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U N N I N G H AM S M AN U AL

P R AC TI C A L AN ATO M Y

R EV I S ED AN D ED I TED B Y

ART H U R RO B I N SO N
P RO E R
F A N AT M
SS O OF O Y IN T E U NI ER S I T Y O F E IN U R G
H V D B H

S EV E N T H EDI TI O N

I E FI RS T
V O L U /V

S U P E R I O R E X T R E M IT Y ; IN F E R I O R E X T R E M IT Y

WI TH 2 0 3 I L L U S TR A TI ON S , (! A N Y OF WH I C H A R E C OL O U R E D

N EW Y O R K L

W I LL I A M W O O D AN D C O M P ANY
ED I N B U R G H G L ASG O W AN D L O N D O N
'

. ,

H E N RY F R O W D E AN D HO DD E R S T O U GH T ON
1 9 2 1
P m n t ea in t t in (By LA R LI M I T E D E din o n ng/z

Gre a B ri a R 8: R
. . C K , ,
.

1 st Edi ti n
o , 1 89 6 .

3 rd E d iti n o ,
1 90 6 .

5 th E d iti no , 1 91 2 .

6 t /z E di t i n
o ,
1
91 4 .

6 t h Ed iti no ,
2 nd l mfi re ss z o n , 1 9 1 7 .

6 t /z E dit i n
o , 3 rd I mp re ss o , 1 9 1 8 in .

'
A ll rig /i ts resa we d .
P R E F AC E TO
TH E SE V E N T H ED ITION

I N t his d it io n th e ge n e ral t e xt has be e n r e v ise d man y n e w


e ,

figure s r e p re se n t in g d isse ct io n s se ct io n s an d rad iogra p h s


, , ,

hav e be e n in troduc e d The in struct io n s fo r d isse ct io n hav e


.

be e n p r in t e d in a d ist in ct iv e in d e n t e d ty p e ; in ma n y ca se s
th e y hav e be e n r e wr itt e n an d in so me ca se s a mp lifi e d .

The latt e r cha n g e s t o g e th e r w ith th e add it io n a l figur e s


, ,

hav e cau se d so much in cre a se o f siz e that it has be e n d e e m e d


advisa ble to p u blish t he book in thr e e vo lu me s V o l I . .

Su p e r ior E x tr e m ity an d I n fe r ior E x tr e mity V o l I I Thora x . .

an d A bdo me n ; V o l I I I H e ad an d N e ck
. . .

As was th e ca se in p r e v iou s e d it io n s I am in d e bt e d to ,

D r E B Ja m ie so n fo r m a n y sugg e st io n s fo r h is in va lua ble


. . .
,

h e lp in the re v isio n o f th e t e x t an d fo r the p r e p arat io n o f


t h e I n de x .

M y tha n k s are du e to D r R o be rt K n o x to M ajor A W


.
, . .

P ir ie an d to M aj or T Ra n k in fo r th e u se o f rad io gra p h s
.
,

wh ich th e y v e ry k ind ly p re p ar e d fo r me an d to M r J T ,
. . .

M urray fo r th e n e w draw in g s o f se ct io n s an d d isse ct io n s .

ART H U R RO B I N SO N .

Oct . 1 1, 19 19 .
CONTENTS

TH E S U P E R I O R E X T R EM IT Y .

A X I LL A
,

D I SSE C T I O N O F T H E BA C K ,

S H O U LD ER — S C A P U L A R R E G I O N ,

T H E F R O NT O F T H E A R M ,

DO RS U M O F T H E A R M ,

S H O U LD ER JO I NT
-
,

FO R EA R M A N D H A N D ,

V O L A R S U R F A C E A N D M E D IA L B O R D E R O F T H E FO R EA R M ,

W R I ST A N D P A L M ,

DO RS U M A ND L A T ERA L B O R D E R O F T H E FO R EAR M ,

DO RSA L A S P E C T O F T H E W R I S T A N D H A N D ,

A R T I C U LAT I O N S ,

TH E I N F E R I O R E X T R EM IT Y .

