Anatomy_ A Regional Atlas of the Human Body

CLEMENTE | ANATOMY

CHAPTER 1: Pectoral Region, Axilla, Shoulder, and Upper Limb Plates 1–138

CHAPTER 2: The Thorax Plates 139–218

CHAPTER 3: The Abdomen Plates 219–322

CHAPTER 4: The Pelvis and Perineum Plates 323–370

CHAPTER 5: The Back, Vertebral Column, and Spinal Cord Plates 371–408

CHAPTER 6: The Lower Limb Plates 409–516

CHAPTER 7: The Neck and Head Plates 517–668

CHAPTER 8: Cranial Nerves Plates 669–694
Index I-1–I-24





Acquisitions Editor: Crystal Taylor
Marketing Manager: Brian Moody
Product Manager: Julie Montalbano
Designer: Terry Mallon
Compositor: Aptara, Inc.

Copyright © 2011, 2007, 1997, 1987, 1981, 1975 Lippincott Williams & Wilkins, a Wolters Kluwer business.

351 West Camden Street 530 Walnut Street
Baltimore, MD 21201 Philadelphia, PA 19106

Printed in China.

All rights reserved. This book is protected by copyright. No part of this book may be reproduced or transmitted in any form
or by any means, including photocopies or scanned-in or other electronic copies, or utilized by any information storage and
retrieval system without written permission from the copyright owner, except for brief quotations embodied in critical articles
and reviews. Materials appearing in this book prepared by individuals as part of their official duties as U.S. government employees
are not covered by the above-mentioned copyright. To request permission, please contact Lippincott Williams & Wilkins at 530
Walnut Street, Philadelphia, PA 19106, via email at [email protected], or via Web site at lww.com (products and services).

987654321

This 6th edition of Anatomy: A Regional Atlas of the Human Body is published by arrangement with Elsevier Germany GmbH,
publisher and copyright holder of Sobotta Atlas der Anatomie des Menschen, 22. Auflage, Band 1, Band 2; München: Elsevier/
Urban & Fischer ©2006. The English translation was undertaken by Lippincott Williams & Wilkins.

Most of the illustrations in this atlas have been previously published in the following:
Clemente, Carmine D. Anatomy: A Regional Atlas of the Human Body, 4th Edition. Baltimore: Williams & Wilkins, 1997.
Sobotta, J. Atlas of Human Anatomy, 21st German Edition/13th English Edition, Volumes 1 and 2. Edited by R. Putz and R. Pabst.
Munich: Urban & Fischer, 2000; Baltimore: Lippincott Williams & Wilkins, 2001.
Sobotta, J. Atlas of Human Anatomy, 11th English Edition, Volume 1. Edited by J. Staubesand. Baltimore, Munich: Urban &
Schwarzenberg, 1990.
Sobotta, J. Atlas der Anatomie des Menschen, 18. Auflage, Band 2. Edited by H. Ferner. Munich: Urban & Schwarzenberg, 1982.
Wicke, L. Atlas of Radiologic Anatomy, 6th English Edition. Edited and translated by A.N. Taylor. Baltimore: Williams & Wilkins,
1998.

Library of Congress Cataloging-in-Publication Data

Clemente, Carmine D. 2009037389
Anatomy : a regional atlas of the human body / Carmine D. Clemente. – 6th ed.

p. ; cm.
Includes bibliographical references and index.
ISBN 978-1-58255-889-9 (alk. paper)
1. Anatomy, Surgical and topographical–Atlases. I. Title.
[DNLM: 1. Anatomy, Regional–Atlases. QS 17 C626a 2011]
QM531.C57 2011
611–dc22

DISCLAIMER

Care has been taken to confirm the accuracy of the information present and to describe generally accepted practices.
However, the authors, editors, and publisher are not responsible for errors or omissions or for any consequences from application
of the information in this book and make no warranty, expressed or implied, with respect to the currency, completeness, or
accuracy of the contents of the publication. Application of this information in a particular situation remains the professional
responsibility of the practitioner; the clinical treatments described and recommended may not be considered absolute and
universal recommendations.

The authors, editors, and publisher have exerted every effort to ensure that drug selection and dosage set forth in this text are
in accordance with the current recommendations and practice at the time of publication. However, in view of ongoing research,
changes in government regulations, and the constant flow of information relating to drug therapy and drug reactions, the reader is
urged to check the package insert for each drug for any change in indications and dosage and for added warnings and precautions.
This is particularly important when the recommended agent is a new or infrequently employed drug.

Some drugs and medical devices presented in this publication have Food and Drug Administration (FDA) clearance for
limited use in restricted research settings. It is the responsibility of the health care providers to ascertain the FDA status of each
drug or device planned for use in their clinical practice.

To purchase additional copies of this book, call our customer service department at (800) 638-3030 or fax orders to (301) 223-
2320. International customers should call (301) 223-2300.

Visit Lippincott Williams & Wilkins on the Internet: http://www.lww.com. Lippincott Williams & Wilkins customer service
representatives are available from 8:30 am to 6:00 pm, EST.

Preface to the Sixth Edition

It is always reinforcing and rewarding for an author when the from Madrid, Spain, on the progressive unfolding of cardiac
publisher of a book requests another edition. I have now had muscle as shown in Plate 186. These studies have given insight-
this pleasure five times after the first edition of this atlas was ful information on the manner by which the heart muscle devel-
published 34 years ago in 1975. Previous editions, as well as this ops and matures.
edition, have benefited greatly by the many suggestions from
colleagues and especially students. Students often approach this Most of the figures in this atlas come from the Sobotta
in a thoughtful subtle manner. First, the student may say how atlases, recent editions of which have been published by Pro-
much he or she has learned from the book and give praise to the fessor R. Putz in Munich, Germany, and Professor R. Pabst in
nature and color of the figures and then point out a mistaken Hanover, Germany. My deepest appreciation to these two bril-
label in one of the figures that may not have caught my eye. Of liant anatomists knows no bounds. Their German editions of
course, I am always grateful for these suggestions. Sobotta have been recently reproduced as the 14th English Edi-
tion in 2006. A number of drawings, some of which were also
In this edition, I have added many new figures—for exam- used in the 5th edition, were made by a former resident artist
ple, 14 new figures on 5 plates dealing with the brachial plexus. here at UCLA, Ms. Jill Penkhus. I am most grateful for her artis-
At the same time, a few figures that did not prove to be excellent tic creativity.
teaching items have been removed. Perhaps the most important
change in the book is the addition of a significant number of I am most indebted to the editors at Lippincott Williams &
X-rays, CT scans, and ultrasound scans. I am most grateful to Wilkins in Baltimore, and especially to Ms. Crystal Taylor, with
Edward J. H. Nathanial, M.D., Ph.D., Emeritus Professor at the whom I have interacted for more than 20 years on several ear-
University of Winnipeg School of Medicine in Canada, for pro- lier editions of this atlas, and Ms. Julie Montalbano, the Prod-
viding at least 15 figures of clinical significance. Several figures uct Manager of this edition. Here at UCLA, I am privileged to
also were contributed by Dr. G.L. Colborn, Emeritus Professor have worked with outstanding associates who form the gross
from the Medical College of Georgia in Augusta, Georgia. I have anatomy faculty for both the medical and dental school at this
also had the pleasure of discussions with Dr. James D. Collins, university. These include Dr. Shelley Metten, the Chairperson
Professor of Radiologic Sciences here at UCLA. I thank Dr. of the Anatomy Division, and Drs. Robert Trelease, Richard
Constantine Karakousis, Professor of Surgery and Chief of Sur- Braun, Joseph Miller, Elena Stark, Yau Shi Lin, Jonathan
gical Oncology at the University of Buffalo in Buffalo, New York, Wisco, Quynh Pham, Guido Zampighi, David Hovda, Anna
for the use of several of his figures and for comments on the clin- Taylor, Robin Fisher, Charles Olmstead, Francesco Chiap-
ical importance of several plates. Certain X-rays from Dr. Lothar pelli, and Jayc Sedlmayr. Dr. Sedlmayr is now on the faculty
Wicke’s 6th English edition of Atlas of Radiologic Anatomy, edited of the Louisiana State University School of Medicine in New
by Dr. Anna Taylor here at UCLA, were also used. Orleans. In my 57 years of active teaching here at UCLA, col-
lectively, these anatomists are the finest anatomy colleagues I
There are more than 200 plates of clinical importance in have ever worked with.
this atlas, and I have benefited greatly from my discussions and
collaboration with Professor Gerald Buckberg, M.D., Professor Finally, but by no means least, I must say that my wife, Julie,
of Cardiac Surgery here at UCLA, and the late Dr. F. Torrent Guasp has been a steadfast inspiration to me and my academic life, and
I am eternally grateful to her.

Carmine D. Clemente
Los Angeles, California—October 2009

From the Preface to the Fifth Edition

I continue to observe the use of this atlas in the anatomy class- of no one else. I would be most grateful to any student or pro-
room and laboratory here at the UCLA Center for the Health fessor who may have suggestions or who may identify errors, if
Sciences, and many suggestions I have received over the past these were transmitted to me here in Los Angeles.
six years from students and from friends around the world
have been incorporated in this edition. Further, students have Many new clinically related plates have been added to those
convinced me that a special section on the cranial nerves in the 4th edition. This atlas now contains more than 150 plates
would be helpful to them. This has now been included and a that are of direct clinical importance. These are listed in the front
series of diagrammatic drawings (patterned after Grant and pages of the book and they include surface anatomy, radiographs
other authors) along with a number of figures relevant to the (many of which come from the outstanding collection of Profes-
cranial nerves have been collected in a group of 29 plates at sor L. Wicke of Vienna), MRIs, CT scans, arteriograms, lymp-
the end of the Neck and Head section. Most of the new cranial hangiograms, bronchograms, and even a series of arthroscopic
nerve drawings were done by Ms. Jill Penkhus several years ago images of the knee joint. These have been added because of the
when she was the resident artist in the Department of Anatomy increased emphasis on the clinical relevance to the teaching of
here. In addition to these, several new pieces of art have been Anatomy that has become common in medical schools, not only
included in this atlas. in the United States but in many other countries as well. One
plate (#146) is based on the work of Drs. R. Torrent-Guasp of
Among the new illustrations in this edition are modified Madrid and Gerald Buckberg of UCLA here in Los Angeles.
replacements of the nine remaining illustrations in the 4th edi-
tion that originated from the controversial atlas Topographical There are many who have helped to make this atlas
Human Anatomy by Pernkopf. These new color illustrations possible. Among them are Ms. Betty Sun, Ms. Crystal Taylor,
were expertly rendered by the medical illustrators at Anatomi- Ms. Kathleen Scogna, and Ms. Cheryl Stringfellow at Lippincott
cal Chart Company (ACC) and David Rini. By far, however, Williams & Wilkins in Baltimore and, of course, many at the
my deepest appreciation is extended to Professors R. Putz in Elsevier Corporation, the publishers that acquired the Sobotta
Munich and R. Pabst in Hanover, Germany, for their exceed- collection from Urban & Fischer. I am especially grateful to
ingly creative contributions for the 21st German and 13th Dr. Constantine Karakousis, Professor of Surgery and Chief of
English editions of the Sobotta Atlas of Human Anatomy. More Surgical Oncology at the University of Buffalo in Buffalo, New
than 325 figures in their most recent two-volume set are the York, for his recommendations and comments on the clinical
principal new drawings on which this edition is based. The importance of several of the plates. Perhaps most of all, my con-
other figures are ones that were used in my 4th edition. I am tinuing gratitude goes to Julie, my wife, who has helped me both
responsible for all the notes that accompany all of the figures, at the computer and in being considerate for all the time it has
and any mistakes that may be found in these are mine and those taken me to do this manuscript, time that could have been given
to some of her interests.

