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The scapula

The borders of the scapula are equal ossis scapula. It has two surfaces,
three borders, three angles and three processes. It extends from the
second to the seventh ribs in the posterior aspect of the thorax. Although
it is thickly covered by the muscles most of its outline can be felt in the
living subject.

The surfaces
1. The costal surface is concave and is directed medially and
forwards. It is marked by three longitudinal ridges another thick
ridge adjoins the lateral border.
2. The dorsal surface gives attachment to the spine of the scapular
which divides the surface into a smaller supraspinous fossa and a
larger infraspinous fossa. The two fossae are connected by the
spinoglenoid notch, situated lateral to the root of spine.

The angles
1. The superior angle is covered by the trapezius.
2. The inferior angle is covered by the latissimus dorsi.
3. The lateral (or glenoid) angle is broad and bears the glenoid cavity
(or fossa) which is directed forwards, laterally and slightly
upwards.

The skin and fasciae of the back are adapted to sustain pressure of the
body weight. Accordingly, the skin is thick and fixed to the underlying
fasciae, the superficial fascia, which contain variable amount of fat, is
thick and strong and is connected to overlying skin by connective tissue;
and the deep fascia is dense in texture.
The cutaneous nerves of the back are derived from the posterior primary
rami of the spinal nerves. Their distribution extends up to the posterior
axillary lines.
Fascia propria consists of two lamines: lamina superficial covers the
scapulae, musculus trapezius, musculus teres major, musculus latissimus
dorsi. Lamina profound covers all ossis scapulae and forms fibrosis
place for m. supra and infraspinatus.
The spine divides the dorsal surface of the scapula into the supraspinous
and infraspinous fossae. In the fossa supraspinous m. supraspinatus lies,
in the fossa infraspinous m. infraspinatus, m. teres minor lie.
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Musculus subscapularis arises from the medial two thirds of the

subscapular fossa.
The vein and artery form the anastomosis round the body of the scapula.
The anastomosis occurs in the three fossae: subscapular, supraspinous
and infraspinous. It is formed by:
1) the suprascapular artery, a branch of the thyrocervical trunk, which
arises from the first part of the subclavian artery itself;
2) the deep branch of the transverse cervical artery, another branch of
the thyrocervical trunk;
3) the circumflex scapular artery, a branch of the subscapular artery,
which arises from the third part of the axillary artery.
This is an anastomosis between the first part of the subclavian artery and
the third part of the axillary artery.
These anastomoses provide a collateral circulation through which blood
can flow to the limb when the distal part of the axillary artery is blocked.

Nerves of scapular
Nervus scapularis from brachial plexus. It comes with arteria
suprascapularis.
Nervus dorsalis scapulae comes from brachial plexus and lies down the
lateral border of ossis scapulae.

Regio subclavia

The pectoral region = region subclavia lies on the front of the chest. It
essentially consists of structures, which form the anterior wall of fossa
axillaries.
The following features of the pectoral region can be seen or felt on the
surface of body.
The clavicle lies horizontally at the root of the neck, separating it from
the front of the chest. The bone is subcutaneous, and therefore palpable
throughout its length. It is convex forwards in its medial two thirds, and
concave forwards in its lateral one third. Medially, it articulates with the
sternum at the sternoclavicular joint, and laterally with the acromion at
the acromioclavicular joint. Both the joints are palpable because of the
upward projection ends of the clavicle. The sternoclavicular joint may
be masked by the sternoclaidomastoid muscle.
The board of this region is:
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superior – clavicular
inferior – the low border of the m. pectoralis major
medial – the angle of the sternal
lateral – the deltoideopectoral groove
The skin is thin, mobile. The superficial fascia of the pectoral region
contains moderate amount of fat, and continues with that of surrounding
regions. The mammary gland, which is well developed at females, is the
most important in all contents of this fascia. The fibrous septa given off
by the fascia’s support the lobes of the gland. In addition to fat, the
superficial fascia of the pectoral region contains cutaneous nerves
derived from the cervical plexus and from the intercostals nerves,
cutaneous branches from the internal thoracic and intercostals arteries.
Cutaneous vessels are very small. The anterior cutaneous nerves are
accompanied by the perforating branches of the internal thoracic artery.
The second, third and fourth or these branches are large at females for
supplying the breast. The lateral cutaneous nerves are accompanied by
the lateral cutaneous branches of the posterior intercostals arteries.
The deep fascia, covering the major pectoral muscle, is called the
pectoral fascia. It is attached to the clavicle superiorly, and to the
sternum anteriorly. Laterally, it passes over the infraclavicular fossa and
deltipectoiral groove and becomes the deltoid fascia. Interolaterally,
fascia becomes continuous to the axillary fascia. Inferiorly it covers m.
serratus anterior superior and m. obliqus abdominis externus.
The pectoral fascia is connected with the clavipectoral fascia by a
septum, which passes deep along the deltopectoral groove. The cephalic
vein, the deltoid branch of the thoraco-acromial artery and one or two
deltopectoral lymph nodes lie in the deltopectoral groove, under the
deep fascia on the medial side of the septum.
Clavipectoral fascia is a fibrous sheet, which situated deep to the major
pectoral muscle. It extends from the clavicle above, to the axillary fascia
below. This fascia incloses the minor pectoral muscle. It continues
below this muscle and gathered with pectoral fascia (pic.36, p.32).
The deep nerves and vessels are: a. thoracica interna, a. thoracica
lateralis, aa. intercostales, n. thoracicus longus, n. thoracodorsalis, nn.
intercostales.

