Transcript 10 - shoulder j-forearm

Skin of the back and scapular
region :
Sensory nerve supply of
skin :post. Rami of spinal N.
1-skin of the neck : by post. Rami
of cervical Ns. C2-C7 except C1
and C8 spinal Ns.
2-skin of back of chest : by
post.rami of upper 6 thoracic Ns.
3-skin of back of (loin) abdomen :
by lower 6 thoracic Ns.
4-skin of buttock (gluteal): by
upper 3 lumbar Ns.
Blood Supply : post branches of
post. Intercostal & lumbar
arteries. Veins drain into azygos
veins & I.V.C.
Lymph drainage : above iliac
crest into post.axillary L.Ns.
Muscles of the back and scapular regions
Rotator Cuff
4 muscles : supraspinatus
,infraspinatus,teres minor &
subscapularis.
They assist in holding
head of humerus in glenoid
cavity of scapula during
movements of shoulder
joint, so, they assist in
stabilizing shoulder joint.
The cuff lies on the
anterior, posterior &
superior aspects of shoulder
joint.
It is deficient inferiorly,so
it is the site of weakness
Quadrangular space
It is an intermuscular
space ,bounded above by
subscapularis & capsule of
shoulder j. and inferiorly
by teres major, medially by
long head of triceps
,laterally by surgical neck
of humerus.
Axillary N. + post.
Circumflex humeral vessels
pass backward through
this space.
Spinal root of accessory nerve :
It runs downward in the
post.triangle of neck on
the levator scapulae.
It is accompanied by 3rd
& 4th cervical nerves +
transverse (superficial )
cervical artery.
It passes deep to
trapezius to supply it.
It can be injured in case
of stab wounds in the
neck.
Suprascapular nerve
It arises from upper trunk
of brachial plexus(C5+C6)
in the post. Triangle of
neck.
It runs downward deep to
suprascapular ligament,
which bridges
suprascapular notch, to
reach supraspinous fossa.
It supplies supraspinatus
& infraspinatus & shoulder
joint.
Axillary Nerve :
It arises from post.cord of brachial
plexus(C5 & C6) in the axilla.
It passes backward through
quadrangular space, inferior to
capsule of shoulder joint and medial
to surgical neck of humerus,
accompanied with post. Circumflex
humeral artery.
Branches :
1-articular branch to shoulder joint.
2-anterior terminal branch :it winds
around surgical neck of humerus
deep to deltoid to supply it & skin
over lower ½ of deltoid.
3-post.terminal branch : it gives
branches to teres minor + deltoidthen turns around post.border of
deltoid as upper lateral cutaneous
N.of arm to supply skin over lower
½ of deltoid muscle.
Sterno-clavicular
joint :
Articular surfaces : between
sternal end of clavicle, manubrium
sterni, and 1st costal cartilage.
Type :plane synovial joint.
Capsule : is attached to margin
of articular surfaces.
Ligaments :
1-anterior & post. sternoclavicular
ligaments to reinforce the capsule
in front & behind joint.
2-Accessory ligament (costoclavicular ligament) : connects
inferior surface of medial(sternal)
end of clavicle to the junction of 1st
rib & its costal cartilage.
Articular disc : it is fibrocartilaginous disc,which divides
joint cavity into 2 cavities.
Synovial membrane : lines the
capsule inside the joint.
Sterno-clavicular
joint :
Nerve supply : supraclavicular +
nerve to subclavius.
Movements :
1-forward & backward movement of
clavicle takes place in medial
compartement.
2-elevation & depression of clavicle
takes place in lateral compartement
Forward movement of clavicle :
by serratus anterior.
Backward movement of clavicle
: by trapezius & rhomboids.
Elevation of clavicle : by
trapezius, sterno-cleidomastoid,
levator scapulae & rhomboids.
Depression of clavicle : by
pectoralis minor & subclavius.
Acromio-clavicular joint
Articulation : between
acromion & lateral end of clavicle.
Type :plane synovial j.
Capsule : surrounds j.and is
attached to the articular surfaces.
Ligaments :
1-sup.& inf. acromio-clavicular
ligaments : reinforce the capsule.
2-accessory ligament (coracoclavicular lig.) :from coracoid
process to undersurface of
clavicle.
Articular disc :a wedge-shaped
fibrocartilaginous disc projects into
joint cavity from above.
Acromio-clavicular joint
Synovial membrane : lines
capsule.
Nerve supply : supra-scapular
N.
Movements :a gliding
movement takes place when
scapula rotates or when clavicle is
elevated or depressed.
Relations;
-anterior :deltoid
-posterior : trapezius.
-superiorly :skin
Muscles of Shoulder Region
•Deltoid.
•Supraspinatus.
•Infraspinatus.
•Subscapularis.
•Teres minor.
•Teres major.
N.B : Supraspinatus,
infraspinatus, teres minor
and Subscapularis--- these
are Rotator cuff muscles,
playing an important role in
keeping the head od humerus
in contact with the glenoid
cavity during movements of
shoulder joint.