Carmine D. Clemente
Los Angeles, California—February 2006

From the Preface to the First Edition

Twenty-five years ago, while a student at the University of Penn- the Sobotta plates in a regional sequence—the pectoral region
sylvania, I marvelled at the clarity, completeness, and boldness and upper extremity, the thorax, the abdomen, the pelvis and
of the anatomical illustrations of the original German editions perineum, the lower extremity, the back, vertebral column and
of Professor Johannes Sobotta’s atlas and their excellent three- spinal cord, and finally, the neck and head. This sequence is
volume English counterparts, the recent editions of which were consistent with that followed in many courses presented in the
authored by the late Professor Frank H. J. Figge. It is a matter United States and Canada and one which should be useful to
of record that before World War II these atlases were the most students in other countries.
popular ones consulted by American medical students. In the
United States, with the advent of other anatomical atlases, the Many have contributed to bringing this Atlas to fruition. I
shortening of courses of anatomy in the medical schools, and thank Dr. David S. Maxwell, Professor and Vice Chairman for
the increase in publishing cost, the excellent but larger editions Gross Anatomy and my colleague at UCLA, for his encourage-
of the Sobotta atlases have become virtually unknown to a full ment and suggestions. I also wish to express my appreciation
generation of students. During the past 20 years of teaching to Caroline Belz and Louise Campbell, who spent many hours
Gross Anatomy at the University of California at Los Angeles, I proofreading and typing the original text. I especially wish to
have found only a handful of students who are familiar with the thank Mary Mansor for constructing the index—a most labo-
beautiful and still unexcelled Sobotta illustration. rious task. I am grateful to Barbara Robins for her assistance
in typing some of the early parts of the manuscript, and above
This volume introduces several departures from the for- all, to her sister Julie, who is my wife and who makes all of my
mer Sobotta atlases. It is the first English edition that represents efforts worthwhile through her encouragement and devotion.

Carmine D. Clemente
Los Angeles, California—January 1975

Chapter 5 The Back, Vertebral Column, and Spinal Cord

Contents

CHAPTER 1: Pectoral Region, Axilla, Shoulder, and Upper Limb Plates

Body Regions 1

Anterior Thorax, Superficial Pectoral Region Including Female Breast 2–18

Axilla, Deep Pectoral Region 19–27

Arteries and Superficial Veins of Upper Limb 29–29

Anterior and Posterior Shoulder: Muscles; Neurovascular Structures; Abduction 30–33

Upper Limb: Surface Anatomy and Dermatoses 34–35

Upper Limb: General; Muscles, Vessels and Nerves 36–45

Brachial Plexus 46–53

Shoulder, Anterior and Posterior Arm (Brachium): Muscles, Vessels and Nerves (Detailed) 54–67

Forearm: General (Superficial) 68–69

Forearm: Anterior Aspect, Muscles, Vessels and Nerves 70–79

Forearm: Posterior Aspect, Muscles, Vessels and Nerves 80–89

Hand: Dorsal Aspect 90–93

Hand: Palmar Aspect 94–111

Bones and Joints of the Upper Limb 112–131

Cross Sections of the Upper Limb 132–137

Anatomy of Fingers 90–93; 95–98; 100–105; 107–110; 130

CHAPTER 2: The Thorax Plates

Surface Anatomy: Thoracic and Abdominal Wall 139
Anterior Thoracic Wall 140–149
Thymus, Pleura, Lungs, Trachea, and Bronchi 150–165
Pericardium and Heart 166–187
Conduction System of the Heart; Heart Valves 188–191
Circulation of Blood 192–195
Posterior and Superior Mediastina 196–205
Sympathetic Trunks and Vagus Nerves 206–209
Thoracic Duct and Lymphatic System 210–211
Frontal Sections and MRIs and Cross Sections of the Chest 212–218

CHAPTER 3: The Abdomen Plates

Regions of the Body, Diagram of the GI System 219
Anterior Abdominal Wall 220–231

Female Inguinal Region; Autonomic Innervation of Female Genital Organs 232–233
Male Inguinal Region and Genital Organs 234–240
Direct and Indirect Inguinal Hernias
Abdominal Structures in the Newborn 241
Topographic Views of Thoracic, Abdominal, and Pelvic Organs 242–243
Development of the Mesenteries 244–247
Topographic Views of the Abdominal Organs In Situ 248–249
Stomach: Blood Supply; Surface Projections; X Rays; Lymphatics 250–253
Duodenum 254–267
Liver 268–269
Gallbladder; Bile Duct System; Pancreas; Spleen 270–277
Small Intestine 278–287
Large Intestine 288–293
Posterior Abdominal Wall; Lumbar Nerves 294–305
Cross Sections of Abdomen 306–317
318–322

CHAPTER 4: The Pelvis and Perineum Plates

Bones of the Pelvis and Sex Differences; Ligaments of the Pelvis 323–329
Female Pelvic Organs 330–335
Placenta; Pregnant Uterus 336–338
Female Pelvic Vessels; Median Sagittal Section of Female Pelvis 339–342
Female Perineum: Muscles, Urogenital Diaphragm; Vessels and Nerves; External Genitalia 343–350
Male Pelvic Organs 351–355
Male Perineum 355–358
Rectum 359–362
Cross Sections and CT Scans: Female and Male Pelvis 363–364
Male Urogenital Region: Surface Anatomy, Vessels and Nerves 365–366
Male External Genitalia: Penis (Corpora), Spermatic Cord, Vessels, Nerves, and Cross Sections 367–370

CHAPTER 5: The Back, Vertebral Column, and Spinal Cord Plates

Back: Surface Anatomy; Skeleton; Dermatomes; Cutaneous Nerves; Superficial Muscles 371–373
Back: Superficial and Intermediate Muscle Layers 373–374
Back: Intermediate and Deep Muscle Layers; Semispinalis Capitis Muscle; Muscle Charts 375–381
Upper Back and Suboccipital Triangle 381–385
Cross Sections Showing Typical Spinal Nerve and Deep Back Muscles
Vertebral Column and Vertebrae: Ligaments and Intervertebral Disks 386
Spinal Cord 387–401
402–408

CHAPTER 6: The Lower Limb Plates

Anterior and Medial Thigh: Muscles, Vessels, and Nerves 409–427
Gluteal Region and Posterior Thigh 428–439
Anterior, Medial and Posterior Nerves of the Lower Limb 440–441
Popliteal Fossa: Muscles, Vessels and Nerves 442–445
Anterior and Lateral Compartments of the Leg 446–453
Dorsum of the Foot 454–459

Posterior Compartment of the Leg 460–469
Plantar Aspect of the Foot 470–477
Bones and Joints of the Lower Limb 478–509
Cross Sections and MRIs of the Lower Limb 510–516

CHAPTER 7: The Neck and Head Plates

Surface Anatomy of the Head and Neck 517–518
Triangles of the Neck; Platysma Muscle; Fascias; Nerves and Lymphatics 519–528
Cervical Plexus of Nerves; Trunks of the Brachial Plexus; Accessory Nerve 529–534
Arteries and Veins of the Neck; Thyroid Gland; Lymphatics 535–540
Prevertebral Region; Subclavian and Vertebral Arteries 541–544
Submental and Submandibular Regions 545–546
Superficial Muscles of the Face; Facial Nerve Diagram; Muscle Charts 547–550
Parotid Gland; Muscles of Mastication; Facial Nerve Branches 551–556
Temporomandibular Joint 557–558
Internal Carotid Artery; Superficial and Deep Veins of the Head 559–562
Vessels and Nerves of the Deep Face 563–566
Bones of the Skull: Adult and Newborn 567–572
Scalp; Diploic Veins; Radiographs of the Internal Carotid Artery 573–574
Dura Mater; Dural Sinuses 575–578
Internal Carotid and Vertebral Arteries to the Brain 579–584
Base of the Skulls; Bones, Vessels, Nerves; Inferior Surface of the Brain 585–590
Inferior Surface of the Bony Skull 591–592
Eye: Anterior View; Bony Socket; Nasolacrimal System 593–599
Eye: External Structure and Bones of the Nasal Cavity 600–612
Nose: External Structure and Bones of the Nasal Cavity 613–616
Paranasal Sinuses 617–618
Oral Cavity: Anterior View; Lips; Palatine Tonsil and Oropharynx 619–620
Oral Cavity: Sublingual Region; Palate; Submandibular Gland 621–623
Floor of the Oral Cavity 624–626
Tongue 627–632
Mandibular and Maxillary Teeth 633–640
Pharynx: Muscles, Arteries and Nerves 641–649
Larynx 650–656
External, Middle and Internal Ear 657–668

CHAPTER 8: Cranial Nerves Plates

Cranial Nerves: Attachments to the Brain, Foramina; Base of Skull 669–670
Cranial Nerves I to XII 671–694

Index I-1–I-24

Plates of Direct Clinical Importance

Plates 1–3 Male and Female Surface Anatomy Plate 181 Right Coronary Arteriogram
Plate 191
Plates 4, 6, 7–9 Anatomy of the Female Breast and Plate 196 Heart Valves: Projection on Chest
Lymphatic Channels Plate 200 Wall and Their Structure
Plate 205
Plates 10, 12–14 Surface Vessels and Nerves of the Plates 212, 213, 218 Frontal Section of the Thorax and
Anterior Trunk Plate 219 Upper Abdomen
Plate 229
Plates 22–24 Arteries, Veins, and Nerves of the Plates 240, 241 Radiograph of Esophagus and View
Axilla Plate 244 through Esophagoscope
Plate 245
Plates 28, 29 Arteries and Superficial Veins in the Plates 246, 247 Angiogram of the Aortic Arch and Its
Upper Limb Plate 256 Branches
Plate 257
Plates 30–32, 54, 55 Muscles That Form the Rotator Cuff Plate 261 MRIs and CT of the Chest
in the Shoulder Plate 263
Plate 265 Surface Anatomy: Regions of the
Plate 35 Dermatomes of the Upper Limb Plate 267 Body; GI System Organs
Plate 270
Plates 36, 37 Vessels and Nerves: Anterior and Plate 273 CT Scans of the Body Wall and
Posterior Brachium Plate 275 Abdomen
Plate 276
Plates 38, 39 Arteries and Nerves of the Upper Plate 277 Descent of Testis and Congenital and
Limb; Brachial Arteriogram Plate 279 Direct Inguinal Hernias
Plate 280
Plate 41 Variations in the Superficial Veins of Plate 281 Surface Projections: Thorax,
the Upper Limb Plate 282 Abdomen, Male Pelvic Organs
Plate 284
Plate 46–53 Brachial Plexus Plate 285 Surface Projections: Thorax,
Plate 286 Abdomen, Female Pelvic Organs
Plate 67 Course of the Radial Nerve Along the
Radial Groove Median and Paramedian Sections of
Male Abdomen and Pelvis
Plates 68, 69 Superficial Vessels and Nerves of the
Forearm; Cubital Fossa Celiac Trunk Arteriogram