I NT R O DU C T I O N,

T H E TH IGH ,

T H E ANT ER I O R F E MO RA L A N D M E D IA L F E M O RA L R E G I O N S
A N D T H E ANTE R I O R R E G I O N O F T H E K N E E ,

D E E P D I SSE C T I O N O F T H E ANT ER I O R A N D M E D IA L P A R T S OF
TH E TH IGH ,

M E D IA L S I D E O F T H E T H I G H ,

G LUT EA L R E G I O N ,

P O P L I T EA L S P A C E ,

BACK O F TH E T H I G H ,
C O N TE N TS
P A E
G

TH E L EG ,
ANT ER I O R C R U RA L R E G I ON A N D
L A T E RA L C R U RA L O R P E R ON E A L
M E D IA L C R U RA L R E G I O N
,

P O S T E R I O R C R U RA L R E G I O N
,

S O L E O F T H E FOO T ,

A RT I C U LAT I O N S
,

I N D EX ,
A G L O S SA RY

OF TH E

I N T E R N AT I O N A L

A N AT O M I CAL T E R M I N O L O GY

G E N ERA L TER M S .

T ER M S I N D I C ATI N G S I TU ATI ON AN D D I R ECTI O N .

L o n g itu dinalis Lo n gitu dinal R e fe rrin g to the lo n g a is o f t he bo dy x .

R e fe rrin g to th e p o sit io n o f th e lo ng
V e rticalis V e rtical x
a is o f t h e bo dy in the e re c t p o stu re .

R e fe rrin g to the fro n t an d back f th e


[ o

I bo dy o r o f the limbs .

R e fe rrin g to the an te rio r an d


p o st e rio r

as e ct s,
p re spe cti e l v y , o f the bo dy ,
an d to fie x o r an d e te nso r
th e x
asp e c ts o f th e limbs, re s e c t iv e ly
p .

R e fe rrin g to po sitio n n e are r the h e ad


o r th e tai l
e n d o f the lo n g a is x .

U se d o n y in re fe re n ce to parts o f
l
th e h e ad, n e ck , o r t ru n k .

U se d in re fe re n ce to the h e ad, n e ck ,
an d tru n k Equ ivale n t to cran ia
. l
an d cau da re spe c tiv e ly l .

U se d o n ly in re fe re n ce to t he limbs .

P xro im al n e are r th e attach e d e nd .

D istalis D istal D istal n e are r th e fre e e n d .

U se d in re fe re n ce t o plan e s p ara e l ll
Sagittalis Sag it t al
w ith the sagitta su tu re o f the l
Sk u l, i e l v e rtical an te ro p o ste rio r
. .
-

p lan e s .

U se d in re fe re n ce to p lan e s p ara e l ll
F ro n tal is F ro n tal w ith the co ro n al su tu re o f the sku l, l
z e t ran sv e rse v e rt ical
'

. .
p lan es .
G L OSSARY

H o riz o n talis H o riz o n tal U se d in re fe re n ce to p l an es at righ t


ang le s to v e rtical lan e s
p .

R e fe rrin g to th e m e dian v e rtic al


M e dian u s M e dian
an te ro p o ste rio r
-

p lan e o f th e bo dy .

M e dialis M e dial R e fe rrin g to struct u re s re lativ e l y


n e are r to o rfu rt h e r aw ay f ro m th e

L ate ralis L ate ral me dian p lan e .

R e fe rrin g to struc tu re s situ ate d be


I n t e rm e dius I n te rm e diat e t we e n mo re m e dial an d mo re

late ral stru ctu re s .

R e fe rring to stru c tu re s n e are r to and


fu rth e r aw ay fro m th e su rface .

R efe rrin g , w ith fe w e ce p tio n s, to th e x


walls o f cav itie s an d h o llo w o rg an s .

N o t to be u se d as syn o nymo u s w ith


m e dia] an d late ral .

U se d in re fe re n ce to th e me dial an d
late ral bo rde rs o f th e fo re arm ,
re sp e ctive ly .

U sed in re fe re n ce to the me dial an d


late ral bo rde rs o f the le g, re
F ibu lar F ibu lar sp e c tiv e ly .

TH E B O N ES .

B N A
. . . TER MIN O L OG Y . OL D TER MIN O L OG Y .