Practical importance of cellular space

Under the musculus pectoralis major, on the musculus pectoralis minor
the cellurar tissue lies – it is a spatium subpectoralis superficialis. It
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connects with fossa axillaries of cellular tissue. There are the second
cellular tissue – spatium subpectoralis profundae, between the fascia
clavipectoralis and musculus pectoralis minor.

Regio deltoidea

The upper half of the humerus is covered on its anterior, lateral and
posterior aspects by the deltoid muscle. This muscle is triangular in
shape and forms the rounded contour of the shoulder.
The borders of the region are equal to position of muscle deltoid. The
skin is thick. The superficial fascia is not thick. It contains (in addition
to moderate amounts of fat and cutaneous nerves) the interolateral part
of the platysma arising from the deltoid fascia. Then fascia propria lays.
It is thick and covered the whole muscle. It gives spurs into the muscle
and form intra-muscular septa. Deltoid muscle arranges of its fibres,
those near the anterior and posterior border are long and linea; but the
middle fibres are bipenniform, rising from and being inserted into
fibrous.
The deltoid is an example of a multipennate muscle. A multipennate
arrangement allows a large number of muscle fibres to be packed into a
relatively small volume. As the strength of contraction of a muscle is
proportional to the number of muscle fibres present in it, a multipennate
muscle is much stronger than other muscles having the same volume.
The structures, deep to the deltoid muscle are: spatium subdeltoidea
which contain fatty tissue, art. circumphlexia humeri anterior, art.
circumphlexia humeri posterior and nervus axillaries.
Axillary nerve (nervus axillaris) and posterior circumflex fumeral
vessels ( art. et v. circumphlexia humeri postetior) come to spatium
subdeltoidea through the for. quadrilaterum which connect this space
with fossa axillaris. Art. circumphlexia humeri anterior dive os humeri
from anterior to posterior. Deeper to the spatium subdeltoideum are now
displayed; they include the coracoid of the scapula, both tuberosities and
upper part of the shaft of the humerus, the insertions of subscapularis,
spraspinatus, intraspinatus and teres minor muscles and subdeltoidea and
subacromial burses. These burses not open into the shoulder joint.
The functions of m. deltoidea are:
- it is the abductor of the arm ( at the shoulder joint);
- it is flexor and medial rotator of the arm;
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- it is extensor and lateral rotator of the arm.

Intramuscular injections are often given into the deltoid. They should be
given in the lower half of the muscle to avoid injury to the axillary
nerve.

Regio axillaris

The axilla is a pyramidal space situated between the upper part of the
arm and the chest wall. It resembles a four side pyramid and has an
apex, a base and four walls – anterior, posterior, medial and lateral.
The axilla is disposed obliquely in such a way that the apex is directed
upwards and medially towards the root of the neck and the base is
directed downwards.
Boundaries
1. Apex. It is directed upwards and medially towards the root of the
neck.
2. Base or floor. It is directed downwards and is formed by skin and
fascia.
3. Anterior wall – formed by the musculus pectorals major and
musculus pectorals minor.
4. Posterior wall – formed by the musculus subscapularis, musculus
teres major,musculus latissimus dorsi.
5. Medial wall. It is formed by: upper four ribs with their intercostals
muscles, upper part of the m. serratus anterior superior.
6. Lateral wall. It is very narrow because the anterior and posterior
walls converge on it. It is formed by: musculus coracobrahialis and
short head of the musculus biceps.
The principal contents of the axilla are:
1. Axillary artery and its branches.
2. Axillary vein and its tributaries.
3. Infraclavicular part of the brachial plexus.
4. Five groups of axillary lymph and the associated lymphatics.
5. Axillary fat and areolar tissue in which the other contents are
embedded. The blood vessels and nerves enter the axilla through
the opening at the apex and cross the space obliquely downwards
and laterally reach the medial aspect of the arm at the lower
opening of the axilla. The axillary vein lies to the medial side of
the artery throughout its course. The large nerve cords of the
brachial plexus are mainly lateral to the axillary artery as they
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enter the axilla: subsequently the cords and the nerves derived
from them become rearranged round the artery.
The plexus in the upper part of the axilla consists of three cords: lateral,
medial and posterior. Just below the clavicle, the lateral and posterior
cords are usually behind it. Behind the pectoralis minor plexus has
become so arranged that the three cords lie around the artery – each in
the position relative to the artery indicated by its name. In the lower part
of the axilla this position is maintained, but each cord has broken up into
the individual branches.

