Sobotta Atlas vol-1

M uscles -» T o p o g ra p h y -» S ections

Tendinous sheaths of the dorsum of the hand

Vagina tendinis m usculi Vagina tendinum m usculorum
e xten s o ris p ollicis longi e xten s o ru m c arp i radialium
Vagina tendinis m usculi
extensoris c arp i ulnaris Retinaculum m usculorum extensorum
Vagina tendinum m usculorum
Vagina tendinum m usculorum extensoris a b d u cto ris p ollicis longi e t
d igitorum e t e xten s o ris indicis extensoris pollicis brevis

V agina tendinis m usculi M . interosseus
extensoris digiti m inim i dorsalis I

Connexus
in te r te n d in e i

M. e xtensor d igito ru m , Tendines

Fig. 3.92 Dorsal carpal te ndinou s sheaths, V aginae te n d in u m , of of the M m . interossei palmares and dorsales radiate into the lateral
th e dorsum of th e hand, right side; dorsal view. tracts o f the digital dorsal aponeuroses. They reach the dorsal side of
Beneath the Retinaculum m usculorum extensorum the tendons of the the transverse axis of the distal interphalangeal joints and act as exten­
extensor m uscles are positioned in six osseofibrous tunnels sors thereof. This explains w h y the M m . lumbricales are the main ex­
(-» Fig. 3.87). The respective ten don s are covered in m o stly individual tensors of the distal interphalangeal joints.
tendinous sheaths to reduce friction during m ovem ents of the tendons
between the retinaculum and the bones of the w rist. metacarpophalangeal joints and proximal interphalangeal
Extensor muscles of th e finger joints: joints: M. extensor digitorum , M. extensor digiti minim i, M. exten­
W ith the exception of the tendon of the M . extensor pollicis longus, sor indicis
w hich reaches th e distal phalanx, the tendons of the M m . extensores distal interphalangeal joints: M m . lumbricales, w eakly also M m .
digitorum , extensor digiti minim i, and extensor indicis insert together interossei palmares and dorsales
w ith th e m iddle tra c t o f th e dorsal aponeuroses (-♦ Fig. 3.91) at the carpom etacarpal jo int of th e thum b: M . extensor pollicis brevis
m iddle phalanx and therefore cannot extend the distal interphalangeal proxim al and distal interphalangeal joints of the thum b: M. ex­
joints. Flowever, tendons of the M m . lumbricales and to som e extent tensor pollicis longus

3 Upper Extremity S urface a n a to m y -► D e ve lo p m e n t -► Skeleton -► Im aging

Muscles of the hand

M. palm aris longus, Tendo M. palm aris brevis
Retinaculum m usculorum flexorum
A poneurosis palm aris H ypothenar
M. abd ucto r pollicis M. a bd ucto r digiti minim i

Thenar Lig. m etacarpale transversum superficiale
M . fle xor p ollicis brevis

Mm . lum bricales

Fig. 3.93 Superficial layer of muscles in th e palm of th e hand, phalangeal jo in ts (Lig. metacarpale transversum superficiale). The
Palma manus, right side; palmar view. palm ar aponeurosis is fixed proxim ally to th e R etinaculum m usculorum
There are th ree groups of muscles in the palm o f the hand. On both fle xo ru m und stre tch e d by th e M . palm aris longus. Distally, it is fixed to
sides o f the palm, m uscles o f the thu m b and the fifth fing er form the the tendinous sheaths of the finger flexors and to the ligam ents of the
thenar and hypothenar, respectively. Between the tw o groups are the metacarpophalangeal joints.
m uscles o f th e palm o f th e hand. These th re e groups are arranged in A t th e thenar, th e M . abductor pollicis brevis is located on th e radial
three consecutive muscle layers. The neurovascular structures be­ side and the M . flexor pollicis brevis is located Ulnar to the abductor
tw e e n these layers need to be considered w hen dissecting the palm of m uscle. A t the Hypothenar, th e M . palmaris brevis and M. abductor
th e hand (-» pp. 235-23 7). Located m o s t superficially is th e palm ar digiti m inim i are superficial.
aponeurosis (Aponeurosis palmaris) w hich consists o f longitudinal and
transverse fibres; the latter being prom inent just be lo w th e metacarpo­ -►T 31, 36-3 8

188

M uscles -» T o p o g ra p h y -► S ections

Muscles of the hand

Radius J
M. pronator quadratus
M. brachioradialis, Tendo
M. fle x o r carpi ulnaris, Tendo
M . flexor p ollicis longus, Tendo M . fle x o r d ig ito ru m p ro fu n d u s , Tendines

Retinaculum m usculorum flexorum O s pisiform e

M. a bd ucto r pollicis brevis M . a b d u cto r d igiti m inim i
M. fle xor p ollicis brevis, M . fle x o r digiti m inim i
M . o p ponens digiti m inim i
C aput superficiale M m . lum bricales
M . o p ponens pollicis M. a b d u cto r digiti minim i
M. a b d u cto r p ollicis brevis
M. fle xor pollicis brevis, Mm. interossei dorsales

C aput profundum
M . fle x o r p ollicis brevis,

C aput superficiale
M . a d d u c to r pollicis,

Caput transversum

interossei palm ares

M . flexor
s u p e rfic ia lis ,

Fig. 3.94 In term e d iate layer o f muscles in th e palm of th e hand, fle xo r d igito rum superficialis (cut in th is illustration) insert at th e m iddle
Palm a m anus, right side; palm ar view ; after removal o f the palmar phalanx w ith a split tendon.The tendons of M . flexor digitorum profun­
aponeurosis and the superficial muscles. dus pass through the split tendon to reach the distal phalanx of the
The three m uscle groups o f the palm o f the hand (Palma manus) are fingers. The ten don s o f th e M . fle xo r d igito rum profundus serve as
arranged in th re e con secutive layers. W hen th e superficial m uscles are origin fo r the four M m . lumbricales w hich also belong to the interm edi­
removed, the m uscles o f th e interm ediate layer are visible. These com ­ ate layer o f m uscles (for th e fun ction o f M m . lum bricales -» Fig. 3.101).
prise the M. opponens pollicis and M . abductor pollicis at the Thenar, The tendon of th e M . flexor pollicis longus inserts at the distal phalanx
and the M. flexor digiti m inim i and M. opponens digiti m inim i at the of the thumb.
Hypothenar, both o f w hich are positioned radial to the superficial M.
ab ducto r digiti m inim i. In th e palm o f th e hand, th e ten don s o f th e M. —►T 32, 3 6 -3 8

3 Upper Extremity S urface a n a to m y -► D e ve lo p m e n t -► Skeleton -► Im aging

Tendinous sheaths of the palmar hand

V ag in a te n d in is m usculi fle xo ris p ollicis longi V agina co m m u n is tendinum
Vagina tendinum m usculorum abductoris m usculorum flexorum
longi e t extensoris pollicis brevis
M. fle xor carpi ulnaris, Tendo
V agina tendinis m usculi fle xo ris c arp i radialis

M. opponens pollicis R etinaculum m usculorum flexorum
M. fle xor pollicis brevis M . a b d u cto r d igiti m inim i
M. a b d u cto r pollicis brevis

Vagina tendinis m usculi M. fle x o r d igiti m inim i brevis
fle xo ris p ollicis longi M . opponens d igiti m inim i

M . a d d u cto r pollicis, V agina co m m u n is tendinum
Caput transversum m usculorum flexorum

V aginae synoviales digitorum
manus

Fig. 3.95 Palmar, carpal, and digital
tendinous sheaths. Vaginae tendinum , of
th e hand, right side; palmar view.

Figs. 3.96a to d Variants of palm ar tendinous sheaths. all tendons o f the M m . flexores digitorum superficialis and profundus at
In con trast to th e situation in th e dorsal aspect o f th e hand, ten don s of the w ris t and reaches the distal phalanx only at the fifth digit. The other
the fing er flexors usually have only tw o tendinous sheaths. The radial fingers have independent tendinous sheaths surrounding the flexor
tendinous sheath surrounds th e tendon o f th e M . flexor pollicis longus tendons.
and reaches to its distal phalanx. The ulnar tendinous sheath surrounds

i- Clinical Remarks-----------------------------------------------------------------------------------------------------

The arrangem ent o f th e ten dinou s sheaths is o f clinical im portancespread to th e fifth finger. Inadequate an tibiotic therapy m ay result in

as bacterial infections (phlegm on) quickly spread in th e tendinous stiffening of the entire hand,

sheaths. An inflam m ation involving the ulnar tendinous sheath can

190

M uscles -» T o p o g ra p h y -► S ections Muscles of the hand

Radius Canalis carpi
M . a b d u cto r p ollicis longus, Tendines M. fle xor p ollicis brevis, C aput profundum
O s pisiform e
M. fle xor carpi radialis, Tendo
Retinaculum m usculorum flexorum M. a bd ucto r digiti minim i
R etinaculum m usculorum flexorum
M. a b d u cto r pollicis brevis M. opponens digiti minim i
M. fle xor p ollicis brevis, C aput superficiale M. fle xor digiti m inim i brevis
M. fle xor pollicis brevis, C aput profundum M . in te ro ss e u s d o rs alis IV
M . in te ro ss e u s p a lm a ris III
M. opponens pollicis M. a b d u cto r d igiti m inim i
M . a b d u cto r pollicis brevis
M . fle x o r p ollicis brevis, M . lum bricalis

C aput superficiale M . flexor digitorum
M. add ucto r pollicis s uperficialis, Tendo

M. flexor pollicis
longus, Tendo

M . interosseus
dorsalis I

M . fle x o r dig ito ru m superficialis, Tendo
Vincula longa

V incula te n d in u m
Vinculum breve

M . fle x o r d igitorum profun dus, Tendo

Fig. 3.97 Deep layer of m uscles of th e palm of th e hand, Palma palmar side to the transverse axis of the metacarpophalangeal joints.
m anus, right side; palm ar view ; after removal of the tendons of the Thus, the M m . interossei and, to a lesser extent, also th e M m . lumbri­
long flexors of the fingers. cales are the main flexors o f the metacarpophalangeal joints.
The three m uscle groups o f th e palm o f th e hand are arranged in three The illustration show s ho w the tendons o f th e deep flexors pierce
consecutive layers. Upon removal o f the tendons of the long flexors the through the tendon gaps of the superficial flexors.The tendons are at­
m uscles of the deep layer becom e visible. The M m . interossei and tached to the phalanges by small ligam ents (Vincula tendinum ).
M m . lumbricales are flexors of the metacarpophalangeal joints (for
course and fu n c tio n o f M m . interossei -*■ Figs. 3.98 to 3.100). The te n ­ —»T 31, 36, 37
dons of the M m . interossei and M m . lumbricales are positioned at the

Clinical Remarks interphalangeal joints is reduced w h ile flexion o f th e distal interpha-
langeal jo in ts is possible an isolated injury o f M . fle xo r digitorum
Knowledge of the function and the course of th e flexor m uscle superficialis is indicated.
ten don s at th e fing ers is im po rtan t w h e n exam inin g cuts. The M.
fle xo r d igito rum profundus is a ffe c te d if flexion o f th e distal inter-
phalangeal jo in ts is im possible. If, how ever, flexion o f th e proximal

3 Upper Extremity S urface a n a to m y -► D e ve lo p m e n t -► Skeleton -► Im aging

Muscles of the hand

Fig. 3.98 M m . interossei palmares, right side; palmar view. M . in te ro sse u s p alm aris III
The three M m . interossei palmares originate from the ulnar aspect of M . in terosse us p a lm a ris II
th e Os m etacarpi II and fro m th e radial aspect o f th e Ossa m etacarpi IV M. interosseus palm aris I
and V. They insert on th e sam e side o f th e corresponding proxim al pha­
lanx o f the fingers and radiate into the lateral tracts o f the dorsal apo­
neurosis (arrows).

—»T 37

M. interosseus M . interosseus
d o rsa lis III d o rs a lis II

M . interosseus M. interosseus
d o rsa lis IV dorsalis I

M m . interossei e x te n s o r Fig. 3.99 M m . interossei dorsales, righ t side; dorsal view .
palm ares digitorum , The fo u r M m . interossei dorsales have their origin w ith tw o heads from
Tendines the opposing surfaces o f the Ossa m etacarpi l-V. They insert on both
Dorsal sides of the proximal phalanx of the middle finger, on the ulnar side of
m edial tra cts M m . lum bricales, the ring finger, and on th e radial side o f the index finger. A small portion
Tendines of their tendons also merges w ith the lateral tracts of the dorsal apo­
192 neurosis. Thus, these m uscles are flexors of the metacarpophalangeal
Dorsal aponeurosis: joints and extensors of the proximal and distal interphalangeal joints.
lateral tra cts Flexor muscles of th e interphalangeal joints:
Each jo in t has a predom inant flexor muscle. The exclusive flexor fo r the
distal interphalangeal jo in ts is th e M . fle xo r d igito rum profundus,

m etacarpophalangeal joints: M m . interossei palmares and dorsa­
les, also M m . lum bricales, but w eaker
• proxim al interphalangeal joints: Mm . flexor digitorum superficialis
distal interphalangeal joints: M. flexor digitorum profundus

—►T 37

M uscles -» T o p o g ra p h y -► S ections Muscles of the hand

M m . interossei dorsales M m . interossei palm ares

Fig. 3.100 S chem atic d raw in g of th e po sitions o f th e M m . m edially and laterally. In contrast, th e M m . interossei palm ares adduct
interossei and their actions on abduction and adduction of the the fingers. Their effects on the m ovem ents of flexion and extension
fingers, (according to [1]) can be deduced fro m the course o f the ir tendons in relation to the
According to their course described on -* p. 192, the M m . interossei transverse axis o f th e fing er jo in ts and is explained on -» pages 191 and
dorsales spread the fingers (abduction) and can m ove the m iddle fing er 192.