Plates 77–79 Median, Ulnar, and Radial Nerves in Variations in Blood Supply to the
the Forearm; Brachial Artery Liver and Stomach

Plate 86 Dermatomes on Posterior Aspect of Surface Projections and Radiographs
Upper Limb of the Stomach

Plates 90, 91 Local Anesthesia of Fingers X-Ray of the Stomach

Plate 99 Synovial Sheathes of the Fingers X-Ray of the Stomach Showing a
Small Ulcer
Plate 115 X-Ray of Should Joint Bones
X-Rays Showing Gastric and
Plates 120, 121 Radiographic Anatomy of the Right Duodenal Ulcers
Should Joint Bones
Surface Projections of the Liver
Plate 123 X-Rays of Elbow Joint: Adult and
Child Ultrasound Scans of the Hepatic and
Portal Veins
Plate 127 Radiograph of the Wrist and Hand
CT Scan of Upper Abdomen at
Plate 129 Radiograph of the Right Wrist Level T10-T11

Plate 131 Radiograph of the Right Hand CT Scan of Abdomen at Level L1
(Lateral Projection)
Ultrasound Scans: Upper Abdomen
Plates 132, 133, 135, 136 CT Scans of the Arm, Forearm, and and Tumor Mass in Liver
Wrist
Cholangiogram and X-Ray of Biliary
Plate 139 Surface Anatomy of Anterior Body Duct System
Wall (Male and Female)
Ultrasound Scan: Abdomen Showing
Plate 151 Radiograph of the Chest Showing the Parts of the Gallbladder
Heart and Lungs
Ultrasound Scans of Gallbladder and
Plates 154–156 Surface Projections of the Pleura and Gallstones
Lungs
Surface Projection: Duodenum and
Plate 163 Surface Projection of the Trachea Pancreas

Plate 165 Bronchogram of Bronchial Tree; CT Scan: Abdomen at Level L2
Bronchoscope of Trachea Showing Pancreas, etc.

Plate 168 Radiograph of the Thorax CT Scan Showing a Tumor in the
Head of the Pancreas
Plate 171 Anterior Wall Projection of
Underlying Heart Valves CT Scan: Diffuse Inflammation of
the Pancreas (Pancreatitis)
Plate 180 Left Coronary Arteriogram

Plate 287 CT Scan Showing a Hemorrhage Plate 453 Ankle and Foot Movements
within the Spleen Plate 454 Vessels and Nerves of the Dorsal Foot
Plate 289 Plate 460 Vessels and Nerves on the Posterior
Radiograph of the Jejunum, Ileum,
Plate 291 Cecum, and Ascending Colon Plates 474, 476 Aspect of the Leg (Calf)
Plate 293 Vessels and Nerves on the Plantar
Plate 295 Radiograph of the Small Intestine Plates 483
Plate 302 Aspect of the Foot
Superior Mesenteric Arteriogram Plate 484 Blood Supply and Radiograph of the
Plate 305 Plate 489
Plate 310 Inferior Mesenteric Arteriogram Plate 490 Hip Joint
Plate 311 Plate 491 Radiograph of the Knee Joint
Variations in the Location of the Plate 493 Four MRIs of the Knee Joint
Plate 313 Vermiform Appendix Plate 494 Arthrogram of the Knee Joint
Plates 318–322 Plate 498 Arthroscopic Images of the Knee Joint
Plate 325 Radiograph of the Large Intestine Plate 508 Radiographs of the Knee Joint
Plate 330 Movements at the Knee Joint
Plate 332 Arteriogram of the Renal Artery Plates 511–513 X-Ray of the Ankle Joint
Radiograph, MRI of Ankle, Subtalar,
Plate 334 Surface Anatomy of the Back Plate 515
Plate 337 Showing Location of the Kidneys and Talonavicular Joints
Plate 338 Plates 517, 518 CT Scans of the Mid and Distal
Plate 339 Retrograde Pyelogram Plate 599
Thigh and Mid Leg
Plate 340 CT Scans of the Abdomen Plate 525 MRI through the Metatarsal Bones of

Plate 344 Radiograph of the Pelvis Plate 535 the Foot
Plate 353 Plates 536–538 Surface Anatomy of the Face and Neck
Uterosalpingogram Plates 548, 553, 554 Surgical Entry into the Respiratory
Plate 356 Plates 557, 558
Plates 363, 364 Variations in the Position of the Plate 560 System
Plate 371 Uterus in the Pelvis Plate 571, 572 Drainage of Lymph of Superficial
Plate 372 Plates 573, 574
CT Scan of the Female Pelvis Lateral Scalp and Face
Plate 391 Plate 582 Jugular Veins in the Neck
X-Ray of the Pregnant Uterus Thyroid Gland
Plate 398 Plates 583, 584 Facial Nerve on the Face
Plates 400, 401 Pregnant Uterus: Fetal Sonograms Temporomandibular Joint
Plates 402–407 Plates 588–590 Variations in the Maxillary Artery
Plate 408 Variations in the Divisions of the Newborn Skull
Internal Iliac Artery Plate 593 Scalp, Diploic Veins, Internal Carotid
Plates 409–412 Plates 601–604
Arteriogram of the Iliac Arteries in Plate 609 Artery
Plates 413–415 the Female Plates 611, 612 Variations in the Formation of the

Plate 422 Female External Genitalia Plate 616 Circle of Willis
Plates 617, 618 Arteriogram of the Internal Carotid
Plate 428 Peritoneum over Empty and Full Plates 619–622
Bladders Plates 625, 626 and Vertebral Arteries
Plates 434, 435 Plates 633–640 Base of the Skull and Brain: Cranial
Radiographs of Male Pelvic Organs
Plates 440, 441 Plates 641–648 Nerves and Vessels
Plate 444 CT Scans of the Female and Male Pelvis Plates 649–656 Eye from Anterior
Plates 657–668 Nerve in the Orbit
Plate 446 Surface Anatomy of the Back Plate 669–694 Horizontal Section of the Eyeball
MRI, Vessels and Nerves within the
Cutaneous Nerves and Dermatomes
of the Back Orbit and Retina
Vessels and Nerves in the Nasal Cavity
Radiograph of Odontoid Process Paranasal Sinuses
and Atlantoaxial Joints Oral Cavity
Salivary Glands
Intervertebral Disks Anatomy of the Dental Arches and

Radiograph of the Vertebral Column Teeth; Their Innervation
Pharynx
Spinal Cord Larynx
External, Middle, and Internal Ear
Lumbar and Sacral Punctures into Cranial Nerves I–XII
the Spinal Column

Lower Limb: Surface Anatomy,
Cutaneous Nerves, Bones

Lower Limb: Arteries, Muscles:
Anterior and Posterior Aspects

Variations in the Deep Femoral
Artery and Circumflex Arteries

Surface Vessels and Nerves: Gluteal
Region, Posterior Thigh

Safe Zones for Intramuscular
Injections in Gluteal Region

Nerves of the Lower Limb

Variations in Branching of Anterior
Tibial Fibular Arteries

Superficial Veins and Nerves of
Anterior and Medial Leg, Foot

Plates Containing Muscle Charts

Pectoral Muscle Plates 15, 20 Muscles of the Gluteal Region Plate 434
Shoulder Muscles Plates 30, 33 Muscles of the Posterior Thigh Plate 436
Anterior Brachial Muscles (Flexors) Plates 56, 57 Muscles of the Anterior and Lateral Plate 448
Posterior Brachial Muscles (Extensors) Plate 65
Anterior Forearm Muscles (Flexors) Plates 73, 74 Compartments of the Leg Plate 457
Posterior Forearm Muscles (Extensors) Plates 80, 81, Muscles of the Dorsum of the Foot Plates 468, 469
Muscles of the Posterior Compartment
Thenar Muscles of the Hand 85, 87 Plate 477
Hypothenar Muscles of the Hand Plates 96, 97 of the Leg Plate 519
Dorsal Interosseous Muscles of the Hand Plate 98 Muscles of the Sole of the Foot Plate 520
Palmar Interosseous Muscles of the Hand Plate 102 Infrahyoid Muscles of the Neck Plate 528
Intercostal Muscles Plate 103 Sternocleidomastoid Muscle Plate 542
Subclavius Muscles Plate 143 Muscles of the Posterior Triangle of the Neck Plate 549
Anterior Abdominal Wall Muscles Plate 148 Anterior Vertebral Muscles
Plates 225–227, Muscles of Face and Head: Suprahyoid, Plate 550
Posterior Abdominal Wall Muscles and the
Diaphragm 230 Scalp Muscles; Ear, Eyelids Plates 555, 556
Plate 314 Muscles of Face and Head: Muscles of Plate 607
Muscles of the Pelvic Diaphragm and the Plate 632
Urogenital Diaphragm Plate 346 Nose and Mouth Plate 648
Muscles of Mastication Plates 653, 654
Intermediate and Deep Back Muscles Plate 379 Schema of Extraocular Muscles
Deep Muscles of the Back (Continued) Plate 380 Extrinsic Muscles of the Tongue Plates 657,
Muscles of the Suboccipital Region Plate 385 Muscles of the Palate and Pharynx 663–665
Anterior Muscles of the Hip and Anterior Plate 426 Muscles of the Larynx (see notes under

Thigh Muscles Figs. 653.1–653.4 and Figs. 654.1–654.3)
Medial, Lateral, and Posterior Thigh Muscles Muscles of the Middle Ear

Plate 427



1C H A P T E R Pectoral Region, Axilla,
Shoulder, and Upper Limb

Plates

1 Regions of the Body 23 The Axillary Vein and Its Tributaries
24 The Axillary Artery and Its Branches
2 Surface Anatomy of the Male Body 25 The Internal Thoracic–Epigastric Anastomosis
26 Dissection of Axilla: Superficial Vessels and Nerves
3 Surface Anatomy of the Female Body 27 Dissection of Axilla: Deep Vessels and Nerves
28 Arterial Supply to the Upper Extremity
4 Superficial Dissection of the Breast; Milk Line 29 Superficial Veins of the Upper Extremity
30 Shoulder Region, Anterior Aspect: Muscles
5 Surface Anatomy of Female Thoracic Wall; 31 Anterior Shoulder Region: Vessels and Nerves;
Female Breast
Shoulder Joint Movements
6 Breast: Nipple and Areola (Sagittal Section) 32 Shoulder Region, Posterior Aspect: Muscles
33 Posterior Shoulder: Vessels and Nerves; Abduction
7 Lymph Nodes that Drain the Breast;
Lymphangiogram of the Axilla of the Upper Limb
34 Surface Anatomy of the Upper Limb
8 Lymphatic Drainage from Breast; Medial and 35 Dermatomes of the Upper Limb
Lateral Mammary Arteries 36 Superficial Dissection of the Arm (Anterior View)
37 Superficial Dissection of the Arm (Posterior View)
9 Lateral View of the Female Breast and a 38 Blood Vessels of the Upper Limb
Dissected Nipple 39 Nerves of the Upper Limb
40 Cutaneous (Superficial) Nerves of the Upper Limb
10 Dermatomes; Anterior Thoracic Segmental Nerves 41 Superficial Venous Patterns in the Upper Limb
42 Surface and Skeletal Anatomy of the Upper Limb
11 Superficial Thoracic and Abdominal Wall Muscles 43 Muscular Contours of the Upper Limb: Anterior
(Lateral View)
and Posterior Views
12 Superficial Veins of the Anterior Trunk (Male) 44 Muscles of the Upper Limb: Lateral View
45 Muscles of the Upper Limb: Anterior and
13 Superficial Vessels and Nerves of the Anterior
Trunk (Female) Posterior Views
46 The Brachial Plexus and Its Three Cords
14 A Typical Segmental Spinal Nerve and 47 Brachial Plexus: Roots of Origin and
Intercostal Artery
General Schema
15 Superficial Thoracic and Abdominal Wall Muscles
Chapter 1 Pectoral Region, Axilla, Shoulder, and Upper Limb
16 Pectoral Region: Superficial Vessels and
Cutaneous Nerves