Shoulder joint
Articulation :
1-head of humerus.
2-glenoid cavity of scapula,
which is deepened by
fibrocartilaginous rim called the
glenoid labrum (intra-capsular).
Type : ball & socket synovial j
Capsule :it surrounds joint
–medially : it is attached to
margin of glenoid cavity outside
the labrum.
Anterior view
-laterally : it is attached to
anatomical neck of humerus
+transverse humeral ligament.
Shoulder joint
Capsule :
-It is thin & lax specially
inferiorly, thus allowing
a wide range of mobility.
-It is strengthened by
ligaments & tendons of
rotator cuff muscles :
(supra-spinatus, infraspinatus, teres minor &
subscapularis).
Sagittal section
Long head of biceps is
intracapsular.
Long head of triceps
supports the capsule
during abduction of arm.
Shoulder joint
openings in the capsule:
1-an opening in anteromedial
part, the synovial membrane
passes through this opening to
form subcapsularis bursae
beneath subscapularis, and
separates subscapularis from front
of capsule.
Anterior view
2-an opening deep to
transverse ligament of
humerus at upper end of bicipital
groove, it transmits tendon of
biceps, surrounded by a synovial
tube.
Ligaments of Shoulder joint
Intra-capsular Ligaments
1-Glenohumeral ligaments :
are 3 bands of fibrous tissue that
strengthen the front of capsule.
2- Transverse humeral ligament
: strengthens the capsule and
bridges the groove between the 2
tuberosities- tendon of long head of
biceps passes beneath the ligament
Extrapsular ligament :
3- Coraco-humeral ligament :
strengthens the capsule above and
extends from root of coracoid
process to greater tuberosity of
humerus.
Accessory ligaments :
4-Coraco-acromial ligament :
extends between coracoid process
& acromion of scapula.
Shoulder joint
Interior of joint
Sagittal section
Synovial membrane :
-lines the capsule interiorly.
-it is attached to margins of hyaline cartilage covering the articular
surfaces.
-it forms a tubular sheath around tendon of long head of biceps.
-it passes through opening in the capsule to form subscapularis bursa
(between capsule & subscapularis).
Nerve supply : axillary N. & supra-scapular nerve(C5,6).
Shoulder joint
Relations :
Anteriorly :
subscapularis , axillary
vessels & brachial plexus.
Posteriorly :
infraspinatus & teres minor
.
Superiorly :
Supraspinatus,
subacromial bursa,
coraco-acromial ligament
& deltoid mus.
Sagittal section
Inferiorly :
long head of triceps,
axillary N.& post.
circumflex humeral ves.
Tendon of long head
of biceps passes through
the joint and emerges
beneath the transverse lig.
Movements of shoulder joint
Flexion :carries arm
forwards & medially, it is
performed by :
-Anterior Fs.of deltoid.
-Pectoralis major (clavicular
-Biceps (short head) &
Coracobrachialis.
head)
Extension :carries arm
backwards, it is performed by:
-Posterior Fs.of deltoid.
--Teres major.
-Latissimus dorsi.
Abduction :movement of
arm laterally & upwards, it
occurs in 3 stages :
-1st stage from 0-15, by
supraspinatus, it initiate
movement of abduction.
Movements of shoulder joint
-2nd stage : from 15-90, occurs
by middle Fs. Of deltoid.
-3rd stage : more than 90,
occurs by combined action of
Serratus anterior & Trapezius.
Adduction : by
-Pectoralis major.
-Teres major.
-latissimus dorsi.
-helped by subscapularis &
Teres minor.
Medial rotation :
-Anterior Fs. Of deltoid.
-pectoralis major. –Teres major
–latissimus dorsi. -Subscapularis
Lateral rotation : by
-Posterior Fs. Of deltoid.
-Infraspinatus.
-Teres minor.
Movements of shoulder joint
(S)
0-15
Circumduction :
is a combination of flexion,
abduction, extension &
adduction
Scapula & upper limb are
suspended from clavicle by
strong coraco-clavicular lig.
(D)Middle
fibers
15-90
(T+SA)
Above
90
In abduction above head,
greater tuberosity of humerus
comes in contact with
acromion of scapula.
Arterial Anastomosis around Scapula &
Shoulder
It occurs between the branches
of 1st part of subclavian & 3rd part
of axillary artery.
It occurs on the bone at inferior
angle of scapula, in subscapular,
supraspinous & infraspinous
fossae.
Branches from 1st part of
subclavian artery :
1-Suprascapular artery :lies
above suprascapular ligament, is
distributed to supraspinous &
infraspinous fossae.
2-Deep branch of superficial
cervical artery : It runs down on
medial border of scapula into inferior
angle of scapula.
Arterial anastomosis around the
scapula & shoulder
Branches from 3rd part of
axillary artery :
1-Subscapular artery:
-It descends along lower border
of subscapularis (into inferior
angle & subscapular fossa).
