Superior extremity

Pectoralis major
Cruciate ms

Ms fibers cross in a Letter X

Other ms: sternocleidomastoid, masseter

Arises from external oblique, sternum

Actions: internal rotation, adduction, flexion at the shoulder joint

Supplied by medial and lateral pectoral nerve

Known as composite/ hybrid ms( supply by two dierent nerves)

Insertion is at lateral lip of bicipital groove

Medial lip: teres major

Lesser tubercle: sub scapularis

Action is to medial rotate

Infra spinatus and teres minor: lateral rotation

Supra spinatus: abduction from 0-15 degrees

Above three attached on greater tubercle

Thus an injury of greater tubercle leads to loss of abduction and lateral

rotation

All four form the rotator cu

Structures lying in Deltopectoral groove

Cephalic vein

Ilio psoas groove

Femoral nerve

Tracheo esophageal groove

Recurrent laryngeal nerve

Cephalic vein

Dorsal aspect of the hand

Has dorso venous arch

formed by joining of

Lateral end of the dorsal venous arch

With

The 1st metacarpal vein

Lies in the roof of anatomical snu box

Lies in delto pectoral groove

Pierces the clavipectoral fascia

Drains into the axillary vein

basalic vein
Formed by joining of the medial end of the dorsal venous arch

With

The 5th metacarpal vein

Joins with the venae comitans around the brachial artery in the arms and
forms the axillary vein

Serratous anterior

Protraction of scapula

Swimmers ms/ boxers ms

Attached on the medial border of the coastal aspect

Comes from ribs from the lateral side

Retraction is done by Rhomboids

Cause retraction of scapula

Christmas tree ms appearance on (removing the trapezius)

Clavipectoral fascia

Clavicle gives attachment to

Inferiorly( superior: investing layer of deep cervical fascia)

Clavipectoral fascia

Encloses subclavius and pectoralis minor

Inserted into the axilla

Structures piercing the fascia

1. Cephalic vein

2. Thoracoacromial vessels

3. Lateral pectoral nerve

4. Lymphatics from the breast

Axilla

Walls

Anterior wall
Pectoralis major

Pectoralis minor

Subclavius

Climbers ms is lattismus dorsi

Posterior wall
Lattismus dorsi

Subscapularis

Teres major

Medial wall
Ribs

Serratus anterior

Lateral wall
Humerus

Apex of the axilla

Aka cervicoaxillary canal

Boundaries

Anterior is clavicle

Posterior is superior border of the scapula

Medially is the outer border

of 1st rib

axillary artery is divided into three parts by the pectoralis minor

Subclavian artery by scalenus anterior

Maxillary artery by lateral pterygoid

Lingual artery by hyoglossus ms

axilary artery

Continuation of subclavian artery at the outer border of first rib

Continues as brachial artery below the lower border of teres major

Divided into 3 part by pectoralis minor

Branches

1st part

Superior thoracic artery

2nd part

Lateral thoracic(chief artery supplying the breast)

Thoracoacromial artery

3rd part

Anterior Circumflex humeral

Posterior circumflex humeral

Subscapularis artery

Subscapular artery
Gives a branch: circumflex scapular artery

Which takes part in anastamosis on the dorsal aspect of scapula

Continuation of the subscapular artery is known as Thoracodorsal artery

Which accompanies the Thoracodorsal nerve( nerve to lattismus dorsi)

Anastomoses on the dorsal aspect of scapula

3 branches

1. Subscapular artery (is the continuation of the 3rd part of axillary artery)
or the circumflex scapular artery

2. 1st part of subclavian gives suprascapular artery

3. Dorsal scapular artery/ deep descending branch of transverse cervical

Brachial plexus

As a rule, a plexus is always formed by ventral rami of the corresponding

spinal nerves

But there is no thoracic plexus

There the ventral rami of thoracic spinal nerves lie in the intercostal
grooves and are called intercostal nerves

