Topographic anatomy of extremity

Upper limb

Department of Human Anatomy, Operative

surgery and Topographic Anatomy
YHU
 Upper limb
Upper limb consists of sholder girdle and free upper limb

Sholder girdle consists of Free upper limb consist of:

four region: Regio brachii anterior et
Regio axillaris posterior
Regio cubiti anterior et
Regio deltoidea
posterior
Regio scapularies
Regio antebrachii anterior et
Regio infraclavicularis posterior
Regio palme manus
Regio dorsi manus
Regio
digiti(palmaris/dorsalis)
 Axillary Region(Regio axillaris)

Boundary:
 Anteriorly-lower border of pectoralis
major muscle
 Posteriorly- lower border of
latissimus dorsi muscle
 Laterally- an imaginary line which
connect lower borders of the above
mentioned muscles on the arm
 Medially- the same line on the chest.
 Axillary Region(Regio axillaris)
Layers:
 Skin
 Subcutaneous fatty tissue
 Superficial fascia
 Proper fascia-pierced by the arteries and
nervs.
After taking away proper fascia discovered the
cavity(fossa axillaris).
 Axillary fossa has 4 walls;
 Anterior-pectoralis major and minor
muscles.
Here distinguish 3 triangles; claviopectoralis,
pectoralis, subpectoralis
 Posterior wall- scapula, mm. subscapularis
ters major and minor, latisimus dorsi.
 Lateral wall-humerus covered by the
coracobrachialis muscle, and short head of
biceps brachii muscle.
 Medial wall-first to fourth ribs, intercostal
muscle and overlying serratus anterior
muscle.
 Trigonum claviopectorale
Superiorly-clavicle
Inferiorly-upper border pectoral minor muscle.
In this triangle the vien lies medialy axillar artery. The brachial plexus is formed by the union
of the ventral rami of C5-C8, T1 nerves. Brachial plexus the lies superiorly and laterally to the
artery. From axillar artery beginning two branches. a. thoracica suprema, and
thoracoacromialis.
Inferior parts of claviopectoral fascia support the axillary fascia and forming the (ligamentum
suspensorium axillae).
Coincides with pectoralis minorTrigonum
muscles.
pectorale.

Artery- a.thoracica lateralis, n. thoracicus longus. Brachial plexus

passes by 3 cords(fasciculi); medial lateral, posterior. Axillar vien
again is medial to the artery.
 Trigonum subpectorale
Between inferior border of both pectoral musceles.
Axillaris gives of 3 branches; a. circumflexa humery anterior, a. circumflexa humery posterior, a.
subscapularis. The last one divided into a.circumflexa scapulae and a. thoracodorsalis.
The first 2 branches curve around the surgical neck of humerus and make anastamosis with each
other.
Brachial plexus started; n. medianus, n. musculocutaneus, n. ulnaris, n. cutaneus brachii
medialis, n. cutaneus antebrachii medialis, n. radialis and n. axillaris.
Axillar fossa
Anterior Wall
 Axillary region(posterior wall)
Posterior wall is made by scapular region where we describe two openings.

Quadrilateral and trilateral (foramen quadrilaterum, trilaterum).

Between teres minor and subscapularis muscles above
Teres major, latissimus dorsi muscles below and humerus laterally there is left a
space, which is crossed by the long head of triceps brachii muscles.
Axillary region(posterior wall)
 Axillary fossa(posterior wall)
From trilateral opening passes- a.v. circumflexa scapule (a. subscapularis)
From quadrilateral opening passes- a.v. circumflexa humery posterior, n. axillaris.
The limphatic nodes in region arranged in 5 principle groups.
(lateral, central, medial and subscapular).
Projection of a. axillaris has a practical importance.
According to Pirogov it is projected through the anterior border of the hair covering of the axilla.
According to the Langenbek it is projected by the continuation of the sulcus bicipitalis medialis in the
axillary fossa.
 Deltoid region(regio deltoidea)