Ve rt ebr as V e rt ebr ae
F o v e a co stal is su p e rio r I n co m p le te face t fo r h e ad o f rib,

u e r
p p
F o ve a co stalis in fe rio r I n co m p le te face t fo r h e ad o f rib,

lo we r
F o v e a c o sta l is t ran sve rsal is Face t fo r tu be rcle o f th e rib

R adix arc u s v e rte brae P e dicle

t
A las At las
F o ve a de n tis F ace t fo r O do n t o id p ro c e ss

Ep is tro p h eus Ax is
D e ns O do n to id p ro ce ss

Ste r n um S t e r n um
C o rp u s s t e rn i G l di l
a o us

P ro ce ssu s x iph o ide u s En sifo rm p ro ce ss


I n cisu ra j ugu laris Su p ra st e rn al n o t ch
-

Pl an u m St e rn ale An te rio r su rface

O ssa Cran ii . B o n es o f Sk ull .

osf r o n t ale F r o n t al
Sp ina fro n ta li s N asal sp in e
P ro ce ssu s zyg o maticus x
E te rn al an g u lar p ro c e ss

F acie s ce re bral is I n te rn al su rface


F acie s fro n tal is F ro n ta surface l
P ars o rbital is O rbita l pl at e
GL OSSARY xi

B N A
. . . TER MIN O L OG Y . OLD TER MI N O L OG Y .

o s p a ie r tale P arietal
L in eae te m p o rale s Te mpo ral rid e s g
Su lcu s t ran sv e rsus G ro o ve fo r late ral sin us
Su lcu s sag it talis G ro o v e fo r sup lo n g sin u s
. .

Os o ccip i ale t O ccip ital


l
C an a is hyp o glo ssi An t e rio r co n dylo id fo ram e n
F o rame n o ccip itale m ag nu m F o rame n m agn u m
C an alis co n dylo ide u s P o ste rio r co n dy lo id fo ram e n

Sulcus t ran sv e rsu s G ro o v e fo r late ral sin u s


Su lcu s sagit talis G ro o ve fo r su p . lo n g . sin us

l
C ivu s M e dian p art f u pp e r su rface
o

basi o c cip ital


-

L in e a hae
nuc sup re ma H igh e st cu rv e d line
L in e a n uch ae su p e rio r S u pe rio r cu rv e d lin e
L in e a n u ch ae in fe rio r I n fe rio r cu rv e d lin e

Os sp h en o idale Sp h en o id
C rista infrate mp o ralis P t yg
er o id ridg e
Su lcus ch iasmatis O p t ic g ro o v e
C rista Sph e n o idalis Eth mo idal c re st
Spina an gu laris Spino u s p ro c e ss
L am in a m e dialis p ro cessu s p te ry I n te rn al p te ryg o id p late
g o ide i
Lamin a late ralis pro ce ssu s p te ry x
E te rn al p te rygo id p late
go ide i
Canalis p te rygo ide us [ V idu ] V idian canal

F o ssa hypo physe o s Pit u itar y fo ssa


Su lcus caro ticu s C av e rn o us gro o v e
Co n ch ae Sp h e n o idale s Sph e n o idal tu rbinal bo n e s
H am ulu s p te rygo ide u s H amu lar pro ce ss
C analis p h ary n ge u s l
P te ry go pa atin e can al
-

Tu be rcu lu m se llae O livary e m in e n ce


F issu ra o rbitalis su pe rio r Sph e n o idal fi ssu re

Os t emp o rale Temp o r al B o n e


C analis facialis [ F allo p u ] A q u e du ct f F allo p iu s
o

H iatu s can alis facia is l H iatu s F allo pii


Vagin a p ro ce ssus sty o ide i l V aginal p ro ce ss o f tympan ic bo n e
I n cisu ra m ast o ide a D ig astric fo ssa
I mp re ssio trig e min i I mp re ssio n fo r G asse rian gan g lio n
Emin en tia arcu a a t Emin e n ce fo r sup . se micircu lar

c anal

Su lcus sig mo ide u s F o ssa sig mo ide a


F issu ra p e tro ty mpan ica G lase rian fissure
F o ssa m andibularis G le n o id ca ity v
Se micanalis tubae au ditiv ae Eu stach ian tu be

os e t hmo idale t
E h mo id
L abyrinth u s e th m o idalis Lat e ral mass
L amina p apy race a O s plan um
P r ce
o ssus u ncina u st U n cifo rm pro ce ss
x ii G L OSSARY

EN A
. . . TER MIN O L OG Y . OL D TER MIN OL OG Y .