Branches of lateral cord

Lateral pectoral

Lateral root of median nerve

Musculocutaneous

Branches of medial cord

Medial pectoral nerve

Medial root of median nerve

Medial cutaneous nerve of arm

Medial cutaneous nerve of forearm

Ulnar nerve

Branches of the Posterior cord

Upper subscapular

Lower subscapular

Nerve to lattismus dorsi/ Thoracodorsal nerve

Radial nerve

Axillary nerve

Axillary nerve supplies

Deltoid

Teres minor

And gives a cutaneous branch: upper lateral cutaneous nerve of arm

Branches from the roots

C5: nerve to Rhomboids/ dorsal scapular nerve

C5,6,7: nerve to serratus anterior/ Long thoracic nerve

C5: accessory phrenic nerve( reason for phrenic crush failure)

C5,6: nerve to subclavius

Branches from the trunk

Upper trunk
Suprascapular nerve

Supra clavicular part of brachial plexus

Roots

Trunks

Divisions

They lie in the posterior triangle of the neck

In between the Scalenus anterior( phrenic nerve passes through it) and
the scalenus medius

Infra clavicular part of brachial plexus

Lie in the axilla around the axillary artery

Cords present in(1st and 2nd part of axillary artery)

Cords are placed according to their names in the 2nd part of axillary
artery

Branches/ nerves( 3rd part of axillary artery)

All the branches of lateral cord found in the lateral aspect of third part

Similarly medial and posterior cord branches lie as well

Front of arm
Biceps brachii

Brachialis ( below the biceps)

Coracobrachialis

Musculocutaneous nerve

Branch of lateral cord

Present on the lateral aspect of third part of the axillary artery

Pierces the coracobrachialis

Lies on Brachialis below the biceps

Continues as lateral cutaneous nerve of forearm

Erb's paralysis
Injury to upper trunk of brachial plexus

C5,6 aected

Nerves involved

Main contribution in axillary nerve and musculocutaneous nerve

Axillary nerve supplies

Deltoid: abduction from 15-90 degrees(0-15 by supraspinatus), thus arm

remains adducted

Teres minor: arm is Medially rotated as it helps in lateral rotation

Musculocutaneous supplies

Brachialis : elbow extended

Biceps: forearm pronated

Policeman tip attitude

Front of forearm

Superficial muscles: origin at medial epicondyle

1. Pronator teres

2. Flexor carpi radialis

3. Palmaris longus

4. Flexor digitorum superficialis

5. Flexor carpi ulnaris

Intermediate ms: origin with the forearm bones

1. Flexor pollicis longus( origin at radius)

2. Flexor digitorum profundus

Deep muscles

1. Pronator quadratus: quadrangular ms

flexor pollicis longus, pronator quadratus and lateral half of flexor

digitorum profundus are supplied by Anterior introsseus nerve( deep
branch of median nerve given after it passes between the two heads of
pronator teres)

medial half of flexor digitorum profundus is supplied by ulnar nerve

Flexor digitorum profundus is also a hybrid/ composite muscle

Forearm space of Parona

Boundaries
Superficial

Flexor policis longus

Flexor digitorum profundus

Deep boundary

Pronator quadratus

Flexor retinaculum

Ulnar Bursa

Encloses the tendons of

Flexor digitorum superficialis

Flexor digitorum profundus

It is continuous with the little finger

Radial bursa

Encloses the tendon of flexor pollicis longus

It is continuous with the thumb

The remaining three fingers have separate synovial sheath

Thus only these three fingers are pricked for blood to avoid infection of
the bursa's

