The Anterior Region of the Upper Limb

1. Regional anatomy of upper limb The Anterior Region of the Upper Limb Ling Shucai

2. Parts and regions • Shoulder region－junction of arm and trunk • Arm－between should and elbow • Elbow－bend of arm, joint between arm and forearm • Forearm－between elbow and hand • Hand

3. 1. Surface anatomy 表面解剖 2. The superficial structures 浅层结构 Superficial veins 浅淋巴管 Superficial lymph vessels 浅静脉 Cutaneous nerves 皮神经 3. The deep structures 深层结构 The deep fascia 深筋膜 The muscles 肌肉 The vessels 血管 The nerves 神经 4. Regional anatomy 局部解剖 Cubital fossa 肘窝 The carpal canal 腕管 The palmar fascial space 手掌筋膜间隙 The Anterior Region of the Upper Limb

4. 1.Surface anatomy

5. Surface anatomy • Shoulder region: acromion, spine of scapula, coracoid process, greater tubercle, anterior and posterior axillary folds • Arm－medial and lateral biceps brachii furrow, deltoid tuberosity • Elbow－medial and lateral epicondyles, head of radius, olecranon, tendon of biceps brachii • Forearm－between elbow and hand • Hand－styloid process, dorsal tubercle

6. Carring angle 提携角 1650～1700

7. 2.The superficial structures

8. Cephalic vein Basilic vein Median cubital vein The superficial structures Superficial veins • Cephalic vein 头静脉 • Basilic vein贵要静脉 • Median cubital vein 肘正中静脉

9. The lymphatic drainage of upper limb Lymphatic vessels • Superficial－follow the superficial veins, drain into supratrochlear(滑车上淋巴结）and axillary lymph nodes（腋淋巴结） • Deep－accompany main vessels, end in axillary lymph nodes lymph nodes • Superficial cubital lymph node (Supratrochlear lymph node): 肘浅淋巴结（滑车上淋巴结） • Axillary lymph node－arranged in five groups

10. Cutaneous nerves Lateral antebrachial cutaneous n. & cephelic v. 前臂外侧皮神经和头静脉 Medial antebrachial cutaneous n. & basiic v. 前臂内侧皮神经和贵要静脉 Median cubital v 肘正中静脉.

11. 3. The deep structures

12. Ⅰ.The Muscles Muscles of arm • Antererior group • Biceps brachii 肱二头肌 • Coracobrachialis喙肱肌 • Brachialis 肱肌 • Posterior group – triceps brachii 肱三头肌

13. Muscles of forearm • Superficial layer • Brachioradialis 肱桡肌 • Pronator teres 旋前圆肌 • Flexor carpi radialis 桡侧腕屈肌 • Palmaris longus 掌长肌 • Flexor carpi ulnaris 尺侧腕屈肌

14. Second layer Flexor digitorum superficials 指浅屈肌

15. Third layer • Flexor digitorum profundus 指深屈肌 • Flexor pollicis longus 拇长屈肌 • Fourth layer Pronator quadratus 旋前方肌

16. Muscles of hand • Lateral group－thenar 鱼际(4) • Abductor pollicis brevis拇短展肌 • Flexor pollicis brevis 拇短屈肌 • Opponens pollicis 拇对掌肌 • Adductor pollicis 拇收肌 • Medial group－hypothenar (3) • Abductor digiti minimi 小指展肌 • Flexor digiti minimi brevis 小指短屈肌 • Opponens digiti minimi小指对掌肌

17. Intermedial group • Lumbricales 蚓状肌(4) • Palmar interossei 骨间掌侧肌(3) • Dorsal interossei 骨间背侧肌(4)

18. Ⅱ. The vessels Arteries

19. Brachial artery • Continuation of axillary artery • Divides into radial and ulnar arteries at level of neck of radius • Branches • Deep brachial a. 肱深动脉 － accompanies with radial nerve • Superior ulnar collaeral a. 尺侧上副动脉 －accompanies with ulnar nerve • Inferior ulnar collateral a. 尺侧下副动脉

20. Radial artery and branches • Radial recurrent a. 桡侧返动脉 • Superfical palmar branch掌浅支 • Principal artery of thumb 拇主要动脉 Ulnar artery and branches • Ulnar recurrent a. 尺侧返动脉 • Common interosseous artery 骨间总动脉 • Anterior interossous a.骨间前动脉 • Posterior interosseous a. 骨间后动脉 • Deep palmar branch 掌深支

21. Muscolocutaneous n. Brachial a. Radial n. Radial recurrent a. Ulnar recurrent a. Radial a. Common interosseous a. Median n. Ulnar a., v. & n.