17 Pectoral Region: Pectoralis Major and Deltoid Muscles

18 The Pectoralis Major and Minor Muscles

19 The Anterior Surface of the Rib Cage

20 Lateral Thoracic Wall and Superficial Axilla

21 The Pectoral Muscles: Intact and Reflected;
Serratus Anterior Muscle

22 Deltopectoral Triangle and the Deep Lateral
Thoracic Muscles

CHAPTER 1 Pectoral Region, Axilla, Shoulder, and Upper Limb

48 Complete Brachial Plexus Diagram 74 Anterior View of Radius and Ulna: Muscle
Attachments; Muscle Chart
49 Musculocutaneous Nerve: Distribution and
Spinal Segments 75 Fracture of the Radius and the Pronator
Teres Muscle
50 Median Nerve: Distribution, Spinal Segments, and
Median Nerve Palsy 76 Anterior Forearm Vessels and Nerves
(Superficial Dissection)
51 Ulnar Nerve: Distribution, Spinal Segments, and
Ulnar Nerve Palsy 77 Anterior Forearm Vessels and Nerves
(Intermediate Dissection)
52 Axillary Nerve: Distribution, Spinal Segments, and
Axillary Nerve Palsy 78 Anterior Forearm Vessels and Nerves
(Deep Dissection)
53 Radial Nerve: Distribution, Spinal Segments, and
Radial Nerve Palsy 79 Elbow Region: Vessels and Nerves

54 Anterior Dissection of the Shoulder and Arm: 80 Superficial Extensor Muscles of Forearm
Muscles (Posterior View)

55 The Shoulder Muscles: Anterior and Posterior 81 Superficial Extensor Muscles of the Forearm
Views (Lateral View)

56 Muscles of the Anterior Arm (Superficial 82 Deep Extensor Muscles of the Forearm
Dissection)
83 Deep Extensor Muscles of the Forearm
57 Muscles of the Anterior Arm (Deep Dissection)
84 Supination and Pronation of the Forearm and Hand
58 Brachial Artery and the Median and Ulnar Nerves
in the Arm 85 Extensor Muscles of the Forearm; Muscle Chart

59 Deep Dissection of the Anterior Arm; 86 Posterior Upper Limb Muscles and Dermatomes
Musculocutaneous Nerve (Review)

60 Posterior Dissection of Shoulder and Arm: Muscles 87 Posterior Attachments of Muscles on the Ulna and
Radius; Muscle Chart
61 Shoulder Region: Supraspinatus Muscle and the
Rotator Cuff Capsule 88 Nerves and Arteries of the Posterior Forearm
(Superficial Dissection)
62 Muscles on the Lateral and Posterior Aspects
of the Arm 89 Nerves and Arteries of the Posterior Forearm
(Deep Dissection)
63 Posterior Arm; The Three Heads of the
Triceps Muscle 90 Dorsum of the Hand: Veins and Nerves; Finger
Injection Site
64 Attachments of Muscles in Upper Limb:
Anterior View 91 Dorsum of the Hand: Tendons and Interosseous
Muscles; Dermatomes
65 Attachments of Muscles in Upper Limb:
Posterior View 92 Dorsal Synovial Tendon Sheaths at the Wrist;
Anatomy of a Finger
66 Posterior Arm: Vessels and Nerves
(Superficial Dissection) 93 Dorsum of the Hand: Tendons and Arteries
(Superficial and Deep Dissections)
67 Arteries and Nerves of the Scapular and Posterior
Brachial Regions 94 Palm of the Hand: Superficial Vessels and Nerves

68 Superficial Dissection of the Anterior Forearm 95 Superficial Dissection of the Palm of the Right
Hand and Two Fingers
69 Superficial Dissection of the Posterior Forearm
96 Palm of the Hand: Muscles and Tendon Sheaths
70 Anterior Forearm: Superficial Muscles
97 Thenar and Hypothenar Muscles; Cutaneous
71 Anterior Forearm: Pronator Teres and Flexor Innervation of the Palm
Digitorum Superficialis
98 Palm of the Hand: Muscles and Flexor
72 Anterior Forearm: Deep Muscles Tendon Insertions

73 Anterior Muscles of the Forearm; Flexor 99 Palm of the Hand: Deep Dissection of Muscles
Muscle Chart and Fingers

CHAPTER 1 Pectoral Region, Axilla, Shoulder, and Upper Limb

100 Muscles of the Deep Palmar Hand Region: 119 Lateral View of Shoulder Joint and Frontal Section
Dissection #1 of the Joint

101 Muscles of the Deep Palmar Hand Region: 120 Radiographic Anatomy of the Right Shoulder
Dissection #2 Joint I

102 Dorsal Interosseous Muscles in the Deep Hand 121 Radiographic Anatomy of the Right Shoulder
Joint II
103 Palmar Interosseous Muscles in the Deep Hand
122 Bones of the Upper Limb: Radius and Ulna
104 Lumbrical Muscles; Tendons and Cross Section
of the Middle Finger 123 Elbow Joint: Radiographs, Adult and Child

105 The Carpal Tunnel; More Distal Cross Section 124 Left Elbow Joint (Anterior, Posterior, and
of the Middle Finger Sagittal Views)

106 Carpal Tunnel; Superficial Palmar Arterial Arch 125 Elbow Joint: Bones; Ligaments (Medial View)

107 Palm of the Hand: Nerves and Arteries 126 Radioulnar Joints
(Superficial Dissection)
127 Radiograph of the Wrist and Hand
108 Palmar Arterial Arches
128 Bones of the Wrist and Hand (Palmar Aspect)
109 Palmar Arteries and Nerves; Variations in the
Deep Palmar Arch 129 Bones of the Wrist and Hand (Dorsal Aspect)

110 Sagittal Section through the Middle Finger 130 Wrist and Hand: Ligaments and Joints
(Ulnar View)
131 Wrist, Hand, and Fingers: Joints
111 Radial Side of the Hand: Arteries and and Ligaments
Superficial Nerves
132 Cross Sections of the Upper Limb: Arm
112 Skeleton of the Thorax; Scapula
133 Cross Sections of the Lower Third of the Arm
113 The Humerus
134 Cross Sections of the Upper Limb: Elbow and
114 Shoulder Joint: Ligaments and Bony Structures Upper Forearm

115 X-Ray of the Right Shoulder Joint 135 Middle Forearm (Cross Section and MRI)

116 Acromioclavicular and Shoulder Joints 136 Computerized Tomographs of the Wrist

117 The Right Shoulder Joint (Anterior and 137 Cross Sections of the Upper Limb: Wrist
Posterior Views) and Hand

118 Glenoid Labrum and Cavity; Clavicular and 138 The Thumb, Index Finger, and Fingernails
Scapular Ligaments



Regions of the Body PLATE 1

Parietal region Frontal region

Temporal region Orbital region Palm
Nasal region
Oral region Anterior antebrachial
Sternocleidomastoid region Mental region (forearm) region
Infraclavicular region Anterior neck region

Deltopectoral triangle Posterior cervical triangle
Deltoid region Axillary region

Sternal region Anterior cubital region
Pectoral region Anterior brachial (arm) region
Axillary fossa
Posterior brachial Lateral pectoral region
(arm) region Hypochondriac region
Epigastric region
Posterior antebrachial Umbilical region
(forearm) region Lateral abdominal region
Inguinal region
Anterior antebrachial Hypogastric (pubic) region
(forearm) region Trochanteric region

Dorsal hand Penis

Anterior femoral (thigh) region Femoral triangle

Posterior crural (leg) region Anterior knee region
Anterior crural (leg) region Posterior crural (leg) region

Lateral malleolus

Dorsal foot

Calcaneal region

FIGURE 1 Regions of the Body: Anterior View

NOTE: (1) Surface areas are identified by specific names to describe the location of structures and symptoms precisely.
(2) Some regions are named after bones (sternal, parietal, infraclavicular, etc.), others for muscles (deltoid, pectoral, sternocleidomastoid), and

still others for specialized anatomical structures (umbilical, oral, nasal, etc.).
(3) The principal regions of the body include the pectoral region and upper extremity, thorax, abdomen, pelvis and perineum, lower extremity,

back and spinal column, and neck and head.

Chapter 1 Pectoral Region, Axilla, Shoulder, and Upper Limb

PLATE 2 Surface Anatomy of the Male Body

Arm FIGURE 2.1 Regions and Longitudinal Lines on the Anterior
Upper Surface of the Male Body

limb Forearm NOTE: (1) The lateral sternal line descends along the lateral border of the
Hand sternum.
Thigh
(2) Other lines parallel to this are called parasternal lines.
(3) The male nipple lies near the midclavicular line.
(4) The anterior axillary line descends from the anterior axillary fold.

Anterior axillary line

Midclavicular line
Lateral sternal line

Anterior midline

Lower
limb

Leg

Foot FIGURE 2.2 Surface Contours on
Infraclavicular fossa, deltopectoral triangle the Male Thorax

Deltoid muscle Certain contours on the chest, upper abdo-
men, and upper limb reveal the shape of
Pectoralis major underlying muscles.
muscle
Pectoralis major muscle
Biceps brachii
muscle Rectus abdominis muscle

Umbilicus

Chapter 1 Pectoral Region, Axilla, Shoulder, and Upper Limb

Surface Anatomy of the Female Body PLATE 3

Suprasternal plane Head
Neck
Sternal angle plane Thorax
Xiphisternal plane Abdomen Trunk
Pelvis
Transpyloric plane
Subcostal plane

FIGURE 3.1 Transverse Planes Shown on the Surface of the
Female Thorax

NOTE: (1) The suprasternal plane projects back to the T2 vertebra, the sternal
angle to T4, the xiphisternal junction to T9, and the transpyloric plane to L1.

(2) The subcostal plane, below the 10th rib anteriorly, projects back to L2.