Structures passing above the flexor retinaculum

1. Ulnar nerve and vessels, passes below the Volar carpel ligament
through the Guyon's tunnel

2. Palmar cutaneous branch of ulnar nerve, supplies the skin over the
hypothenar eminence

3. Palmaris longus

4. Palmar cutaneous branch of medial nerve

5. Superficial palmar branch of Radial artery

Hand

Superficial palmar arch

Is a continuation of

Superficial branch of ulnar artery

It is completed by superficial palmar branch of radial artery

Deep palmar arch

Formed by radial artery

Completed by deep branch of ulnar artery

Unipinnate muscles
Arise from a single tendon

Eg. 1st and 2nd lumbricals

Bipinnate
Arises from two tendons or both the sides of the tendon

Eg. 3rd and 4th lumbricals

Lumbricals
Cause flexion at MCP joints and extension at IP joints

First and second are supplied by the Median nerve

Third and fourth are supplied by the Ulnar nerve

Paralysis leads to claw hand

Muscles supplied by the medial nerve in the Hand

1. Abductor pollicis brevis

2. Flexor pollicis brevis: superficial head

3. Opponens pollicis

4. First and second lumbricals

Muscles supplied by deep branch of Ulnar nerve in the hand

Total 15 ms

Flexor pollicis brevis is a composite ms

1. Anductor digiti minimi brevis

2. Flexor digiti minimi brevis

3. Opponens digiti minimi

4. Third and fourth lumbricals

5. Four palmar Introssei( adduction of fingers)

6. Four dorsal Introssei ( abduction of fingers)

7. Adductor pollicis

8. Deep head of flexor pollicis brevis

The ulnar nerve ends in the Adductor pollicis: graveyard of Ulnar nerve

Cutaneous nerve supply of the hand

Cutaneous supply of the dorsal aspect of the hand

index finger is known as the Eye finger of the hand

Nerve supplying is the median nerve thus ka the Eye nerve of the hand

Radial nerve

Branch of the posterior cord

Present on the posterior aspect of the third part of the axillary artery

1. In axilla

Gives two muscular branches

Long head of triceps

Medial head of triceps

And 1 cutaneous branch

Posterior cutaneous nerve of arm

2. In the spiral/ radial groove

3 muscular branches

Lateral head of triceps

Medial head of triceps

Anconeus( detached part of the medial head of triceps)

2 cutaneous branches

Posterior cutaneous nerve of forearm

Lower lateral cutaneous nerve of arm

3. Lateral aspect of the arm

Supplies

Brachialis lateral half( also supplied by musculocutaneous, medial half )

Composite ms

Brachioradialis

Extensor carpi radialis longus( origin at supra condylar ridge laterally)

4. In the cubital fossa

Superficial branch

Runs below the Brachioradialis

Lies in the roof of the anatomical snu box along with Cephalic vein

Supplies the skin on the dorsum of the hand and proximal phalanges of
lateral 3 and a half fingers

Deep branch/ Posterior introsseus nerve

Pierces the supinator muscle and supplies all the muscles on the dorsal
aspect

Back of forearm

Superficial muscles
1. Anconeus supplied by the radial nerve in the spiral groove

2. Brachioradialis. Radial nerve on the lateral aspect of arm

3. Extensor carpi radialis longus

4. Extensor carpi radialis brevis

5. Extensor digitorum

6. Extensor digiti minimi. Posterior introsseus nerve

7. Extensor carpi ulnaris

Deep muscles
Abductor pollicis longus( begin from both radius and ulna)

Extensor pollicis brevis(radius)

Extensor pollicis longus(ulna)

Extensor indices

Supinator

Anatomical snu box

boundaries

Lateral becomes anterior

Abductor pollicis longus

Extensor pollicis brevis

Medial becomes posterior

Extensor pollicis longus

Floor
Styloid process of radius

Scaphoid

Trapezium

Floor is carpeted by tendons of Extensor carpi radialis longus and brevis

coming from humerus

Content
Radial artery

Roof
Cephalic vein

Superficial branch of radial nerve

Extensor retinaculum

First compartment

Abductor pollicis longus

Extensor pollicis brevis

Second

ECRL and ECRB

Third

EPL

Fourth

Extensor digitorum

Extensor indices

Posterior introsseus nerve and vessels

Fifth

Extensor digiti minimi

Sixth

Extensor carpi ulnaris

Dermatomes

Come lateral to medial

C3,4: shoulder

C5 : lateral arm and forearm

C6 is thumb

C7 is middle three fingers

C8 is little finger

T1 is medial forearm

T2 is medial arm

contents of cubital fossa

Medial to lateral

Median nerve

Brachial artery

Tendon of biceps

Radial nerve

Floor of cubital fossa

Brachialis( inserts at ulna)

