surface anatomy of upper limb,Nerves,Artery,

1. SURFACE ANATOMY
Dr. Mehwish
Lecture

3. PECTORAL REGION
■ The pectoral region lies on the front of the chest.
■ It essentially consists of structure which connect the upper limb to the anterolateral chest wall
■ Muscles of the Pectoral Region.
It contains four muscles that exert a force on the upper limb;
■ pectoralis major,
■ pectoralis minor,
■ serratus anterior
■ subclavius.

4. AXILLA
■ The axilla or armpit is pyramidal space situated wall.
■ It resembles a four-sided pyramid
■ Apex, it is directed upward and medially toward the root
of the neck.
■ Base or floor, it is directed downwards, and is formed by skin and fasciae
Walls
■ Anterior wall: pectoralis major, minor
■ Posterior wall: subscapularis ,teres major, latissimus dorsi
■ Medial wall: upper for ribs their intercostal muscle.& upper part of the serratus
anterior muscles.
■ Lateral wall: it is very narrow b/c the anterior &posterior walls converge on it.

7. THE BREAST / MAMMARY GLAND
■ The breast or mammary gland is the important structure parent in the pectoral
region.
■ The breast is found in both sexes, but is rudimentary in the male, and well
developed in female after puberty
 MODIFIED
■ sweat gland , and provides nutrition to the newborn in the form of milk.
 LOCATION &EXTENT
VERTICALLY
From second to sixth rib in the mid clavicular line
HORIZONTALLY
From lateral border of sternum to the mid axillary line along the fourth rib

8. IMPORTANT RELATIONS
■ The base of the mammary gland called as
mammary bed rests upon the
following structures (From superficial to deep).
MUSCLES-
Pectoralis major, serratus anterior,
External oblique
RETROMAMMARY SPACE
A space deep to the base of the gland, lies superficial
to deep fascia, contains loose areolar tissue, makes
the gland freely movable.

10. PRESENTING PARTS
NIPPLE
 Narrow projection in the center of the anterior part of the breast,
 lies in the fourth intercostal space, pink in color,
 it has high nervous innervation and openings of 15-20 lactiferous ducts
 AREOLA
 Circular pigmented area of skin around the base of the nipple, becomes darker
during pregnancy and lactation, contains modified sebaceous glands which
becomes enlarged during pregnancy and lactation forming tubercles
of Montgomery

11. Structure of breast
■ The structure of the breast may be conveniently studied by dividing it into
skin, the parenchyma ,the stroma.
THE SKIN.
It covers the gland, the skin surrounding the base of the nipple is pigmented &
forms a circular area called the areola.
THE PARENCHYMA.
It is made of glandular tissue which secretes milk
Each lobe is a cluster of alveoli, and is drained by lactiferous duct.
Each duct has a dilatation called a lactiferous sinus.
THE STROMA.
It forms the supporting frame work of the gland.
It is partly fibrous & partly fatty.

15. (AXILLARY) LYMPH NODES
■ Level I – located laterally or below the lower margin of pectoralis minor
■ Level II – located deeply in relation to pectoralis minor
■ Level III – located medially or superiorly to upper margin of pectoralis minor
 LYMPHATIC DRAINAGE
Lymphatic spread of a growth of the breast may occur further afield when these normal
pathways have become interrupted by malignant deposits, surgery or radiotherapy.
Secondaries may then be found in the
lymphatics of the opposite breast or in the opposite axillary lymph nodes
the projection lymph nodes (via lymph vessels in the trunk wall)
the cervical nodes
in peritoneal lymphatics spreading there in a forward way from the lower internal
mammary nodes

16. LYMPHATIC VESSELS
• Superficial
• follow the superficial veins, drain into supratrochlear and axillary lymph nodes
• The superficial lymphatics drain the skin over the breast except for the nipple
and areola. The lymphatics pass radially to the surrounding lymph nodes
(axillary, internal mammary, supraclavicular and cephalic).
• Deep
• Accompany main vessels, end in axillary lymph nodes
• The deep lymphatics drain the parenchyma of the breast. They also drain the nipple
and areola

17. BLOOD SUPPLY
■ Thoracoaromial artery
■ Lateral thoracic artery
■ Intercostal artery
■ Posterior intercostal artery
■ Nipple
■ Superior vena cava
■ Axillary vein.