M . lu m b ric a lis II M. fle x o r d igito ru m profundus, Tendines
M. lum bricalis I lu m b rica lis IV

M . lu m b ric a lis III

M . fle xor d igito ru m superficialis, Tendines

M . flexor digitorum

T e n d in e s

M. fle x o r d igito ru m profundus, Tendines

Fig. 3.101 M m . lum bricales, righ t side; palm ar view . fibres of the dorsal aponeurosis of the fingers. They weakly flex the
The tw o radial M m . lumbricales originate w ith one head, the tw o ulnar metacarpophalangeal joints and extend the proximal and distal inter-
M m . lumbricales w ith tw o heads from the tendons of M . flexor digito­ phalangeal joints.
rum profundus. All m uscles insert on the radial side o f the proximal
phalanx o f th e fing ers II—V and th e ir ten don s m erge w ith th e lateral —►T 37

193

Upper Extremity S urface a n a to m y -► D e ve lo p m e n t -► Skeleton -► Im aging

Plexus brachialis

C4

Pars ^ * Nn. spinales, Rr. anteriores C5
Truncus superior
supraclavicularis i C6
b Truncus m edius
c Truncus inferior C7

Fasciculus lateralis C 8 1 N. phrenicus (Plexus cervicalis)
2 N. dorsalis scapulae
b Fasciculus posterior 3 Rr. m usculares
c Fasciculus medialis 4 N. suprascapularis
5 N. subclavius
D ivisiones anteriore 6 N. pecto ra lis lateralis
Divisiones posterior
T1 7 N. subscapularis
Pars ! A. axillaris 8 N. th o ra c o d o rs a l is
9 N. pectoralis m edialis
infraclavicularis ▼
10 N. tho ra cicu s longus
11 N. in te rco sta lis

N. m usculocutaneus N. cutaneus brachii m edialis
N. m edianus N. cutaneus antebrachii medialis
N. axillaris N. ulnaris
N. radialis

Fig. 3.102 Brachial plexus, Plexus brachialis (C5-T1): segm ental duct the com position of the different peripheral nerves, w ith a fe w ex­
arrangem ent of nerves, right side; ventral view. ceptions only.
Innervation o f th e upper e x tre m ity is derived fro m th e Plexus brachialis. The Plexus brachialis has tw o topographical parts: The supraclavicular
The brachial plexus is fo rm e d by Rr. anteriores o f spinal nerves o f the pa rt (Pars supraclavicularis) com prises th e tru nks and th o se peripheral
low er cervical and upper thoracic spinal cord segm ents (C5-T1). First, nerves derived fro m th e trunks or th e Rr. anteriores o f th e spinal nerves
th e Rr. anteriores com bine to fo rm three tru n ks (Trunci) w h ich then (C5-T1). The infraclavicular p a rt (Pars infraclavicularis) con sists o f the
rearrange at th e level o f th e clavicle to fo rm three cords (Fasciculi). fascicles (Fasciculi). The nerves o f th e arm (-» Fig. 3.103) branch o ff the
These are nam ed according to the ir position in relation to the A. axillaris infraclavicular part. Nerves to the shoulder, however, branch o ff the
as lateral, m edial, and po sterior cords. N erve fibres fro m C5 and C6 supraclavicular part.
assemble into the Truncus superior, from C7 into the Truncus medius,
and fro m C8 to T1 into th e Truncus inferior. The dorsal divisions (Divi­ Pars supraclavicularis:
siones posteriores) o f all three trunks form the posterior cord (Fascicu­ • Nerve branches fo r the M m . scaleni and M . longus colli (C5-C8)
lus posterior; fibres from C5-T1). The ventral divisions (Divisiones ante­ • N. dorsalis scapulae (C3-C5)
riores) of Truncus superior and Truncus medius continue as lateral cord • N. thoracicus longus (C5-C7)
(Fasciculus lateralis; lateral o f A. axillaris; nerve fibres fro m C5-C7), the • N. suprascapularis (C4-C6)
ventral part of Truncus inferior continues as medial cord (Fasciculus • N. subclavius (C5-C6)
medialis, m edial o f A. axillaris, nerve fibres fro m C 8 -T 1). U nderstanding
this structure of the brachial plexus allow s to easily m em orise and de- -» T 22, 23

i- Clinical Remarks------------------------------------ Low er brachial plexus paralysis (KLUMPKE's palsy, roots of
C 8-T1) w ith paresis of the long flexors of the fingers and short
Severe injuries of the shoulder and arm (m otorcycle accidents, mal­ m uscles of the hand, partially w ith HORNER's syndrom e (m io­
position at birth, im proper po sitioning during surgery) can lead to sis, ptosis, enophthalm us) due to additional lesion o f the cervi­
lesions of th e Plexus brachialis. Depending on the affected trunks cal sym pathetic chain w ith normal shoulder and elbo w function.
one distinguishes: Pathomechanism: increase o f the distance between the trunk
• U pp er brachial plexus paralysis (ERB's palsy, roots of C5-C6) and shoulder.
The Truncus m edialis (C7) m ay be involved in both, th e upper and
w ith paresis (paralysis) of th e abductors and lateral rotators of the low er lesion, and this is indicated by paralysis o f the M. triceps
th e shoulder, and the upper arm flexors as w ell as the M . supina­ brachii and th e extensors o f th e fingers. In case o f a co m p lete le­
tor. A s a result, th e re is an adduction and m edial rotation o f the sion, m ovem ents of the entire arm including the hand are affected.
arm w ith extended elbow jo in t but normal hand function. Patho-
mechanism: increase of the distance betw een neck and shoul­
der.

194

M uscles -» T o p o g ra p h y -► S ections

Nerves to the arm derived from the Plexus brachialis

Fig. 3.103 Brachial plexus. Plexus brachialis (C 5-T1); nerves of Pars infraclavicularis:
th e arm , right side; ventral view. Fasciculus posterior (C5-T1):
The nerves of the arm derive from the infraclavicular part of the bra­ • N. axillaris (C5-C6)
chial plexus. The Fasciculus posterior gives rise to the N. axillaris and • N. radialis (C5-T1)
th e N. radialis. The Fasciculus lateralis con tributes to th e N. m usculo- • Nn. subscapulares (C5-C7)
cutaneus and th e lateral root (Radix lateralis) o f th e N. m edianus. The • N. thoracodorsalis (C6-C8)
Fasciculus m edialis gives rise to th e N. ulnaris, th e m edial root (Radix Fasciculus lateralis (C5-C7):
medialis) of the N. medianus, and the cutaneous nerves of the medial • N. musculocutaneus (C5-C7)
upper arm (N. cutaneus brachii medialis) and forearm (N. cutaneus an- • N. m edianus, Radix lateralis (C6-C7)
tebrachii medialis). • N. pectoralis lateralis (C5-C7)
Fasciculus m edialis (C8-T1):
T 22, 23 • N. m edianus, Radix m edialis (C8-T1)
• N. ulnaris (C8-T1)
• N. cutaneus brachii m edialis (C8-T1)
• N. cutaneus antebrachii m edialis (C8-T1)
• N. pectoralis m edialis (C8-T1)

3 Upper Extremity S urface a n a to m y -► D e ve lo p m e n t -► Skeleton -► Im aging

Innervation of the skin

N. m u s c u lo c u ta n e u s , N. cutaneus N . ra d ia lis, N. cutaneus
antebrachii lateralis brachii lateralis inferior

R. palm aris N. axillaris, N. cutaneus brachii
lateralis superior
N. m edianus Nn. d ig ita le s ------------
palm ares com m unes

Nn. digitales
palm ares proprii

Nn. supraclaviculares

Rr. cu ta n e i a n te rio re s '
p e c to ra le s

Nn. intercostales

Nn. digitales Rr. cu ta n e i laterales
palm ares proprii p e c to ra le s

N . u ln a ris N n. d ig ita le s -------------- N. intercostobrachialis
palm ares com m unes N. c u ta n eu s b rachii m edialis

R. p a lm a ris ----------------

3.104 N . c u ta n e u s a n te b r a c h ini [ r . a n te rio r
m e d ia liss \ r. p o s te rio r -

N . axillaris, - N. cutaneus brachii posterior 1
N. cutaneus brachii N. cutaneus brachii lateralis inferior > N. ra d ia lis

lateralis superior N. cutaneus antebrachii posterior J
Nn. supraclaviculares
---------------R. s u p e rfic ia lis "
Nn. thoracici,
Rr. cuta n ei p oste rio re s R. com m unicans ulnaris N. radialis

N . rad ialis, N. cutaneus brachii posterior Nn. digitales
N. cu tan eu s b rachii m edialis d o rs a le s

3.105 N. m edianus, Nn. digitales
palm ares proprii

Nn. digitales
palm ares proprii
------Nn. d ig ita le s d orsale s N . u ln a ris

N . cu tan eu s a n te b rac h ii m edialis

Fig. 3.104 and Fig. 3.105 Cutaneous nerves of th e upper extrem i­ m usculocutaneus conveys sensory innervation to the lateral aspect of
ty , righ t side; ventral (-» Fig. 3.104) and dorsal (-» Fig. 3.105) view . th e forearm . The N. cutaneus brachii m edialis and N. cutaneus antebra­
All nerves of the infraclavicular part of the Plexus brachialis contribute chii m edialis innervate th e m edial aspect o f th e arm. The N. m edianus
to the sensory innervation of shoulder and arm . The lateral aspect of (palmar side o f th e radial 3 1/2 fingers) and N. ulnaris (palmar side o f the
th e shoulder is innervated by th e N. axillaris. The lateral and dorsal ulnar 2Vi fingers) innervate the hand.
sides of the upper arm, the dorsal side o f th e forearm , and the dorsal
side o f th e radial 2Vi fing ers are innervated by th e N. radialis. The N. —»T 23

196

M uscles -» T o p o g ra p h y -► S ections

Innervation of the skin

C3

3.107

Fig. 3.106 and Fig. 3.107 S egm en tal cutaneous innervation spinal cord segm ents, derm atom es are not exactly congruent w ith the
(derm atom es) of th e upper extrem ity, right side; ventral cutaneous area supplied by th e peripheral nerves (-» p. 196). In contrast
(-» Fig. 3.106) and dorsal (-» Fig. 3.107) view . to the belt-like orientation of the derm atom es o f th e trunk, derma­
Specific areas of the skin are innervated by one single spinal cord seg­ tom es of the arm are oriented along the longitudinal axis (see Devel­
m ent. These areas of the skin are term ed derm atom es. As peripheral op m ent, -» Fig. 3.7).
cutaneous nerves of the arm contain sensory nerve fibres from several
—» T 2 3

i- Clinical Rem arks-----------------------------------------------------------------------------------------------------

The dem arcation o f derm atom es is o f great significance in th e diag- the third fing er and the adjacent halves o f the fourth and second
nosis of herniated discs and narrowing (stenosis) of th e vertebral fingers. Sensory innervations of the fifth finger and the ulnar side of
canal and intervertebral foram ina fo r exiting spinal nerves: w hile the the forearm are linked to segm ents C8 and T1, respectively,
segm ent C6 innervates the radial forearm and thum b, C7 supplies

Upper Extremity S urface a n a to m y -► D e ve lo p m e n t -► Skeleton -► Im aging

Nerves to the shoulder from the Pars supraclavicularis of the Plexus brachialis

N. dorsalis scapulae M. serratus anterior s u b c la v iu s
M. levator scapulae Clavicula
M . rhom boideus M . subclavius
m ino r Costa I

N. thoracicus longus

C o s ta IX

Fig. 3.108 N. dorsalis scapulae (C3-C5), right side; dorsal view. Fig. 3.109 N. thoracicus longus (C5-C7) and N. subclavius (C 5-
The N. dorsalis scapulae innervates th e M m . rhom boidei and M . levator C6), right side; lateral v ie w from the right side.
scapulae, both o f w h ic h fix th e Scapula to th e tru n k and pull it m edially The N. thoracicus longus innervates th e M. serratus an terior w h ich is
and superiorly. The N. dorsalis scapulae is th e m o s t cranial nerve to responsible fo r the elevation of the arm. This nerve pierces the M. sca­
branch o ff the Plexus brachialis, it pierces through the M. scalenus me- lenus m edius and courses underneath th e Plexus brachialis and Cla­
dius, and runs dorsally along the inferior border of the M . levator scapu­ vicula to the lateral side of the thorax to descend along the outer sur­
lae (indicator muscle). face o f th e M. serratus anterior. The N. subclavius innervates the
corresponding m uscle w hich actively stabilises the sternoclavicular
s u p r a s c a p u la ris joint. The N. subclavius runs adjacent to th e M. subclavius and often
s u p ra s p in a tu s sends a branch to th e N. phrenicus ("a ccessory phrenic nerve").
The nerves to th e shoulder derive fro m th e Pars supraclavicularis
(-* Figs. 3.108 to 3.110) and th e Pars infraclavicularis (-» Figs. 3.111 to
3.113) of the Plexus brachialis.
Nerves to th e shoulder from the Pars supraclavicularis:
• N. dorsalis scapulae (C3-C5)
• N. thoracicus longus (C5-C7)
• N. suprascapularis (C4-C6)
• N. subclavius (C5-C6)

—»T 22, 23

in fra s p in a tu s Fig. 3.110 N. suprascapularis (C 4-C 6), righ t side; dorsal view .
The N. suprascapularis innervates th e M . supraspinatus (supports ab­
duction) and M. infraspinatus (m ost im portant lateral rotator of the
arm !). The N. suprascapularis derives fro m th e Truncus superior, runs
dorsally along the clavicle, and reaches the dorsal aspect of the shoul­
der blade by traversing the Incisura scapulae underneath the Lig. trans-
versum scapulae superius.

i- Clinical Remarks------------------------------------ N. suprascapularis: A ffe c ts lateral rotation (M . infraspinatus is
the m ost im portant muscle) and, to a lesser degree, abduction
Lesions of th e shoulder nerves from th e Pars supraclavicularis: (M . supraspinatus). In addition to injuries o f th e lateral neck,
• N. dorsalis scapulae: The Scapula is displaced laterally and pinching o f nerves in the suprascapular notch (Incisura scapulae)
is also possible.
slightly protruding fro m th e thorax. A n isolated injury is rare be­ • The isolated lesion o f th e N. subclavius is very rare and has no
cause of its sheltered position. clear clinical sym ptom s.
• N. thoracicus longus: Elevation is im possible! The medial bor­
de r o f th e Scapula protrudes w ing-like fro m th e body (Scapula
alata; w inged scapula). This lesion is relatively com m on w hen
carrying heavy loads on the back ("backpacker's palsy") because
this nerve can be pinched under the clavicle.