Pectoralis major FIGURE 3.2 Surface Contours on
muscle the Lateral Thorax of a Young
Woman
Teres major muscle
NOTE the contours of well-developed
Latissimus dorsi latissimus dorsi, pectoralis major, teres
muscle major, and serratus anterior muscles.

Serratus anterior Rectus abdominis muscle
muscle
Chapter 1 Pectoral Region, Axilla, Shoulder, and Upper Limb

PLATE 4 Superficial Dissection of the Breast; Milk Line

Anterior layer of pectoral Deltoid fascia Cephalic vein
fascia (deep fascia)

Costal margin Brachial fascia
Median nerve
FIGURE 4.1 Anterior Pectoral Region and Female Breast ▲ Fascia over triceps muscle
Axillary sweat glands
NOTE: (1) The lobular nature of the breast. Axillary fat pad
(2) It extends from the lateral sternal line to the midaxillary line and from the Axillary fascia
and lymph nodes
second to the sixth rib. Lateral thoracic artery and vein
(3) The breast is located in the superficial fascia anterior to the pectoral fascia. Fascia over latissimus
(4) Shown are the superficial axillary lymph nodes and the axillary sweat glands. dorsi muscle
Nipple
FIGURE 4.2 Milk Line and Accessory Nipples and Breasts ᭤ Mammary lobes
Serratus anterior muscle
NOTE: (1) Supernumerary nipples (polythelia) and/or multiple breasts on the same
side (polymastia) occur in about 1% of people. Pectoralis major muscle

(2) These are found along the curved milk line extending from the axillary fossa to External oblique muscle
the groin.
Rectus sheath (anterior layer)
(3) This condition occurs slightly more frequently in males than in females and may
easily be handled surgically. Milk line

Chapter 1 Pectoral Region, Axilla, Shoulder, and Upper Limb Accessory breast
Accessory nipple
Milk line

Surface Anatomy of Female Thoracic Wall; Female Breast PLATE 5

Sternoclavicular joint Jugular notch
Shaft of clavicle (body of clavicle)

Sternal angle

Costal margin (costal arch) Infrasternal angle (subcostal angle)
Anterior superior iliac spine Umbilicus

FIGURE 5.1 Surface Anatomy of the Anterior Thoracic and Abdominal Walls of a Young Female

NOTE: Bony structures and the umbilicus are labeled.

Pectoralis major Pectoralis major
muscle muscle

Areola Nipple
Areola
Nipple
Areolar glands

Serratus anterior
muscle

FIGURE 5.2 Female Breast (Anterior View) FIGURE 5.3 Female Breast (Lateral View)

NOTE: The nipple and areolar glands project from the surface of the pigmented areola. Also observe the muscular contours of the pectoralis major
and serratus anterior muscles.

Chapter 1 Pectoral Region, Axilla, Shoulder, and Upper Limb

PLATE 6 Breast: Nipple and Areola (Sagittal Section)

Fat body of breast FIGURE 6.1 Sagittal Section through Mammary Gland of
Gravid Female

NOTE: (1) The radial arrangement of the lobes, separated by connective
tissue and fat.

(2) In the lactiferous duct system, each of the 15 to 20 lobes has its own duct.
(3) The pectoral fascia separates the breast from the pectoralis major muscle.
(4) The connective-tissue suspensory ligaments (of Cooper) extend to the

pectoral fascia.

Lactiferous Pectoral
ducts fascia

Nipple Suspensory
Lactiferous ligaments

sinus

Mammary lobes

Mammary lobules

FIGURE 6.2 Right Mammary Gland:
Dissection of the Nipple

NOTE: (1) A circular piece of skin has been incised Cut skin
from around the nipple. margins

(2) The 15 to 20 lactiferous ducts are arranged radially Nipple
around the nipple and seen just deep to the skin.

Lactiferous ducts

FIGURE 6.3 Radiograph of Normal Cancer of the Breast
Female Breast
Cancer of the breast usually develops in the epithelial cells that line the ducts of the glan-
Lateral mammograph of a 47-year-old woman. dular tissue. Often, the initial clinical sign of breast cancer is a painless lump in the upper
lateral quadrant of the organ. This may progress:

(1) to invade the connective tissue between the lobules (suspensory ligaments of Cooper)
and cause a retraction of the nipple;

(2) to grow more deeply and fix the breast to the pectoral fascia overlying the pectoralis
major muscle. This causes the breast to be less movable and it tends to elevate when the
underlying pectoralis major contracts;

(3) to cause a dimpling, a thickening, and a discoloration of the skin over the tumor. The
skin then assumes an appearance of an orange peel and hence has been called the peau
d’orange sign of advanced breast carcinoma.

From the local primary tumor site, malignant cells spread by entering lymphatic capil-
laries and proceed to lymph nodes, where they may multiply to form metastatic secondary
tumors. The most frequent routes of early metastatic spread involve the lateral thoracic and
axillary lymph nodes as well as nodes that accompany the internal thoracic vessels lateral
and parallel to the sternum. Spread of tumor cells also occurs by way of venous capillaries to
larger veins and then to more widespread organs.

Chapter 1 Pectoral Region, Axilla, Shoulder, and Upper Limb

Lymph Nodes that Drain the Breast; Lymphangiogram of the Axilla PLATE 7

FIGURE 7.1 Axillary and Parasternal Deep axillary set
Nodes and Lymph Channels from
the Female Breast Deltopectoral nodes Lateral axillary Medial (apical) axillary nodes
nodes (infraclavicular)
NOTE the central and anterior axillary nodes.
Also observe the deep lateral and deep medial Deep cervical nodes
axillary nodes more superiorly along with the (infraclavicular)
parasternal and deep cervical nodes.

Central axillary nodes Parasternal
mammary nodes
Anterior axillary nodes
(pectoral nodes) Lymph drainage to
the opposite breast
Subareolar plexus and to the rectus
abdominus muscle

Supraclavicular Clavicle Infraclavicular Coracoid process
lymph nodes lymph nodes

Head of humerus

Infraglenoid
tubercle

Axillary
lymph nodes

Pectoral lymph
nodes

Scapula

FIGURE 7.2 Lymphangiogram of the Pectoral and Axillary Lymph Nodes

(From Wicke, 6th ed.)
Chapter 1 Pectoral Region, Axilla, Shoulder, and Upper Limb

PLATE 8 Lymphatic Drainage from Breast; Medial and Lateral Mammary Arteries

Deep cervical lymph nodes Parasternal lymph nodes
Supraclavicular lymph nodes
Apical axillary lymph nodes

Central axillary
lymph nodes

Subscapular (posterior)
axillary lymph nodes

Anterior axillary (pectoral)
lymph nodes

Inframammary lymph nodes

FIGURE 8.1 Lymphatic Drainage from the Adult Female Breast

NOTE: (1) Numerous lymph vessels in the breast communicate in a subareolar plexus deep to and around the nipple.
(2) About 85% of the lymph from the breast courses laterally and upward to axillary and infraclavicular nodes.
(3) Most of the remaining lymph passes medially to parasternal nodes along the internal thoracic vessels.
(4) Some lymph vessels drain downward to upper abdominal nodes and some go to the opposite breast.

Pectoralis major muscle Subclavian artery
Axillary artery
Deltoid muscle Internal thoracic
artery
Lateral thoracic
artery

Lateral mammary Medial mammary
branches branches

FIGURE 8.2 Medial and Lateral Mammary Arteries

NOTE that lateral branches from the lateral thoracic artery and medial perforating branches from the internal thoracic artery supply the breast anteriorly.
(From Clemente’s Anatomy Dissector, 2nd Edition. Baltimore: Lippincott Williams & Wilkins, 2007.)

Chapter 1 Pectoral Region, Axilla, Shoulder, and Upper Limb

Lateral View of the Female Breast and a Dissected Nipple PLATE 9

Lactiferous ducts Lactiferous sinus
Suspensory ligaments

Pectoral fascia
(deep fascia)

Pectoralis major muscle

Serratus anterior muscle

FIGURE 9.1 Lateral View of the Female Breast in a Reclined Thorax

NOTE: (1) The duct system originating in the mammary gland lobules. The individual ducts course forward through the superficial fascia of the
breast to the nipple.

(2) The suspensory ligaments (of Cooper) that separate the mammary lobules. These support the breast by attaching to the deep pectoral fascia.
In aging, the ligaments loose strength and result in the characteristic sagging breasts of the elderly.

(From Clemente’s Anatomy Dissector, 1st Edition. Baltimore: Lippincott Williams & Wilkins, 2002.)

Areola Areola
Nipple
Fat lobule
Lactiferous ducts
Ampullae of
lactiferous
ducts

Mammary
lobules

FIGURE 9.2 The Dissected Nipple and Lactiferous Duct System

NOTE the lactiferous ducts as they commence in the mammary lobules and course forward to open on the surface of the nipple. Also observe how
the ducts enlarge into lactiferous sinuses within which milk collects prior to ejection as the infant suckles.

Chapter 1 Pectoral Region, Axilla, Shoulder, and Upper Limb

PLATE 10 Dermatomes; Anterior Thoracic Segmental Nerves

Supraclavicular
nerves (C3,4,5)

C3 T2 T2
C4
Lateral T5
T2 cutaneous Anterior
T3 nerves cutaneous
T4 nerves
T12
T5 L1 T10
T6
T7 L1
T8
T9
T10
T11
T12
L1

L2

L3

FIGURE 10.1 Segmental Sensory Innervation of
Anterior Body Wall (Dermatomes)

NOTE: C5 to C8 and most of T1 do not supply the body wall,
since they supply the upper limb.

Pectoralis
major muscle

Latissimus ▲ FIGURE 10.2 Cutaneous Branches
dorsi muscle of Spinal Nerves

Serratus Lateral NOTE the segmental cutaneous nerves to
anterior cutaneous nerves lateral cutaneous branches in the midaxil-
muscle (ant. branches) lary line and anterior cutaneous branches
just lateral to the sternum.
Lateral (From Clemente’s Anatomy Dissector, 2nd
cutaneous nerves Edition. Baltimore: Lippincott Williams &
(post. branches) Wilkins, 2007.)

External oblique
muscle

FIGURE 10.3 Lateral Cutaneous Branches of Thoracic Nerves

NOTE that as the lateral cutaneous nerves penetrate the intercostal space, each
divides into anterior and posterior cutaneous branches.

Chapter 1 Pectoral Region, Axilla, Shoulder, and Upper Limb

Superficial Thoracic and Abdominal Wall Muscles (Lateral View) PLATE 11

Trapezius muscle Clavicle
Spine of scapula Pectoralis major muscle,
Infraspinatus muscle sternocostal head
Teres minor muscle Body of breast,
Teres major muscle lobes of mammary gland
Nipple
Deltoid muscle Serratus anterior muscle
Triceps brachii muscle: Pectoralis major muscle, abdominal part

lateral head, Costal margin (costal arch)
long head
Umbilicus
Brachialis muscle
Biceps brachii Rectus sheath, anterior layer
External oblique aponeurosis
Latissimus dorsi muscle Anterior superior iliac spine

External oblique muscle Tensor fasciae latae muscle
Thoracolumbar fascia
Lumbar triangle Sartorius muscle

Posterior superior iliac spine
Gluteal fascia

Gluteus maximus muscle

FIGURE 11 Muscles of the Lateral Thoracic and Abdominal Wall

NOTE: (1) The interdigitations of the external oblique muscle with the serratus anterior muscle superiorly and the latissimus dorsal muscle
inferiorly.