18. BRACHIA PLEXUS

19. BRACHIA PLEXUS
■ Plexus -means collection of nerves.
■ THE plexus consists of ROOTS,TRUNKS,DIVISION,
CORD and BRANCHES.
■ ROOTS-Formed by anterior primary rami of spinal nerves C5-C8,T1.
■ CORD
■ LATERAL CORD
Formed by union of Anterior divisions of Superior & Middle trunk.
■ MEDIAL CORD-
Formed by Anterior division of Lower trunk
■ POSTERIOR CORD-
Formed by Posterior division of all 3 trunks.

20. BRANCHES
■ The branches of the different parts of the brachial plexus are:
■ Branches of the Roots:
■ Dorsal scapular nerve (C5)
■ Long thoracic nerve (C5, C6 & C7)
■ BRANCHES OF THE TRUNK:
■ The only trunk which gives branches is the upper trunk, it gives:
■ Nerve to Subclavius (C5 & C6)
■ Suprascapular nerve (C5 & C6)-
(supplies the supraspinatus and infraspinatus muscles)

21. ■ Branches of the Lateral Cord:
■ Lateral pectoral nerve (C5,C6 &C7)
■ Musculocutaneous nerve (C5,C6 &C7)
■ Lateral root of median nerve (C5,C6 &C7)
■ Branches of medial cord:
■ Medial pectoral nerve (C8 &T1)
■ Medial cutaneous nerve of the arm (C8 &T1)
■ Medial cutaneous nerve of the forearm (C8 &T1)
■ Medial root of median nerve (C8 &T1)
■ Ulnar nerve (C7,C8 &T1)

22. ■ Branches of the posterior cord
■ Upper subscapular nerves (C5 & C6)
■ Lower subscapular nerves (C5 & C6)
■ Axillary nerve (C5 & C6)
■ Thoracodorsal nerve (C6,C7 & C8)
■ Radial nerve (C5,C8 &T1)

23. ■ TRUNKS-
It is divided into 3 trunks
■ SUPERIOR TRUNK -Formed by C5&C6
■ MIDDLE TRUNK-Formed by C7
■ INFERIOR TRUNK-Formed by C8&T1
■ DIVISIONS-
Each Trunk divides into ANTERIOR & POSTERIOR divisions.

24. BRACHIAL PLEXUS

25. AXILLARY ARTERY

27. AXILLARY ARTERY
■ Axillary artery is the continuation of the subclavian artery
■ EXTENDS.
■ Outer border (First rib)
■ Medial border (pectoralis minor muscles)
■ Lower border (teres major muscle)
■ PARTS.
■ The pectoralis minor muscle crosses artery & divides it into three parts.
■ First part, superior (proximal) to the muscles
■ Second part, posterior (deep) to the muscles
■ Third part, inferior (distal) to the muscles

30. Relations of axillary artery
Relations of First Part
■ ANTERIORLY
(i) Skin.
(ii) Superficial fascia,
(iii) Deep fascia.
(iv) pectoralis major.
(v) cephalic vein, lateral pectoral nerve, and
thoracoacromial vessels.
(vi) medial pectoral nerves.
■ LATERALLY
(i)Lateral and posterior cords of the brachial
plexus.
■ POSTERIORLY
■ First intercostal space with the
■ external intercostal
muscle.
■ (ii) First and second digitations
■ of the serratus anterior
■ (iii) Medial cord of brachial
■ MEDIA
■ (I) Axillary vein
■ The first part of the axillary
artery is enclosed (together
with the brachial plexus) in the
axillary sheath,

31. Relations of Second Part
■ ANTERIORLY
(i) Skin.
(ii) Superficial fascia.
(iii) Deep fascia.
(iv) Pectoralis major.
(v) Pectoralis minor.
■ POSTERIORLY
(i) Posterior cord of brachial plexus.
(ii) Coracobrachialis.
■ MEDIALLY
(i) Medial cord of brachial plexus,
(ii) Medial pectoral nerve,
(iii) Axillary vein.
■ Laterally
(i)Lateral cord of brachial plexus