Axillaries artery
It is the continuation of the subclavian artery. It extends from the outer
border of the first rib to the lower border of the teres major muscle. It
continues as the brachial artery. Its direction varies with the position of
the arm.
The pectoralis minor muscle crosses it and divides it into three parts:
1. First part, superior (proximal) to the muscle.
2. Second part, posterior (deep) to the muscle.
3. Third part, inferior (distal) to the muscle.
The axillaries artery gives next branches:
- from the first part arteria thoracica suprema, arteria
thoracoacromialis arise;
- from the second part arteria thoracica lateralis arises;
- from the third part arteria subscapularis, arteria circumphlexia
humeri anterior and arteria circumphlexia humeri posterior arise.
Arteria thoracica suprema (superior thoracic artery) – this is very small
branch. It arises from the first of art. axillaris, runs downwards, forwards
and medially, passes between the two pectoral muscles and supplying
these muscles and the thoracic wall.
Arteria thoracoacromialis (thoraco-acromial artery). It emerges at the
upper border of the m. pectoralis minor, pierces the claviapectoral fascia
and soon divides into terminal branches.
Arteria thoracica lateralis (lateral thoracic artery). It emerges at and runs
along the lower border of the pectoral minor. At females the artery is
large and gives off the lateral mammary branches to mamma and to the
breast.
Arteria subscapularis ( subscapular artery ). This is the largest branch of
art. axillaris. It runs along the lower border of the subscapularis to
terminate near the inferior angle of the scapula. It supplies the latissimus
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dorsi and the serratus anterior muscles. It gives off art. circumphlexia
scapulae which is larger than the continuation of the main artery. This
branch passes through the foramen trilaterum, winds round the lateral
border of the scapular deep to the teres minor and gives a branch to the
subscapular fossa and to the fossa infraspinatus, both of which take part
in the anastomosis round the scapula. The terminal part of the
subscapular artery is arteria thoracodorsalis.to the m. latissimus dorsi.
Arteria circumphlexia humeri anterior (anterior circumflex humeral
artery).This is a small branch. It passes laterally in front of the
intertubecular sulcus of the humerus and anastomoses with the art.
circumphlexia humeri posterior. It gives off an ascending branch which
runs in the intertubercular sulcus and supplies the head of the humerus
and the shoulder joint.
Arteria circumphlexia humeri posterior (posterior circumflex humeral
artery). This is much lager than the anterior artery. It runs backwards,
accompanied by the axillaries nerve, passes through the foramen
quadrilaterum and ends by anastomosing with the art. circumphlexia
humeri anterior round the surgical neck of the humerus. It supplies the
shoulder joint, deltoid muscle and the muscles bounding the foramen
quadrilaterum. It gives off a descending branch which anastomoses with
the ascending branch of the art. profunda brahii.

Axillaries vein
The axillaries vein is the continuation of the basilica vein. The axillaries
vein is jointed by the venae comitantes of the brachial artery a little
above the lower border of the m. teres major. It lies on the medial side of
the axillaries artery. At the outer border of the first rib it becomes the
subclavian vein. In addition to the tributaries corresponding to the
branches of the axillaries artery, it receives the cephalic vein in its upper
part.
The axillaries nerve
This is an important nerve because it supplies the deltoid muscle which
is the main abductor of the arm. Surgically it is commonly involved in
dislocation of the shoulder and in fractures of the surgical neck of the
humerus.
The axillaries nerve is a branch of the posterior cord of the brachial
plexus.
Lateral cord consists of:
- nervus musculocutaneus;
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- lateral root of nervus medianus.

Medial cord gives:
- nervus ulnaris;
- medial root of the nervus medianus;
- nervus cutaneus brahii medialis;
- nervus cutaneus antebrahii medialis.
Posterior cord gives:
- nervus radialis;
- nervus axillaries.
The axillaries lymph nodes
The axillaries lymph nodes are scattered in the fibro-batty tissue of the
axilla. They are divided into five groups.
1. The nodes of the anterior (pectoral) group lie along the lateral
thoracic vessels. They receive lymph from the upper half of the
anterior wall of the trunk and from the major parts of the breast.
2. The nodes of the posterior (scapular) group lie along the
subscapular vessels on the posterior fold of the axilla. They receive
lymph from the posterior wall of the upper half of the trunk and
from the axillaries tail of the breast.
3. The nodes of the lateral group lie along the upper part of the
humerus, medial to the axillaries vein. They receive lymph from
the upper limb.
4. The nodes of the central group lie in the fat of the upper axilla.
They receive lymph from the preceding group and drain into the
apical group.
5. The nodes of the apical (intraclavicular) group lie deep to the
claviapectoral fascia along the axillaries vessels. They receive
lymph from the central group. From the upper part of the breast
and from the thumb and its web. The lymphatic from the thumb
accompanies the cephalic vein.

Intermuscular spaces
There are two intermuscular spaces in the posterior wall of fossa
axillaris.
Triangular space – foramen trilaterum.
Boundaries:
superior - m. teres minor
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inferior - m. teres major

lateral – long head of the m. triceps
Contents: art. circumphlexia scapulae.
It connects fossa axillaris with fossa infraspinata of scapula.
Quadrangular space – foramen quadrilaterum.
Boundaries:
superior – m. teres minor
inferior – m. teres major
lateral – surgical neck of the humerus
Contents: axillaries nerve (nervus axillaris), posterior circumflex
humeral vessels (art. circumphlexia humeri posterior).
This space connects fossa axillaris with spatium subdeltoidea.
Anastomosis and collateral circulation
The branches of the axillaries artery anastomose with one another and
with branches derived from neighbouring arteries (art. thoracica interna,
art. intercostalis, art. suprascapularis, art. profunda brahii, ramus
profundus arteria transversae coli). When the axillaries artery is blocked
a collateral circulation is established through the anastomosis round the
scapula which lincs the first part of the subclavian artery with the third
part of the axillaries artery ( a part from the communication with the
posterior intercostals arteries).
Applied anatomy
Suppurations are common in the axilla and the spread of pus is governed
by the arrangement of the fascia. When suppuration occurs superficial to
the clavipectoral fascia, between the pectoral muscles, the pus points
either at the anterior axillaries fold, or in the deltopectoral groove. When
suppuration takes place deep to the clavipectoral fascia, behind the
pectoralis minor, the pus surrounds the neurovascular bundle and
commonly ascends into the neck (This being the line of least resistance),
but rarely it may descend along the vessels into the arm.
An axillaries abscess should be incised through the floor or the axilla,
midway between the anterior and posterior axillaries folds, and nearer to
the medial wall in order to avoid injury to the main vessels running
along the anterior, posterior and lateral walls.
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The shoulder joint

The shoulder joint is formed by the head of humerus and glenoid cavity
of the scapulas.
The glenoid cavity articulates only with the lower half of the head of the
humerus (when the arm is in the anatomical position). The upper part of
the head lies beneath the acromion process. The greater tuberosity forms
the lateral bony point in the shoulder region.
The disproportionate size of the head of the humerus and the small,
shallow glenoid cavity combined with a lax articular capsule, which
gives this joint a wide range of movements but makes the joint
inherently unstable. This instability is overcome by the powerful
muscles, which immediately surrounded the joint. These muscles are
capable of supporting the joint in any position without the restriction of
movement, which ligaments would inevitable produce. However, this
arrangement brings with it an increased risk of displacement of the head
of humerus from the glenoid cavity (dislocation), when the joint is
suddenly wrenched – a displacement, which not infrequently occurs
through the lower part of the capsule, which is inadequately supported
by the long head of triceps. This can result in damage to the adjacent
axillary nerve.