198

M uscles -» T o p o g ra p h y -► S ections

Nerves to the shoulder from the Pars infraclavicularis of the Plexus brachialis

Fasciculus posterior Fasciculus lateralis Fasciculus m edialis
N. pectoralis
M . pectoralis m ajor N. p ectoralis lateralis
M . pectoralis m inor

Fig. 3.111 Nn. subscapulares (C5-C7), right side; ventral view. Fig. 3.112 Nn. pectorales lateralis (C5-C7) and m edialis (C8-T1),
Both nerves innervate the M. subscapularis (m ost im portant medial ro­ right side; ventral view.
tator of the arm!). The Nn. subscapulares are w ell protected since they The term s "lateralis" and "m e dialis" are related to their origins from
branch o ff the posterior cord and im m ediately descend to the anterior the lateral or medial cord, respectively, not to th e ir topographical posi­
side o f th e Scapula. tion (the N. pectoralis m edialis is often positioned lateral). Both nerves
innervate the M m . pectorales m ajor and minor. The M . pectoralis major
is th e m o s t im po rtan t m uscle fo r th e adduction and anteversion o f the
arm.

N. thoracodorsalis
M. teres major

M. latissim us dorsi

Fig. 3.113 N. thoracodorsalis (C6-C8), right side; dorsal view.
To geth er w ith th e corresponding artery, th e N. thoracodorsalis courses
to the medial side of the M. latissim us dorsi and innervates this muscle
and the M . teres major.
The nerves to th e shoulder derive fro m th e Pars supraclavicularis
(-* Figs. 3.108 to 3.110) and th e Pars infraclavicularis (-* Figs. 3.111 to
3.113) of the Plexus brachialis.
Nerves to th e shoulder from th e Pars infraclavicularis:
• Nn. subscapulares (C5-C7) from Fasciculus posterior
• N. thoracodorsalis (C6-C8) fro m Fasciculus posterior
• N. pectoralis lateralis (C5-C7) fro m Fasciculus lateralis
• N. pectoralis m edialis (C8-T1) fro m Fasciculus medialis

—»T 22, 23 |

i- Clinical Remarks------------------------------------ fold is collapsed. Considering the size o f the M. latissim us dorsi,
the sym ptom s are m ostly minor!
Lesions of th e shoulder nerves from th e Pars infraclavicularis: Nn. pectorales: Im pairm ent of adduction and anteversion. The
In general, isolated injuries o f individual infraclavicular nerves o f the arms cannot be crossed in fron t of the trunk. The anterior axillary
brachial plexus are rare due to the ir sheltered location. fo ld is collapsed.
• Nn. subscapulares: W eak medial rotation of the Humerus
• N. thoracodorsalis: Impaired adduction of the retroverted arm.

A rm s cannot be crossed behind the back. The posterior axillary

199

3 Upper Extremity S urface a n a to m y -► D e ve lo p m e n t -► Skeleton -► Im aging

N. axillaris

Fasciculus posterior

M . deltoideus

N. axillaris
M. teres minor
N . c u ta n eu s brachii
lateralis superior

Fig. 3.114 Course, m otor and sensory innervation of th e N.
axillaris, right side; dorsal view.
The N. axillaris originates fro m th e Fasciculus posterior, traverses the
qu adrangular space in th e Axilla to g e th e r w ith th e A. circum flexa hu­
meri posterior and courses around the Collum chirurgicum of the
Humerus to reach the dorsal side of the arm. The axillary nerve inner­
vates the M . deltoideus (m ost im portant abductor of the arm) and the
M. teres m inor. The sensory term inal branch (N. cutaneus brachii late­
ralis superior [purple]) em erges at th e inferior dorsal border o f th e M.
deltoideus and innervates the lateral aspect of the shoulder.

C7

Fig. 3.115 Segm ental organisation of th e N. axillaris, right side; Fig. 3.116 Lesion of th e N. axillaris: paralysis and atro p h y o f th e
ventral view. M . deltoideus.

—* T 22, 23

i- Clinical Remarks-----------------------------------------------------------------------------------------------------

Lesions of th e N. axillaris: The N. axillaris may be injured in proxi- shoulder is lost. Long-lasting injury causes m uscle atrophy, such
mal humeral fractures and shoulder luxations. Abduction of the arm th a t th e dom e shape o f th e shoulder is gone (-» Fig. 3.116).
is severely im paired and sensory input fro m the lateral side o f the

200

M uscles -» T o p o g ra p h y -► S ections

N. m usculocutaneus

Fasciculus lateralis
N . m usculocutaneus

M. coracobrachialis

M. b icep s brachii
M. brachialis

N. c u ta n eu s a n te b rac h ii lateralis

C5
C6
C7
C8
T1

Fig. 3.118 S eg m en tal organisation o f th e l\l. m usculocutaneus,
right side; ventral view.

-► T 22, 23

Fig. 3.117 Course, m o to r and sensory in nervation of th e N. at th e elbow . The N. m usculocutaneus provides m o to r innervation to
m usculocutaneus (C 5-C 7), righ t side; ventral view . the three ventral m uscles of the upper arm and sensory innervation to
Originating fro m th e Fasciculus lateralis, the N. m usculocutaneus the radial forearm .
pierces the M . coracobrachialis, descends distally betw een the M. Because th e N. m usculocutaneus pierces th e M. coracobrachialis,
biceps brachii and M . brachialis, and appears w ith its sensory branch finding the nerve during dissection helps to get oriented in dissecting
(N. cutaneus antebrachii lateralis [purple]) b e tw een th e se tw o m uscles th e Plexus brachialis (-» Figs. 3.148 and 3.149).

i- Clinical Remarks------------------------------------

Lesions of th e N. m usculocutaneus: The N. m usculocutaneus is medianus) also prom ote flexion in the elbo w joint. Supination o f the
at risk during shoulder luxations. Flexion o f the e lb o w is significantly flexed arm and the biceps reflex are weakened due to the paralysis
reduced as a result o f injury, but remains w eakly preserved because o f the M . biceps brachii. The sensory d e ficit on the radial forearm
th e radial group o f th e forearm extensors (innervated by th e N. radi- can be mild, because overlap occurs w ith the innervations of the
alis) and th e superficial flexo rs o f th e forearm (innervated by th e N. medial and the dorsal sensory nerves.

201

3 Upper Extremity S urface a n a to m y -► D e ve lo p m e n t -► Skeleton -► Im aging

N. radialis

Fasciculus posterior

N. M. brachialis
c u ta n e u s b ra ch ii p o s te rio r (Sulcus nervi radia R. profundus
R. superficialis
Triceps A rcaste o f FROHSE

N. c u ta n eu s b rachii lateralis inferio r M . brachioradialis
M. triceps brachii M . extensor carpi radialis longus
M . extensor carpi radialis brevis
N. cutaneus antebrachii M . a b d u cto r pollicis longus

M. M. extensor pollicis brevis
M. extensor carpi radialis extensor p ollicis longus
M. e xtensor carpi radialis brevis
M. extensor indicis
R a d ia l
M . extensor R. superficialis

S upinator N n. dig itales d orsales
M. extensor digiti

M.
N. interosseus p o sterio r

Fig. 3.120 S egm en tal organisation of th e N. radialis, righ t side;
ventral view.

-» T 22, 23

Fig. 3.119 Course, m otor and sensory innervation of th e N. the M . brachioradialis and M m . extensores carpi radialis longus and
radialis (C 5-T1), right side; dorsal view . Sensory cutaneous branches brevis branch off. Together w ith th e A. radialis, th e R. superficialis
are show n in purple. descends beneath th e M. brachioradialis. Further distally, th e R. super­
The N. radialis derives fro m th e Fasciculus po sterior and reaches the ficialis courses to the dorsal side of the hand fo r the sensory innerva­
dorsal side o f th e H um erus through th e "triceps slit" (-» Fig. 3.77) b e t­ tion o f the skin betw een the thum b and the index finger (Spatium inter-
w een the Caput longum and Caput laterale of the M . triceps brachii. osseum ; au tonom ic area!) and th e dorsal side o f th e radial 2Vz fingers.
Before w indin g around th e H um erus in th e Sulcus nervi radialis, th e N. Inferior to th e elbow , th e R. profundus pierces th e M . supinator (supi­
radialis sends m otor branches to the M . triceps brachii and a sensory nator canal) and reaches the dorsal side o f the forearm to provide
branch to the dorsal side of the upper arm. The sensory branch to the m o tor innervation to all extensor m uscles o f the forearm . The M. supi­
forearm branches o ff during its course in the Sulcus nervi radialis. The nator reveals a sharp-edged tendinous arch (arcade o f FROHSE). The
N. radialis the n en ters th e cubital fossa fro m laterally b e tw een th e M. term inal branch is th e N. interosseus antebrachii po sterior w h ich pro­
brachioradialis and M . brachialis (radial tu nn el), and divides into a R. vides sensory innervation to the dorsal w ris t joints.
s u p e r fic ia l and R. profundus. B efore th is division, m o to r branches to Sensory autonom ic area: first interdigital space.

202

M uscles -» T o p o g ra p h y -► S ections

N. radialis

A utonom ic area o f the N. radialis

1
N. radialis

N. c utaneus brachii
p o sterio r

M. triceps brachii,
C aput laterale

M. triceps brachii, Fig. 3.122 Proxim al lesion o f th e N. radialis: " w ris t drop " w ith
C aput longum sensory de ficits in th e firs t interdigital space.

M. triceps brachii, N. cutaneus antebrachii
C aput m ediale po sterio r

R. profundus

r- Clinical Remarks---------------------------------

N. interosseus antebrachii Lesions of th e N. radialis: There are three types of lesions:
p o s te rio r • Proxim al lesion in th e region o f th e axilla: In th e past, often

3 caused by crutches; however, presently this type of injury oc­
curs m ainly due to im proper po sitioning in th e OR. In addition
R. superficialis to th e sym p to m s associated w ith dam age in th e area o f the
humeral shaft, im pairm ent o f the M. triceps w ith reduction of
Fig. 3.121 Locations of com m on N. radialis lesions (C 5-T1), right elbo w extension exclusively occurs w ith proximal lesions. This
side; dorsal view (marked by bars). The skin areas of sensory also affects the triceps tendon reflex and causes loss of sensa­
innervation are highlighted (purple shading). tion on th e back of the upper arm, as these nerve fibres branch
Sensory autonom ic area: first interdigital space o ff before entering the Sulcus nervi radialis.
1 proxim al lesion in th e axilla • In te rm e d ia te lesion in th e region o f th e hum eral sh aft or
2 in term e d iate lesion near th e sh aft of H um erus (a) o r cubital elbow: caused by a humeral shaft fracture or crush injuries
(contusion) against th e H um erus. In th e e lb o w region, Radi­
fossa (b) us dislocations or proximal fractures may contribute to the
3 distal lesion near the w rist joints interm ediate lesion as w e ll as a com pression by the arca­
de of FROHSE. Lesions in th e region o f the hum eral shaft
(-» Fig. 3.121, 2a) result in a " w ris t drop " (-» Fig. 3.122)
due to im pa irm e nt o f all forearm extensors, including th e ra­
dial group as w ell as an im pairm ent o f the fing er and thum b
extension and supination o f th e extended arm. In addition, a
sensory d e fic it occurs at th e back o f th e forearm , in th e firs t
interdigital space (autonomic region), and on the back of the
radial 2Vi fingers. If o n ly th e R. profundus is pinched w hile
passing through th e M . supinator (-» Fig. 3.121, 2b), sensory
de ficits are m issing and th e lack o f innervation o f the w ris t
is negligible. A "w ris t drop" does no t occur since only the
finger extensors are impaired, w hereas the M m . extensores
carpi radiales as part o f th e intact radial m uscle group can suf­
ficiently stabilise the w rist. Due to active insufficiency of the
flexors which cannot be compensated fo r by extension of the
w rists, a strong fist closure is no t achievable.
• Distal lesion o f th e R. superficialis in the w ris t regions due
to a distal Radius fra cture (m ost com m on fra cture in humans):
The sensory d e ficit is confined to the firs t interdigital space
and to th e back o f th e radial 2Vi fingers. M o tor de ficits are
absent!

203

Upper Extremity S urface a n a to m y -► D e ve lo p m e n t -► Skeleton -► Im aging

N. medianus

Fasciculus medialis
Fasciculus lateralis

N. m ed ian u s

S eptum interm usculare
brachii m ediale

M. pronator teres M . palm aris longus
M. fle xor carpi radialis
M. flexor digitorum s u p e rfic ia l
M . fle xor pollicis N . interosseus a n te b rac h ii a n te rio r
M. flexor digitorum profundus
N. m edianus, R.
M .opponens a b d u cto r pollicis brevis
M . fle xor pollicis Carpal tunnel, Retinaculum m m . flexorum
N n. dig itales pa lm a re s c o m m u n es
C aput superficiale
Fig. 3.124 S egm en tal organisation of th e N . m edianus, right
side; ventral view.