32. Relations of Third Part
■ ANTERIORLY
(i) Skin.
(ii) Superficial fascia,
(iii) Deep fascia.
(iv) pectoralis major and median
nerve.
■ POSTERIORLY
(i) Radial nerve.
(ii) Axillary nerve in the upper part,
(iii) Subscapularis in the upper part,
(iv) Tendons of the latissimus dorsi
and teres major in the lower part.
■ LATERALLY
(i) Coracobrachialis.
(ii) Musculocutaneous nerve
in the upper part,
(iii) Lateral root of median nerve
in the upper part,
(iv) median nerve in the lower part.
■ MEDIALLY
(i) Axillary vein,
(ii) Medial cutaneous nerve of the
forearm and ulnar nerve,
(iii) Medial cutaneous nerve of arm,
medial to the axillary vein

33. BRANCHES OF AXILLARY ARTERY
■ The axillary artery gives six branches.
■ Superior thoracic artery
■ Thoracoacromial (acromiothoracic) artery
■ Lateral thoracic artery
■ Subscapular artery
■ Anterior circumflex humeral artery
■ Posterior circumflex humeral artery

36. 1.SUPERIOR THORACIC ARTERY
■ The superior thoracic artery is a
small branches
■ Running forward and medial ward
along the upper border of the
Pectoralis minor,
■ it passes between it and the
Pectoralis major to the side of the
chest.

37. THORACOACROMIAL (ACROMIOTHORACIC) ARTERY
■ Thoracoacromial artery is a branch of the second part
of the axillary artery.
■ ARISES from the upper border of the pectoralis minor,
■ pierces the clavipectoral fascia, and soon divides into
four
■ BRANCHES.
■ Pectoral Branch.(pectoral muscles)
■ Deltoid Branch.(deltopectoral groove, along with the
cephalic vein;)
■ Acromial Branch.(coracoid process and ends by joining
the anastomosis over the acromion)
■ Clavicular branch.(superomedial deep to the pectoralis
major, and supplies the sternoclavicular joint and
subclavius.)

38. LATERAL THORACIC ARTERY
■ Lateral thoracic artery is a branch of the
second part of the axillary artery.
■ Emerges at, and runs along, the lower
border of the pectoralis minor
■ Close relation with the anterior group of
axillary lymph nodes.
■ In females, the artery is large and gives off
the lateral mammary branches to the
breast.

39. ■ Subscapular artery is the largest branch of the
axillary artery,
■ ARISING from its third part.
■ RUNS along the lower border of the
subscapularis
■ TERMINATE near to the inferior angle of the
scapula
■ SUPPLIES the latissimus dorsi and the serratus
anterior.
■ It gives large branch, the circumflex scapular
artery,
SUBSCAPULAR ARTERY

40. Anterior circumflex humeral artery
■ Anterior circumflex humeral artery is a small branch
■ ARISING from the third part of the axillary artery, at the
lower border of the subscapularis.
■ It passes laterally in front of the intertubercular sulcus of
the humerus,
■ ANASTOMOSES with the posterior circumflex humeral
artery, to form an arterial circle round the surgical neck of
the humerus.

42. POSTERIOR CIRCUMFLEX HUMERAL ARTERY
■ Posterior circumflex humeral artery is much larger than the anterior artery
■ It arises from the third part of the axillary artery at the lower border of the
subscapularis,
■ close to its anterior counterpart

43. AXILLARY SHEATH
■ The axillary sheath is a fibrous sheath that encloses the axillary
artery and the three cords of the brachial plexus to form the
neurovascular bundle, surrounded by the axillary fat.
■ ANASTOMOSIS COLLATERAL CIRCULATION
■ Collateral circulation:
Subclavian artery-----Suprascapular artery circumflex scapular artery-
---
subscapular artery----axillary artery

45. Axillary vein
■ The axillary vein begins at the lower margin of the teres major muscle and is the continuation of
the basilic vein.
■ The axillary vein passes through the axilla medial and anterior to the axillary artery and becomes
the subclavian vein.
■ Tributaries of the axillary vein generally follow the branches of the axillary artery.
■ Other tributaries include brachial veins that follow the brachial artery, and the cephalic vein.