Os lac imale r r
Lach y mal B o n e
H am ulu s lacrimalis H amu lar p ro ce ss
C rista lac rim alis p o ste rio r Lach ry ma c re st l
Os a
n sale Nasal B o n e
Su l cu s e t h mo idalis G ro o v e fo r n asal n e r e v
Max illa Sup e io r r M ax illar y B o n e
Facie s ant e rio r F acial o r e x te rn al su rface
F acie s in fra te m po ral is
-
Zygo matic surface
Sinu s m a illaris x An t rum o f H igh m o re
Pro ce ssu s fro n talis N asal p ro ce ss
P ro ce ssu s zyg o maticus M alar p ro ce ss
C anale s alv e o lare s P o s te rio r de n ta l c anals

C an alis n aso lacrimalis -


L ac rimal g ro o ve
O s in cisiv um Pre m a illa x
F o rame n in cisivu m An te rio r p l
a at in e fo ram e n

Os p alatinu m P ala t e Bo n e
Pa p e rpe n dicu laris
rs V e rtical p late
C rista c o n ch alis I n fe rio r tu rbin at e c re st

C rista e th mo ida is l Su pe rio r tu rbin ate cre st

Pars h o ri o n talis z z
H o ri o n ta p ate l l
Os z y go ma icum t Malar B o n e
P
ro ce ssu s te m p o ralis Zyg m atic p ro ce ss
o

P ro ce ssu s fro n to -
sp h e n o idal is F ro n tal pro ce ss
F o rame n zygo m at ico -
o rbita e l Te mp o ra m alar can al -

F o rame n z yg o matico -
facia l e M alar fo ram e n

Man dibu la I nfe io r r Max illary Bo n e


Spin a m e n talis G e n ial tube rcle o r sp in e

L in e a o bliq u a x
E te rn al o bliq u e lin e
L in e a m ylo hyo ide a I n te rn al o bliq u e lin e
I n cisu ra man dibu lae S ig m o id n o tch
F o rame n man dibu lare I n fe rio r de n tal fo ram e n
l
C an a is m an dibu lae I nfe rio r de n tal canal
P ro tu be ran tia m e n alis t M e n tal p ro ce ss

The Sk u ll as a W h o le .

O ssa su tu raru m W o rmian bo nes

F o ve o lae g ranu lare s ( Pacch io n i) P acc h io n ian de p re ssio n s


F o ssa p te ry go p al atina -
Sph e n o m a -
x illary fo ssa
C an alis p te ry go p alatin u s -
Po ste rio r p alatin e can al

F o rame n lace ru m l
F o rame n ace rum m e diu m
C h o an ae P
o ste rio r nare s

F issu ra o rbitalis su p e rio r Sph e n o idal fissu re


F issu ra o rbitalis in fe rio r Sph e no ma illary fi ssure
-
x
GL OSSARY

U pp e r Ex t re mit y .

EN A
. . . TER MIN O L OG Y . OL D TER MIN O L OG Y .

a
Cl vicu la v
Cla icle
Tube ro sitas c o raco ide a I m p re ssio n fo id lig am e n t
r co n o

Tube ro sitas co sta l is I m p re ssio n fo rr o h mbo id ligam e n t

Scap u la a
Sc p u la
I ncisu ra scap u laris S u p ra ~
scap u lar n o tc h
An g u lu s late ra is l An te rio r o r late ral an g le
An g ulu s me dia is l Su p e rio r an g e l
H umerus H u me u s r
l
Su cu s in t e rtu be rc ularis B icipital gro o v e
C rista tu be rc u i m aj o ris l x
E te rn al lip
C rista tu be rcu li m in o ris I n te rn al lip
Facies ante rio r me dialis I n te rn al su rface
F acie s an te rio r ate ralis l x
E te rnal su rface
M arg o m e dialis I n te rn al bo rde r
M arg o late ralis x
E t e rn al bo rde r
Su lcu s n e rvi radialis M u scu lo spiral g ro
-
o ve
C ap it ulu m C ap ite l u m l
Ep ico n dylu s m e dialis I n t e rn al co n dyle
Ep ico n dylus late ra is l x
E te rn a co n dy lel
U ln a U lna
I n cisura se m ilu naris G re ate r Sig mo id cav ity
I nc isu ra radialis L e sse r sigmo id cav ity
C rista in te ro sse a x
E te rn al o r in te ro sse o u s bo rde r
F acie s do rsa is l P o st e rio r su rfac e