-» T 22, 23

Fig. 3.123 Course, m otor and sensory innervation and locations anus then enters th e palm o f th e hand via th e carpal tu n n el (Canalis
of lesions of th e N. m edianus (C 6-T1), right side; ventral view. carpalis) b e tw e e n th e ten don s o f th e fle xo r m uscles. In th e palm o f the
Sensory cutaneous branches are s ho w n in purple. hand, the median nerve divides into three Nn. digitales palmares com ­
The N. m edianus originates fro m a lateral and a m edial root, w h ich de­ m unes. These provide m otor innervation to the m uscles o f the thum b
rive from the corresponding cords, and initially descends along th e m e­ (except fo r the M . adductor pollicis and Caput profundum of th e M.
dially side o f the upper arm in th e Sulcus bicipitalis m edialis w ith o u t fle xo r pollicis brevis) and th e tw o radial M m . lum bricales. Their term inal
providing any branches. The nerve then enters the cubital fossa from branches provide sensory innervation of the respective palmar side of
medially and traverses betw een both heads of M . pronator teres into the radial 3Vi fing ers and th e dorsal side o f th e distal phalanges.
the interm uscular layer betw een the superficial and deep flexor m us­ Sensory autonom ic area: distal phalanges of the second and third
cles of the forearm . W ith th e exception of th e M . flexor carpi ulnaris fingers.
and th e ulnar part o f M . fle x o r d igito rum profundus, th e N. m edianus C om m o n locations of lesions (m arked by bars):
innervates all flexor m uscles o f the forearm . The deep flexors are inner­ 1 proxim al lesion in th e Sulcus bicipitalis m edialis (a) and in the
vated by th e N. interosseus antebrachii an terior w h ich also provides
sensory innervation to th e palm ar side o f th e w ris t joints. The N. m edi­ cubital fossa (b)
2 distal lesion near the w rist joints and the carpal tunnel

204

M uscles -► T o p o g ra p h y -► S ections

N. medianus

M . fle x o r dig ito ru m superficialis, (Lig. carpi palmare)
Tendines A.; N. ulnaris

R etinaculum m usculorum flexorum

N. m edianus H a m u lu s
ossis ham ati

M . fle xo r pollicis longus, Tendo

Vagina tendinis m usculi V agina co m m u n is
fle xo ris pollicis longi tendinum m usculorum
fle x o ru m
M. fle xor carpi radialis, Tendo
ham atum
Os trapezium
fle xo r digitorum profundus,
Vagina ten d inis m usculi Tendines
flexoris carpi radialis

Ligg. carpom etacarpalia palm aria

Os trapezoideum
O s capitatum

Fig. 3.125 Carpal tu n n el, Canalis carpalis, righ t side; distal view ; tio n s o f th e tendinous sheaths o r sw ellings in th e area o f th e carpal
transverse section at the level o f the carpometacarpal joints. tun nel m ay result in com pression o f th e N. m edianus. Functional de fi­
Together w ith the carpal bones the Retinaculum m usculorum flexorum cits caused by com pression o f th e N. m edianus in th e carpal tunnel are
fo rm s th e carpal tunnel w h ic h is traversed by th e N. m edianus and the referred to as carpal tunnel syndrome.
ten don s o f th e long fle x o r m uscles (—> Fig. 3.164). Infla m m a tory reac­

A utonom ic area
o f the N. medianus

Fig. 3.126 Proxim al lesion o f th e N. m edianus: "han d of
benediction" w ith sensory deficits at the distal phalanx of the second
and third fingers.

Clinical Remarks in a suicide attem pt) o r by com pression o f th e N. m edianus in
the carpal tunnel (carpal tunnel syndrome): These do not result
Lesions of th e N. medianus: There are proximal and distal lesions: in a "hand o f be ne d ictio n " because th e m o to r branches o f th e
Proxim al lesions in th e area o f th e Sulcus bicipitalis medialis finger flexors already separate at the forearm ! However, this le­
(-» Fig. 3.123, 1a; e.g. cuts) or in th e cubital fossa (—> Fig. 3.123, sion presents w ith an "ape hand" displaying thenar atrophy and
1b): In th e cubital fossa, th e N. m edianus m ay be pinched by distal an adducted thu m b due to the predom inating e ffects of the M.
fractures of the Humerus, em ploying incorrect procedures during adductor pollicis (innervated by th e N. ulnaris). Grasping an object
phlebotom y or intravenous injections, or at its passage between b e tw een th e th u m b and th e index fin g e r is im possible because of
the tw o heads o f the M. pronator teres (pronator syndrome; me­ the inability to oppose the thu m b (deficit o f M . opponens pollicis)
dian nerve entrapm ent syndrome). Only the proximal lesion pre­ and th e distal phalanges o f both fing ers cannot approxim ate. In
sents w ith the "hand of benediction" position, characterised by addition, the impaired ability to abduct the thum b (M. abductor
the inability to fle x the proximal and distal interphalangeal joints pollicis brevis) does not allow com plete enclosure of an object
o f th e firs t, second and third fing ers (-* Fig. 3.126). The reason is w ith the hand. Sensory deficiencies occur on the palmar side
the absence of innervation to the superficial finger flexor and the o f th e radial 31/2 fingers. Proxim ally radiating pain typica lly occurs
radial c om pone nt o f th e deep fin g e r flexor. A ll o th e r sym p tom s at night.
are sim ilar to those of the distal lesion.
Distal lesions in th e w ris t region (such as "c u ttin g th e arte rie s"

205

3 Upper Extremity S urface a n a to m y -► D e ve lo p m e n t -► Skeleton -► Im aging

N. ulnaris Fasciculus medialis

N. ulnaris

S eptum interm usculare
brachii m ediale

E picondylus medialis

M. fle xor carpi ulnaris

R. profundus M. fle xor d igitorum profundus
ulnaris, R. dorsalis
M. fle xor pollicis brevis,
C aput profundum G U Y O N 's canal (Lig. carpi palmare)
R. superficialis

M m . interossei

M. adductor

Fig. 3.128 S egm en tal organisation of th e N. ulnaris, righ t side;
ventral view.

—»T 22, 23

Fig. 3.127 Course, m otor and sensory innervation and locations o f the M. fle xo r d igito rum profundus. In th e palm o f th e hand, th e R.
of lesions of th e N. ulnaris (C 8-T1), right side; ventral view. profundus branches o ff follow ing the deep palmar arterial arch to pro­
Sensory cutaneous branches are s ho w n in purple. vide m o tor innervation to the m uscles o f the Hypothenar, all interos-
The N. ulnaris originates fro m th e Fasciculus m edialis and courses sous muscles, th e ulnar M m . lumbricales, M. adductor pollicis, and the
along the medial upper arm in the Sulcus bicipitalis medialis. A fter deep head o f th e M . fle xo r pollicis brevis. The R. superficialis provides
piercing th e S eptum interm usculare brachii m edialis, th e N. ulnaris ap­ m o tor innervation to the M. palmaris brevis and continues as sensory
pears on the dorsal side o f the Epicondylus medialis and runs directly R. digitalis palm aris com m unis, w h ich divides into th e final branches
adjacent to th e bone in th e Sulcus nervi ulnaris ("fu n n y bo ne"). The N. innervating th e palm ar side o f th e ulnar 1Vi d ig its (and th e dorsal sides
ulnaris has no branches in th e upper arm . In th e forearm , it courses of their distal phalanges).
together w ith the A. ulnaris beneath the M . flexor carpi ulnaris to the Sensory autonom ic area: distal phalanx o f the fifth finger
w ris t and enters the palm of th e hand through the GUYON's canal. Its Frequent locations of lesions (marked by bars):
R. dorsalis reaches th e dorsal side o f th e hand and supplies sensory 1 proximal lesion at the Epicondylus medialis ("fun n y bone")
innervation to th e ulnar digits. In th e forearm , th e ulnar nerve pro­ 2 distal lesion in th e area of G U Y O N 's canal
vides m otor innervation to the M . flexor carpi ulnaris and the ulnar head

206

M uscles -» T o p o g ra p h y -► S ections

N. ulnaris

M. fle x o r d igito ru m superficialis, Tendines (Lig. c arp i p alm are)
R etinaculum m usculorum flexorum A.; N . ulnaris
N. medianus
M . fle xor pollicis longus, Tendo Ham ulus ossis hamati

Vagina tendinis m usculi flexoris pollicis longi Vagina com m unis tendinum
M . flexor carpi radialis, Tendo m usculorum flexorum

Os trapezium

Vagina tendinis m usculi flexoris carpi radialis Os ham atum
Ligg. carpom etacarpalia palm aria
Os trapezoideum M. fle xor digitorum profundus,
Os capitatum Tendines

Fig. 3.129 G UYO N's canal, right side; distal view ; transverse ris, to g e th e r w ith th e A. and V. ulnaris traverse th e G U YO N 's canal
section at th e level of the metacarpophalangeal joints. (-» Fig. 3.164). S w elling o r chronic pressure in th is area m ay cause a
The GUYON's canal is form ed by the Retinaculum m usculorum flexo­ com pression o f th e N. ulnaris (G U Y O N 's canal syndrom e).
rum and its superficial separation, th e "L ig carpi pa lm are ". The N. ulna­

A utonom ic area
o f the N. ulnaris

Fig. 3.130 Proxim al and distal lesions of th e N. ulnaris: "claw ed
hand" w ith impaired sensation at the distal phalanx of the fifth finger.

j- Clinical Remarks------------------------------------ langeal joints and fo r extension in th e distal interphalangeal joints.
Bringing th e fin g e r tip s o f th e th u m b and fifth d ig it in con tact is
Lesions of th e N. ulnaris: A lthough proximal and distal lesions are impossible because of the deficit of M. opponens digiti minimi
distinguished, a clear clinical differentiation betw een the m is not w ith resulting inability to oppose the fifth digit. The FROMENT's
possible: sign (holding a sheet o f paper betw een the thum b and index
• Proxim al lesions in th e area o f th e Sulcus nervi ulnaris ("fu n ­ finger) proves th a t th e lack o f adduction o f th e th u m b is com ­
pensated by flexing its distal phalanx (M. flexor pollicis longus
ny bone"), usually due to chronic com pression w hen leaning is innervated by th e m edian nerve). Sensory deficits occur in
on the arm: This is th e m ost com m on nerve lesion o f the upper th e palm ar side o f th e ulnar 1Vi fingers. S ensory s y m p to m s may
extre m ity . be absent, if th e lesion o n ly a ffe cts th e R. profundus, such as in
• Distal lesions in th e region o f G U Y O N 's canal, usually due to com pression injuries in the palm (jackhammer).
chronic pressure. Both cases present w ith a "clawed hand".
A trophy of the M m . interossei (visible) and th e tw o ulnar M m .
lum bricales results in th e inability fo r flexion in th e m etacarpopha­

207

3 Upper Extremity S urface a n a to m y -► D e ve lo p m e n t -► Skeleton -► Im aging

Arteries of the arm

Arteries of the Upper Extrem ity

Branches of the A. axillaris:
• A. thoracica superior (inconsistent)
• A. thoracoacrom ialis
• A. thoracica lateralis
• A. subscapularis

- A circum flexa scapulae
- A. thoracodorsalis
• A. circum flexa humeri posterior
• A. circum flexa humeri anterior

Branches of th e A. brachialis:
• A. profunda brachii

- A. collateralis media
- A. collateralis radialis
• A. collateralis ulnaris superior
• A. collateralis ulnaris inferior

Branches of th e A. radialis:
• A. recurrens radialis
• R. carpalis palm aris
• R. carpalis dorsalis -> Rete carpale dorsale Aa. m etacarpales

dorsales Aa. digitales dorsales
• R. palm aris superficialis A rcus palm aris superficialis
• A. princeps pollicis
• A. radialis indicis
• A rcus palmaris profundus -> Aa. metacarpales palmares

Branches of th e A. ulnaris:
• A. recurrens ulnaris
• A. interossea com m unis

- A. interossea anterior
- A. com itans nervi mediani

- A. interossea posterior m it A. interossea recurrens
• R. carpalis dorsalis
• R. carpalis palm aris
• R. palm aris profundus -> A rcus palm aris profundus
• Arcus palmaris superficialis Aa. digitales palmares

Rete articulare cubiti:
Collateral arteries (A. collateralis media, A. collateralis radialis,
A. collateralis ulnaris superior, A. collateralis ulnaris inferior) and
recurrent arteries (A. recurrens radialis, A. recurrens ulnaris,
A. interossea recurrens) contribute to a collateral circulation in the
elbo w area (Rete articulare cubiti).

Clinical Remarks Fig. 3.131 A rteries of th e upper ex tre m ity, rig h t side;
ventral view.
In a c om plete physical exam, th e pulses o f th e A. radialis and A. The A. axillaris is a continuation o f th e A. subclavia and stre tches fro m
ulnaris are palpated on the radial and ulnar side o f the proxim al w rist, the firs t rib to the inferior margin o f the M. pectoralis major. It is posi­
respectively, to exclude an occlusion of the blood vessels by arte­ tioned betw een the three cords o f the brachial plexus and the tw o
riosclerosis and blood clots (emboli). The existing vascular netw ork roots o f the median nerve. A t the level o f the upper arm, the A. axillaris
continues as A. brachialis and courses to g e th e r w ith the N. m edianus
in th e Sulcus bicipitalis m edialis to enter m edially the cubital fossa w h e ­
re it divides into the A. radialis and A. ulnaris. The A. radialis descends
betw een the superficial and deep flexor m uscles of the forearm to the
w ris t. Traversing the Fovea radialis (anatomical snuff box; Tabatière),
the A. radialis then runs betw een both heads of the M. interosseus
dorsalis I and enters th e palm of the hand to provide the major input fo r
the deep palmar arterial arch (Arcus palm aris profundus). The A. ul­
naris sends ou t the A. interosseus com m unis and runs together w ith
th e N. ulnaris to th e w ris t jo in ts and through th e G U YO N 's canal to the
palm o f th e hand. Flere, it continues in th e superficial palm ar arterial
arch (Arcus palmaris superficialis).

of collateral and recurrent arteries allows fo r the ligation of the A.
brachialis in th e cubital fossa in case o f injury, w ith o u t jeopardizing
the blood supply to the forearm .