-It gives circumflex scapular
artery.
2-Circumflex scapular artery:
it pass deep to teres minor to
pass into infraspinous fossa.
 Both anterior & posterior
circumflex humeral arteries
form anastomosing circle around
surgical neck of humerus to
supply shoulder joint.
The Cubital Fossa
It is a triangular depression that
lies in front of ellbow.
Boundaries :
-base : imaginary line between 2
epicondyles of humerus
–apex : overlapping of
brachioradialis to pronator teres.
-laterally : brachioradialis
-medially : pronator teres.
–floor : supinator . & brachialis.
-Roof : skin, fascia, & bicipital
aponeurosis.
Contents :from medial to lateral:
1-median N.
2-bifurcation of brachial artery into
ulnar & radial arteries.
3-tendon of biceps.
4-radial N. & its deep branch.
5-supratrochlear Lymph Node.
The Cubital Fossa
Brachial artery
terminates into radial &
ulnar arteries at the neck
of radius.
Radial artery leaves
fossa by passing undercover of brachioradialis.
Ulnar artery leaves
fossa by passing deep to
pronator teres.
Median nerve leaves
fossa by passing between
2 heads of pronator teres.
Supratrochlear lymph node
It lies in superficial fascia
over upper part of fossa,
above trochlea.
It recevies afferent lymph
vessels from :
1-3rd ,4th & 5th fingers.
2-medial part of hand.
3-medial side of forearm.
Its efferent lymph vessels
accompany basilic vein to
end in lateral group of
axillary L.Ns.
Cutaneous nerves of forearm
Lateral cutaneous nerve of
forearm :
-it is the continuation of
musculocutaneous nerve
–it gives anterior & posterior
branches.
Medial cutaneous nerve of
forearm :
-it is a branch of medial cord
of brachial plexus.
-it gives anterior & posterior
branches to supply medial ½ of
front of forearm & medial side
of forearm respectively.
Posterior cutaneous nerve of
forearm :
-it is a branch of radial N.
-it supplies skin of back of
forearm.
Superficial veins
Cephalic vein :
-arises from lateral side of
dorsal venous arch on the back
of hand.
-it ascends on lateral side of
forearm into the front of cubital
fossa.
-In the cubital fossa, it gives
median cubital vein to join the
basilic vein.
Basilic vein :
-arises from medial side of
dorsal venous arch on back of
hand.
-it ascends on medial side of
forearm.
-In front of cubital fossa, it
recevies median cubital vein.
Fascial compartments of forearm &
interosseous membrane
The forearm is enclosed in
a sheath of deep fascia, which is
attached to the periosteum of posterior
border of ulna.
Fascial sheath together with I.M.+
fibrous intermuscular septa, divides
forearm into anterior, lateral &
posterior compartments.
Interosseous membrane (I.M) : is
a thin strong membrane uniting radius
& ulna between their interosseous
borders, its Fs.run obliquely downward
& medially. Its lower part is pierced by
anterior interosseous vessels.
Oblique cord : is a fibrous cord that
extends from the radius (below
tuberosity) to apex of coronoid process
of ulna.
T.S in Forearm to show anterioer &
posterior compartments
Contents of front of forearm
Anterior Fascial
compartment of forearm :
Superficial muscles (lateral to media)
1-pronator teres.
2-flexor carpi radialis.
3-palmaris longus.
4-flexor digitorum superficialis
5-flexor carpi ulnaris.
Deep muscles:
1-flexor digitorum profundus.medially
2-flexor pollicis longus. laterally
3-pronator Quadratus.
Median N. : supplies all Ms.except
flexor carpi ulnaris & medial ½ of
flexor digitorum profundus.
Ulnar N. : supplies
flexor carpi ulnaris & medial ½ of
flexor digitorum profundus.
Superficial branch of radial N--has no
branches in forearm.
Radial & ulnar arteries.
Deep group of muscles of Forearm
Flexor digitorum
profundus…medially
Flexor pollicis
longus…laterally.
Pronator quadratus.
Median Nerve in forearm
It leaves cubital fossa to enter
forearm between 2 heads of
pronator teres.
In the forearm, it descends in the
middle, between flexor digitorum
superficialis , & flexor digitorum
profundus.
At the wrist, it enters hand by
passing deep to flexor retinaculum.
Branches in forearm :
-muscular : pronator teres,+ flexor
carpi radialis, +palmaris longus +
flexor digitorum superficialis.
-articular : elbow, sup.radio-ulnar,
wrist joints.
-anterior interosseous nerve : it
descends in front of interosseous
membrane.
Median Nerve
Branches of anterior
interoseous nerve :
-muscular : flexor pollicis longus _
lateral ½ of flexor digit.profundus +
pronator Q.
-articular : inferior radio-ulnar joint
+ wrist joint.
-palmar cutaneous nerve : arises
above wrist j., to pierce deep fascia
to descend superficial to flexor
retinaculum to supply skin of
lateral 2/3 of palm.