F acie s vo laris An te rio r su rface


Facie s me dialis I nte rn al su rface
M arg o do rsa is l P o st e rio r bo rde r

M arg o v o laris An te rio r bo rde r

Radius
Tube ro sitas radi i B icip ital tube ro sity
I n cisu ra u ln aris Sigm o id cavity
C rist a in te ro sse a I n te rn al o r in te ro sse o us bo rde r
F acie s do rsa is l Po ste rio r su rface

F acie s v o laris An t e rio r su rface


F acie s late ralis x
E te rn a su rface l
M arg o do rsalis Po ste rio r bo rde r

M arg o v o laris An t e rio r bo rde r

Carp us
Os n a i cul ev ar
Os lun a u m t
tr
Os i qu e um tr
t
Os mul an gu lu m m ju s a
Os multan gulum minus
Os cap i um tat
Os h amatum
i
x v GL O SSARY

L o w e r Ext re mit y .

B N A. . . TER MI NO LOG Y . OLD TER MIN O L OG Y .

Os co x as I n n o min a e B o n e t
L in e a gl u tae t
a an e rio r M iddle curv e d line
L in e a glu taea p o ste rio r Sup e rio r cu rve d lin e
L in e a te rm in alis M argin o f in le t o f t rue p e v is l
Sp in a isch iadica Spin e o f the isch iu m
I n cisu ra isch iadica m aj o r G re at sacro sciatic n o tch -

I n cisu ra isch iadica m in o r L e sse r sacro sciatic n o tch -

l
Tube rcu u m p ubicu m Sp ine o f pu bis
R amu s infe rio r o ss p u bis . D e sce n din g ramu s o f p ubis
R am us su p e rio r Oss p u bis . Asce n din g ram u s o f p u bis
R amu s su pe rio r o ssis isch i i B o dy o f isch iu m
R am u s in fe rio r o ss isch ii . R am u s o f isch iu m
Pe c te n o ssis
p u bis P
u bic
p t
ar o f ilio p e ct in e al lin e -

F acie s sy mphyse o s Sy mphysis p ubis


v
P el i s P el i s v
P
e lv is m aj o r False pe lvis
P
e lv is min o r Tru e p e lvis
Ap e rtu ra p e lv is m in o ris sup e rio r P
e lvic in le t

Ap e rtu ra p e lv is min o ris in fe rio r P


e lv ic o u t e t l
L in e a te rm ina is l M arg in o f in le t o f t ru e p e lv is

F emu r F emur
F o ssa h an te rica
tro c D ig ital fo ssa
L in e a in te rtro ch an te rica Sp iral lin e
C rista in te rtro ch an t e rica P o st . in te rt ro ch an te ric lin e
C o n dylu s m e dialis I yle
nn e r co nd

C o n dy lu s late ralis O u te r co n dy le
Ep ico n dylus m e dialis I n n e r tube ro sity
Epico n dylus late ralis O u te r tu be ro sity

Tibia Tibia
C o ndylu s m e dialis I n t e rn al ube ro sityt
C o n dylu s late ralis x
E t e rn al tu be ro sity
Emin e n tia inte rco n dylo ide a Sp in e
Tu be ro sitas tibiae Tube rcle
M alle o lu s m e dialis I n te rn al malle o lus

F ibula Fibula
M alle o lus late ralis x
E te rn al malle o lu s
Ap e x cap itu li fibulae Sty lo id p ro ce ss

B o n es o f t he F o o t .

Talu s Astr agalus


Calcaneus Os calcis
Tu be r calcan e i Tu be ro sity o f
P
ro ce ssu s m e dialis t u be ris calcan e i I nne r
Pr o ce ssu s late ralis tube ris calcan e i O u te r
Os me p r imum
cu n eif o r I nn e r cun eif o rm
Os cun eif o rme secun du m Middle cu n eif o r m
Os cuneifo rme tertium O uter cun eifo r m
GL OSSARY xv

TH E L I G A M E N TS .

L ig ament s of t h e Sp ine .

B N A
. . . TER MI NO L OG Y . TER MIN O L OG Y
OL D .

L ig lo n gitu dinale an te riu s


. An te rio r co mmo n ligame n t
l
L ig o n g itu dinale p o ste rius
. Po ste rio r co mm o n l igame n t
L ig fl av a
. L ig am e n ta su bfl ava
M e mbrana te c o ria t P o ste rio r o ccipito ax ial ligame n t -

A rticu latio atlan to -


e p istro ph ica Jo in t be tw e e n the atl as an d the ax is
L ig alaria
. O do n to id o r ch e ck ligam e n ts
L ig ap icis de n tis
. S u sp e nso ry ligame n t

The R ibs .