208

M uscles -» T o p o g ra p h y -► S ections Veins and lymph vessels of the arm

N odus lym phoideus V. ce p h a lica
d e lto id o p e c to ra lis V. axilla ris

Nodi lym phoidei V. p ro fu n d a b ra chii
axillares V. th o ra c o e p ig a s tric a
(Hiatus basilicus)
N odi lym phoidei
Vv. brachiales axillares

V. m e d ian a S uperficial Deep
N odi lym phoidei cubitales lym ph co llectors lym ph collectors

V. m e d ian a a n te b ra ch ii Vv. radiales
Vv. ulnares
V. c e p h a lic a a nte brach ii Vv. interosseae
V. b a silica a nte brach ii

A rcus venosus palm aris superficialis Arcus venosus
palm aris profundus

Vv. metacarpales
palm ares

Vv. digitales palm ares

Figs. 3.132a and b Superficial (a) and deep (b) veins and lym ph continues on th e ulnar ventral side o f th e forearm and enters th e Vv.
vessels, righ t side; ventral view . brachiales at the Hiatus basilicus on the distal portion o f the upper arm.
The superficial venous system of the arm consists of tw o major lines The superficial epifascial lym ph collectors form a radial, ulnar and
w hich collect venous blood fro m the hand: m edial bundle in th e forearm . In th e upper arm , th e m edial bundle fol­
On the dorsal side of the thum b, the V. cephalica antebrachii collects low s th e V. basilica and drains into th e axillary lym ph nodes. The dorso­
blood fro m th e dorsal venous n e tw o rk o f th e hand and runs on th e ra­ lateral bundle courses along th e V. cephalica and additionally drains into
dial ventral side o f th e forearm to th e cubital fossa to join th e V. basilica th e supraclavicular lymph nodes.
antebrachii via the V. mediana cubiti. On th e upper arm , th e V. cephalica The regional lym ph node stations fo r both system s are positioned in
courses in th e Sulcus bicipitalis lateralis and m erges in th e Trigonum th e axilla (Nodi lym phoidei axillares). There are only fe w lym ph nodes in
clavipectorale (M O H R E N H E IM 's fossa) w ith th e V. axillaris. In th e up­ the cubital fossa (Nodi lym phoidei cubitales).
per arm, this superficial vein may be very w eak or missing. The deep venous system and the deep subfascial lymph collectors
The V. basilica antebrachii begins on the ulnar dorsum o f the hand, accompany the respective arteries.

209

Upper Extremity S urface a n a to m y -► D e ve lo p m e n t -► Skeleton -► Im aging

Lymph nodes and lymph vessels of the axilla

Vasa lym phatica superficialia V. axilla ris
V. ce p h a lica V. th o ra c o e p ig a s tric a

N odi lym pho idei
a x illa re s

D o rso lateral bundle P a p illa
o f lym ph c ollectors mamm aria
S uperficial lym ph
in th e u p p e r a rm c o lle c to rs

Vasa Vv. tho ra co -
lym phatica e p ig a s tric a e
s u p e rfic ia lia

Fig. 3.133 Superficial lym ph vessels and lym ph nodes in th e V. cephalica, both o f w h ich con nect to th e axillary lym ph nodes. The
axilla. Fossa axillaris, and th e lateral w all of th e thorax, Regio axillary lym ph nodes (Nodi lym phoidei axillares) not only serve as
thoracica lateralis, right side; ventral view. regional lymph nodes fo r the arm but also fo r the w all of the upper
In th e upper arm , th e superficial epifascial lym ph collectors co n s titu te a quadrants of the trunk, namely thorax and back.
m edial bundle along th e V. basilica and a dorsolateral bundle along the

210

M uscles -► T o p o g ra p h y -► S ections

Axillary lymph nodes

N odi lym pho idei axillares N odi lym pho idei
c e n tra le s in terp ecto rales

N odi lym pho idei axillares Aa.; Vv. m am m ariae mediales
hum erales [laterales]

A . axillaris
V. axilla ris

N odi lym pho idei axillares
s u b s c a p u la re s

N odi lym pho idei axillares pectorales

Aa.; Vv. mamm ariae
N odi lym pho idei p a ram a m m arii

A .; V. th o ra c ic a lateralis

Fig. 3.134 Levels of lym ph node hierarchy in th e axilla. Fossa Levels of axillary lym ph nodes: Level I, inferior group lateral of
axillaris, right side; ventral view. the M . pectoralis minor:
The adipose tissue o f the axilla harbours up to 50 lym ph nodes (Nodi • Nodi lym phoidei paramammarii (lateral of the breast)
lymphoidei axillares) w hich collect lymph from the arm, the upper tho­ • Nodi lym phoidei axillares pectorales (along A. and V. thoracica late­
racic w all including the breast, and the w all o f the upper back. Because
o f th e ir clinical relevance in breast cancer, these lym ph nodes are cate­ ralis)
gorised in three levels in topographical relation to the M . pectoralis mi­ • Nodi lym phoidei axillares subscapulares (along A. and V. subscapu-
nor. Superficial and deep lym ph nodes are associated w ith all three
levels, b u t o fte n th e ir affiliation w ith eith er level is n o t clear. H ow ever, laris and thoracodorsalis)
th e apical lym ph nodes fro m level III co lle ct lym ph fro m all o th e r lym ph • Nodi lym phoidei axillares laterales (along A. and V. axillaris)
nodes in th is region and serve as th e last lym ph node station prior to Level II, in te rm e d ia te group above and b e lo w th e M . pectoralis
the Truncus subclavius w hich drains into the Ductus thoracicus (left minor:
side) or into the Ductus lym phaticus dexter (right side; topography of • Nodi lymphoidei interpectorales (betw een M. pectoralis m inor and
th e axillary lym ph nodes -* Fig. 3.147).
M . pectoralis major)
• Nodi lym phoidei axillares centrales (beneath M . pectoralis minor)
Level III, superior group m edial of th e M . pectoralis minor:
• Nodi lym phoidei axillares apicales (subfascial in the Trigonum clavi-

pectorale = M O H R EN H EIM 's fossa)

i- Clinical Remarks------------------------------------ adenectom y) as part o f th e surgical tre a tm e n t in breast cancer
patients is discussed controversially since it is not proven that this
Palpation o f th e lym ph nodes is part o f a c o m p le te physical exam i­ procedure, in addition to removal o f the prim ary tum our, increases
nation. The physician should keep in m ind that axillary lym ph nodes the survival rate in patients. H ow ever, th e diagnostic lym phadenec-
are the regional lym ph nodes of the arm as w ell as of the w all of the to m y to d e term in e potential m etastases (staging) o f th e tu m o u r is of
upper trunk. Because of the high incidence o f breast cancer (about great importance and requires knowledge of the topography of the
one in te n w o m e n acquires breast cancer, but it m ay also affe ct axillary lymph nodes.
men), any palpable axillary lym ph node en largem ent in a w o m a n is
considered indicative of potential breast cancer.
Currently, the surgical removal of axillary lymph nodes (lymph-

211

Upper Extremity S urface a n a to m y -► D e ve lo p m e n t -► Skeleton -► Im aging

Superficial vessels and nerves of the axilla

Fig. 3.135 Epifascial vessels and nerves of th e axilla, Fossa th e lateral w all o f th e thorax. The V. thoracoepigastrica is variable and
axillaris, and th e lateral thoracic w all. Regio thoracica lateralis, descends at the level o f the anterior axillary fold form ed by the M . pec-
righ t side; ventral view . toralis major. A branch of the A. thoracica lateralis may accompany this
Next to the superficial axillary lymph nodes (Nodi lymphoidei axillares vein. Cutaneous branches of the Nn. intercostales exit from the respec­
superficiales), blood vessels and nerves are located in th e axilla and in tive intercostal spaces into th e axilla (Rr. cutanei laterales pectorales).

212 dissection link

M uscles -» T o p o g ra p h y -► S ections

Superficial vessels and nerves of the upper arm and shoulder

Nn. supraclaviculares laterales

V. c ep h a lica N . in terco sto b rach ialis
N. cu tan eu s b rachii m edialis

N. c u ta n eu s a n te b rac h ii lateralis N. c u ta n eu s a n te b rac h ii m edialis
(N. m usculocutaneus) V. b a s ilic a

V. m e d ia n a cubiti

N. c u ta n eu s a n te b rac h ii p o sterio r
(N. radialis)

V. m e d ia n a a nte brach ii

Fig. 3.136 Epifascial veins and nerves of th e shoulder, Regio level of the axilla to distribute along the medial aspect of the upper arm.
deltoidea, of th e upper arm , Regio brachii anterior, and cubital There are connections to the Nn. intercostobrachiales o f the Nn.
fossa, Regio cubitalis anterior, right side; ventral view. intercostales. In th e distal part o f th e upper arm, th e cutaneous branches
In th e upper arm, th e V. cephalica ascends in th e Sulcus bicipitalis la­ fo r th e forearm exit the fascia. The N. cutaneus antebrachii m edialis
teralis and runs betw een the origins of the M. deltoideus and M. pecto- accom panies th e V. basilica, and th e N . cutaneus antebrachii lateralis
ralis major. In th e cubital fossa, it con nects w ith th e V. basilica via th e V. descends next to th e V. cephalica. A s th e sensory term inal branch of
m ediana cubiti. In th e inferior part o f th e upper arm, th e V. basilica th e N. m usculocutaneus running b e tw een th e M. biceps brachii and
courses in th e Sulcus bicipitalis medialis and pierces through th e Fascia th e m ore deeply positioned M. brachialis, th e N. cutaneus antebrachii
brachii to enter one of the Vv. brachiales. Several cutaneous branches lateralis pierces the fascia betw een these tw o muscles. The N. cutane­
o f the N. cutaneus brachii m edialis penetrate the fascia at the us antebrachii posterior appears furth e r lateral.

I- Clinical Rem arks-----------------------------------------------------------------------------------------------------

Due to the accessibility, the V. cephalica is frequently used fo r the catheters (CVC, "central line") m ay be inserted through th e V. ce-
implantation of cardiac pacem akers and port system s (for applica- phalica into th e superior V. cava,
tion of chem otherapeutics or parenteral nutrition). Central venous

dissection link 213

3 Upper Extremity S urface a n a to m y -► D e ve lo p m e n t -► Skeleton -► Im aging

Superficial vessels and nerves of the upper arm and shoulder

Nn. supraclaviculares laterales

A .; V. c irc u m fle x a h um eri p o s te rio r N . c utaneus brachii po sterio r N. radialis
N. c u ta n eu s b rachii lateralis su p erio r N . cu tan eu s b rachii latera lis inferio r

(N. axillaris) V. c e p h a lic a

N. cutaneus brachii medialis N. c u ta n eu s a n te b rac h ii p o sterio r
(N. radialis)
O lecranon

E picondylus lateralis

Fig. 3.137 Epifascial vessels and nerves of th e shoulder, Regio us brachii lateralis inferior, N. cutaneus brachii posterior and N.
deltoidea, of the upper arm , Regio brachii posterior, and cubital cutaneus antebrachii posterior are term inal branches o f th e N. radia­
fossa, Regio cubitalis posterior, right side; dorsolateral view. lis and pierce through the fascia lateral to the M. triceps brachii. The exit
The N. cutaneus brachii lateralis superior is th e term inal sensory o f th e N. cutaneus antebrachii po sterior is often localised b e tw e e n the
branch o f the N. axillaris. It pierces the fascia at th e inferior margin of M. triceps brachii and the ventrally located M . brachialis.
the M. deltoideus w hich is innervated by the axillary nerve. N. cutane-

214— ► dissection link

M uscles -» T o p o g ra p h y -► S ections

Veins of the cubital fossa

V. c e p h a lic a V. c e p h a lic a V. b a s ilic a V. b a s ilic a
V. m e d ia n a cubiti V. m e d ia n a c u b iti (A. b ra ch ia lis
V. m e d ia n a s u p erfic ialis , Var.)
V. basilica a n te b ra c h ii V. m e d ia n a b a silica

V. c ep h a lica V. b a s ilic a a nte brach ii

V. m e d ia n a ce p h a lica

V. m e d ia n a
a n te b ra c h ii
V. ce p h a lica
a n te b ra c h ii

Figs. 3.138a to c Variations of th e epifascial veins in th e cubital d ire ct connections w ith a V. mediana antebrachii on th e anterior aspect
fossa, Regio cubitalis anterior, right side; ventral view. o f th e forearm (-» Fig. 3.138c). O f im portance is th e potential existence
The V. cephalica m ay vary substantially in the upper arm (-» Figs. 3.138a o f an additional A. brachialis superficialis in the cubital fossa w ith a
and b). Occasionally, th e V. mediana cubiti is m issing, and instead, the course in parallel to th e veins.
V. cephalica antebrachii and V. basilica antebrachii com m unica te via in­

Clinical Remarks consider the existence of a superficial A. brachialis. Drugs should
not be injected into the artery, because som e substances may have
The veins in th e cubital fossa are im po rtan t fo r d raw in g blood and toxic effects upon intra-arterial injection due to lack of dilution.
for intravenous adm inistration of drugs. Because of their exten­
sive variability, it is re com m ended to exam ine th e exact course o f the
veins and palpate them . If an arterial pulse is palpated, one should