Cutaneous nerves of palm &
fingers
(supplies base of thenar eminence)
Ulnar Nerve
At the elbow : it passes behind medial
epicondyle to enter forearm by passing
between 2 heads of flexor carpi ulnaris.
In the forearm, it descends in the
medial side, medial to ulnar artery, deep
to flexor carpi ulnaris, superficial to flexor
digit.profundus.
Above wrist, it pierces deep fascia to
descend superficial to flexor retinaculum
and lateral to pisiform bone, between
tendon of F.C.U.& F.D.S.
Branches :
-muscular : flexor carpi ulnaris + medial
½ of F.D.P.
-articular : to elbow joint.
-palmar cutaneous : pierces deep fascia
to supply skin over hypothenar eminence
+ skin of medial 1/3 of palm.
-posterior cutaneous branch : passes
posteriorly to supply skin of back of
medial 1/3 of hand + skin of back of
proximal phalanx of medial 1 ½ fingers,
( by 2 dorsal digital nerves).
Radial Nerve
It pierces lateral intermuscular septum of
lower arm to pass into cubital fossa.
It then passes in front of lateral epicondyle ,
between brachialis(medially) and /
brachioradialis & ext.carpi radialis longus.
At level of lateral epicondyle, it divides into
superfical & deep branches.
Branches :
-muscular : lateral part of brachialis +
brachioradialis + ext.C.R.longus.
-articular : elbow joint.
-deep branch of radial N. (posterior interoseous
N.) : arises from radial N. in cubital fossa in
front of lateral epicondyle. It pierces supinator
muscle to wind around neck of radius and
reach posterior compartment of forearm
between superficial & deep muscles to supply
the extensor muscles.
-Superficial branch :it is direct continuation of
radial N., descending deep to brachioradialis.
Above wrist, it pierces deep fascia and turns
backwards to supply skin of lateral 2/3 of back
of hand + skin of back of proximal phalanges of
lateral 3 1/2 fingers.
Ulnar artery
It begins in cubital fossa at level of
neck of radius as the largest terminal
branch of brachial artery.
In upper part, it lies deep to flexors of
forearm.
Below it becomes superficial , lies
between tendons of F.C.U. & F.D.S. to
pass in front of flexor retinaculum,
lateral to pisiform bone (site for ulnar
pulse)
Branches :
-muscular.
-Recurrent branches: anterior &
posterior ulnar recurrent to take part in
anastomosis around elbow.
-Common interosseous : divides into
anterior & posterior , lying in front &
behind interosseous membrane and
provide nutrient arteries to radius &
ulna.
Branches of ulnar artery in
forearm :
Muscular.
Recurrent branches that
take part in anastomosis around
elbow.
Branches that take part in
anastomosis around wrist.
Common interosseous
artery : arises from upper part
of ulnar artery and after a short
course divides into anterior &
posterior interosseous
arteries in front & behind I.M.,
they are nutrient to radius &
ulna.
Radial artery
It is the smaller terminal branch of
brachial artery , begins in cubital
fossa, at level of neck of radius.
It passes laterally, in front of
forearm deep to brachioradialis.
Its distal part is superficial, covered
by skin, superficial fascia & deep
fascia. (site of radial pulse on lateral
end of radius close to lateral side of
tendon of flexor carpi radialis).
At wrist, it turns backwards to
posterior surface of hand.
Branches :
-muscular
-Radial recurrent artery : takes part
in anastomosis around elbow.
-Superficial palmar branch : arises
just above wrist, enters palm of
hand to join ulnar artery to form
superficial palmar arch.
Flexor Retinaculum
(Anterior carpal tunnel)
it is a thickening of deep fascia
that holds long flexor tendons in
position in front of the wrist.
The bones of hand & flexor
retinaculum form osteofascial
tunnel, (carpal tunnel),for
passage of median N. & flexor
tendons of thumb & fingers.
Median N. lies in restricted space
between tendons of F.D.S & F.C.R.
Cross section of the hand
It is attached medially to pisiform
bone & hook of hamate, and
laterally to tubercle of scaphoid &
trapezium (in which the attachment
consists of superficial & deep parts
to form a tunnel for passage of
flexor carpi radialis tendon).
Flexor Retinaculum
(Anterior carpal tunnel)
Structures passing superficial to
flexor retinaculum, from medial to
lateral :
1-tendon of flexor C.U.
2-ulnar N.
3-ulnar artery.
4-palmar cutaneous branch of ulnar N.
5-tendon of palmaris longus.
6-palmar cutaneous branch of median
N.
Cross section of the hand
Structures passing deep to flexor
retinaculum from medial to lateral :
1-tendons of F.D.S + F.D.P in a
common synovial sheath.
2-median N. + anterior interosseous
branch.
3-anterior interosseous artery.
4-tendon of flexor pollicis longus.
5-tendon of flexor carpi radialis.
Muscles of Anterior Compartment
of Forearm
2/3 of
¾ of
+ interosseous
membrane.