Articular capsule
Most of the surface of the capsule has already been exposed by the
removal of the muscles, which closely surround it. These muscles are
partly fused to the fibrous membrane so that they prevent it from passing
between the joint surfaces when they contract.
The outer, fibrous membrane of the articular capsule is a thin but
relatively strong, tubular structure. It is attached to the margin of the
glenoid cavity and to the anatomical neck of the humerus except
inferiorly where it extends downwards on the surgical neck of the bone.
There are three apertures in the fibrous membrane. One of them forms a
synoviallined tunnel through which the tendon of the long head of
biceps muscle escapes from the interior of the joint. The other two are
also extensions of the synovial membrane to form the subscapular and
infraspinatus bursae. The subscapular bursa is larger and more
commonly present. It lies close to the root of the coracoid process and
occasionally allows dislocation of the head of the humerus at this point.
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There are four slight thickening of the fibrous membrane. The

coracohumeral ligament lies obliquely across the upper surface from
coracoid process to the superior surface of the greater tubercular of the
humerus. Three glenohumeral ligaments may be visible as thickenings
of the anteriorly medially and inferiorly part of the membrane when
viewed from the interior of the joint.
The synovial membrane lines of the fibrous membrane and covers the
part of the surgical neck of the humerus, which lies within the fibrous
membrane. Synovial membrane also formes a sheath round the tendon
of the long head of biceps and is continuous with the lining of the
bursae, which are extensions of the joint.
The nerve supply of the shoulder joint is by the axillary, suprascapular
and lateral pectoral nerves.

The arm (shoulder)

The upper border of the arm is a line connects the lower part of
musculus pectoralis major and musculus latissimus dorsi. The lower
border is the line connects the epicondyles of the os humeri. The skin of
the arm on anterior side is thin and mobile, and on the posterior side is
thick. Under the skin there are little layer of the fat and fascia
superficialis. The skin of the arm is supplied by the sets of cutaneous
nerves. They derived from the cervical plexus, from the
intercostobrachial nerve and from the brachial plexus.
In front of the arm is the prominence of the biceps and on each side of
this is a groove, the lateral and medial bicipital sulcus. Deep to the
medial bicipital sulcus the basilica vein lies, and still deeper, the brachial
artery and median nerve. Deep to the lateral bicipital sulcus, which is not
marked so good as the medial, the cephalic vein lies.
There are two superficial veins on the arm: cephalic vein and basilica
vein. They are the main superficial veins of the upper limb assume
importance in medical practice because these are the most commonly
used for intravenous injections and for withdrawing blood for
transfusion or for testing.
The superficial veins run away from pressure points. Therefore, they are
absent in the palm. That makes the course of the veins spiral, from the
dorsal to the ventral surface of the limb.
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Cephalic vein
It is the preaxial vein of the upper limb. It begins from the lateral end of
the dorsal venous arch. It runs upwards, winds round the lateral border
of the distal part of the forearm, continues upwards in front of the elbow
and along the lateral border of the brachial biceps, pierces the deep
fascia at the lower border of the pectoralis major, runs in the
deltopectoral groove up to the infraclavicular fossa where it joins the
axillary vein.

Basilica vein
It is the postaxial vein of the upper limbs. It begins from the medial end
of the dorsal venous arch.
It runs upwards along the back of the medial border of the forearm,
winds round this border near the elbow, continues upwards in front of
the elbow and along the medial margin of the brachial biceps up to the
middle of the arm where it pierces the deep fascia and runs along the
medial side of the brachial artery up to the lower border of the teres
major, where it becomes the axillary vein.
It is accompanied by the posterior branch of the medial cutaneous nerve
of the forearm.

The arm is divided into anterior and posterior compartments by

extension of deep fascia, which are called the medial and lateral
intermuscular septa. This septa provides additional surfaces for the
attachment of muscles. They also form planes along which nerves and
blood vessels travel. The septa is attached to the medial and lateral
borders and supracondylar ridges of the humerus.
The medial septum is pierced by the ulnar nerve and the superior ulnar
collateral artery; the lateral septum is pierced by the radial nerve and the
anterior descending branch of the profound brachial artery.
The anterior compartment includes musculus biceps brachii, musculus
coracobrachialis and musculus brachialis, nervus musculocutaneus,
nerves ulnaris and nervus radialis.
Musculus biceps arises from the scapula by two heads. They fuse in the
distal third of the arm, and form a short tendon, which gives off the
bicipital aponeurosis. The tendon of the biceps can be felt in the front of
the elbow. The tendon is a guide to the brachial artery, which lies on its
medial side.
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Musculus coracobrachialis forms an inconspicuous rounded ridge in the