47. AXILLARY LYMPH NODES
■ All lymphatic from the upper limb drain into lymph nodes in the axilla.
■ The axillary nodes are generally divided into five groups on the basis of location
1. HUMERAL (LATERAL) NODES
■ Lateral lymph nodes lie around the distal end of axillary vein , receiving drainage from the arm, forearm,
and hand
2. PECTORAL (ANTERIOR) NODES
■ Pectoral lymph nodes lie along lateral thoracic vessels, receive afferents from anterior thoracic wall
including central and lateral portion of mamma
3. SUBSCAPULAR (POSTERIOR) NODES
■ Subscapular lymph node along subscapular vessels, receive lymph from nape and scapular region
4. CENTRAL NODES
■ Efferent above three groups pass to central lymph node
5. APICAL NODES
■ lie in fat of axillary fossa, receive drainage from all the above nodes, efferent pass to apical lymph node
Apical lymph node Lie in the apex of the axilla, along the proximal end of axillary vessels

48. BACK

49. BACK MUSCLES
■ The muscles of the back can be divided into three groups – superficial, intermediate and
deep:
■ Superficial – associated with movements of the shoulder.
■ Intermediate – associated with movements of the thoracic cage.
■ Deep – associated with movements of the vertebral column.
■ The deep muscles develop embryologically in the back, and are thus described
as intrinsicmuscles.
■ The superficial and intermediate muscles do not develop in the back, and are classified
as extrinsic muscles.

50. BACK MUSCLES
■ The superficial back muscles are situated underneath the skin and superficial fascia. They
originate from the vertebral column and attach to the bones of the shoulder – the clavicle,
scapula and humerus.
■ All these muscles are therefore associated with movements of the upper limb.
■ The muscles in this group are the trapezius, latissimus dorsi, levator scapulae and the
rhomboids. The trapezius and the latissimus dorsi lie the most superficially, with the trapezius
covering the rhomboids and levator scapulae.

51. Trapezius
■ The trapezius is a broad, flat and triangular muscle. The muscles on each side form a trapezoid
shape. It is the most superficial of all the back muscles.
■ Attachments: Originates from the skull, ligamentum nuchae and the spinous processes of C7-T12.
The fibres attach to the clavicle, acromion and the scapula spine.
■ Innervation: Motor innervation is from the accessory nerve. It also receives proprioceptor fibres
from C3 and C4 spinal nerves.
■ Actions: The upper fibres of the trapezius elevates the scapula and rotates it during abduction of
the arm. The middle fibres retract the scapula and the lower fibres pull the scapula inferiorly.

52. LATISSIMUS DORSI
■ The latissimus dorsi originates from the lower part of the back, where it covers a wide area.
■ Attachments: Has a broad origin – arising from the spinous processes of T6-T12, iliac crest, and
the inferior three ribs. The fibres converge into a tendon that attaches to the intertubercular sulcus
of the humerus.
■ Innervation: Thoracodorsal nerve.
■ Actions: Extends, adducts and medially rotates the upper limb.

53. LEVATOR SCAPULAE
■ The levator scapulae is a small strap-like muscle. It begins in the neck, and descends to attach to
the scapula.
■ Attachments: Originates from the transverse processes of the
C1-C4 vertebrae and attaches to the medial border of the scapula.
■ Innervation: Dorsal scapular nerve.
■ Actions: Elevates the scapula.

54. RHOMBOIDS
■ There are two rhomboid muscles – major and minor. The rhomboid minor is situated superiorly to
the major.
■ Rhomboid Major
■ Attachments: Originates from the spinous processes of T2-T5 vertebrae. Attaches to the medial
border of the scapula, between the scapula spine and inferior angle.
■ Innervation: Dorsal scapular nerve.
■ Actions: Pull in (pull back) and rotates the scapula.
■ Rhomboid Minor
■ Attachments: Originates from the spinous processes of C7-T1 vertebrae. Attaches to the medial
border of the scapula, at the level of the spine of scapula.
■ Innervation: Dorsal scapular nerve.
■ Actions: Retracts and rotates the scapula.