(2) The lumbar triangle. Its boundaries are the external oblique muscle (anteriorly), the latissimus dorsi muscle (posteriorly), and the crest of the
ilium (inferiorly).

(3) The external oblique muscle ends in a broad and strong aponeurosis medially.

Chapter 1 Pectoral Region, Axilla, Shoulder, and Upper Limb

PLATE 12 Superficial Veins of the Anterior Trunk (Male)

Axillary vein

Lateral thoracic
vein

Thoracoepigastric vein

Thoracoepigastric vein

Paraumbilical veins

Superficial epigastric
vein
Superficial circumflex
iliac vein

Great saphenous
vein

FIGURE 12 Anterior Thoracic Wall; Superficial Dissection in the Male

NOTE: (1) The thoracoepigastric veins along both lateral aspects of the thoracic wall; realize that these veins drain superiorly into the lateral tho-
racic veins, which flow into the axillary veins.

(2) The paraumbilical veins. Surrounding the umbilicus, these form an anastomosis between the systemic anterior abdominal wall veins and the
intra-abdominal portal vein.

(3) Usually surface venous blood flow above the umbilicus drains into vessels that feed into the superior vena cava, while surface veins below the
umbilicus drain into the femoral veins and thence into the inferior vena cava.

(4) The surface veins can become greatly enlarged if flow through the inferior vena cava is significantly reduced, as in cirrhosis of the liver
(From C.D. Clemente. Gray’s Anatomy, 30th American Edition. Philadelphia: Lea & Febiger, 1985.)

Chapter 1 Pectoral Region, Axilla, Shoulder, and Upper Limb

Superficial Vessels and Nerves of the Anterior Trunk (Female) PLATE 13

Supraclavicular nerves Cephalic vein
(C3, C4)

Intercostobrachial Internal thoracic
nerve (T2); artery, vein

Lateral mammary artery, vein Anterior cutaneous
(from lateral thoracic) nerves (T1–T4)

Cephalic vein 9

Lateral thoracic artery; Superior epigastric
thoracoepigastric vein artery, vein

T5 5 8
67
External
oblique muscle

Lateral cutaneous nerves T8 8
(branches of intercostal
nerves T5–T12) 7 T5
99 T 12
10 9 Anterior cutaneous
9 nerves (branches of
intercostal nerves
T5 –T12)

T 12 10
Periumbilical veins
11 Medial umbilical
ligament
11
12 Pyramidalis muscle

Superficial iliac 12
circumflex artery, vein

Superficial Inferior epigastric
epigastric artery, vein artery, vein

Superficial external IIiohypogastric nerve
pudendal artery, vein
Rectus
Anterior femoral abdominis muscle
cutaneous nerve IIioinguinal nerve

Great saphenous vein

FIGURE 13 Superficial Vessels and Nerves of the Anterior Trunk: Pectoral Region and Anterior Abdominal Wall

NOTE: (1) Cutaneous innervation of the trunk: supraclavicular nerves (C3, C4), intercostal nerves (T1–T12), and the ilioinguinal and iliohypo-
gastric branches of L1.

(2) The intercostal nerves give off lateral and anterior cutaneous branches.
(3) Anastomoses between the thoracoepigastric vein above and the superficial iliac circumflex and inferior epigastric veins below.
(4) The breast, its innervation (T2–T6 intercostal nerves), and its blood supply (internal thoracic artery, lateral thoracic artery, and intercostal

arteries).
(5) The nipple at the level of T4 and the umbilicus at the level of T10.

Chapter 1 Pectoral Region, Axilla, Shoulder, and Upper Limb

PLATE 14 A Typical Segmental Spinal Nerve and Intercostal Artery

Lateral branch FIGURE 14.1 A Typical Segmental Spinal Nerve and
Its Branches
Medial branch
(From Clemente’s Anatomy Dissector, 2nd Edition. Baltimore:
Dorsal root Dorsal root (sensory) Lippincott Williams & Wilkins, 2007.)
ganglion
Ventral root (motor)
Dorsal primary ramus Sympathetic ganglion

Spinal nerve (mixed)
Ventral primary ramus

Posterior
branch

Anterior Rami
branch communicantes

Lateral cutaneous Ventral primary ramus Anterior
branch Lateral branch cutaneous branch

Medial branch

Intercostal vein, artery, and nerve

Spinal cord

Posterior primary Posterior branch of posterior
nerve ramus intercostal artery
Internal intercostal
membrane Posterior intercostal
artery
Anterior primary
nerve ramus

External intercostal muscle

Internal intercostal muscle Innermost intercostal Aorta
muscle
Posterior cutaneous Lateral cutaneous branch
nerve branch Vertebral body of intercostal artery

Lateral cutaneous branch of
anterior primary nerve ramus

Anterior intercostal artery

Anterior cutaneous Anterior perforating Internal thoracic artery
nerve branch cutaneous nerve (in cross section)
branch

Perforating cutaneous
branch

External intercostal membrane

Sternum

FIGURE 14.2 A Segmental Thoracic Nerve and Intercostal Artery and Their Branches

NOTE: (1) Segmental intercostal nerves are formed by the junction of dorsal and ventral spinal roots. Distal to this junction, the mixed spinal
nerve divides into dorsal and ventral primary rami. The posterior primary ramus courses to the back, while the anterior primary ramus courses
between adjacent ribs as an intercostal nerve and gives off lateral and anterior cutaneous branches.

(2) Posterior intercostal arteries are derived from the aorta. Each sends a posterior branch to the back. The anterior branch becomes the anterior
intercostal artery, and it also gives off lateral and anterior cutaneous branches.

Chapter 1 Pectoral Region, Axilla, Shoulder, and Upper Limb

Superficial Thoracic and Abdominal Wall Muscles PLATE 15

Sternocleidomastoid muscle Pectoralis major muscle
Platysma muscle (cut)
Deltoid muscle
Deltopectoral triangle
Cephalic vein Brachial
Deltoid muscle fascia
Axillary fascia

Deltopectoral triangle

Pectoralis major muscle

Serratus anterior muscle Serratus anterior muscle
Costoxiphoid ligaments
Latissimus dorsi muscle External oblique muscle

Pectoralis major muscle
(abdominal portion)
Linea alba

External oblique muscle Rectus sheath (anterior layer)

Umbilicus Anterior superior iliac spine
Intercrural fibers
Anterior superior iliac
spine

Superficial fascia

External oblique Medial crus of superficial
aponeurosis inguinal ring

Cremaster muscle

Spermatic cord Reflected inguinal ligament

Fudiform ligament of penis Suspensory ligament of penis
Body of penis

FIGURE 15 Muscles of the Superficial Thoracic and Abdominal Walls

Muscle Origin Insertion Innervation Action
Pectoralis major
Medial half of clavicle; Humerus, lateral lip of Lateral (C5, C6, C7) and Adducts and rotates arm
second to sixth ribs; intertubercular sulcus medial (C8, T1) pectoral medially; sternal part: helps
costal margin of sternum; nerves extend humerus; clavicular
aponeurosis of external part: helps flex humerus
oblique

Chapter 1 Pectoral Region, Axilla, Shoulder, and Upper Limb

PLATE 16 Pectoral Region: Superficial Vessels and Cutaneous Nerves

Intermediate supraclavicular nerves Medial supraclavicular
Lateral supraclavicular nerves nerves

Deltoid fascia Pectoralis major, fascia

Thoracoacromial artery, Anterior cutaneous
pectoral branch branches (intercostal
nerves)
Cephalic vein
External oblique fascia
Brachial fascia
Superficial axillary lymph nodes Rectus sheath

Lateral thoracic artery
Thoracoepigastric vein
Latissimus dorsi fascia
Lateral cutaneous branches
(intercostal nerves)
Serratus anterior fascia

FIGURE 16 Anterior Thoracic Wall; Superficial Dissection in the Male

NOTE: (1) The skin and superficial fascia have been removed, but the cutaneous vessels and nerves have been retained.
(2) The cutaneous neurovascular structures penetrate through the deep fascia (pectoral fascia) to get to the superficial fascia and skin.
(3) Most cutaneous vessels and nerves are anterior and lateral cutaneous branches of the intercostal nerves and vessels.
(4) The deep fascia that covers the pectoralis major muscle and the manner in which it blends inferiorly with the sheath of the rectus abdominus

muscle (the rectus sheath) and medially across the sternum with the fascia on the opposite side.
(5) The pectoral fascia also has a deep layer that covers the deep surface of the muscle.
(6) The supraclavicular nerves are derived from C3 and C4, but overwhelmingly C4.
(7) The intercostobrachial nerve (T2) joins the medial brachial cutaneous nerve to supply the skin of the axillary fossa and upper medial arm.

Chapter 1 Pectoral Region, Axilla, Shoulder, and Upper Limb

Pectoral Region: Pectoralis Major and Deltoid Muscles PLATE 17

Platysma muscle Supraclavicular nerves
Clavipectoral fascia
Pectoralis major muscle
Subcutaneous (clavicular head)
acromial bursa

Deltoid muscle
Cephalic vein

Coracobrachialis 4 Anterior cutaneous
muscle 5 branch of intercostal
nerve (T2)
Anterior axillary
lymph nodes Pectoralis
(pectoral) major muscle
(sternocostal part)
Biceps brachii
muscle Anterior cutaneous
branch of intercostal
Medial brachial nerve (T4)
cutaneous
nerve Pectoralis major
muscle
Brachial (abdominal part)
fascia

Lateral thoracic artery; Lateral cutaneous 6 Anterior cutaneous
thoracoepigastric vein branch of intercostal 7 branch of intercostal
8 nerve (T6)
nerve (T4)
Anterior sheath,
Lateral cutaneous branch rectus abdominis muscle
of intercostal nerve (T6)
Anterior cutaneous
Lateral cutaneous branch branch of intercostal
of intercostal nerve (T8) nerve (T8)

Fascia over external oblique muscle

Fascia over serratus anterior muscle

FIGURE 17 Pectoralis Major and Deltoid Muscles (Anterior View)

NOTE: (1) The anterior layer of the pectoral fascia and the deltoid fascia as seen in Figure 16 have been removed.
(2) The lateral cutaneous vessels and nerves penetrating through the intercostal spaces in the midaxillary line.
(3) The anterior cutaneous vessels and nerves piercing the pectoralis major muscle along the lateral border of the sternum.
(4) The clavicular fibers of this muscle course obliquely downward, and laterally, the upper sternocostal fibers are directed nearly horizontally, and

the lower sternocostal and abdominal fibers ascend nearly vertically to the humerus.
(5) The natural cleft between the clavicular and sternocostal heads. Detaching the clavicular head uncovers some of the vessels and nerves that

supply this muscle (see Fig. 22.1).
(6) The fourth to the eighth ribs are numbered sequentially.