upper part of the medial side of the arm. Pulsation of the brachial artery
can be felt, and often seen in the depression behind it.
Musculus brachialis arises from the anterior surface of the distal half of
the humerus. It descends across the anterior surface of the elbow joint to
the coronoid process of the ulna.
Principal neurovascular bundle of the arm consists of the brachial artery,
the basilica and brachial veins and the median nerve.
The brachial artery passes from the medial side of the arm to its anterior
aspect. Their main branches are: arteria profunda brachii, the superior
and inferior ulnar collateral arteries. The median nerve crossed the
brachial artery from the lateral to the medial side.
The ulnar nerve arises from the medial cord of the brachial plexus. At
the middle of the arm it pierces the medial intermuscular septum with
the superior ulnar collateral artery and goes to the posterior
compartment.
The median nerve is formed in the axilla by one root each from the
medial and lateral cords of the brachial plexus. It crossed the brachial
artery from the lateral to the medial side.
Nervus musculocutaneus arises from the lateral cord of the brachial
plexus. It pierces musculus coracobrachialis, descends between biceps
and brachialis, emerges from beneath the lateral boeder of the tendon of
biceps as the lateral cutaneus nerve of the forearm.
Arteria brachialis and nervus musculocutaneus supply the muscles of the
anteriorly compartment.
Posterior compartment includes musculus triceps, arteria profunda
brachii and nervus radialis.
Musculus triceps brachii consists of three heads: the long head, lateral
and medial head. The long head withes the lateral head from the
superficial part of the muscle. They descend posterior to the groove for
the radial nerve and fusing with one another, are joined on their deep
surfaces by the medial head, which arises from the posterior surface of
the humerus distal to that groove. The three heads form a common
tendon, which is inserted into the superior surface of the olecranon and
the surrounding deep fascia. It is supplied by the nervus radialis and
arteria pfofunda brachii.
The profound brachial artery runs in the spiral groove and divides into
its two branches: arteria collateralis medialis (anterior) and arteria
collateralis radialis (posterior).
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Nervus radialis. This nerve is a continuation of the posterior cord of the

brachial plexus in the axilla. Here it gives off the nerve to the musculus
triceps and then passes into the arm posterior to the brachial artery. Then
it gives the posterior cutaneous nerve of the arm, passes into the groove
for the radial nerve on the posterior surface of the humerus, winding
spirally round the posterior surface of the humerus with the profound
brachial artery in contact with periosteum. Thus it is liable to be
damsged in fractures of the middle third of the humerus in the same
manner as the axillary nerve may be in fractures of the surgical neck.
Then the nerve pierces the lateral intermuscular septum and descends in
the anterior compartment between brachial and brachioradialis. It
divides into superficial and deep branches. The superficial branch is a
sensory nerve to the back of the fingers and hand. The deep branch
supplies the muscles of the back of the forearm and the joints at the
wrist. The radial nerve also is sensory to the elbow joint.

The cubital fossa

This is a triangular hollow situated on the front of the elbow.

Boundaries
Laterally – musculus brachioradialis
Medially – musculus pronator teres
Base – is a line drawn between the two epicondyles of the humerus
Apex – is directed downwards and is formed by the meeting point of the
lateral and medial boundaries.
The roof of the cubital fossa is formed by: skin is thin and agile;
superficial fascia containing the median cubital vein, the lateral
cutaneous nerve of the forearm and the medial cutaneous nerve of the
forearm.
Deep fascia is thick, than bicipital aponeurosis.
Floor. It is formed by the brachial and the supinator muscles.
Contents. The fossa is actually very narrow. From medial to lateral side
the contents are:
1. The median nerve. It gives a branch to the pronator teres and
leaves the cubital fossa by passing between the two heads of the
muscle.
2. The termination of the brachial artery and beginning of the radial
ulnar arteries lie in the fossa. The radial artery is smaller and more
superficial than the ulnar artery. It gives off the radial recurrent
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branch. The ulnar artery goes deep and runs downwards, and
medially. It gives off the anterior ulnar recurrent and the common
interosseous branches. The common interosseous branch divides
into the anterior and posterior interosseous arteries and latter gives
off the interosseous recurrent branch.
3. The tendon of the biceps with the bicipital aponeurosis.
4. The radial nerve (accompanied by the radial collateral artery).
Superficial fascia contains the cephalic vein, the basilica vein and the
medial cubital vein. It connects vena cephalica et vena basilica. It is a
large communicating vein which shunts blood from the cephalic to the
basilica vein. It is separated from the brachial artery by the bicipital
aponeurosis.
It may receive tributaries from the front of the forearm (median vein of
the forearm) and is connected to the deep veins through a perforator vein
which pierces the bicipital aponeurosis. The perforator vein fixes the
median cubital vein and thus makes it ideal for intravenous injections.
Applied anatomy
1. The median cubital vein is often the vein of choice for intravenous
injections.
2. The blood pressure is universally recorded by auscultating the
brachial artery in front of the elbow.
3. The anatomy of the cubital fossa is useful while dealing with the
fractures around the elbow, like the supracondylar fracture of the
humerus.
Anastomosis around the elbow joint
These anastomosis link the brachial artery wiyh upper ends of the radial
and ulnar arteries. It supply the ligaments and bones of the joint. The
anastomosis can be subdivided into the following parts.
A. In front of the lateral epicondyle of the humerus the anterior
descending (radial collateral) branch of the profunda brachii
anastomoses with the radial recurrent branch of the radial artery.
B. Behind the lateral epicondyle of the humerus the posterior
descending branch (collateral medial) of the profound brachial
artery anastomoses with the interosseus recurrent branch of the
posterior interosseus artery.
C. In front of the medial epicondyle of the humerus the inferior ulnar
collateral branch of the brachial artery and occasionally a branch
from the superior ulnar collateral artery, anastomose with the
anterior ulnar recurrent branch of the ulnar artery.
 16

D. Behind the medial epicondyle of the humerus the superior ulnar

collateral branch of the brachial arteryanastomoses with the
posterior ulnar recurrent branch of the ulnar collateral artery.
E. Just above the olecranon fossa, a branch from the posterior
descending branch of the profound brachial artery (from the lateral
side) anastomoses with a branch from the inferior ulnar collateral
artery (from the medial side).