Supinator ( inserts at radius )

cubital tunnel

Lispes between the two heads of flexor Carpi Ilnaris

Ulnar nerve passes through this in forearm

Anterior axillary LN drain the breast

Involvement of cutaneous lymphatics in Ca breast: Peau d orange

Lactiferous ducts: retraction of nipple

Cooper's ligament: puckering of the skin over the breast

Joints of upper limb

Sternoclavicular joint
Saddle joint

Acromioclavicular joint
Plain synovial

Shoulder joint
Ball and socket

Elbow joint
Hinge

Superior and inferior radio ulnar

Pivot

Intermediate radio ulnar

Syndesmosis type of fibrous joints

Wrist
Ellipsoidal

1st carpo metacarpal

Saddle

Metacarpophalangeal
Condylar

Interphalangeal
Hinge

Bones participating in wrist joint

Lower end of the Radius

Scaphoid

Lunate

Triquetral

Pisiform and ulna not involved

Thenar space and Mid palmar space

Formed by joining a line from the center of the palmar aponeurosis to the
third metacarpal divides the space below the profundus tendons into
lateral Thenar space and medial mid palmar space

Infection of index finger would lead to thenar space infection

While other three tendons will lead to infection of mid palmar space

Dorsal Introssei
Bipinnate

Ventral Introssei
Unipinnate

embryology

Fertilization occurs in the ampulla of the Fallopian tube

The zygote divides to form a 16 cell morula

As it enters the uterine cavity, fluid from the uterus enters the morula and
divides it into

1. Outer cell mass/ trophoblast

2. Inner cell mass/ embryoblast

The cavity is known as Blastocyst

Thus structure is ka Blastula

The outer cell mass dierentiates into

1. Syncitiotrophoblast: cell boundaries are not clear, scattered nuclei

2. Cytotrophoblast: cell walls are distinct, one nucleus in each cell

Inner cell mass

Dierentiates into

1. Epiblast: tall and columnar cells

2. Hypoblast: cuboidal cells

The Epiblast grows around the cytotrophoblast to enclose the amniotic

cavity

The hypoblast grows around the cytotrophoblast and encloses the yolk
sac

The germ disc is bilamellar

The hypoblast forms extra embryonic mesoderm which lies between the
amniotic cavity, yolk sac and cytotrophoblast

Small cavities appear here which join to form the Extra embryonic coelom

This coelom divides the mesoderm into

1. Extra embryonic splanchnopleuric: which lines the yolk sac

2. Extra embryonic somatopleuric: which lines the amniotic cavity and the
inner aspect of cytotrophoblast

1. Formation of prochordal plate

The hypoblastic cells at one end becomes columnar

They form an elevation in the amniotic cavity: prochordal plate

It forms the future mouth

It determines the Cephalic end of the embryo

2. Formation of primitive streak

The epiblastic cells at the caudal end grow rapidly

They form an elevation in the amniotic cavity: Primitive streak

The rounded anterior end is known as Primitive node/ know

The depression in it is known as the Primitive pit/ Blastopore

Functions of primitive streak

1. Formation of three germ layers

2. Formation of Notochordal process

Fate of primitive streak

It disappears

If it persists: Sacrococcygeal teratoma

All three layers formed from Epiblast

3. Formation of notochord

Derived from the Notochordal process

It disappears except

1. Nucleus pulposus

2. Apical ligament of Dens

4. Intraembryonic mesoderm

1. Paraxial mesoderm
2. Intermediate plate
3. Lateral plate

Paraxial mesoderm
Forms somites

Which in turn form

Dermomyotome: form dermis and muscles

Sclerotome: vertebral column and the ribs

Intermediate plate mesoderm

Forms the

Genitourinary system

Lateral plate mesoderm

Encloses a cavity called intraembryonic coelom which forms the pleural,
peritoneal and pericardial cavity

Development of neural tube

Derived from ectoderm

Forms the brain and the spinal cord

Anterior neuropore closes by 25th day of IUL

Anencephaly if it doesn't close

Posterior neuropore closes by 27th day

Spina bifida if it does not close

Derivatives of neural crest cells

Ectodermal in origin

Adrenal medulla

Leptomeninges : piamater and arachnoidmater

Odontoblasts: teeth forming cells

Melanocytes

Schwann cells

Dorsal root ganglion

Sympathetic ganglion

Ciliary body

Parafollicular C cells of thyroid( ultimobrachial body)

Top to bottom

Septum tranversum

Developing heart

Prochordal plate

Notochord

Primitive streak

Cloaca