215

3 Upper Extremity S urface a n a to m y -► D e ve lo p m e n t -► Skeleton -► Im aging

Superficial vessels and nerves of the forearm

(N. radialis)
N. cutaneus brachii posterior

V. b a silica

N. cutaneus
brachii medialis

V. ce p h a lica N. cutaneus brachii N . cutaneus
m e d ia lis a n te b ra c h ii
N. cutaneus antebrachii
la te ra lis N. cutaneus p o sterio r
a n te b rac h ii m edialis (N. radialis)
(N. m usculocutaneus)
V. m e d ia n a c u b iti V. ce p h a lica

V. m e d ian a a nte brach ii O lecranon

(V. m e d ian a basilica) N. cutaneus antebrachii
m edialis

V. b a s ilic a a n te b r a c h ii

V. c e p h a lic a a n te b r a c h ii N. cutaneus
a n te b ra c h ii
p o sterio r
(N. radialis)

R. s u p erfic ialis (N . radialis) V. b a s ilic a a n te b r a c h ii R. superficialis
A. radialis R. palm aris (N. ulnaris) (N . radialis)

R. palm aris V. c e p h a lic a a nte brach ii
(N. m edianus)

R. d orsalis (N. ulnaris)

3.140

Fig. 3.139 and Fig. 3.140 Epifascial veins and nerves of the forearm . Upon exiting the fascia, the N. cutaneus antebrachii m edia­
forearm , Regio antebrachii anterior and Regio antebrachii lis runs adjacent to th e V. basilica; th e INI. cutaneus antebrachii latera­
posterior, and of the cubital fossa, Regio cubitalis anterior, right lis starts its course to g e th e r w ith th e V. cephalica. The N. cutaneus
side; ventral (-* Fig. 3.139) and dorsal (-* Fig. 3.140) view . antebrachii posterior pierces the fascia betw een the M . triceps bra­
A t the dorsal side of the thum b, the V. cephalica antebrachii emerges chii and M. brachialis. A t th e distal forearm , th e R. superficialis of th e
from the superficial venous netw ork (Rete venosum dorsale manus) N. radialis pierces the fascia beneath the tendon of the M . brachioradi-
and the n courses on th e radial and ventral side o f th e forearm , w hereas alis and th u s reaches th e dorsum o f th e hand. Sim ilarly, th e R. dorsalis
the V. basilica antebrachii continues fro m the ulnar dorsum o f the of th e N. ulnaris exits beneath the tendon of th e M . flexor carpi ulnaris
hand to th e ulnar ventral side o f th e forearm . In th e cubital fossa, both to reach th e dorsal side. The palm ar branches o f N. m edianus and N.
veins usually com m unicate via the V. m ediana cubiti. The cutaneous ulnaris proxim al o f th e w ris ts are usually n o t easily sho w n in th e dis­
nerves of the forearm radiate w ith their branches to both sides of the section.

216—♦ dissection link

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Superficial vessels and nerves of the dorsum of the hand

V. b a s ilic a a n te b r a c h ii N. cutaneus antebrachii poste rio r (N. radialis)
N. ulnaris, R. dorsalis V. c e p h a lic a a n te b r a c h ii
N . radialis, R. superficialis
Rete venosum dorsale m anus

Nn. digitales dorsales

Fig. 3.141 Epifascial vessels and nerves on th e dorsum of th e th e N. radialis pierces the fascia beneath the tendon of the M. brachi-
hand. Dorsum manus, right side; dorsal view. oradialis. Its divisions, the Nn. digitales dorsales, convey sensory inner­
A t the dorsal side of the thum b, the V. cephalica antebrachii em erges vation o f the radial 2Vi digits. The ulnar 2Vi digits are innervated by the
from the superficial venous ne tw ork on the dorsum of the hand, and R. dorsalis o f th e INI. ulnaris em erging beneath th e ten don o f th e M.
the V. basilica antebrachii em erges on the veins from on ulnar dor­ flexor carpi ulnaris.
sum o f th e hand. A bove th e proxim al w ris t joint, the R. s u p e r fic ia l of

dissecti on l ink 217

3 Upper Extremity S urface a n a to m y -► D e ve lo p m e n t -► Skeleton -► Im aging

Trigonum clavipectorale Fasciculus posterior
Fasciculus lateralis
Rete acrom iale Fasciculus m edialis
Acrom ion C lavicula

M . deltoideus, A. axillaris
Pars clavicu laris V. axilla ris

V. c e p h a lic a M . subclavius

Fascia c la v ip e c to ra lis
N. pectoralis medialis

A. thoracoacrom ialis,
Rr. p e cto rale s
M . p e cto ralis m ajor,
Pars cla vicu laris

Fig. 3.142 Trigonum clavipectorale (M OHRENHEIM 's fossa) on cephalica pierces th e Fascia clavipectoralis to e m p ty into th e V. axilla­
th e right side. ris. In addition, th e A. th oraco acrom ialis em erges fro m th e A. axillaris
The Trigonum clavipectorale is a small triangular space betw een the and divides into fou r term inal branches. The Nn. pectorales medialis
clavicle and and th e origins of the M. pectoralis major and M. deltoide­ and laterales w hich originate fro m the respective cords o f the brachial
us. To reveal the Trigonum clavipectorale during dissection, the origin plexus course together w ith th e arterial branches to the pectoral m us­
o f the M. pectoralis major is separated fro m the clavicle and reflected cles w hich the y supply.
laterally and th e Fascia clavipectoralis is rem oved. A t th e trigone, th e V.

Rete acrom iale Clavicula A. subclavia
R. acrom ialis A . axillaris
R. delto id eu s R. clavicularis
A . th o raco acro m ialis
Rr. p e cto rale s

Fig. 3.143 Branches of th e A. thoracoacrom ialis.
The four term inal branches of th e A. thoracoacrom ialis are:
• Rr. pectorales to th e M m . pectorales
• R. clavicularis to th e M . subclavius
• R. deltoideus to th e M . deltoideus
• R. acrom ialis to th e Rete acrom iale

218—♦ dissection link

M uscles -» T o p o g ra p h y -► S ections

V. th o ra c o e p ig a s tric a N . in terco sto b rach ialis Axillary fossa
V. a x illa ris A .; V. t h o r a c ic a la te r a lis
M. pectoralis m ajor M. serratus
V. s u b scap u laris
A .; V. c irc u m fle x a h um eri p o ste rio r

Vv. brachiales

Plexus brachialis,
Pars infraclavicularis

N. axillaris
M. teres major
A.; V. c irc u m fle x a s ca p u lae
M. latissim us dorsi

A .; V. th o r a c o d o r s a lis
N. thoracodorsalis
N . th o ra c ic u s longus

Fig. 3.144 A xillary fossa, Fossa axillaris, righ t side; laterocaudal les derive fro m th e Nn. intercostales, cross the axilla, and run along­
view. side th e N. cutaneus brachii medialis. The N. thoracodorsalis courses
The anterior and posterior borders of the axillary fossa are the M. pec­ together w ith the corresponding blood vessels to the medial side o f the
toralis major and the M . latissim us dorsi, respectively, both o f which M . latissim us dorsi. Further ventral, the N. thoracicus longus de­
are fo rm in g th e axillary folds. In th e axillary fossa, all th re e cords o f the scends on the lateral aspect of the M. serratus anterior w hich it inner­
Pars infraclavicularis o f th e Plexus brachialis surround th e A. axillaris vates.
w hile covered ventrally by the V. axillaris. The Nn. intercostobrachia-

A. subclavia

Rete acromiale
R. acromialis
R. deltoideus

A. circum flexa hum eri posterior A. thoracoacrom ialis

A. circum flexa hum eri anterior
A. thoracica lateralis
A. subscapularis
A. brachialis
A. profunda brachii
A. circum flexa scapulae

Fig. 3.145 A rteries of th e shoulder, righ t side; ventral view . triangular axillary space and anastom oses (*) w ith the A. suprasca-
Branches of the A. axillaris: pularis.
• A. thoracica superior: variable on the M m . pectorales • A. circum flexa hum eri anterior: anastom oses (**) w ith the A. cir­
• A. thoracoacrom ialis (-» Fig. 3.143) cum flexa humeri posterior w hich traverses the quadrangular axillary
• A. thoracica lateralis: lateral of th e M. pectoralis m inor space.
• A. subscapularis: divides into the A. thoracodorsalis to the M . latis­ The R. acrom ialis o f th e A. thoracoacrom ialis m ay also anastom ose
w ith the A. suprascapularis (***).
sim us dorsi, and the A. circum flexa scapulae w hich traverses the

dissection link 219

3 Upper Extremity S urface a n a to m y -► D e ve lo p m e n t -► Skeleton -► Im aging

Axillary fossa Plexus brachialis,
P ars infraclavicularis
A . th o r a c o - f Rr. p e cto ra le s
a c r o m ia lis \ R. a cro m ia lis A . axillaris
M. deltoideus
M . pectoralis m ajor
V. ce p h a lica
A . axillaris
M. pectoralis m ajor

V. axillaris
M . pectoralis m inor

N. intercostobrachialis
N . thoracodorsalis
A .; V. th o r a c ic a la te r a lis
A.; V. th o ra c o d o rsa lis
N. thoracicus longus

M . latissim us dorsi
V. t h o r a c o e p ig a s t r ic a

Fig. 3.146 Axillary fossa. Fossa axillaris, and lateral thoracic w hich th e y innervate. The M. pectoralis m inor serves as an im portant
w all. Regio thoracica lateralis, right side; lateral view. landm ark fo r th e classification o f axillary lym ph nodes (-» Fig. 3.134).
Com pared to -» Figure 3.144, th e M . pectoralis m ajor is split to visuali­ The A. and V. thoracica lateralis course at its lateral border and lateral
se the M . pectoralis m inor underneath and the anatomical structures thereof, the A., V. and N. thoracodorsalis descend to reach the m edi­
appearing in th e Trigonum clavipectorale. The A. thoracoacrom ialis al aspect o f th e M. serratus an terior th e y supply. The V. thoracoepigas­
and its branches are visible at the upper border of M. pectoralis minor. trica sh o w s variable dim ensions (here sho w n as a strong vessel) and is
The associated Rr. pectorales course to g e th e r w ith th e Nn. pectorales not accompanied by an artery during its course in the subcutaneous
of th e Plexus brachialis tow ards the M m . pectorales major and minor adipose tissue of th e lateral thoracic wall.

220—♦ d i s s e c t i o n li n k

M uscles -» T o p o g ra p h y -► S ections

Axillary fossa

V. ju g u la ris e x te rn a N odi lym phoidei cervicales anteriores,
M. sternocleidom astoideus N odi superficiales et profundi

M. scalenus medius

N odi lym phoidei cervicales
laterales, N odi superficiales

M . om ohyoideus,
Venter superior

A .; V. tra n sve rsa colli, M. pectoralis m inor
R. s u p e rficia lis
V. ce p h a lica
Nodi lym phoidei N odi lym pho idei
cervicales anteriores axillares centrales
superficialis et profundi M . pectoralis m ajor

M. scalenus anterior N. m usculocutaneus

Truncus jugularis sinister N. m edianus

V. ju g u la ris V. ce p h a lica

D uctus thoracicus N. ulnaris
(confluence) N odi lym pho idei
axillares laterales
Nodi lym phoidei N. cutaneus brachii medialis
supraclaviculares
N odi lym pho idei
Trunci subclavius axillares subscapulares
e t b ronchom ed iastinalis N. thoracicus longus
A.; V. th o ra c ic a lateralis
s in is te r

M. subclavius

M . pectoralis m ajor lynipi luiuci
axillares pectorales
M. pectoralis m inor
N odi lym pho idei axillares a p icales

A. thoracica superior
N odi lym pho idei axillares centrales

Fig. 3.147 Axillary fossa. Fossa axillaris, and lateral thoracic ca lateralis and, furth e r lateral, the Nodi lym phoidei axillares subscapu­
w all, Regio thoracica lateralis, left side; ventral view. lares and th e Nodi lym phoidei axillares laterales next to th e V. axillaris.
In con trast to -* Fig. 3.146, th e le ft side is s ho w n to de m onstrate the The second level (at the level of M. pectoralis minor) depicts the Nodi
confluence o f th e axillary lym ph vessels in th e D uctus thoracicus. The lym phoidei axillares centrales beneath the m uscle. Medial of M . pecto­
M. pectoralis m inor is sp lit fo r a be tter visualisation o f the axillary lymph ralis minor, th e third level is positioned as a last filte r station prior to the
nodes. W ith respect to their topographical relation to the M . pectoralis junction w ith the Truncus subclavius. The latter conveys the lymph
m inor, th e axillary lym ph nodes are organised in th re e levels fro m the le ft thorax via the Ductus thoracicus to the le ft venous angle
(-» Fig. 3.134). The firs t level (lateral o f M. pectoralis m inor) contains b e tw een V. jugularis interna and V. subclavia.
th e Nodi lym phoidei axillares pectorales alongside th e A. and V. thoraci­

Clinical Remarks------------------------------------ Truncus subclavius sinister fro m the le ft arm, and via the Truncus
jugularis sinister fro m the left head and neck region. Therefore, mé­
The Ductus thoracicus carries the lymph of the entire low er body tastasés o f m alignant tu m o u rs in th e abdom en m ay m a nifest in the
(including abdominal and pelvic organs) and em pties into the left left supraclavicular lym ph nodes VIRCHOW 's node.
venous angle. Before doing so, it receives additional lym ph via the
Truncus bronchom ediastinalis sinister fro m the le ft thorax, via the

d i s s e c t i o n l i n k 221

3 Upper Extremity S urface a n a to m y -► D e ve lo p m e n t -► Skeleton -► Im aging

Vessels and nerves of the upper arm

Fasciculus lateralis N. suprascapularis
A. axillaris N. subscapularis
Fasciculus m edialis
M . coracobrachialis Fasciculus p o sterio r
M. pectoralis m ajor M . subscapularis
A. circum flexa hum eri anterior A. c ircu m flexa
N. m usculocutaneus hum eri p o sterio r
M. teres m ajor
N. m edianus
C aput longum A. subscapularis
N. thoracodorsalis
M. b icep s brachii M. latissim us dorsi
C aput breve N. cutaneus brachii medialis