The elbow joint

This is a synovial joint of the hinge variety.

This joint is formed by the capitulum and throchlea of the humerus,
upper surface of the head of the radians articulates with the capitulum.
Trochlear notch of the ulna articulates with the trochlea of humerus.
The elbow joint is continuous with the superior radioulnar joint. The
humeroradial and the superior radioulnar joints are known together as
cubital articulations.

Ligaments
Capsular ligament. Superiorly it is attached to the lower end of the
humerus in such a way that the capitulum, the trochlea, the radial fossa,
the coronoid fossa and the olecranon fossa are intracapsular.
Inferomedially it is attached to the margin of the trochlear notch of the
ulna except laterally; inferolaterally it is attached to the annular ligament
of the superior radioulnar joint. The synovial membrane lines the
capsule and the fossae named above. The anterior and posterior
ligaments are thickenings of the capsule.
The ulnar collateral ligament is triangular in shape. Its apex is attached
to the medial epicondyle of the humerus, and its base to the ulna.
The radial collateral ligament. It is a fan-shaped band extending from the
lateral epicondyle to the annular ligament. It gives origin to the supinator
and to the extensor carpi radialis brevis.
Ligamentum annylare radii connects os ulna and os radius. It is a strong
band that encircles the head of the radius and retains it in contact with
the radial notch of the ulna.

Relations of the elbow joint

Anteriorly: brachial, median nerve, brachial artery and tendon of biceps.
Posteriorly: triceps and anconeus.
 17

Medially: ulnar nerve, flexor carpi ulnaris and common flexors.

Laterally: supinator, extensor carpi radialis and other common extensors.

Blood supply from anastomosis round yhe elbow joint. It is rete cubiti.
Nerve supply: ulnar nerve, median nerve, radial nerve and
musculocutaneous nerve through its branch to the brachial.

Movements
1. Flexion is brought about by the brachial, the biceps and
brachioradial.
2. Extension is prodused by the triceps and anconens.

Applied anatomy
1. Distension of the elbow joint by an effusion occurs posteriorly
because here the capsule is weak and the covering deep fascia is
thin. Aspiration is done posteriorly on any side of the olecranon.
2. Dislocation of the elbow is usually posterior, and is often
associated with fracture of the coronoid process. The triangular
relationship between the olecranon and the two humeral
epicondyles is lost.
3. Subluxation of the head of the radius occurs at children when the
forearm is suddenly pulled in pronation. The head of the radius
ships out from the annular ligament.
4. Tennis elbow. Abrupt pronation may lead to pain and tenderness
over the lateral epicondyle. This is possible due to sprain of radial
collateral ligament, tearing the fibres of the extensor carpi radialis
brevis or inflammation of the bursa of the last named muscle.
5. Miner’s (or student’s) elbow is characterized by effusion into the
bursa over the subcutaneous posterior surface of the olecranon
process.
The forearm

The borders of the forearm are: upper border – it’s a line, connecting
epicondyles of the brachial bone; lower border – it’s a line, connecting
two styloideus processes of the os ulna and os radius. The skin is thin.
Under the skin is the superficially fat. In this fat arrange the cephalic
vein, the basilica vein, the medial, lateral and posterior cutaneous nerves
of the forearm. The lateral cutaneous nerve of the forearm is the
continuation of the musculocutaneous nerve. The medial cutaneous
 18

nerve of the forearm is a branch of the medial cord of the brachial

plexus. The posterior cutaneous nerve of the forearm arises from the
radial nerve. The deep fascia gives three intermuscular septas: one of
them is septum intermusculare medialis to the os ulna and another two –
to the os radius. It forms three compartments: anterior, posterior and
lateral.
The anterior compartment includes musculus pronator teres, musculus
flexor carpi radialis, musculus palmaris longus, musculus flexor carpi
ulnaris, musculus flexor digitorum superficialis. There are the superficial
muscles. The deep muscles are: musculus flexor digitorum profundus,
musculus flexor policis longus, musculus pronator quadratus, arteria,
vena et nervus ulnaris, arteria radialis, nervus medianus, arteria, vena et
nervus interrossea anterior. The most conspicuous arteries of the forearm
are the radial and ulnararteries. However, they mainly supply the hand
through the deep and superficial palmer aches. The arterial supply of the
forearm is chiefly derived from the common interosseus arteries.

The radial artery

It is a terminal branch of the brachial artery in the cubital fossa. It runs
downwards to the wrist. It leaves the forearm by turning posteriorly and
entering the anatomical snuff box. It is quite superficial throughout its
whole course. The artery is accompanied by a pair of venae cubitantes. It
gives the radial recurrent artery and muscular branches to the lateral
muscles of the forearm.

The ulnar artery

It is the lager terminal branch of the brachial artery and begins in the
cubital fossa. The artery runs obliquely downwards and medially in the
upper one third of the forearm its course is vertical. It enters the palm by
passing superficial to the flexor retinalulum.
The common interosseus artery arises just below the radial tuberosity. It
passes backwards to reach the upper border of the interosseus
membrane, and ends dividing into the anterior and posterior interosseus
arteries.
The anterior interosseus artery. It is the deepest artery of the front of the
forearm. It accompanies the anterior interosseus nerve. It descends on
the surface of the interosseus membrane, pierces the interosseus
membrane at the upper border of the pronator quadratus to enter the
extensor compartment. The artery gives muscular branches to the deep
 19

muscles of the front of the forearm and a median artery, which

accompanies the median nerve.
The posterior interosseus artery goes to the posterior compartment.
The muscular branches of the ulnar artery supply the medial muscles of
the forearm.