L ig. c ap itu li co stae radiatu m An te rio r co sto -


v e rte bral o r ste l ate l
lig ame n t
L ig. ste rn o -
co stale in te rartic u lare I n te rartic u l ar c h o n dro -
ste rn al l ig a

men t
L ig. st e rno -
co stalia radiata An te rio r an d
p o ste rio r C h o ndro
ste rn al l ig m ta en

L ig. c o sto x ip ho ide a Cho n dro -


x iph id lig o am e n ts

Th e J aw .

L ig te m p o
. ro -
m an dibu lare x
E te rn al late ral ligam e n t o f th e ja w
L ig. S
p h e no -
m andibu lare ll
I n te rnal late ra igame n t o f the ja w
L ig. sty lo m an dibu lare-
Sty lo ma i ary igam e n t
-
x ll l

U p p e r Ext re mi t y .

L ig. co sto -
clav ic ulat e R h o m bo id ligame nt
L abru m g le n o idale G le n o id lig am e n t
Articu latio radio u ln aris p ro -
x im alis S u p e rio r radio -
u n ar l j o in t
L ig co l ate rale u n are
. l l I n te rn a l late ral ig ame n t l o f e lbo w
j o in t
L ig . co ll t a e rale radiale Ex t e rn al late ra ligame n t l
L ig . an n u lare radii l
O rbicu ar lig am e n t
C h o rda o bliq u a Obliq u e ligam e n t o f u ln a
Articu latio radio u ln aris dista is -
l I n fe rio r radio —u ln ar j o in t
D iscu s articu laris Trian g u lar fibro carti ag e -
l
R e ce ssu s saccifo rm is M e mbran a saccifo rm is
L ig radio carp e u m v o lare
.
-
An t e rio r ligam e n t o f the radio

carp al j o in t

L ig . radio -
carp e u m do rsale P o ste rio r l
ig am e n t o f the radio

carp al j o int

L ig . co ll ate rale carpi u ln are I n t e rnal late ral ligame n t o f th e


w rist j o in t
V OL . I — o
xv i GL OSSARY

B N A . . . TER MIN O L OG Y . OL D TER MIN O L OG Y .

L ig . co llate ra l e carp i radiale x


E te rn al late ral lig am e n t
o f t he

w rist j o in t
A rticu latio n e s in te rcarpae C arp al j o in ts
L ig . acce sso ria v o laria P l l
a m ar ig am e n ts o f th e m e tacarp o

l
p h a an g e al j o in ts
L ig . cap itu lo ru m
( o ss
. m e tacar Tran sv e rse m e tacarp al lig am e n t
p aliu m
) tran s v e rsa
L ig . co llate ralia L ate ral ph alan g e a ligam e n ts l

Th e L o w er Ex t re mit y .

L ig . arc u atu m Su bpu bic ligame n t


L ig . sacro -
t u be ro su m G re at sacro sciatic ligam e n t -

P ro c e ssu s fa l cifo rm is Falcifo rm p ro ce ss


L ig . sacro -
Sp in o su m S mall sacro sciatic lig ame n t
L abru m gle n o idale C o ty lo id ligame n t
Z o n a o rbicu laris Z o n u lar ban d

L ig am e n tu m ilio fe m o rale Y Sh ap e d ligame n t


-

L ig isch io cap su lare


.
-
lsch io capsu ar ban d
-
l
L ig p ubo cap su lare
.
-
P u bo fe mo ra ligam e n t
-
l
L ig p o p lite u m o bliq uu m
. L ig am e n t o f W in s o w l
l
Lig co late rale fibu lare
.
x
L o n g e te rn al late ral lig am e n t
l
L ig co late ra e tibiale
.
l I n te rn al late ral ligam e n t
L ig p o p lite u m arcu atu m
. Arcu ate p o p ite al ligame n l t
M e n iscu s late ralis x
E te rn al se m i u n ar carti ag e l l
M e n iscu s m e dialis I n te rnal se m i u n ar carti ag e l l
P l i y vi li
ca s no a s p ate llaris L ig m uco su m
.