Boundaries.
The coincides with the portion of the deltoid muscle.
Layers.
Skin-thick; innervated(n. cutaneus brachii lateralis
superior, n. supraclavicularis lateralis cerv. plx)
Subcutaneous fat is developed well.
Superfitial fascia.
Proper fascia forms a sheath for the deltoid muscle.
Subdeltoid loose connective tissues where situated
followings bursa; subdeltoidea, subacromialis, subtendinea.
 Deltoid region(regio deltoidea)
The region innervated by the axillary nerve which passes through the quadrilateral opening from the
axillary region together with the posterior circumflex artery of the humerus. The last one
anastamoses with the anterior circumflex artery arround the surgical neck of humerus, and make
anastamoses with the branches of a.thoracoacromialis; r.acromialis, r. deltoideus. Subdeltoid space
communicates with fibrofatty conective tissues of the and the supraspinatus and infraspinatus fossa
of the scapula.(way for infection)
Projection of n.Axillaris-vertical line descending from the acromion, which intersects with the
posterior margin of the deltoid muscle. The loss of the function and the atrophy of the deltoid occur
when the axillrary nerve is severely damaget.
Boundaries;
Infraclavicular region:
Superiorly-clavicle
Inferiorly- horizontal line wich passes throuth 3rd rib in a men, and throuth upper
border of the breast in women.
Medialy-outer border of the sternum
Lateraly-anterior border of the deltoid m.
Layers.
1.The skin is fine
2.Subcutaneus fatty tissues-especialy developed in women. n.supraclaviculares from
the cervical plexus innervate the skin.
3. Superficial fascia connected with a proper one from the clavicle up to upper
border of the breast and forming the ligamentum suspensorium mammae.
4. Proper fascia which called here fascia pectoralis forms a sheath for the pectoral
major muscle. The muscle dividing in into 3 parts: pars clavicularis, pars sternalis,
pars abdominalis. Beetween pectoralis major and deltoid muscles a groove is
formed(sulcus deltoidopectoralis). Vena cephalica passes throuth this groove and
drains into v.axillaris or v. subclavia. a.v. thoracoacromialis, nn. pectorales medialis
et lateralis pass throuth the subpectoral space. Artery gives 3 branches; r.pectoralis,
r.deltoideus, r.acromialis.
Infraclavicular region:
 The Arm(Brachium)
Boundaries:

Superiorly-circular line which connect

inferior margin of the pectoralis and
latissimus dorsi muscles.