The nerves of the front of the forearm

These are the median, ulnar and radial nerves. The radial and ulnar
nerves run along the margins of the forearm.
The median nerve.
It is the main nerve of the front of the forearm. It also supplies the thenar
muscles of the hand.
In the cubital fossa it lies medial to the brachial artery, behind the
bicipital aponeurosis.
The median nerve enters the forearm by passing between the two heads
of the pronator teres. Here it crosses the ulnar artery. The nerve goes
beneath the fibrous arch of the flexor digitorum superficialis and runs
deep to the muscle on the surface of the flexor digitorum profundus. It is
accompanied by the median artery, a branch of the anterior interosseus
artery. It becomes superficial. The median nerve enters the palm by
passing deep to the flexor retinaculum (through the carpal tunnel).
Their branches are:
1. The muscular branches are given off to all the superficial flexors of
the forearm, exept the flexor carpi ulnaris.
2. The anterior interosseus branch.
3. The palmar cutaneous branch.
4. Articular branches.
The ulnar nerve
At the elbow, the ulnar nerve lies behind the medial epicondyle of the
humerus. It enters the forearm by passing between the two heads of the
flexor carpi ulnaris.
In the forearm the nerve runs between the flexor digitorum profundus
and the flexor digitorum superficialis. The nerve enters the palm by
passing superficial to the flexor lateral retinaculum to the pisiform bone.
At the ulnar neurovascular bundle lies between the flexor carpi ulnaris
and flexor digitorum superficialis. The bundle enters the palm by
passing superficial to the flexor retinaculum, lateral to the pisiform bone.
Branches: 1. Muscular
2. Palm and dorsal cutaneous
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3. Articular
Radial nerve in the front of the forearm
The radial nerve divides into its two terminal branches in the cubital
fossa at the level of the lateral epicondyle of the humerus. The deep
terminal branch soon enters the back of the forearm by passing through
the supinator muscle.
The superficial terminal branch (the main continuation of the nerve) runs
down in front of the forearm. It is closely related the radial artery only in
the middle one third of the forearm. It is purely cutaneous and is
distributed to the lateral half of the dorsum of the hand and to the
proximal parts of the dorsal surfaces of the thumb, the index finger and
half of the middle finger.

The lateral compartment

It includes musculus brachioradialis, musculus extensor carpi radialis
longus et musculus extensor carpi radialis brevis. Between these muscles
lies ramus superficialis nervi radialis.

The posterior compartment

It consists of two layers of muscles. They are: musculus abductor policis
longus, musculus extensor policis brevis, musculus extensor digitorum
communis, musculus extensor digiti minimi, musculus extensor carpi
ulnaris, musculus extensor indicis and musculus supinator.

The palmar aspect of the wrist and hand

The human hand is designed for grasping, for precise movements and
for serving as a tactile organ.
The skin of the palm is thick for protection of underlying tissues
immobile because of its firm attachment to the underlying palmar
aponeurosis, and creased. All of these characters increase the efficiency
of the grip.
The skin is supplied by spinal nerves C6, 7, 8 through the median and
ulnar nerves.
The superficial fascia of the palm is made up of dense fibrous bands
which bind the skin to the deep fascia (palmar aponeurosis) and divide
 21

the subcutaneous fat into small tight compartments which serve as

water-cushions during firm gripping. The fascia contains a subcutaneous
muscle, the palmaris brevis, which helps in improving the grip by
steadying the skin on the ulnar side of the hand. The superficial
metacarpal ligament which stretches across the roots of the fingers over
the digital vessels and nerve, is a part of this fascia.
The deep fascia is specialized to form the flexor retinaculum at the wrist,
the palmar aponeurosis in the palm, and the fibrous flexor sheathes in
the fingers. All three form a continuous structure which holds the
tendons in position and thus increases the efficiency of the grip.

Palmar aponeurosis
This term is often used for the entire deep fascia of the palm. However,
it is better to restrict this term to the central part of the deep fascia of the
palm which covers the superficial palmar arch, the long flexor tendons,
the terminal part of the median nerve, and the superficial branch of the
ulnar nerve.
Features
It is triangular in shape. The apex which is proximal blends with the
flexor retinaculum and is continuous with the tendon of the palmaris
longus. The base is directed distally. It divides into four slips opposite
the heads of the metacarpalis of the medial four fingers. Each slip
divides into two parts which are continuous with the fibrous flexor
sheaths. Extensions pass to the deep transverse metacarpal ligament, the
capsule of the metacarpophalangeal joints and the sides of the base of
the proximal phalanx. The digital vessels and nerves, and the tendons of
the lumbricals emerge through the intervals between the slips. From the
lateral and medial margins of the palmar aponeurosis, the lateral and
medial palmar septa pass backwards and divide the palm into
compartments.
Morphology. Phylogenetally, the palmar aponeurosis represents the
degenerated tendon of the palmaris longus.
Functions. It fixes the skin of the palm and thus improves the grip. It
also protects the underlying tendons, vessels and nerves.