((
)
Impression on middle of
lateral surface of shaft of
radius
Pronator Teres +
Pronator Quadratus.
Flexor carpi radialis
(
Plmaris Longus
)
Olecranon process of
ulna+ upper 2/3
post.border of ulna
Flexor Carpi Ulnaris
 Their tendons pass superficial to flexor retinaculum
(
(
)
)
(By 4 tendons into sides of middle
phalanges of medial 4 fingers.)
Flexor Digitorum Superficialis
Insertion :
by 4 tendons into medial 4 fingers, each tendon divides into 2 slips on palmar
surface of proximal phalanx to surround tendon of flexor digitorum profundus.
The 2 slips are inserted into sides of middle phalanx of medial 4 fingers.
From upper 2/3 of anterior surface of radius+ I.M.
upper ¾ of antero-medial surface of ulna +
I.M.
Into base of
Base of
Flexor Pollicis Longus
Flexor Digitorum Profundus
Flexion of interphalangeal &
Flexion of interphalangeal &
metacarpo-phalangeal joints of
metacarpo-phalangeal joints of
thumb.
medial 4 fingers.
Sensory nerves of dorsum of hand
Superficial branch of radial N. :
skin of lateral 2/3 of back of hand.
Dorsal cutaneous branch of
ulnar N.: skin of medial 1/3 of back
of hand
Skin of back of fingers by :
1-dorsal digital branches of radial N.:
skin of back of proximal phalanges of
lateral 3 ½ fingers.
2-palmar digital branches of median
nerve : skin of back of middle & distal
phalanges of lateral 3 ½ fingers.
3-dorsal digital branches of ulnar N.:
skin of back of proximal phalanges of
medial 1 ½ fingers.
4-palmar digital branches of ulnar N.:
skin of back of middle & distal
phalanges of medial 1 ½ fingers.
Contents of Lateral fascial
compartment of forearm
Upper
2/3 of
It helps in initiation of pronation &
supination
Lower 1/3 of
Blood supply : radial & brachial arteries.
Nerve supply : radial N.
Lower 1/3 of
(Upper 2/3 )
Styloid process
of radius
Dorsum of base of
Brachioradialis
Extensor carpi radialis longus.
Posterior fascial compartment of
forearm
 Superficial Group of
Muscles :
1-extensor carpi radialis brevis.
2-extensor digitorum.
3-extensor digiti minimi.
4-extensor carpi ulnaris.
5-anconeus.
 Deep Group of Muscles
1-supinator.
2-abductor pollicis longus.
3-extensor pollicis brevis.
4-extensor pollicis longus.
5-extensor indicis.
Blood supply :
posterior & anterior interosseous
arteries of ulnar artery.
Nerve supply : deep branch of
radial N.(post.interosseous N.).
Muscles of Posterior fascial
Compartment of Forearm
(Superficial muscles)
Post. Interosseous N.
(N.to Anconeous)
Muscles of Posterior fascial
Compartment of Forearm
(Deep muscles)
Post.interosseous
N.
(Common ext.
origin)
+ supinator crest
& fossa of ulna
V-shaped area,Upper 1/3
of front,lateral & back of
radius
Extensor Retinaculum
it is a thickening of deep fascia
that stretches across back of wrist
and holds long extensor tendons in
position.
It converts grooves of posterior
surface of distal ends of radius &
ulna into 6 separate tunnels or
compartments for passage of long
extensor tendons, the tunnels are
separated by fibrous septa.
It is attached medially to pisiform
bone & hook of hamate, and
laterally to distal end of radius.
Cross section of the hand
Extensor Retinaculum
Structures passing superficial to
extensor retinaculum from medial to
lateral :
1-dorsal(posterior) cutaneous
branch of ulnar N.
2-basilic vein.
3-cephalic vein.
4-superficial branch of radial N.
Cross section of the hand
Posterior carpal tunnel=
Structures passing deep to extensor
retinaculim in each compartments
(from lateral to medial) :Tendons of
1- abductor P.L +extensor P.B +
radial artery.
2-extensor C.R.L +extensor C.R.B.
3-extensor pollicis longus.
4-extensor digit.+ extensor indicis
5-extensor digiti minimi.
6-extensor carpi ulnaris.
Structures passing deep to extensor
retinaculum (posterior carpal tunnel)
(from lateral to medial)
Structures passing deep to extensor
retinaculum (posterior carpal tunnel)
Insertion of long extensor tendons
Extensor digitorum muscle gives rise to 4 tendons for medial 4 fingers.
Tendon to index finger is joined on its medial side by tendon of extensor
indicis, and tendon to little finger is joined on its medial side by 2 tendons of
extensor digiti minimi.
On back of each finger, the extensor tendon expands to join the fascial
expansion called extensor expansion.
Each extensor expansion divides into : a central part, inserted into base of
middle phalanx, and 2 collateral parts to insert into base of distal phalanx.