22. Superficial palmar arch 掌浅弓 • Formed by ulnar artery（尺动脉）and superficial palmar branch of radial artery（桡动脉） • Curve of arch lies across the palm, level with the distal border of fully extended thumb • Gives rise to three common palmar digital arteries（指掌侧总动脉）each then divides into two proper palmar digital arteries（指固有动脉）

23. Deep palmar arch 掌深弓 • Formed by radial artery and deep palmar branch of ulnar artery • Curve of arch lies across upper part of palmar at level with proximal border of extended thumb • Gives rise to three palmar metacarpal arteries

24. Deep veins The deep veins of upper limb: accompany the arteries of the same region and bear similar names

25. Ⅲ.Nerves • Musculocutaneous肌皮神经 Distribution: Biceps brachii, brachalis and coracobrachialis ‘BBC nerve’; skin on anterior aspect of forearm

26. Median nerve 正中神经 • Distribution: • Injury: Apehand 猿掌 produces sign of benediction, in which the index and middle fingers cannot be flexed and the thumb cannot be opposed

27. Ulnar nerve • Distribution: • Injury: Clawhand 爪形手

28. Ulnar n. Brachial a. Median n. Radial a. Radial recurrent a. Ulnar a. Radial n. Ulnar recurrent a. Ulnar n.

29. Innervation of hand • Median n. • Ulnar n. • Radial n.

30. Median n. • Ulnar n. • Radial n.

31. 4. Regional anatomy

32. Musculocutaneous n. Median n. Medial brachial cutaneous n. Deep brachial a. Ulnar n. Superior ulnar coleteral a. Medial antebrachial cutaneous n. Ⅰ. Medial bicepital brachii furrow 肱二头肌内侧沟

33. Musculocutaneous n. Median n. Medial antebrachial cutaneous n. Axillary a. Medial brachial cutaneous n. Deep brachial a. Brachial a. Superior ulnar coleteral a. & Ulnar n. Inferior ulnar coleteral a.

34. aponeurosis of biceps Ⅱ. Cubiral fossa 肘窝 Boundaries • Base－line drawn through epicondylesof humerus （肱骨上髁） • Apex－brachioradialis laterally and pronator teres medially • Roof－skin, superficial faxcia, deep faxcia and aponeurosis of biceps（肱二头肌腱膜） • Floor－brachialis, supinator（旋后肌） and capsule of elbow joint

35. Contents－from lateral to medial • Biceps brachii tendon • Brachial a.－divides into radial and ulnar a.,usually at apex of fossa • Median n. Lateral to the biceps brachii tendon－radial n. and lateral antebrachial cutaneous n.

36. Ⅲ. Carpal tunnel 腕管 Flexor retinaculum屈肌支持带 • Thickening of deep fascia in the hand • Attached laterally to scaphoid and trapeziun and medially to pisiform and hamate Carpal tunnel 腕管 • Formed by flexor retinaculum and carpal groove • Transmits • Median n. • Flexor digitorum superficialis and flexor digitorum profundus enclosed by common flexor sheath • Flexor pollicus longus enclosed by tendinous sheath of flexor pollicus longus

38. Teninous sheath of flexor pollicislongus Common flexor sheath Ⅳ. Teninous sheath 腱鞘

39. Ⅴ. The palmar fascial space 手掌筋膜间隙

40. Deep palmar fascia 掌部深筋膜 Superficial layer • Thenar fascia 鱼际筋膜 • Hypothenar fascia 小鱼际筋膜 • Palmar aponeurosis 掌腱膜thick triangular membrane Deep layer palmar interosseous fascia 骨间掌侧筋膜

41. Osseofascial compartments of palm手掌骨筋膜鞘 Lateral compartment 外侧鞘 Medial compartment 内侧鞘 Intermediate compartment 中间鞘

42. Laeral intermuscular septum Medialintermuscular septum Palmar aponeurosis Thenar fascia Hypothenar fascia Adductor pollicis Palmar interosseous fascia Intermediate compartment 中间鞘 • Formedbypalmar aponeurosis, Laeral and medial intermuscular septum, palmar interosseous fascia and abductor policis fascia • Contents: superficial palmar arch, a., v.,n., tendons of flexor digitorum superficialis and profundus, lumbricales, common flexor sheath

43. Thenar space 鱼际间隙 Midplmar septum 掌中隔 Midpalmar space 掌中间隙 Fascia spaces 筋膜间隙 • Thenar space 鱼际间隙 • Midpalmar space掌中间隙

44. Pulp space指髓间隙On the palmar side of the tips of the fingers and thumb. They contain fatty tissue that is divided into numerous compartments by fibrous septa that pass between the distal phalanx and the skin. The pulp space is limited proximally by the firm adherence of skin and the distal flexion crease to the underlying tissue; this prevents pulp infection from spreading proximally along the finger.

45. Skin incisions

46. 思考题 • 试述肘窝的境界、内容及排列关系。 • 试述腕管的境界及穿行结构。 • 试述掌中间隙和鱼际间隙的境界及炎症蔓延途径。 • 由浅入深叙述手掌的层次结构。 • 试述手的神经支配情况（包括皮支和肌支）。 • 名词解释：肱骨肌管、前臂屈肌后间隙、腕尺侧管、桡侧囊、尺侧囊、指髓间隙。