The intrinsic muscles of the hand serve the function of adjusting the
hand during gripping, and also for carrying out fine skilled movements.
There are 20 muscles in the hand, as follows.
1. Four thenar muscles
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Abductor pollicis brevis

Flexor pollicis brevis
Opponens pollicis
Adductor pollicis
2. Four hypothenar muscles
Palmaris brevis
Abductor digiti minimi
Flexor digiti minimi
Opponens digiti minimi
3. Four lumbricals
4. Four palmar intмerossei
5. Four dorsal interossei

Abductor pollicis brevis

Insertion
1. Lateral side of the base of the proximal phalanx of the thumb.
2. Some fibres are inserted into the dorsal digital expansion.
Nerve supply: median nerve (C8, T1)
Action: abduction of the thumb at the metacarpophalangeal and
carpometacarpal joints. Abduction is associated with medial rotation.

Flexor pollicis brevis

Insertion
1. Lateral side of the base of the proximal phalanx.
Nerve supply: the superficial hand is supplied by the median nerve; and
the deep head by the deep branch of the ulnar nerve.
Action: flexion of the thumb.

Opponens pollicis
Insertion
Lateral half of the palmar surface of the first metacarpal bone.
Nerve supply: median nerve
Action: opposition of the thumb. This is a combination of flexion and
medial rotation.

Adductor pollicis
Insertion
Medial side of the base of the proximal phalax of the thumb. Some
fibres are inserted into the dorsaldigital expansion.
 23

Nerve supply: deep branch of ulnar nerve (C8,T1).

Action: the muscle adducts the thumb from the flexed or abducted
position. The movement is forceful in gripping.

Note on actions of thenar muscles

In studying the actions of the thenar muscles it must be remembered that
the movements of the thumb take place in planes at right angles to those
of the other digits because the thumb (first metacarpal) is rotated
medially through 90 degrees. Flexion and extension of the thumb take
place in the plane of the palm; and abduction and adduction at right
angles to the plane of palm. Movement is a combination of flexion and
medial rotation.

Palmaris brevis
This muscle is superficial and lies just under the skin.
Insertion:skin along medial border of the hand.
Nerve supply: ulnar nerve, superficial branch (C8, T1).
Action: helps in gripping by making the hypothenar eminence more
prominent, and by wrinkling the skin over it.

Abductor digiti minimi

Insertion: ulnar side of the base of the proximal phalanx of the little
finger.
Nerve supply: deep branch of ulnar nerve (C8, T1).
Action: abduction of little finger at the metacarpophalangeal joint.

Flexor digiti minimi

Insertion: ulnar side of the base of the proximal phalanx of the little
finger.
Nerve supply: deep branch of ulnar nerve (C8, T1).
Action: flexion of the little finger at the metacarpophalangeal joint.

Opponens digiti minimi

Insertion: medial surface of the shaft of the fifth metacarpal bone.
Nerve supply: deep branch of ulnar nerve (C8, T1).
Action: flexes the fifth metacarpal and rotates it laterally ( as in making
the palm hollow).

The lumbrical muscles

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These are four small muscles that take origin from the tendons of the
flexor digitorum profundus.
Insertion
The tendons of the first, second, third and fourth lumbricals pass
backwards on the radial side of the second, third, fourth and fifth
metacarpophalangeal joints respectively. They are inserted into the
dorsal digital expansions of the corresponding digits.
Nerve supply
1. The first and second lumbricals by the median nerve (C8, T1).
2. The third and fourth lumbricals by the deep branch of the ulnar
nerve (C8, T1).
Actions
The lumbrical muscles flex the metacarpophalangeal joints, and extend
the interphalangeal joints of the digit into which they are inserted.

The palmar interossei

These are four small muscles placed between the shafts of the
metacarpal bones. They are numbered from lateral to medial side.
Insertion
Each muscle is inserted into the dorsal digital expansion of one digit. It
may also be attached to the base of the proximal phalanx of the same
digit. The digits into which individual palmar interossei are inserted are
as follows.
1. First muscle: medial side of thumb.
2. Second muscle: medial side of the index finger.
3. Third muscle: lateral side of the fouth digit.
4. Fouth muscle: lateral side of the fifth digit.
Note that the middle finger does not receive the insertion of any palmar
interosseus muscle.
Actions
All palmar interossei adduct the digit to which they are attached towards
the middle finger. In addition they flex the digit at the
metacarpophalangeal joint and extend it at the interphalangeal joints.
Nerve supply
All dorsal interossei are supplied by the deep branch of the ulnar nerve
(C8, T1).

The dorsal interossei

 25

Like the palmar interossei the dorsal interossei are four small muscles
placed between the metacarpal bones, and are numbered from lateral to
medial side.
Insertion
Each muscle is inserted into the dorsal digital expansion of the digit; and
into the base of the proximal phalanx of that digit. The digits into which
individual muscles are inserted are as follows.
1. First: lateral
2. Second: lateral side of middle finger.
3. Third: medial side of middle finger.
4. Fourth: medial side of fourth digit.
Note that the middle finger receives one dorsal interosseus muscle on
either side; and that the first and fifth digits do not receive any insertion.
Action
All dorsal interossei are abductors of the digits away from the line of the
middle finger. Note that movement of the middle finger to either the
medial or lateral side constitutes abduction. Also note that the first and
fifth digits do not require dorsal interossei as they have their own
abductors.
In addition (like the palmar interossei) the dorsal interossei flex the
metacarpophalangeal joint of the digit concerned and extend the
interphalageal joints.
Nerve supply: all dorsal interossei are supplied by the deep branch of the
ulnar nerve.

Applied anatomy
Dupuytren’s contracture: this condition is due to inflammation involving
the ulnar side of the palmar aponeurosis. There is thickening and
contraction of the aponeurosis. As a result the proximal phalanx (and
later) the middle phalanx become flexed and cannot be straightened. The
terminal phalanx remains unaffected. The ring finger is most commonly
involved.