P li a l
c e a are s L igam e n ta alaria
Articu latio tibio fibu laris -
S u p e rio r tibio fibu lar artic u latio n -

L ig cap itu li fibu lae


. A n te rio r an d p o ste rio r su p e rio r
t ibio fibu lar ligame n t s
-

Sy n de sm o sis tibio fi bu laris -


I n fe rio r tibio fibu lar articu latio n -

Lig de lto ide u m


. I n te rnal late ral ligam e n t o f an k le
L ig talo fibu lare an te riu s
.
-
An te rio r fasc icu u s o f e te rn al l x
late ral lig am e n t
L ig talo fibu lare p o ste riu s
.
-
P o ste rio r fascicu lu s o f e te rn al x
late ral lig am e n t
L ig . c alcan e o -
fibu lare M iddle fascicu lu s o f e te rn al late ra x l
ligam e n t
L ig talo
.
-
calcane u m late ra l e x
E te rn al calcan e o astrag alo id lig a -

men t
L ig t alo
.
-
calcan e u m m e diale I n te rn al calcan e o astrag alo id lig a -

me n t
L ig calcan e o n av icu lare p lan tare
.
-
l
I n fe rio r ca can e o n av icu lar ligam e n t -

L ig talo n av icu lare


.
-
l
Astrag a o scaph o id ligam e n t
-

Pars c alcan e o n av icu aris lig -


l . Su p e rio r ca can e o scaph o id lig a l -

bifu r me nt
P ars calc an e o -
cu bo ide a catu m I n t e rnal calcan e o cu bo id lig ame n t -
G L OSSA R Y x v ii

T HE M U S C L ES .

M u scle s o f t h e B ack .

r
Sup e fi cial .

B N A
. . . TER MIN OLOG Y . OLD TER MIN O L OG Y .

L e vato r scap u lae L e vato r an g u li scap u lae

Muscle s o f t h e Ch e st .

Se rratu s an te rio r Se rratu s m ag n u s

M u sc le s o f U p p e r Ext re mit y .

B ice ps brachn B ice p s


L ace rtus fibro su s B icip ital fascia
B rach ialis l
B rach ia is an t icu s
Trice p s brach n Trice ps
Capu me diale t I nne r h e ad
C apu t late rale O u te r h e ad
P ro n ato r t e re s P ro n ato r radi i t e re s
C ap u t u ln are Co ro n o id h e ad
B rach io radialis-
Su pinato r lo n g u s
Su p inato r Su pinato r bre v is
Ex te n so r carpi radialis lo ng u s x
E t e n so r carp i radialis lo n g io r
x
E te nso r carp i radialis bre vis x
E te n so r ca rp i radialis bre v io r
x
E t e n so r in dicis p ro p rius x
E te n so r indicis
x
E te n so r dig iti q u in ti p ro p rius x
E te n so r m in imi digi t i
Abdu cto r p o l icis lo n gu s l x
E te nso r o ssis m e tacarp i po llicis
Abdu cto r p o llicis bre v is Abducto r p o llicis
x
E te nso r p o l icis bre v is l x
E te nso r p rimi in te rno di i p o licis l
x
E te n so r p o llicis lo n g us x
E te nso r se cun di in te rn o dii po llicis
L ig carpi tran sve rsu m
. An te rio r an n u lar ligam e n t
L ig carpi do rsale
. Po ste rio r ann u lar lig am e n t

M u scles o f L o w e r Ex t re mit y .

Te n so r fasciae latae Te nso r fasciae fe m o ris


C analis addu cto riu s ( H un t e ri) H un te r s can al’

Trig o n u m fe mo ra e ( fo ssa Scarp ae l Scarpa s t rian g le


maj o r)
l
C ana is fe m o ralis C ru ral can al
An nu lus fe mo ralis C ru ral ring
M q u adrice ps fe m o ris
.
Qu adrice ps
R e c tu s fe mo ris R e ctu s fe m o ris
V astus late ralis V astus e xt e rn u s

Vastus in te rme dius C rure u s


V astu s me dialis Vastu s in te rn u s
M art icu laris g e n u
. Su bcru re u s
Tibia is l an te rio r Tibialis an ticu s
x v iii GL OSSARY

B N A
. . . TER MI N O L OG Y . OL D TER MIN O L OG Y .