Dorsal extensor expansion
Each dorsal extensor expansion receives the insertion of :
1-an interosseous muscle on the medial side.
2-an interosseous & lumbrical muscles on the lateral side.
Radial artery in dorsum of hand
It reaches back of hand by
passing between lateral
collateral ligament of wrist
joint
and tendons of abductor
pollicis longus + extensor
pollicis brevis.
It passes beneath tendon
of extensor P.L to reach the
interval between 2 heads of
1st dorsal interosseous to
enter palm of hand.
Anatomic snuffbox : it is a skin
depression on lateral side of wrist, bounded
medially by tendon of extensor pollicis
longus and laterally by tendons of abductor
pollicis longus & extensor pollicis brevis.
On reaching palm, it curves
medially between oblique &
transverse heads of adductor
pollicis to join deep branch of
ulnar artery to form
“deep palmar arch”.
Branches of radial artery on the dorsum
of hand
Dorsal digital artery to
lateral side of dorsum of the
thumb.
1st dorsal metacarpal artery
,which divides into 2 dorsal
digital branches for adjacent
sides of thumb & index
finger.
Anatomic Snuffbox
it is a skin depression on lateral side of wrist, bounded medially by tendon
of extensor pollicis longus and laterally by tendons of abductor pollicis longus
& extensor pollicis brevis.
Clinically ,it is the site for radial artery pulsations.
Dorsal venous arch
It lies in superficial fascia (subcutaneous tissue) ,proximal to metacarophalangeal joints ,and drains on lateral side into cephalic V. and on medial
side into basilic V.
Venous blood from hand drains into the arch via dorsal digital veins.
Radial Nerve in lateral & posterior compartment
It pierces lateral intermuscular septum of lower
arm to pass into cubital fossa.
It then passes in front of lateral epicondyle ,
between brachialis(medially) and / brachioradialis
& ext.carpi radialis longus (laterally).
At level of lateral epicondyle, it divides into
superfical & deep branches.
Branches :
-muscular : lateral part of brachialis +
brachioradialis + ext.C.R.longus.
-articular : elbow joint.
--Superficial branch :it is direct continuation of
radial N., descending deep to brachioradialis.
Above wrist, it pierces deep fascia and turns
backwards to supply skin of lateral 2/3 of back of
hand + skin of back of proximal phalanges of
lateral 3 1/2 fingers.
-Deep branch (posterior interosseous N.) :
Arises from radial N. in cubital fossa in front of
lateral epicondyle. It pierces supinator muscle to
reach posterior compartment of forearm, between
superficial & deep muscles to supply the extensors
and ends in wrist joint.
(so, it gives muscular & articular branches).
Anterior & posterior interosseous arteries
(arteries of posterior compartment of forearm)
They arise from common
interosseous artery, a short
branch of ulnar artery in upper
part of front of forearm,which
divides into 2 branches :
Anterior interosseous artery :
descends in front of I.M. Above
wrist , it pierces I.M.to reach back
descending behind I.M. and takes
part in anastomosis around wrist.
Posterior interosseous artery:
a small branch which passes above
I.M. to reach back of forearm. It
ends by anastomosing anterior
interosseous artery and takes part
in anastomosis around wrist.
The 2 arteries supply radius &
ulna + muscles lying in front &
behind I.M.
Anterior & posterior interosseous arteries
Anterior interosseous artery
Radial artery in the lateral side of forearm ,
where it deviates posteriorly to reach
anatomical snuffbox on the dorsum of hand
Lower 1/3 of
Front of
Front of
Common ext. origin + post. Border of
ulna
Dorsum of base of
Dorsum of Base of
Extensor carpi radialis brevis &
extensor carpi ulnaris.
1-
for
2-
Into its extensor
expansion
Extensor Digitorum & Extensor Digiti minimi
Insertion of ext.digitorum : by 4 tendons into medial 4 fingers.
Each tendon expand to form ext.expansion, which divides into central
part & 2 collateral parts.
Central part is inserted into post.surface of base of middle phalanx.
2 collateral parts are inserted into post.surface of base of distal phalanx.
Olecranon process of ulna(lateral
surface).
Post.surface of shaft of radius
Post.surface of shaft of ulna
Anconeous
Middle of Post.surface of shaft of radius +ulna + I.M.
Middle 1/3 of post.surface of radius +I.M.
Middle 1/3 of Post.surface of shaft of ulna +I.M.
Lower 1/3 of post.surface of
ulna + I.M.
Into extensor expansion of index finger
Abductor pollicis longus, extensor pollicis brevis,
extensor pollicis longus, extensor indicis .
Lateral epicondyle
of humerus.+
supinator crest&
fossa of ulna
Into V-shaped area in Neck & upper
1/3 of shaft of radius
Supinator muscle.
Cutaneous nerves of palm
Palmar cutaneous branch of
median N. : supplies skin of
lateral 2/3 of palm.
Palmar cutaneous branch of
ulnar N. : supplies skin of
medial 1/3 of palm.