Inferiorly- circular line which passes

4cm above the epicondilis of
humerus. Two vertical lines which
passes throuth the
sulcus bicipitalis medialis et lateralis
divide the arm 2 region; anterior and
posterior.
 Anterior region of the Arm
Layers; (regio brachii anterior)
1.Skin-lateral parts is thicker
than a medialy.
2.Subcutaneous fatty tissues-
loose.
3.Superficial fasci- thin,
forming the sheats for
superficial veins and cutaneus
nerves.
Laterally passes v.cephalica
and proximaly passes into
sulcus deltoidopectoralis.
V. basilica passes throuth the
medial edge of the biceps
brachii muscle-
sulcus bicipitalis medialis.
The veins drains into
v.brachialis or. v. axillaris.
 Anterior region of the Arm
(regio brachii anterior)
4. Proper fascia-gives 2 intermuscular septa. Forms 2 osteofascial capsules(anterior, posterior).
Anterior compartment contains muscles of anterior group, which are arranged in 2 layers:
Superficial(m. biceps brachii), and deep(m. coracobrachialis-upper/3, m. brachialis-middle/lower/3, m.
brachioradialis-lower/3 of brachhium. All of them are flexors.
 Anterior region of the Arm
(regio brachii anterior)
Under the deep fascia lies n.musculocutaneus. It innervated all muscles of this group, in
inferior lateral border of the region the as lateral skin nerve of the forearm(n.cutaneus
antebrachii lateralis). Septum intermusculare mediale forming the space for main neuro-
vascular bundle of arm; a. brachialis, vv. brachiales, n.medianus, n. ulnaris.
 Anterior region of the Arm
(regio brachii anterior)
A. brachialis provides
principle arterial supply to the
arm. It is the continuation of
the axillary artery. In the
upper /3 of the artery
a.profunda brachii extend
from the brachialis and ,
together with n.radialis,
pierces medial intermuscular
septum and enters posterior
muscular compartment.
Branches of the Brachial
artery.
A.profunda brachii
A. collateralis ulnaris superior
A. collateralis ulnaris inferior
Veins of Upper Limb
 Posterior Region of the Arm
(Regio brachii posterior)
Layers:
Skin-is thick
Superficial fascia-is a thin layer
Subcutaneous tissues- we can find n. cutaneus brachii laterals superior et
inferior(n.axillaris), n. cutaneus antebrachii posterior, n. cutaneus brachii posterior
(n.radialis).
Posterior osteofacial compartment-m. triceps brachii. n. Radialis innervates this
muscle.
N. Radialis and A.profunda brachii s situated in the spiral canal(canalis
humeromuscularis). The last one formed by the groove of the radial nerve of the
humerus and triceps muscle of the arm.
A.profunda brachii branches-a. collateralis medialis, a. collateralis radialis.
Posterior Region of the Arm
(Regio brachii posterior)
Boundaries:
Proximal and distal-two circular lines 4 cm above and below the epicondyles of arm. By two vertical lines
which passes through the medial and lateral epicondyles, the region is divided into anterior, posterior.
Cubital region
(Regio cubiti)
 Anterior Cubital Region/Cubital fossa
(Regio cubiti anterior/Fossa cubiti)
Layers:
Skin-thin
Subcutaneus tissues has a plated structure-superficial nerves and veins. Laterally-v cephalica, n.
n.cutaneus antebrachii lateralis,medially- v. basilica, n. n.cutaneus antebrachii medialis. Veins are
connected with each other by v.mediana cubiti.
Proper fascia-thickned, medialy fibers forming aponeuroses bicipitalis(lacertus fibrosus or Pirogof’s
fascia).
 Anterior Cubital Region/Cubital fossa
(Regio cubiti anterior/Fossa cubiti)

Muscles are arranged in 3 groups:

medial, middle, lateral.
Lateral group; mm. brachioradilais,
supinator.
Middle group; mm. biceps et
brachialis;
Medial group; mm. pronator teres,
flexor carpii radialis, palmaris
longus, flexor carpii ulnaris et
flexor digitorum superficialis.
 Anterior Cubital Region/Cubital fossa
(Regio cubiti anterior/Fossa cubiti)
Between them 2 grooves in cubital fossa are formed; Sulci cubitales anterior medialis et lateralis.
Lateral sulcus-n. radialis, a. collateralis radialis. Radial nerve divided in 2 branches superficial and deep.
Ramus superficialis- continues its way on the forearm in the radial groove.
Ramus profundus-passes on dorsal region of forearm and is called n.interosseus posterior.
 Posterior cubital region (regio cubiti posterior)
Landmarks:
- Olecranon of ulna.
- Sulci cubitales posteriores lateralis el medialis.
- Ulnar nerve passing along the sulcus cubitalis posterior medialis.
- Head of the radius is palpated in the middle part of sulcus cubitalis posterior lateralis
(especially during supination and pronation of forearm).
 Posterior cubital region (regio cubiti posterior)
Layers:
Skin:
- It is thick and movable.
- It forms skin folds.
Subcutaneous tissue:
- It contains the superficial arteries (medial collateral artery, radial collateral artery and recurrent
interosseous artery).
- It contains the posterior cutaneous nerve of the arm, medial cutaneous nerve of the arm,
posterior cutaneous nerve of the forearm and medial cutaneous nerve of the forearm.
- Bursa of the elbow joint is located in the superior part of the olecranon of the ulna.
- Bursitis may be precipitated by trauma or long-term compression of this part.
Superficial fascia:
- It is a thin layer without fixation.
Deep fascia:
- It is formed by an aponeurosis.
- It is fixed to the tendon of the triceps brachii muscle, medial and lateral epicondyles of the
humerus and olecranon of the ulna.
Muscles:
- Superior: Triceps brachii and anconeus muscles.
- Lateral: Extensor muscle of the wrist (Extensor carpi radialis longus, extensor carpi radialis
brevis and extensor carpi ulnaris muscles) and extensor muscle of the digits (extensor digitorum
and extensor digiti minimi muscles).
Deep: Supinator muscle.
Medial: Flexor digitorum profundus and flexor carpi ulnaris muscles
Posterior cubital region (regio cubiti posterior
 Posterior cubital region (regio cubiti posterior)
Arteries (medial collateral artery, radial collateral artery and
recurrent interosseous artery).
 Topographic anatomy of the forearm
Borders:
- Upper: Circular line drawn 4 cm below the
epicondyles of arm.
- Lower: Circular line drawn 2 cm proximal to the
styloid process of the radius
- 2 vertical lines are drawn through the epicondales
and styloid processes, which divide the
forearm region into the anterior and posterior
regions.
The forearm is divided into anterior and posterior
compartments. These compartments are
separated by:
- the lateral intermuscular septum, which passes
from the anterior border of the radius to
deep fascia surrounding the limb;
- the interosseous membrane, which links adjacent
borders of the radius and ulna along most
of their length;
- the attachment of deep fascia along the posterior
border of the ulna.
 Topography of the anterior region of the forearm
Skin: (regio antebrachii anterior)
- It is thin.
- It contains sweat and sebaceous glands.
- It is innervated by the medial and
lateral cutaneous nerves of the forearm.
Subcutaneous tissue:
- It contains the cephalic vein (in the
medial margin of the brachioradialis
muscle) and basilic vein.
- It contains the lateral cutaneous nerve
of the forearm and medial cutaneous
nerve of the forearm.
- Intermediate antebrachial vein passes
through the middle line of this region.
 Topography of the anterior region of the forearm
(regio antebrachii anterior)
Superficial fascia:
- It is not attached to the bone.
-It covers all structures in the
subcutaneous tissue.
Deep fascia (fascia antebrachii):
- It forms a covering for muscles,
vessels, nerves and bones.
- It is thicker in the proximal part
and thinner in the distal part.
- It sends two septa to the radius
only and divides the forearm into 3
seats for muscles (anterior,
posterior and lateral) in the upper
half of forearm:
 Topography of the anterior region of the forearm
(regio antebrachii anterior)
Lateral muscles groop;
mm. brachioradialis,
extensor carpi radialis
longus and extensor
carpi radialis brevis
 Topography of the anterior region of the forearm
(regio antebrachii anterior)
Anterior:
(Superficial) mm.
pronator teres,
flexor carpi radialis,
flexor digitorum superficialis,
Palmaris longus and
flexor carpi ulnaris muscles;
(Deep) mm.
flexor digitorum profundus
flexor pollicis longus muscles.
 Topography of the anterior region of the forearm
(regio antebrachii anterior, muscles)

Medial margin of the deep fascia is bounded to the posterior margin of

the ulna and divides the muscles into 4 layers:
-1st layer: Pronator teres, flexor carpi radialis, palmaris longus,
flexor carpi ulnaris and brachioradialis muscles.
-2nd layer: Flexor digitorum superficialis muscle.
-3rd layer: Flexor digitorum profundus and flexor pollicis longus
muscles.
-4th layer: Pronator quadratus muscle.
 Topography of the anterior region of the forearm
Grooves
-Sulcus radialis:
It lies between the brachioradialis (laterally) and flexor carpi radialis
muscles (medially).
It contains the superficial branch of the radial nerve, radial artery and
vein.
- Sulcus ulnaris:
It is lodged between the flexor carpi ulnaris (medially) and flexor
digitorum superficialis muscles (laterally).
It contains the ulnar artery, vein and nerve.
- Sulcus medianus:
It lies between the flexor carpi radialis (laterally) and flexor digitorum
superficialis muscles (medially).
It contains the medial nerve.
Topography of the anterior region of the forearm
Grooves
 Topography of the anterior region of the forearm
Neurovascular bundles