N. m usculocutaneus N. ra d ia lis
A. brachialis A. p ro fu n d a b ra c h ii

N. u ln a ris

M . trice p s brachii, C aput m ediale

S eptum interm usculare brachii mediale

Fig. 3.148 Blood vessels and nerves of th e axillary fossa. Fossa m iddle part o f th e " m " , and th e m edial stroke o f th e " m " is fo rm e d by
axillaris, and of th e m edial side of th e upper arm , Regio brachii th e N. ulnaris. W hile th e N. m edianus descends in th e Sulcus bicipitalis
anterior, right side; ventrom edial view. m edialis to reach th e cubital fossa fro m m edial, th e N. ulnaris runs on
To show the infraclavicular part of the Plexus brachialis, the M . pecto­ the posterior side of the Epicondylus medialis. The Fasciculus posteri­
ralis m ajor w a s cut near its origin on th e Crista tub ercu li m ajoris and or w as m obilised fro m its position behind the A. axillaris. One o f its
removed. Proximally, the three " m " are show n. The Fasciculus latera­ peripheral nerves, th e N. axillaris, traverses th e quadrangular space to ­
lis and Fasciculus m edialis position to both sides o f th e A. axillaris and gether w ith the A. circum flexa humeri posterior. Then, the Fasciculus
form a M-shaped structure of nerves w hich serves as helpful orienta­ po sterior con tinues as N. radialis w h ich courses to g e th e r w ith th e A.
tion during dissection. The lateral stroke o f th e " m " is fo rm e d by th e N. profunda brachii through the triceps slit to reach the posterior aspect of
m usculocutaneus w h ic h is easily iden tified piercing th e M. coraco­ the Humerus.
brachialis. The m edial and lateral roots o f th e N. m edianus fo rm the

222—♦ d i s s e c t i o n li n k

M uscles -» T o p o g ra p h y -► S ections Vessels and nerves of the upper arm

M . pectoralis m ajor A . axillaris
M . c o raco b rach ialis N. axillaris

N. m usculocutaneus N. radialis
M . biceps brachii N. m edianus
A. profun da brachii
M . brachialis
N. m usculocutaneus, M. trice p s brachii, C aput longum
N. c u ta n eu s a n te b rac h ii lateralis N. ulnaris
A. co llateralis ulnaris su p erio r
A. brachialis M. triceps brachii, C aput m ediale
N. m edianus
A. c o lla te ralis ulnaris inferio r
E picondylus medialis

Fig. 3.149 A rteries and nerves of th e axillary fossa. Fossa N. m edianus descends to g e th e r w ith th e A. brachialis in the Sulcus
axillaris, and of the m edial side of the upper arm , Regio brachii bicipitalis m edialis to reach th e cubital fossa. The INI. ulnaris continues
anterior, right side; ventrom edial view ; M . biceps brachii hold apart. together w ith th e A. collateralis ulnaris superior to the posterior side of
The M . biceps brachii w as lifted o ff laterally to sho w the course of the the Epicondylus medialis. The A. collateralis ulnaris inferior frequently
N. musculocutaneus. The latter pierces and innervates the M . cora- branches proximal of th e elbow as a thin vessel from the A. brachialis.
cobrachialis and descends betw een the M. brachioradialis and M . bra­ The N. axillaris branches o ff th e Fasciculus posterior proxim ally and
chialis supplying m otor innervation. A t the distal upper arm, the senso­ traverses the quadrangular axillary space. The N. radialis courses to ­
ry term inal branch (N. cutaneus antebrachii lateralis) appears be tw een gether w ith the A. profunda brachii through the triceps slit.
the tw o m uscles and continues on the radial side o f the forearm . The

dissection link 223

3 Upper Extremity S urface a n a to m y -► D e ve lo p m e n t -► Skeleton -► Im aging

Vessels and nerves of the upper arm

M. teres major M . deltoideus
N. axillaris, N. cutaneus brachii
N. radialis, N. c u ta n eu s b rachii p o sterio r
lateralis superior M. tric e p s brachii, C a pu t laterale
profunda brachii, R. deltoideus M. biceps brachii
M. tric e p s brachii, C a pu t longum S eptum interm usculare brachii laterale
M. brachialis
N. radialis A. collateralis radialis
A. profun da brachii N. c u ta n eu s b rachii lateralis inferio r
N. radialis, N. cu tan eu s a n te b rac h ii p o sterio r
A. brachialis M . triceps brachii, C aput mediale
N. m usculocutaneus, N. cutaneus antebrachii lateralis
N. ulnaris E picondylus lateralis
O lecranon

Fig. 3.150 Arteries and nerves of th e lateral side of th e upper nervi radialis o f th e H um erus. The m o to r branches o f th e N. radialis fo r
arm , Regio brachii posterior, right side; dorsolateral view. th e innervation o f th e M. trice ps and th e N. cutaneus brachii posterior
The Caput longum and Caput laterale of the M. triceps brachii w ere already separate at th e level o f th e trice p s slit. H ow ever, th e N. cutane­
separated to sho w the triceps slit betw een both heads. The N. radia- us brachii lateralis infe rior and N. cutaneus antebrachii po sterior leave
lis and A. profunda brachii traverse th is gap to course in th e Sulcus th e N. radialis fro m th e Sulcus nervi radialis.

Clinical Remarks th e trice ps slit. The N. cutaneus brachii lateralis infe rior to g e th e r w ith
th e N. cutaneus antebrachii po sterior m ay be affected by th is injury
In a hum eral shaft fracture w ith injury to th e N. radialis th e fu n c­ because th e y separate in th e region o f th e Sulcus nervi radialis.
tion of the M . triceps brachii usually remains unaffected. The m otor
nerves to innervate th e M . trice ps as w e ll as th e N. cutaneus brachii
po sterior already branch o ff th e N. radialis at th e passage through

224—♦ dissection link

M uscles -» T o p o g ra p h y -► S ections Vessels and nerves of the upper arm

Lig. transversum scapulae superius A. s u prascapularis
N. suprascapularis
Lig. transversum
scapulae inferius

A . c ircu m flexa
s c a p u la e

A. brachialis N . axillaris
N. radialis
A . circum flexa
A. profun da brachii hum eri p o sterio r

M. trice p s brachii, C aput laterale
N. cutaneus brachii
p o sterio r
(N. radialis)
N. c utaneus brachii
latera lis inferio r
(N. radialis)

N. cutaneus
a n te b rac h ii p o sterio r
(N. radialis)

N. cutaneus antebrachii lateralis
(N. m usculocutaneus)

N. ulnaris

Fig. 3.151 A rteries and nerves of th e shoulder, Regio delto idea, stru cture s. N. axillaris and A. circum flexa hum eri po sterior pass through
and th e lateral side of th e upper arm , Regio brachii dorsalis, right the quadrangular axillary space. The A. circum flexa scapulae traverses
side; dorsolateral view. th e triangular axillary space to th e dorsal side. In th e Fossa infraspinata,
This illustration depicts again the localisation of the branches of the N. the A. circum flexa scapulae (derived fro m A. axillaris) fo rm s an im por­
radialis. The triceps slit w as elongated through keen edged separa­ tant anastom osis w ith the A. suprascapularis (derived fro m A. subcla-
tion of the Caput longum and Caput laterale of the M . triceps brachii. via). Frequently, anastom oses w ith the A. dorsalis scapulae (from A.
The m otor branches o f th e N. radialis fo r th e innervation of the M . tri­ subclavia, not shown) also exist. These arterial anastom oses allow for
ceps and th e N. cutaneus brachii po sterior already separate at th e level a collateral arterial circulation to supply the arm, thereby bypassing a
o f th e trice ps slit. H ow ever, th e N. cutaneus brachii lateralis infe rior and proxim al occlusion o f th e A. axillaris.
N. cutaneus antebrachii po sterior leave th e N. radialis in th e Sulcus The A. suprascapularis traverses above th e Lig. transversum scapulae
nervi radialis. The A. profunda brachii runs tog ethe r w ith the N. radialis superius to th e Fossa supraspinata o f th e Scapula. H ow ever, th e N.
and splits into A. collateralis media (to Epicondylus medialis) and A. suprascapularis traverses beneath the ligam ent through the Incisura
collateralis radialis (concom itant w ith the nerve). scapulae. Nerve and artery are then bridged by the Lig. transversum
This illustration also dem onstrates the axillary spaces w ith traversing scapulae inferius during the ir transition into the Fossa infraspinata.

dissection link 225

3 Upper Extremity S urface a n a to m y -► D e ve lo p m e n t -► Skeleton -► Im aging

Vessels and nerves of the forearm

M. biceps brachii N. ulnaris; A. collateralis
M . brachialis ulnaris superior

N . m edianus Hum erus, Epicondylus
A. brachialis m edialis

A poneurosis m usculi M. biceps brachii, Tendo
b icip itis brachii A . ulnaris

A. radialis M . fle xor carpi ulnaris
M. pronator teres
M. palm aris longus
M. fle x o r carpi radialis N. ulnaris
M. extensor carpi radialis brevis
R. dorsalis (N. ulnaris)
M. flexor digitorum superficialis A. ulnaris

M. fle xor pollicis longus

Fig. 3.152 Superficial arteries and nerves of th e forearm , Regio arterial pulses is predom inantly perform ed on the A. radialis ju st above
antebrachii anterior, right side; ventral view. th e proxim al w ris t joint. The A. ulnaris and co n co m ita n t N. ulnaris are
The N. m edianus runs together w ith the A. brachialis to the cubital both covered by the M. flexor carpi ulnaris as dem onstrated at th e dis­
fossa from medial. The A. brachialis splits into A. radialis and A. ulnaris, tal forearm.
both o f w hich descend to the respective sides o f the w rist. Palpation of

226— ► dissection link

M uscles -» T o p o g ra p h y -► S ections Vessels and nerves of the forearm

A. brachialis A. collateralis ulnaris
N. radialis s u p e rio r
M . brachioradialis
A . co llateralis radialis N . ulnaris
N. radialis, R. profundus M . brachialis
M . b icep s brachii, Tendo N. medianus
A. radialis A. ulnaris
A . re cu rre n s radialis M. pronator teres
M. supinator
N. radialis, R. superficialis M. flexor digitorum
s u p e rfic ia lis
A. radialis
N. m edianus N. ulnaris
A. ulnaris

Fig. 3.153 Superficial arteries and nerves of th e forearm , Regio teralis radialis (*). The A. ulnaris branches o ff be lo w the M . pronator
antebrachii anterior, right side; ventral view ; M. brachioradialis and teres and descends next to th e N. ulnaris beneath th e M. fle xo r carpi
Aponeurosis bicipitis antebrachii w ere removed. ulnaris to the ulnar side of the w rist. B etw een M . brachioradialis and M.
The M . brachioradialis and the insertion of the M. biceps brachii to the brachialis (radial tunnel) the N. radialis enters the cubital fossa from
Fascia antebrachii (A poneurosis m usculi bicipitis antebrachii) have been lateral and splits into R. superficialis and R. profundus. The R. superfi­
rem oved to visualise the branching of the A. brachialis and to show cialis runs adjacent to th e A. radialis and deviates to th e dorsal side in
the course o f the A. and N. radialis. As a branch o f th e A. brachialis, the th e distal third o f th e forearm . The R. profundus innervates and pierces
A. radialis continues its course beneath the M . brachioradialis and the M . supinator (supinator canal). The sharp-edged tendinous arch
reaches the radial side o f the w rist. The A. recurrens radialis ascends (arcade of FROHSE) at the entrance to the m uscle may com press the
beneath the M. brachioradialis to th e arterial ne tw ork of the elbow nerve.
(Rete articulare cubiti) and engages in an an astom osis w ith th e A. colla-

dissection link 227

3 Upper Extremity S urface a n a to m y -► D e ve lo p m e n t Skeleton -► Im a g in g -►

Vessels and nerves of the forearm

N. radialis N. ulnaris
N. radialis, R. profundus A. brachialis

A. ulnaris M . brachialis
A. radialis N. m edianus
A. recurrens radialis
N. radialis, R. superficialis M. pronator teres,
M. supinator C a pu t ulnare
A . interossea co m m u n is
M. pronator teres
A. radialis A. recurrens ulnaris
N. radialis, R. superficialis M. fle xor carpi radialis

A. radialis M. fle xor digitorum superficialis,
R. palm aris (N. m edianus) C aput radiale
M. fle xor carpi radialis, Tendo
A. ra d ialis, R. p a lm a ris s u p e rficia lis A. ulnaris
M . palm aris longus, Tendo N . ulnaris

M . fle xor carpi ulnaris, Tendo
R. d o rs alis (N. ulnaris)
A. ulnaris, R. carpalis dorsalis

Fig. 3.154 Deep arteries and nerves of th e forearm , Regio ante- cends beneath the M. pronator teres. The N. medianus appears be­
brachii anterior, right side; ventral view ; M . pronator teres and M. tw een both heads o f the M. pronator teres to enter the space between
flexo r carpi radialis w e re split and the M . palmaris longus w as removed. the deep and interm ediate layers o f the flexo r m uscles o f the forearm .
Once the superficial flexor m uscles o f the forearm are separated, the A t the distal forearm , the tendon of the M . flexor carpi ulnaris w as cut
proximal branches of the A. ulnaris are visible: the A. interossea com ­ to s h o w th e branching o f th e R. dorsalis of N. ulnaris and its course to
m unis descends as a strong vessel, and the A. recurrens ulnaris as­ the dorsum of the hand.