Lateral cutaneous N. of
forearm or/superficial branch
of radial N. : supplies skin over
base of thenar eminence.
Skin of Palmar surfaces of
fingers is supplied by :
1-palmar digital branches of
median N…. For palmar surfaces
of lateral 3 ½ fingers.
2-palmar digital branches of
ulnar N…for palmar surfaces of
medial 1 ½ fingers.
Palmar aponeurosis
It is a triangular thickening of deep
fascia, occuping central part of the palm.
Its apex is directed upwards and is
attached to flexor retinaculum and gives
insertion to palmaris longus muscle.
Its base is directed downwards and is
divided into 4 slips for medial 4 fingers.
Each slip divides into 2 bands which
diverge from each other and pass
backwards and finally fuse with the
fibrous flexor sheath and deep transverse
metacarpal ligaments.
Its medial & lateral borders send
fibrous septa into palm to form palmar
fascial spaces.
Its function to protect tendons,nerves
& blood vessels in the palm.
Palmaris brevis muscle
It is a thin muscle which is present in
superficial fascia of palm, in front of
hypothenar eminence.
Origin : flexor retinaculum & palmar
aponeurosis.
Insertion : skin of medial side of
palm.
Nerve supply : superficial terminal
branch of ulnar N.
Function : it deepens cup of hand and
enables hand to hold a rounded objects.
Structures passing superficial to
flexor retinaculum
The carpal Tunnel
The long tendons of fingers & thumb and median N. pass through
the tunnel. The tendons of F.D.P. lie behind superficialis tendons,
together in a common synovial sheath.
Tendon of F.P.L.muscle runs through lateral part of tunnel in its own
synovial sheath.
Median N. passes beneath flexor retinaculum in a restricted space
between F.D.S & F.C.R muscles.
Carpal tunnel syndrome
It is a burning pain or ‘pins & needles’ along the
distribution of median nerve to lateral 3 ½
fingers + weakness of thenar muscles (abductor
P.brevis, flexor P. brevis + opponens pollicis).
It is due to compression of median N. within
the tunnel as a result of thickening of synovial
sheaths of flexor tendons or arthritis of carpal
bones.
It needs surgical decompression of tunnel.
No paresthesia over thenar eminence due to
palmar cutaneous branch of median N. passes
superficial to flexor retinaculum.
Fibrous flexor sheaths
It extends from head of
metacarpal bone to base of distal
phalanx.
Its proximal end is open and is
contineous with palmar aponeurosis.
Its distal end is closed and is
attached to palmar surface of distal
phalanx.
Its function to hold flexor
tendons (F.D.S + F.D.P, & F.pollicis
longus) and their synovial sheaths.
Flexor synovial sheaths
Synovial sheath of tendon of
flexor pollicis longus (radial
bursa) :
-begins above flexor retinaculum and
extends to the insertion of tendon
(distal phalanx).
Common flexor synovial
sheath :
-surrounds the 8 tendons of F.D.S &
F.D.P (ulnar bursa)
-begins above the flexor retinaculum
-ends in the middle of palm.
-continuous with the synovial sheath
of little finger.
-the sheaths of index,middle & ring
fingers do not communicate with the
common sheath, they have digital
synovial sheaths, that ends at distal
phalanges.
Vincula tendinum
They are long threads (vincula
longa) or short triangular bands
(vincula brevia).
They are vascular folds of
synovial membrane that connect
the tendons to palmar surface of
phalanges.
Their function :
1-allow the long tendons to move
smoothly beneath flexor
retinaculum and fibrous flexor
sheaths.
2-carry blood supply to tendons
4 Lumbrical muscles
Origin : lateral sides of tendons of F.D.P.
Insertion : pass backwards along lateral sides of metacarpo-phalangeal
joints of medial 4 fingers into lateral sides of extensor expansions of these
fingers.
N.supply : lateral 2 lumbricals (1st &2nd )by median N. – medial 2
lumbricals(3rd &4th ) by deep branch of ulnar N.
Action : with interossei, they flex metacarpo-phalangeal joints and
extend interphalangeal joints of medial 4 fingers (Writing position).
Interossei muscles
4 Palmar interossei &
4 dorsal interossei.
Origin : metacarpal bones.
Insertion :proximal phalanges
& dorsal extensor expansion.
N.supply : deep branch of
ulnar N.
Anterior view
Action :
-palmar interossei : adduction of
fingers to the middle line of
middle finger.
dorsal interossei : abduction of
fingers from middle line of
middle finger.
-both lumbricals + interossei
…..’’writing position’’
Origin & insertion & action of
palmar & dorsal interossei muscles
Short muscles of thumb
(thenar eminence muscles)
Abductor pollicis brevis,
laterally.
Flexor pollicis brevis,
medially.
Opponens pollicis, deep.
Adductor pollicis
(obliqe & transvere heads).
N.supply : all are supplied
by median N. EXCEPT
adductor pollicis by
deep branch of ulnar N.