Lateral:

1. Radial artery and vein

2. Superficial branch of the radial nerve:
It is located on the sulcus radialis.
In the upper 1/3 of the forearm, it is bounded by the brachioradialis muscle laterally
and pronator teres muscle medially.
In the middle and lower 1/3 of the forearm, it follows the brachioradialis and flexor
carpi radialis muscles and passes downward along with radial artery.
Then it passes through the tendon of the brachioradialis muscle.
3. Radial artery:
It passes along the middle part of the elbow joint to the styloid process of the radius
and enters the anatomical snuffbox.
 Topography of the anterior region of the forearm
Neurovascular bundles
Medial:
1. Ulnar artery:
It passes from the tendon of the biceps brachii muscle.
In the middle 1/3 of the forearm, it passes under the pronator teres muscle, flexor
digitorum superficialis muscle and sulcus ulnaris.
In the lower 1/3 of the forearm, it passes to the medial margin of the styloid process of
the ulna and reaches the pisiform bone.

2. Ulnar nerve:
It is located on the sulcus ulnaris and is bounded medially by the flexor carpi ulnaris
muscle and laterally b\ the flexor digitorum superficialis in the upper 1/3 of the forearm
Then it passes from the medial epicondyle of the humerus to the medial margin of the
pisiform bone.

3. Posterior interosseous artery:

Common interosseous artery is a branch of the upper pail of the ulnar artery and is
divided into the anterior and posterior interosseous arteries.
Posterior interosseous artery passes through the orifice of the interosseous membrane to
the posterior region of the forearm.
 Topography of the anterior region of the forearm
Neurovascular bundles
Median (Anterior):

1. Median nerve:
It passes from the middle point between the medial epicondyle of the humerus and
tendon of the biceps brachii muscle, along the anterior interosseous artery to the medial
margin of the styloid processes of the ulna and radius.
It goes downward between the pronator teres muscle and exits from the interspace of
the pronator teres muscle in the upper third of forearm.
The middle 1/3 of the median nerve passes between the flexor digitorum superficialis
and flexor digitorum profundus muscles and is strictly fixed to the posterior wall
covering of the flexor digitorum superficialis muscle.
It is located on the sulcus medianus in the lower 1/3 between the tendons of the flexor
carpi radialis and palmaris longus muscles. This landmark is ideal for anesthesia of the
median nerve during operation.

Median (Posterior):
Posterior interosseous artery and nerve.
Topography of the anterior region of the forearm
Grooves& Neurovascular bundles
Topography of the anterior region of the forearm
Grooves& Neurovascular bundles
 Topography of the posterior region of the forearm
(regio antebrachii posterior)
Layers:
Skin:
- It is thick with limited movement.
- It is innervated by the medial and lateral cutaneous nerves of the forearm and posterior
cutaneous nerve of the forearm.
Subcutaneous tissue:
- It contains less fatty tissue.
- Superficial veins form the main trunk of the vein (cephalic vein and basilic vein).
Superficial fascia:
- It is a weak layer.
Deep fascia:
- It is distinguished by its thickness and is strictly fixed to the ulna and radius.
- It is an aponeurosis in the upper half of the forearm.
- It extends downward and forms the extensor retinaculum and dorsal carpal canal.
- It forms cellular space, which contains deep branch of the radial nerve, posterior interosseous
artery, posterior interosseous veins and nerve.
-Deep branch of the radial nerve passes through the canalis supinatorius.
-Posterior interosseous artery passes medial to the posterior interosseous nerve.
 Topography of the posterior region of the forearm
(regio antebrachii posterior)