Chapter 1 Pectoral Region, Axilla, Shoulder, and Upper Limb

PLATE 18 The Pectoralis Major and Minor Muscles

Acromioclavicular Clavicle Pectoralis major muscle FIGURE 18.1 The Pectoralis Major Muscle
joint (clavicular head)
Jugular NOTE: (1) The pectoralis major muscle has fibers that
Acromion notch descend from the clavicle and fibers that ascend
Coracoid process from the lower sternum and the aponeurosis of
Head of humerus Manubrium the external oblique muscle. Between these are the
transverse fibers that cross the chest.
Greater tubercle
(2) This broad mass of muscle fibers inserts onto the
Crest of greater lateral lip of the intertubercular sulcus of the hu-
tubercle merus.

Pectoralis major (3) The ascending and lower transverse fibers form a
muscle rounded inferior border that becomes the anterior
(sternocostal head) axillary fold. This muscle and the pectoralis minor
overlie the nerves of the brachial plexus and the
Body of axillary vessels and their branches.
sternum
(4) The pectoralis major medially rotates and adducts
the humerus. In addition, the clavicular fibers assist
in flexing the humerus, while the inferior sternal
fibers and those attaching to the aponeurosis of the
external oblique assist in extending the humerus.

(Contributed by Dr. Gene L. Colborn, Medical College
of Georgia.)

Xiphoid process

Acromion

Coracoid process
Subclavius muscle
Clavicle

Greater tubercle
Lesser tubercle

FIGURE 18.2 The Pectoralis Minor Muscle Humerus 1 Manubrium
2 Sternal angle
NOTE: (1) The pectoralis minor muscle is often called “the key to Scapula Body of sternum
the axilla”; this is because it crosses the axillary artery, divid- 3
ing it into three parts, medial, deep, and lateral to the pectora- Pectoralis Xiphoid process
lis minor muscle. There is one branch off of the first part of the minor 4
axillary artery, two branches off of the second part, and three muscle 5
branches off of the third part. 6
7
(2) Deep to the pectoralis minor muscle, the cords of the brachial 8
plexus are found. These are called the medial, lateral, and
posterior cords, and they are located medial, lateral, and pos-
terior to the axillary artery.

(3) The pectoralis minor muscle can protract the scapula (i.e.,
draw it forward) when the insertion on the third, fourth, and
fifth ribs is fixed. When the attachment to the coracoid pro-
cess is fixed, the pectoralis minor can help elevate the ribs, and
thus, it becomes an accessory muscle of respiration.

(From Clemente’s Anatomy Dissector, 2nd Edition. Baltimore:
Lippincott Williams & Wilkins, 2007.)

Chapter 1 Pectoral Region, Axilla, Shoulder, and Upper Limb

The Anterior Surface of the Rib Cage PLATE 19

Sternocleidomastoid

Trapezius

Deltoid Clavicular notch

Pectoralis minor Jugular Sternal angle
notch 1
Biceps brachii
and Glenoid Manubrium
fossa
Coracobrachialis

Triceps brachii 2
Subclavius 3
4
Subscapularis Vertebrosternal
or true ribs (1–7)
Pectoralis Body
major Costal
Serratus anterior cartilages
Pectoralis
minor

5

6

Xiphoid process

7

8 Vertebrochondral
or false ribs (8–10)

9
12 10

Vertebral or 11
floating ribs
(11 and 12)

FIGURE 19 The Anterior Surface of the Sternum and Ribs

NOTE: (1) The costal cartilages and the manner in which they articulate with the sternum.
(2) The jugular notch (also called the suprasternal notch) along the superior border of the manubrium.
(3) Lateral to the manubrium, the clavicle articulates into the clavicular notch, and just below this, the first rib articulates with the lateral surface

of the manubrium.
(4) Rib 2 articulates with the sternum lateral to the sternal angle (i.e., between the manubrium and body of the sternum).
(5) Ribs 4, 5, and 6 articulate on the body of the sternum, and rib 7, joined by the costal margins of ribs 8, 9, and 10, attaches to the junction of the

xiphoid process and sternal body (the xiphisternal junction).
(6) The origin of the pectoralis major muscle attaches along the medial half of the clavicle and lateral one-third of the manubrium and body of

the sternum.
(7) The pectoralis minor muscle inserts on the third, fourth, and fifth ribs, and the biceps brachii and coracobrachialis muscles attach just above

the glenoid fossa (supraglenoid tubercle), while the triceps arises from the infraglenoid tubercle below the glenoid fossa.

(From C.D. Clemente. Gray’s Anatomy, 30th American Edition. Philadelphia: Lea & Febiger, 1985.)

Chapter 1 Pectoral Region, Axilla, Shoulder, and Upper Limb

PLATE 20 Lateral Thoracic Wall and Superficial Axilla

Coracobrachialis Deltoid muscle

muscle Biceps muscle Pectoralis major muscle
Musculocutaneous nerve
Median nerve Lateral cord contribution to median nerve
Ulnar nerve
Basilic vein
Axillary vein
Medial antebrachial
cutaneous nerve Axillary lymph nodes

Medial brachial Lateral cutaneous
cutaneous branch of the 3rd
nerve intercostal nerve

Intercostobrachial Pectoralis minor
nerve (T2) muscle

Latissimus dorsi Pectoralis major muscle
muscle
Serratus anterior
Thoracoepigastric vein; muscle
lateral thoracic artery
Long thoracic nerve Lateral cutaneous
branch of the 5th
Lateral cutaneous intercostal nerve
branch of the 4th
intercostal nerve Pectoralis
Latissimus dorsi major muscle
(abdominal part)
muscle

Lateral cutaneous
branch of the 6th
intercostal nerve
Lateral cutaneous
branch of the 8th
intercostal nerve

Serratus
anterior muscle

9th rib origin

Lateral cutaneous
branch of the 10th

intercostal nerve

Rectus sheath
(anterior layer)

External oblique muscle
(part arising from 5th rib)

Lateral cutaneous branch
of the 6th intercostal nerve
Serratus anterior muscle
External oblique muscle 7th rib origin

FIGURE 20 Lateral Aspect of the Upper Right Thoracic Wall and the Superficial Axillary Structures

Muscle Origin Insertion Innervation Action
Ribs 2 to 5
Pectoralis minor Coracoid process of scapula Medial pectoral nerve Protracts scapula; elevates
Medial border of scapula (C8, T1) ribs
Serratus anterior Fleshy slips from upper
nine ribs Long thoracic nerve Protracts and rotates scapula;
(C5, C6, C7) holds scapula close to thoracic wall

Chapter 1 Pectoral Region, Axilla, Shoulder, and Upper Limb

The Pectoral Muscles: Intact and Reflected; Serratus Anterior Muscle PLATE 21

Coracoid process Clavicle
Serratus anterior muscle Subclavius muscle

(superior part) Pectoralis minor muscle
Deltoid muscle
Pectoralis major muscle

Coracobrachialis muscle

Subscapularis muscle Pectoralis major
muscle

Teres major muscle Internal
Serratus anterior muscle intercostal muscle

FIGURE 21.1 Pectoralis Minor, Latissimus Pectoralis
Serratus Anterior, and Latissimus dorsi muscle major muscle
Dorsi Muscles, Lateral View (Right) (abdominal part)
External
NOTE that the pectoralis major muscle has been intercostal Rectus sheath
reflected, revealing: (anterior layer)
muscle
(1) the pectoralis minor muscle extending from
coracoid process to the second to sixth ribs; 11th rib

(2) the serratus anterior, forming the medial
wall of the axilla.

Pectoralis major muscle Pectoralis Posterior scalene
minor muscle

muscle Acromion

Clavicle Levator scapulae muscle
Middle scalene muscle
Deltoid muscle Anterior scalene muscle

Biceps brachii I Omohyoid muscle
(long head) II (inferior belly)

Biceps brachii muscle IV Sternocleidomastoid muscle
(short head) V Subclavius muscle
Coracobrachialis VI Internal intercostal muscles
muscle VII External intercostal muscles
Teres major muscle Pectoralis minor muscle
Subscapularis muscle
Pectoralis major muscle
Serrratus anterior muscle
External oblique muscle
Serratus anterior muscle

Latissimus dorsi muscle

Rectus abdominis muscle

FIGURE 21.2 The Subscapularis and Serratus Anterior Muscles (Right Lateral View)

Chapter 1 Pectoral Region, Axilla, Shoulder, and Upper Limb

PLATE 22 Deltopectoral Triangle and the Deep Lateral Thoracic Muscles

Posterior cord
Lateral cord
Medial cord
Clavicle

Acromial anastomosis Subclavian artery
Acromion Subclavian vein

Deltoid muscle, clavicular part Subclavius muscle
Deltoid muscle, acromial part
Clavipectoral fascia
Cephalic vein Medial pectoral
nerves

Thoracoacromial artery,
pectoral branches

Pectoralis major muscle,
clavicular head

Pectoralis major muscle,
sternocostal head

FIGURE 22.1 Deltopectoral Triangle (Right)

NOTE: (1) The clavicular head of the pectoralis major muscle has been severed and reflected downward.
(2) The investing layer of deep fascia covering the deep surface of the pectoralis major muscle and the clavipectoral fascia, which extends between

the clavicle and the medial border of the pectoralis minor muscle, are exposed.
(3) The cephalic vein pierces the clavipectoral fascia to join the axillary vein.
(4) The thoracoacromial artery (from the axillary artery) and the lateral pectoral nerve (from the lateral cord of the brachial plexus) pierce the

fascia from below to supply blood to the region and to innervate the pectoralis major muscle.

Sternocleidomastoid Pectoralis major, sternocostal head
Pectoralis major, clavicular head (Sternalis, var.)
Internal intercostal muscles Subclavius
Deltoid Axillary vein
Coracobrachialis Pectoralis minor

Biceps brachii, Brachial plexus,
short head infraclavicular part

Axillary artery

Pectoralis Serratus anterior
major

Pectoralis Latissimus dorsi
minor
Serratus anterior
2nd–5th ribs Pectoralis major, sternocostal head
Latissimus dorsi

Serratus anterior

Pectoralis major, abdominal part

External oblique External oblique

FIGURE 22.2 Pectoralis Minor, Serratus Anterior, and Latissimus Dorsi Muscles (Right Lateral View)

NOTE that the pectoralis major muscle has been reflected, revealing the pectoralis minor muscle extending from the second to fifth ribs to the
coracoid process. Also note that the serratus anterior muscle forms the medial wall of the axilla.

Chapter 1 Pectoral Region, Axilla, Shoulder, and Upper Limb

The Axillary Vein and Its Tributaries PLATE 23

Pectoralis minor muscle Axillary artery
Deltoid muscle
Cephalic vein
Musculocutaneous nerve
Brachial vein

Coracobrachialis muscle

Pectoralis Axillary vein 1st rib
major muscle 2nd rib

Biceps brachii
muscle

Basilic vein Ulnar nerve Pectororalis
minor muscle
Median nerve
Posterior humeral Subscapular vein
circumflex vein Long thoracic vein

Latissimus dorsi muscle

Circumflex scapular vein

Subscapularis muscle

FIGURE 23.1 The Veins of the Right Axilla

NOTE the relationship of the axillary vein to the axillary artery and the nerves in the axilla.
(From C.D. Clemente. Gray’s Anatomy, 30th American Edition. Philadelphia: Lea & Febiger, 1985.)