57. ULNAR NERVE(musician's nerve)
■ Ulnar Nerve is one of the terminal branches of brachial plexus. The ulnar nerve
is referred to as “the nerve of fine movements ” (musician's nerve)
■ It is the continuation of medial cord of brachial plexus which arises from the
anterior division of the lower trunk.
■ The fibers of ulnar nerve arise from the eight cervical and first thoracic nerve,
so the root value of ulnar nerve is C8 and T1. These (C8,T1) coordinate to form
the lower trunk of brachial plexus.

58. ■ Origin of the Ulnar Nerve ◦ The ulnar nerve originates from the C8-T1 nerve roots
(and occasionally carries C7 fibres) which form part of the medial cord of the
brachial plexus.
■ Deep branch of ulnar nerve:
■ Runs backward between the abductor & flexor digiti minimi Pierces the oponens
digiti minimi , Winds around the lower border of hook of hamate Finally it turns
laterally, Passes within the concavity of deep palmar arch Ends by supplying
adductor pollicis and palmar and dorsal interossei. Deep branch of ulnar nerve
■ Ulnar nerve injuries usually occur:
■ At thoracic outlet posterior to medial epicondyle ( med. epicondyle)
■ cubital tunnel (compression between the heads of the FCU) at the wrist
(compression in ulnar canal)

59. CUBITAL TUNNEL SYNDROME.
■ This is where the ulnar nerve is compressed the
cubital tunnel of the elbow.
■ Repetitive use of the arm or elbow (including
leaning on the elbow) Leaning on your elbow for
long periods of time can put pressure on the
ulnar nerve.
■ A direct blow to the inside of the elbow

60. Clinical features
■ neck, shoulder, and arm
pain, numbness, impaired
circulation to the
extremities (causing
discoloration).
■ Often symptoms are
reproduced when the arm
is positioned above the
shoulder or extended.
■ Pain can extend to the
fingers and hands,
causing weakness.

61. Median Nerve
■ Median nerve is a nerve which runs through the wrist and into the hand.
■ It provides sensation and some movement to the hand, the thumb, the index
finger, the middle finger, and half of the ring finger.
■ It is one of the terminal branches of the brachial plexus that extends along the
radial parts of the forearm and the hand supplies various muscles and the skin.
■ It arises from the brachial plexus by two large roots, one from the lateral and
one from the medial cord.
■ Nerve roots of the median nerve are from the ventral rami of the C6-T1 nerves.
■ The median nerve is formed by the unification of the medial and lateral cords.
It can be seen as the central line of an
‘M Shaped’ in brachial plexus, the cords of which surround the axillary artery.

62. Structure and Functions of Median Nerve
■ In the upper arm and near the shoulder, the median nerve branches off of the
brachial plexus.
■ A portion of its path covers the medial side of the arm, near both the biceps
brachii and brachialis muscle.
■ Median nerve also extends downward through the forearm, ultimately traversing
the carpal tunnel as it enters the hand.
■ It gives off an articular branch in the upper arm as it passes the elbow joint.
■ A branch to pronator teres may arise from the median nerve immediately
proximal to the elbow joint.

63. M SHAPE

64. RADIAL NERVE(Saturday night
palsy)■ The radial nerve is a major peripheral nerve of the upper limb. It originates from
the brachial plexus, from the ventral roots of spinal nerves C5, C6, C7, C8 & T1.
■ Course of the Radial Nerve
■ It passes behind the axillary artery next through the triangular interval to access
posterior compartment of the arm
■ It then turns around the spiral groove of the humerus among profunda brachii
artery, between the heads of the triceps
■ It enters antecubital fossa in front of the lateral epicondyle of humerus, within
brachialis and brachioradialis muscles.
■ Next its branches in the proximal forearm into two terminal branches:

65. ■ Deep branch (motor supply) – pierces supinator muscle and
descends along posterior interosseous membrane with the
posterior interosseous artery
■ Superficial branch (sensory supply) – descends under the
brachioradialis muscle to end in dorsum of the hand
■ Common Radial nerve injuries
■ Pressure of crutches on armpits (“crutch palsy
■ Somebody else falling asleep with their head lying on patient’s arm
( “honeymoon palsy“)
■ The patient falling asleep with hanging arm over the back of the
chair, classically whilst drunk (“Saturday night palsy“)

67. ■Thank you…