Muscles:
a) Superficial muscles:
Extensor carpi radialis;
Longus muscle;
Extensor carpi radialis brevis muscle;
Extensor digitorum muscle;
Extensor digiti minimi muscle;
Extensor carpi ulnaris muscle.
b) Deep muscles:
Supinator muscle;
Abductor pollicis longus muscle;
Extensor pollicis longus muscle;
Extensor pollicis brevis muscle;
Extensor indicis muscle.
Vascularisation of upper limb
 Anatomical Snuffbox
The anatomic snuffbox is a term commonly used to describe a triangular skin depression on
the lateral side of the wrist that is bounded medially by the tendon of the extensor pollicis
longus and laterally by the tendons of the abductor pollicis longus and extensor pollicis
brevis. Its clinical importance lies in the fact that the scaphoid bone is most easily palpated
here.
 Topographic anatomy of the hand region
(regio manus)
It is subdivided into three
parts:
- the wrist;
- the metacarpus;
- the digits (five fingers).

Borders:
- 2 cm above the styloid process of the ulna.
- 2 vertical lines are drawn along the ulna and radius and divide the
hand region into the anterior (palmar) and posterior (dorsal) regions.
Topographic anatomy of the hand region
(regio manus)
 Topography of the palmar region of the hand
(regio palmare manus)
Layers:
Skin:
- It is thick with limited movement.
- It contains sweat glands and sebaceous glands.
- It is innervated by the, ulnar nerve and median nerve.
Subcutaneous tissue:
- It contains vessels, nerves and lymphatic vessels with lymphatic nodes.
- It contains the superficial palmar branch of the radial artery.
Superficial fascia:
- It is a continuation of the superficial fascia of the forearm.
- It is slightly movable and fixed to the bones.
Deep fascia:
- It stretches from the palmaris longus tendon (proximally) to the ligamentum carpi volare
(distally).
- It forms the palmar aponeurosis, flexor retinaculum (transverse carpal ligament), synovial
sheaths of the hand and fingers.
- The palmar aponeurosis is triangular and occupies the central area of the palm. The apex
of the palmar aponeurosis is attached to the distal border of the flexor retinaculum and receives
the insertion of the palmaris longus tendon.
The function of the palmar aponeurosis is to give firm attachment to the overlying skin
and so improve the grip and to protect the underlying tendons.
 Topography of the palmar region of the hand
(regio palmare manus)
Muscles:
a) Thenar muscles (lateral muscle group)
Abductor pollicis brevis muscle;
Opponens pollicis muscle;
Flexor pollicis brevis muscle;
Adductor pollicis muscle.
b) Hypothenar muscles (medial muscle
group):
Abductor digiti minimi muscle;
Opponens digiti minimi muscle;
Flexor digiti minimi brevis muscle;
Palmaris brevis muscle.
c) Median muscle group:
Lumbrical muscles;
Palmar interosseous muscles;
Dorsal interosseous muscles.
Layers: Topography of the dorsal region of the hand
Skin: (regio dorsi manus)

- It is thin and movable.

- It contains hair follicles, sweat glands and sebaceous glands. Furuncles tend to occur in this
region.
- It is innervated by the ulnar, median and radial nerves.
Subcutaneous tissue:
- It contains loose connective tissue and phlegmon passes from the palmar space to this region.
- It contains the cephalic (radial margin) and basilic veins (ulnar margin) which then form a
vascular network between them.
- It also contains the radial nerve (superficial branch) and ulnar nerve (dorsal branch).
Superficial fascia:
- It is fixed to the styloid process and bones of the wrist.
Deep fascia:
- It forms the extensor retinaculum (retinaculum extensorum).
- It has 6 canals (osteofibrous canals) which are formed by the extensor retinaculum with the
carpal bones.
 Topography of the dorsal region of the hand
(regio dorsi manus)

The 6 canals (from medial to lateral) contain:

1) Tendons of the extensor pollicis brevis and abductor pollicis
longus muscles
2)Tendons of the extensor carpi radialis brevis and extensor carpi
radialis longus muscles
3) Tendon of the extensor pollicis longus muscle
4) Tendons of the extensor digitorum and extensor indicis muscles
5) Tendon of the extensor digiti minimi muscle;
6)Tendon of the extensor carpi ulnaris muscle;

.
Topography of the dorsal region of the hand
(regio dorsi manus)
Vascularisation & Innervation of the hand