1. Axillary vein 7
2. Basilic vein
3. Cephalic vein 6
4. Lateral border of the scapula 3
5. Lateral border of the latissimus dorsi
6. Head of humerus
7. Acromion
8. Venous valve
9. Brachial vein

28 1
4

95

FIGURE 23.2 Radiograph of Veins in the Axillary Region

NOTE: (1) The basilic vein [2] becomes the axillary vein [1].
(2) One of the brachial veins [9] also flows into the axillary vein, as does the cephalic vein [3], the junction of which is medial to the field shown here.
(3) The venous valves [8] along the course of the axillary vein.

Chapter 1 Pectoral Region, Axilla, Shoulder, and Upper Limb

PLATE 24 The Axillary Artery and Its Branches

Subclavian artery Thyrocervical trunk Vertebral artery Common
carotid artery
Internal thoracic
Supreme thoracic artery artery
Thoracoacromial artery
C L AV I C L E FIGURE 24.1 Branches of the
Pectoralis minor muscle 1
Axillary Artery
Axillary artery 2
NOTE: (1) The subclavian artery becomes
Subscapular 3 the axillary artery distal to the clavicle.
artery 4
5 (2) Inferior to the teres major, the axillary
Brachial HUMERUS 6 artery becomes the brachial artery.
artery
(3) The pectoralis minor crosses the axillary
Anterior humeral circumflex artery artery, dividing it into three parts:
Posterior humeral circumflex artery (a) Medial to the muscle
Circumflex scapular artery (b) Beneath the muscle
Lateral thoracic artery (c) Lateral to the muscle
Thoracodorsal artery
(4) From the first part, there is one branch,
the supreme thoracic artery.

(5) From the second part are derived two
branches:
(a) Thoracoacromial artery
(b) Lateral thoracic artery

(6) From the third part come three branches:
(a) Subscapular artery
(b) Anterior humeral circumflex artery
(c) Posterior humeral circumflex artery

Clavicle

Acromial
anastomosis

Subclavian
artery

Deltoid
branch

Acromial branch Clavicular branch FIGURE 24.2 Thoracoacromial
Axillary artery Thoracoacromial artery Artery and Its Branches

Pectoral branches NOTE that the four branches of the thora-
coacromial artery usually are the clavicular,
pectoral, acromial, and deltoid.

Chapter 1 Pectoral Region, Axilla, Shoulder, and Upper Limb

The Internal Thoracic–Epigastric Anastomosis PLATE 25

Scalenus anterior muscle
Thyrocervical trunk
Common carotid artery
Subclavian artery

Brachiocephalic trunk

Internal thoracic artery
Anterior intercostal arteries

Perforating branches

Superior epigastric artery

Musculophrenic artery

Sheath of rectus abdominis
muscle (post. layer)

Transverus abdominis muscle

Inferior epigastric
artery

External iliac artery

FIGURE 25 The Internal Thoracic and Epigastric Arterial Anastomosis

NOTE: (1) The internal thoracic artery arises from the axillary artery, and in its descent in the chest, it gives off perforating branches segmentally.
At the costal margin, the internal thoracic artery terminates by dividing into the musculophrenic and superior epigastric arteries.

(2) The inferior epigastric artery arises from the external iliac artery just superior to the inguinal ligament, and it anastomoses with the superior
epigastric branch of the internal thoracic artery.

(3) This arterial anastomosis forms a major interconnection between the subclavian and external iliac systems and, in effect, between the inferior
vena cava and the superior vena cava.

(From C.D. Clemente. Gray’s Anatomy, 30th American Edition. Philadelphia: Lea & Febiger, 1985.)
Chapter 1 Pectoral Region, Axilla, Shoulder, and Upper Limb

PLATE 26 Dissection of Axilla: Superficial Vessels and Nerves

Brachial plexus Communicating branch,
Brachial veins intercostobrachial nerve
Subscapular vein
Axillary vein Axillary nerve
Thoracoepigastric vein Teres major muscle
Intercostobrachial nerve (T2) Circumflex scapular
artery, vein
Lateral thoracic
artery, vein Latissimus dorsi muscle

Pectoralis major muscle Thoracodorsal
artery, vein
Serratus
anterior Thoracodorsal
muscle nerve
External
Long
oblique thoracic
muscle nerve

Lateral cutaneous
nerves
(T4, T5 branches)

Thoracoepigastric vein

FIGURE 26 Axilla: Superficial Vessels and Nerves (Left)

NOTE: (1) The boundaries of the axilla are:
(a) Anteriorly, the pectoralis major muscle
(b) Posteriorly, the subscapularis, teres major, and latissimus dorsi muscles
(c) Medially, the serratus anterior muscle covering the second to the sixth ribs
(d) Laterally, the bicipital groove of the humerus.

(2) The lower part of the serratus anterior muscle arises from the lower ribs as fleshy interdigitations with the external oblique muscle.
(3) The serratus anterior is innervated by the long thoracic nerve, and the latissimus dorsi by the thoracodorsal nerve.
(4) The axillary vein lies medial to the axillary artery and the brachial plexus.
(5) The ascending course of the thoracoepigastric vein and the lateral thoracic vessels.

Chapter 1 Pectoral Region, Axilla, Shoulder, and Upper Limb

Dissection of Axilla: Deep Vessels and Nerves PLATE 27

Thyrocervical trunk Phrenic Subclavian Clavicle
Vertebral artery nerve artery
Common carotid artery Dorsal scapular artery
Axillary vein
Vagus nerve Axillary artery
Brachial plexus
Left brachiocephalic
vein Pectoral Branches of
thoracoacromial
Acromial artery

Deltoid muscle
(cut)

Pectoralis major Pectoralis
muscle (cut) major muscle
(cut)
Anterior
cutaneous

nerves;
perforating

branches,
internal
thoracic

artery, vein

Axillary artery
Axillary vein
Pectoralis minor muscle

Intercostobrachial nerve
Thoracodorsal nerve
Lateral thoracic artery, vein
Thoracodorsal artery, vein
Long thoracic nerve

Latissimus dorsi muscle
Thoracoepigastric vein

External oblique muscle
Serratus anterior muscle

FIGURE 27 Axilla (Left): Deep Vessels and Nerves

NOTE: (1) The subclavian artery becomes the axillary artery distal to the clavicle.
(2) The pectoralis minor muscle is capable of elevating the ribs if the coracoid attachment is fixed or of protracting the scapula if the costal attach-

ment is fixed.
(3) The axillary artery is surrounded by the three cords of the brachial plexus.
(4) The thoracoacromial artery divides into pectoral, acromial, deltoid, and small clavicular branches.
(5) The intercostobrachial nerve (T2) pierces the second intercostal space in its course toward the axilla and arm, and it communicates with the

medial brachial cutaneous nerve.

Chapter 1 Pectoral Region, Axilla, Shoulder, and Upper Limb

PLATE 28 Arterial Supply to the Upper Extremity

Transverse cervical artery Thyrocervical
Dorsal scapular artery trunk

Thoracoacromial artery Subclavian
artery
Lateral thoracic artery
Axillary artery
Posterior humeral
circumflex artery
Anterior humeral
circumflex artery

Brachial artery Subscapular artery
Profunda brachial artery
Superior ulnar collateral
artery
Inferior ulnar collateral
artery

Radial artery Ulnar recurrent arteries
Common interosseous artery
Ulnar artery
Anterior interosseous artery

Deep palmar arch
Superficial palmar arch
Common palmar digital
arteries

Proper palmar digital
arteries

FIGURE 28 Arteries of the Upper Limb

(Contributed by Dr. Gene L. Colborn, Medical College of Georgia.)

Chapter 1 Pectoral Region, Axilla, Shoulder, and Upper Limb

Superficial Veins of the Upper Extremity PLATE 29

Lateral supraclavicular nerves

Intercostobrachial nerve
Medial brachial cutaneous nerves

Cephalic vein

Basilic vein Medial antebrachial
Median cubital vein cutaneous nerve

Lateral antebrachial cutaneous nerve
(continuation of the musculocutaneous
nerve)

Cephalic vein

Ulnar nerve

Basilic vein Radial nerve
Ulnar nerve (superficial branch)

Median nereve

Palmar cutaneous branch
(ulnar nerve)

FIGURE 29 The Superficial Veins of the Upper Extremity

NOTE: The cephalic vein laterally commencing on the radial (or thumb) side of the hand and the basilic vein commencing on the ulnar (or little
finger) side of the hand. These channels communicate in the antecubital fossa by the median cubital vein.
(Contributed by Dr. Gene L. Colborn, Medical College of Georgia.)

Chapter 1 Pectoral Region, Axilla, Shoulder, and Upper Limb

PLATE 30 Shoulder Region, Anterior Aspect: Muscles

Supraspinatus Trapezius muscle
muscle
Serratus
MEDIAL anterior muscle Clavicle LATERAL
Subclavius muscle

Superior angle of scapula Transverse scapular ligament

Acromion

Omohyoid muscle Coracoid process
Subcoracoid bursa
Serratus
anterior muscle Pectoralis minor muscle

Subscapularis muscle Biceps muscle (short head);
coracobrachialis muscle
Teres major muscle
Deltoid muscle

Serratus Triangular
anterior muscle space

Latissimus dorsi muscle Pectoralis
major muscle
Tendon of latissimus dorsi muscle
Triceps muscle (long head) Coracobrachialis muscle
Brachial vessels
Biceps muscle (short head) Tendon of biceps muscle
Brachial fascia (long head)
Brachial plexus

Biceps muscle (long head)

FIGURE 30 Muscles of Anterior Aspect of the Shoulder (Left)

NOTE: (1) The large triangular mass of the subscapularis muscle occupying the concave subscapular fossa. From this broad origin, its fibers con-
verge toward the humerus, where it inserts on the lesser tubercle.

(2) The subscapularis along with the other muscles that constitute the “rotator cuff” (supraspinatus, infraspinatus, and teres minor) help stabilize
the shoulder joint by keeping the head of the humerus in the glenoid fossa.

(3) Both the short head of the biceps and the coracobrachialis have a common origin from the coracoid process.

Muscle Origin Insertion Innervation Action
Subscapularis Medial rotation of humerus
Subscapular fossa of the Lesser tubercle of Upper and lower
scapula humerus subscapular nerves Extends, adducts, and
(C5, C6) from posterior medially rotates the
Latissimus dorsi Thoracolumbar fascia; Bottom of the cord of brachial plexus humerus
Deltoid spinous processes of lower intertubercular sulcus
six thoracic and lumbar of humerus Thoracodorsal nerve (C6,
vertebrae, and the sacrum C7, C8) from posterior
Deltoid tubercle on cord of brachial plexus
Lateral third of clavicle; lateral surface of
the acromion; spine of humerus Axillary nerve (C5, C6) Abduction of the humerus;
the scapula from posterior cord of anterior fibers assist in flexion
brachial plexus and posterior fibers in
extension of humerus

Chapter 1 Pectoral Region, Axilla, Shoulder, and Upper Limb