the sternum transverse processes: for articulation with the ribs False ribs (8-10) 2 demifacets are located laterally on the body The costal cartilages articulate with the cartilage Superior demifacet: for articulation with of the rib above them, form a costal margin (arc) corresponding rib Floating ribs (11-12) Inferior demifacet: for articulation with the rib There are no articulations of the body of the rib right below it Typical ribs (3-9) Exceptions: there are full facets on T1, T10-12 Head, neck, body, costal cartilage Facets: for articulation with vertebral bodies Movements of the Thoracic Cage Tubercle: has facets for articulation with Range and type of movements of the ribs vary according transverse process of the vertebra to their different shapes and anterior attachments Costal groove: protect intercostal nerve, artery and vein Dimensions: anterior/posterior, transverse, vertical Costal angle: where body changes direction Pump handle movement Atypical ribs (1-2, 10-12) The anterior ends of the ribs are 1st rib elevated/depressed, also travel forward/backward Groove for subclavian artery and vein Correspondingly the body of the sternum moves Scalene tubercle for anterior scalene muscle forward/backward Costal cartilages Increase the anterior-posterior diameter Bars of hyaline cartilage prolonging the ribs anteriorly Predominant movement of the true ribs 1-7 cartilages: connect the rib ends to the sternum Bucket handle movement 8-10 cartilages: articulate with the cartilage of the The middle parts of the ribs are elevated/depressed rib above them Enlarge the transverse diameter Infrasternal angle Widen the infrasternal angle th th Formed by the joint cartilages of the 7 10 ribs Predominant movement of the lower ribs of both sides and the xiphisternal joint

III. Joints of the Thoracic Wall

Intervertebral Joint A symphysis Costochondral Joint Articulating parts: sternal end of rib, lateral end of costal cartilage Cartilaginous joint: no movement Costovertebral Joint Joints of heads of ribs Plane type of synovial joint Articulating parts: the head of each typical rib, costal facets of 2 adjacent vertebrae (same number and the one above), the intervertebral disc between them This joint has 2 cavities The heads of the 1st, 10th-12th ribs articulate with one vertebra only Ligaments: radiate and intra-articular ligaments Costotransverse Joint All except 11th and 12th are synovial joints Articulating parts: tubercle of the rib, transverse process of the corresponding vertebra Ligaments: costotransverse ligaments Sternochondral (sternocostal) Joint Most of them are synovial joints Articulating parts: costal cartilages of true ribs, sternum Manubriosternal Joint A symphysis Xiphisternal Joint Is usually ossified

V. Muscles of the Thoracic Wall

The Serrati Muscles Serratus anterior muscle: protract scapula Serratus posterior superior muscle: elevate ribs Serratus posterior inferior muscle: depress ribs Muscles of Respiration External layer External intercostal muscles Pass obliquely downwards and forward between the adjacent borders of 2 ribs Found in the same layer as the external oblique muscle of the abdominal wall Extend from the tubercles of the ribs posteriorly to the beginning of the costal cartilages anteriorly From the costochondral junction on, the muscles are replaced by tedinous fibers, forming the external intercostal membrane Inspiratory muscles Levator costarum muscles 12 fan-shaped muscles Origin: transverse processes of C7-T11 Insertion: subjacent rib between tubercle and angle Innervation: dorsal primary rami of C8-T11 Function: elevate ribs Middle layer Internal intercostal muscles Fibers pass obliquely downward and backward Extend from the sternal ends of the intercostal space to the angle of the rib, continue then as the internal intercostal membrane Function: form a strong elastic membrane which keeps the contents of the intercostal space from being drawn in and pushed out with respiration Expiratory muscles By Monica Hsu

Internal layer Innermost intercostal muscles Placed on the deep surfaces of the internal intercostals and pass in the same direction (may be considered as part of the internal intercostals) Fibers not easily distinguishable during dissection The neurovascular bundle passes between innermost and internal intercostal muscles Function: act with the internal intercostals Subcostal muscles Fiber bundles run between ribs on the internal surface (near the vertebrae), cross over 2 or 3 intercostal spaces These fibers are discontinuous and are continued by the innermost intercostals Function: act with internal intercostals Transversus thoracis (sternocostalis) muscles Origin: posterior surface of lower sternum Insertion: costal cartilages of ribs 2-6 Function: depress ribs

VII. Nerves of the Thoracic Wall

There are 12 thoracic spinal nerves. After leaving the intervertebral foramen, each divides into a dorsal and a ventral rami Ventral Rami (intercostal nerves) Do not form plexuses Distributed to the corresponding intercostal spaces where they lie in the costal groove below the artery At the anterior end of the space they pierce the muscles and become cutaneous Branches: collateral branch, lateral cutaneous branch Atypical Intercostal Nerves Greater part of ventral ramus of T1 joins brachial plexus Lateral cutaneous nerve of T2 supplies skin over axilla and arm called intercostobrachial nerve 7-12th intercostal nerves pass through the intercostal spaces, but then continue into the abdominal wall called thoracoabdominal nerves 12th intercostal nerve is related to the kidney called subcostal nerve Note that from the angle of the rib, the main intercostal blood vessels and nerves lie in upper part of each intercostal space
Costocervical trunk

VI. Vasculature of the Thoracic Wall

Subclavian Artery
Internal thoracic artery Branches to mediastinum, pericardium, sternum Anterior intercostal arteries - anastomose with posterior intercostal arteries

Superior epigastric artery Superior (highest) intercostal artery Musculophrenic arteriey - termination of internal 1st and 2nd posterior intercostal arteries thoracic artery - supply the corresponding intercostal space

Thoracic Aorta
9 posterior intercostal arteries - pass together with the vein and nerve in the costal groove of the corresponding rib Subcostal artery - supply muscles of anterolateral abdominal wall

Dorsal branch to Lateral cutaneous Collateral branch muscles of back branch

Axillary Artery
Lateral thoracic artery

Posterior intercostal veins (II), subcostal vein Azygos veins

Anterior intercostal veins Internal thoracic vein

Superior vena cava

Brachiocephalic vein

Dorsal horn Ventral horn

Dorsal rootlets Ventral rootlets

Dorsal root Ventral root

Dorsal root ganglion

Mixed spinal nerve

Dorsal primary ramus Ventral primary ramus

Supply joints, muscles, and skin of back in the thoracic region Internal costal nerves

By Monica Hsu