228— ► dissection link

M uscles -» T o p o g ra p h y -► S ections Vessels and nerves of the forearm
Til
A. brachialis l 'f§
N. radialis
E picondylus medialis
A. collateralis radialis
(R. anterior) A. recurrens ulnaris
N. m edianus
N. ra d ialis, R. p ro fu n d u s
A. recurrens radialis A. c o m ita n s nervi m ediani
A. interossea an terio r
M . biceps brachii, Tendo A. ulnaris
A. interossea co m m u n is N. ulnaris

M . p ronator teres M. fle xor digitorum profundus,
A. interossea po sterio r Tendines
N . interosseus a n te b rac h ii R. d o rsa lis (N. ulnaris)
M. fle xor digitorum superficialis,
an terio r Tendines
M. fle xor carpi ulnaris,
N. radialis, R. superficialis Tendo
A. radialis

M. pronator quadratus
M. fle xor p ollicis longus

Fig. 3.155 Deep arteries and nerves of th e fo re arm , Regio artery (A. com itans nervi mediani). A t th e proximal forearm , th e N. inter­
antebrachii anterior, right side; ventral vie w ; all superficial flexor osseus antebrachii anterior branches o ff providing m otor innervation to
m uscles w ere removed. the deep flexo r m uscles and sensory supply to the w ris t joints.The A.
A fte r removal o f all superficial flexor muscles, including the M . flexor interossea anterior accompanies this nerve, and the A. interossea pos­
digitorum superficialis, th e c om plete course o f th e N. m edianus is visi­ terior traverses through the Membrana interossea antebrachii to the
ble. It descends distally in th e m idline o f th e forearm b e tw e e n th e deep dorsal side.
and superficial flexo r m uscles and is com m only accom panied by a thin

dissection link 229

Upper Extremity S urface a n a to m y -► D e ve lo p m e n t -► Skeleton -► Im aging

Vessels and nerves of the cubital fossa and elbow

N . radialis M. biceps brachii

A . co llateralis radialis A. brachialis
(R. an te rio r) N . m edianus
N. radialis,
M. brachioradialis R. superficialis
A. radialis
Mm . extensores carpi radiales A. recurrens radialis
N. radialis, R. profundus
M. extensor carpi radialis brevis
M. extensor digitorum
M . supinator

N. ra d ialis, R. p ro fu n d u s
A . interossea recurrens

N. m edianus E picondylus medialis
A. brachialis N. ulnaris
M . biceps brachii O lecranon
M . brachialis
A. recurrens ulnaris
A poneurosis m usculi
b icip itis brachii N. ulnaris
M. fle xor digitorum profundus
M. brachioradialis
N . radialis

M m . flexores antebrachii

A. ulnaris

M. pronator teres
N. medianus

3.157

Fig. 3.156 and Fig. 3.157 A rteries and nerves of th e elbow ; Regio the M. brachioradialis and M . brachialis (radial tunnel) together w ith
cubitalis anterior, rig h t side; lateral (radial) v ie w (-» Fig. 3.156). th e A. collateralis radialis. Here it divides into the tw o term inal
Arteries and nerves of the elbow, Regio cubitalis posterior, right branches. The R. superficialis continues beneath th e M . brachioradialis.
side; m edial (ulnar) v ie w (-► Fig. 3.157). The R. profundus reaches th e dorsal side through th e M. supinator (su­
These illustrations dem onstrate the course of the nerves of the arm pinator canal). The N . ulnaris is dire ctly adjacent to th e bone in the
after splitting the diverse superficial flexors and extensors. Together Sulcus nervi ulnaris w here it is easily irritated ("funny bo ne"). Then,
w ith the A. brachialis, the N. m edianus enters the cubital fossa from th e N. ulnaris courses beneath th e M . fle xo r carpi ulnaris to th e fle xo r
medial. The N. radialis enters the cubital fossa from lateral betw een side of the forearm.

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M uscles -» T o p o g ra p h y -► S ections

Vessels and nerves of the forearm

N. ulnaris A. collateralis radialis
A. recurrens ulnaris M . extensor carpi radialis longus

O lecranon E picondylus lateralis
Rete articulare cubiti M. extensor carpi radialis
brevis
M. extensor carpi ulnaris
N. radialis, R. profundus
M. e xtensor carpi ulnaris, Tendo A. interossea p o sterio r
M. extensor d igiti m inim i, Tendo M. extensor digitorum
R. dorsalis (N. ulnaris)
M. a bd ucto r pollicis longus
M. extensor p ollicis brevis
N. radialis, R. superficialis
A. interossea anterior

Fig. 3.158 Deep arteries and nerves of th e fo re arm , Regio interossea posterior betw een the superficial and deep extensors. A t
antebrachii posterior, right side; radial view. th e radial side o f th e w ris t, th e R. superficialis o f th e N. radialis ap­
The M. extensor digiti m inim i is deviated to the side to sho w the course pears from beneath the M. brachioradialis and enters the dorsum of the
o f th e R. profundus o f th e N. radialis w h ic h descends w ith th e A. hand.

dissecti on l ink 231

3 Upper Extremity S urface a n a to m y -► D e ve lo p m e n t -► Skeleton -► Im aging

Vessels and nerves of the forearm

§

M. anconeus M. supinator
N . radialis, R. profundus
A. interossea recurrens M. e xtensor carpi radialis brevis
Rr. m usculares
A. in terossea p o sterio r
M. a bd ucto r p ollicis longus
M . extensor digitorum M em brana interossea
R. p rofun dus nervi radialis, N. radialis, R. s u p e rfic ia l
N. interosseus a n te b rac h ii M. extensor pollicis brevis
M. extensor pollicis longus, Tendo
p o sterio r
M. extensor pollicis longus
M. extensor carpi ulnaris, Tendo

Fig. 3.159 Deep arteries and nerves of th e forearm , Regio extensors o f th e forearm and te rm inates as sen sory N. inter­
antebrachii posterior, rig h t side; radial view . osseus antebrachii posterior at the w rist. A fte r its passage through the
The M. extensor digitorum w as lifted sideways to show the branches Membrana interossea antebrachii, the A. interossea posterior branches
o f th e R. profundus o f th e N. radialis and o f th e A. interossea po ste­ o ff the A. interossea recurrens w hich reaches the arterial ne tw ork of
rior. Follow ing its transition through th e supinator m uscle, the the elbow (Rete articulare cubiti) underneath the M . anconeus.
R. profundus o f th e N. radialis innervates all superficial and deep

232—♦ dissection link

M uscles -» T o p o g ra p h y -► S ections Arteries of the hand

A. radialis A. ulnaris
R. c a rp a lis p alm aris R. c a rp a lis palm aris
R. pa lm a ris superficialis R. carpalis dorsalis
A rcus p alm aris profundus
A. princeps pollicis R. p alm aris profundus
A. radialis indicis
Aa. m etacarpales palm ares
Aa. digitales palm ares propriae A rcus p alm aris superficialis

Aa. digitales palm ares com m unes

Aa. digitales palm ares propriae

Fig. 3.160 A rteries o f th e hand, M anus, righ t side; palm ar view . profundus, -* Fig. 3.161) and con tributes a com m unica ting branch to
The palm o f th e hand is supplied by th e A. radialis and A. ulnaris w h ich the superficial palmar arterial arch (Arcus palmaris superficialis). w here­
usually both contribute to the tw o palmar arterial arches. The A. radia­ as, the A. ulnaris term inates in the superficial palm ar arterial arch
lis te rm inates in the deep p alm ar arterial arch (Arcus palmaris (-* Fig. 3.162) and provides a branch to th e A rcus palm aris profundus.

Figs. 3.161a to d Variations of th e deep palm ar arterial arch. Figs. 3.162a to c Variations of the superficial palm ar arterial
The deep palm ar arterial arch gives rise to the Aa. metacarpales palma­ arch.
res w hich supply th e palm of the hand including the M m . interossei. The superficial palmar arterial arch feeds the Aa. digitales palmares for
Frequently, in th e interdigital spaces th e w e a k Aa. m etacarpales palm a­ th e second to fifth digits. The th u m b (A. princeps pollicis) and th e radial
res join th e digital arteries w h ic h derive fro m th e superficial palm ar ar­ side o f th e index fin g e r (A. radialis indicis) are supplied by direct
terial arch. branches o f th e A. radialis. In sum m ary, th e A. radialis supplies the
The deep palm ar arterial arch is usually closed b u t th e A. interossea palm o f th e hand and th e radial 1Vi digits, and th e A. ulnaris supplies the
anterior may be connected (*). ulnar 3 1/2 digits.
Frequently, a com plete superficial palm ar arterial arch is m issing. In
these cases, the A. radialis and A. ulnaris have separate supply zones.

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Vessels and nerves of the palm of the hand

N. m e d ia n u s, R. canal
N. m usculocutaneus, N. ulnaris, R. palm aris
N . ulnaris
N. cutaneus antebrachii lateralis A. ulnaris

A poneurosis palm aris M . palm aris brevis
A. princeps pollicis
N. digitalis palm aris proprius
A. radialis indicis N. m e d ian u s, Rr. p alm ares

N. ulna ris, Rr. p alm ares
N n. dig itales pa lm a re s proprii
A. digitalis p alm aris com m unis
A a. dig itales p alm ares pro p riae

Lig. m etacarpale transversum
s u p e rfic ia le

Fig. 3.163 Superficial arteries and nerves of th e palm of th e neurosis, th e Nn. digitales palm ares derived fro m th e N. m edianus and
hand, Palm a m anus, righ t side; palmar view. N. ulnaris and th e ram ifications o f th e term inal digital branches o f the
In th e palm o f th e hand, blood vessels and nerves are w e ll protecte d by Aa. digitales palm ares com m une s are visible. A s th e N. ulnaris and A.
the palm ar aponeurosis (Aponeurosis palmaris). Proximal o f the m eta­ ulnaris run superficially in the G U YO N 's canal, they may be injured or
carpophalangeal joints and betw een the longitudinal fibres of the apo­ com pressed at this location.

234 dissection link

M uscles -» T o p o g ra p h y -► S ections

Vessels and nerves of the palm of the hand

A. radialis A. ulnaris
N. m edianus M. fle xor carpi ulnaris
M . fle xor carpi radialis, Tendo N. ulnaris
A. radialis, R. pa lm a ris superficialis Os pisiform e
N. m edianus, R. palm aris
M. a bd ucto r p ollicis brevis N. ulnaris, R. profundus
A. ulnaris, R. carpalis dorsalis
M. fle xor pollicis brevis N. ulnaris, R. superficialis
A. ulnaris, R. palm aris profundus
M. a d d u cto r pollicis N. digitalis p alm aris proprius
N. m edianus,
R. co m m u n ic a n s cu m nervo ulnari
N. digitalis palm aris
co m m u n is A rcus pa lm a ris superficialis

Aa. digitales palm ares propriae N. digitalis palm aris proprius

Nn. digitales palm ares proprii A a. dig itales pa lm a re s c o m m u n es

Fig. 3.164 Interm ediate layers of arteries and nerves of th e palm fingers. The N. ulnaris accompanies the A. ulnaris through the
of th e hand, Palma m anus, right side; after removal o f the palmar G U Y O N 's canal. Distal o f th e Os pisiform e, th e N. ulnaris aready splits
view ; palmar aponeurosis. into its R. profundus and R. superficialis and con tinues along th is direc­
The superficial p alm ar arterial arch (Arcus palm aris superficialis) is tion. The R. superficialis divides into Nn. digitales palm ares fo r sensory
essentially form ed by the A. ulnaris and frequently anastom oses w ith a innervation o f th e ulnar 1Vi digits. The radial 31/2 d ig its are supplied by
branch fro m th e A. radialis (R. palm aris superficialis). The Aa. digitales respective branches of the N. m edianus w hich enters the palm o f the
palm ares fo r th e ulnar 31/2 digits branch o ff th e superficial palm ar arteri­ hand through the carpal tu nn el (Canalis carpalis) beneath the Retina­
al arch w h ile it crosses th e tendons o f the long fle xo r m uscles o f the culum m usculorum flexorum.

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3 Upper Extremity S urface a n a to m y -► D e ve lo p m e n t -► Skeleton -► Im aging

Vessels and nerves of the palm of the hand

M. pronator quadratus A. ulnaris
A . radialis
M . fle xor carpi ulnaris
M . fle x o r carpi radialis, Tendo
N . ulnaris
M . opponens pollicis N. ulnaris, R. s u p e rfic ia l
M. fle xor p ollicis brevis, C aput superficiale N. ulnaris, R. profundus
M. a bd ucto r digiti minim i
A rcus p alm aris profundus A . ulnaris,
M . a dd ucto r pollicis R. p alm aris profundus
M m . interossei palm ares
A. princeps pollicis M . a dd ucto r pollicis
M . a b d u cto r pollicis brevis A a. m e tac a rp ale s p alm ares
M m . flexores d igito ru m , Tendines
A . radialis indicis
M. interosseus dorsalis I M m . lum bricales

Fig. 3.165 Deep arteries and nerves of th e palm of th e hand, mal than th e superficial palmar arterial arch. The deep palmar arterial
Palma manus, right side; palmar view ; tendons of the flexor muscles arch releases the thin Aa. metacarpales palmares and courses over the
and M m . lumbricales w e re rem oved and the M . adductor pollicis was M m . interossei to g e th e r w ith the R. profundus of th e N. ulnaris
split. w hich innervates th e hypothenar muscles, the M m . interossei, and the
The deep palm ar arterial arch (Arcus palmaris profundus) derives tw o ulnar M m . lum bricales. The arteries supplying th e th u m b (A.
fro m th e A. radialis and com m unica tes w ith th e R. palm aris profundus princeps pollicis) and th e radial side o f th e index fin g e r (A. radialis indi­
o f the A. ulnaris. This arch is positioned beneath the M . adductor polli­ cis) are also branches o f the A. radialis.
cis and in fro n t o f th e bases o f the Ossa metacarpi, thus, furth e r proxi­

236— ► dissection link