Abduction & adduction =
carpo-metacarpal joint.
Flexion = metacarpo-phalngeal
joint.
Short muscles of little finger
(hypothenar eminence muscles)
Abductor digiti minimi.
Flexor digiti minimi.
Opponens digiti minimi.
N.supply :all these muscles
are supplied by deep branch of
ulnar N.
Anterior view
Ulnar artery in the palm
It enters hand by passing
superficial to flexor retinaculum,
lateral to ulnar N. and pisiform bone.
Anterior view
In the hand it divides into deep &
superficial palmar branch.
-superficial palmar branch : is a
direct continuation of ulnar artery. It
joins superficial palmar branch of
radial to form superficial palmar
arch,.in front of long flexor tendons
and behind palmar aponeurosis.
The curve of arch lies at level with
the distal border of fully extended
thumb. It gives 4 palmar digital
arteries to the fingers.
-deep branch of ulnar artery :
passes backwards (accomppanied by
deep branch of ulnar N.) between
abductor digiti minimi & flexor digiti
minimi to join radial artery to form
deep palmar arch.
Branches of Superficial palmar arch
Palmar digital artery …to medial side of little finger.
3 common palmar digital arteries : each one divides into 2 palmar
digital branches to adjacent sides of fingers. They are joined with :
common palmar metacarpal arteries of deep palmar arch.
Radial artery in the palm
It leaves forearm by winding around lateral aspect of wrist into dorsum of
hand.
It leaves dorsum of hand by turning forward between the 2 heads of 1st
dorsal interosseous muscle.
It enters palm curving medially between the oblique & transverse heads of
adductor pollicis to join deep branch of ulnar artery to form deep palmar
arch, which lies beneatn long flexor tendons and in front of metacarpal
bones & interosseous muscles. The curve of arch lies at a level with
proximal border of extended thumb.
Branches of radial artery in the palm :
Arteria radialis indicis :
supplies lateral side of index
finger.
Arteria princeps pollicis :
divides into two to supply lateral
& medial sides of thumb.
Branches of deep palmar
arch:
3 common palmar
metacarpal arteries : they
run in 2nd ,3rd &4th intermetacarpal spaces to end by
joining common palmar
digital arteries at roots of
fingers.
Median nerve of the palm
Course :
-it leaves forearm to enter hand by
passing deep to flexor retinaculum.
–it ends in the palm by dividing into
terminal lateral & medial branches.
Branches in the hand :
-the 2 terminal branches give rise to :
1-muscular branches : to supply 5
Ms. (Abductor pollicis brevis, flexor
pollicis brevis, Opponens pollicis) +
lateral 2 lumbricals (1st & 2nd ).
2-cutaneous branches : by 5
palmar digital branches to supply
skin of palmar surface of lateral 3
½ of fingers. They also supply nail
beds & skin over back of middle and
distal phalanges of same fingers.
palmar cutaneous branch of
median nerve : in the forearm and
crosses superficial to flexor
retinaculum to supply skin of lateral
2/3 of palm.
Ulnar nerve in the palm
Course :
palmar cutaneous
branch of ulnar nerve :
-arises in forearm above
wrist, passing superficial
to flexor retinaculum to
supply skin of medial 1/3
of palm of hand.
-it enters hand by passing superficial to flexor
retinaculum, it divides into terminal superficial
& deep branch.
-superficial branch :
-passes deep to palmaris brevis to supply it.
-it gives 2 palmar digital branches for
medial 1 ½ fingers.
-deep branch :
-passes backwards between abductor D.M. &
flexor D.M. and then turns laterally across
palm deep to flexor tendons proximal to deep
palmar arch.
-supplies 14 Ms. (3 hypothenar + medial 2
lumbricals 3rd ,4th + 4 palmar interosseoi +
4 dorsal interosseoi + adductor pollicis).
Pulp space of fingers
Deep fascia of pulp of each finger
fuses with periosteum of terminal
phalanx.
Each pulp space is filled with fat and
is subdivided by fibrous septa .
Terminal branch of digital artery that
supplies diaphysis of terminal phalanx,
runs through this pulp space, while the
blood supply of epiphysis is proximal
to pulp space.
Felon (pulp –space infection) :
common case leads to infection of
terminal phalanx and necrosis of
diaphysis, but epiphysis is saved.
Palmar fascial spaces
From medial border of palmar
aponeurosis, a fibrous septum
passes backward and attached to 5th
metacarpal bone. Medial to this
septum is a medial fascial
compartment containing 3
hypothenar muscles + loose C.T.
From the lateral border of
palmar aponeurosis, a second
fibrous septum passes obliquely
backward to 3rd metacarpal bone. It
divides palm into thenar space
(contains 1st lumbrical) & midpalmar
space (contains 2nd ,3rd ,4th
lumbricals).
3rd fibrous septum passes
backward from lateral side to attach
to 1st metacarpal, lateral to this
septum a lateral fascial
compartment containing muscles of
thenar eminence.