Te n do calcane u s Te n do Ach illis


l
Tibia is p o ste rio r l
Tibia is po sticu s
Q uadratu s
p lan tae Acce sso riu s
L ig tran sv e rsu m cruris
. U pp e r an te rio r an n ular ligam e n t
L ig cru ciatu m c ruris
. L o w e r an te rio r ann ular ligam e n t
L ig lacinia u m
. t I n te rnal ann ular lig am e n t
R e tinaculu m m u scu lo ru m p e ro
na eo ru m su e riu s
p
R e tin acu lu m m usc ulo ru m p e ro
x
E te rnal an n u lar lig ame n t

na e o ru m in fe riu s

Ax ia l M u scles .

Mu scle s of t h e Back .

Se rratu s p o ste rio r Se rratu s po sticu s su p e rio r


Se rratus po ste rio r Se rratus p o sticus in fe rio r
Sp le n ius ce rv icis Sple n ius co lli
Sacro sp in alis
-
Ere cto r Spinae
I lio co stali s
-
I lio co stalis
-

L u mbo ru m Sacro lu mbalis -

D o rsi Acce sso riu s


C e rv icis C e rv icalis asce n de n s
Lo n gi ssimu s Lo n gissimu s
Do rsi D o rsi
C e rv icis Tran sv e rsalis ce rv icis
C ap itis Trache lo masto id -

Sp inali s Sp in alis
D o rsi D o rsi
C e rvicis C o lli
C ap itis C ap itis
Se misp in alis Semi sp in lis a
D o rsi D o rsi
C e rvicis C o li l
C apitis C o m p le us x
M u ltifidus Mu ltifidu s Sp in ae

M u sc le s o f H e ad an d N eck .

Epicran ius O ccip ito fro n alis -


t
G ale a ap o n e u ro tica Ep ic ran ial apo n e uro sis
Pr o c e ru s Pyramidalis nasi
P ars trans v e rsa ( n asalis) C o m p re sso r n aris
P ars alaris ( nasalis) D ilato re s n aris
Au ricu laris an te rio r At trah e n s au re m

Au ricu laris p o ste rio r R e trah e n s au re m


Au ricularis su pe rio r At to lle n s au re m
O rbicularis o cu i l O rbic u laris pa p e brarum l
P
ars lacrimalis Te n so r tarsi
xx GL OSSARY

M u scle s o f t h e Abdo men .

B N A
. . . TE R MIN O L OG Y . OL D TER MIN O L OG Y .

L ig am e n tu m in g u in al e ( P o u part i) P o u
p art s

ligam e n t
L igame n tu m lacu nare ( Gimbe rn ati) G imbe rn at s l igame n t

F ibrae in te rcru rale s I n te rc o l u m n ar fi bre s


L ig am e n tu m in gu in ale re fl e x u m Trian gu lar fasc ia
( C o lle si)
An n u lu s in g uin a is su bcutan e us l E xt e rn al abdomin a rin g l
C ru s su pe rius I n te rn al p i ar ll
C ru s in fe rius x
E t e rn al p illar
Falx apo n e uro tica ing u in alis C o nj o in e d t e n do n
M tran sv e rsu s abdo min is
. Tran sv e rsa is muscle l
L in e a se m icircu laris ( D o u glasi) l
F o d o f D o uglas
An n u lu s in gu in a is abdo m in a is l l I n te rn al abdo min a rin g l
P e rin eum an d P elvis .

Tran sv e rsu s p e rin e i su p e rfic ialis Tran sv e rsu s p e rin e i


M sp h in cte r u re th rae m e mbran ace ae
. C o mp re sso r u re th rae
D iaph rag ma u ro ge n ita e l D e e p tran sv e rse m u scle an d s
p hin c
te r u re t h rae
F ascia diaph rag m at is u ro g e n ital is D e e p lay e r o f trian g ular lig am e n t
su e rio r
p
F ascia diap h ragm atis u ro g e n italis Su p e rfi cial lay e r o f the trian gu ar l
in fe rio r lig ame n t
A rcu s te n din e u s fasciae p e lvis W h ite lin e o f p e lv is
L ig am e n ta p u bo p ro static a An te rio r an d late ral t ru e ig ame n t s l
o f bladde r

F ascia diap h rag m atis pe lv is su p e rio r V isc e ral lay e r o f p e lvic fascia
F ascia diap h ragmatis p e lv is in fe rio r An al fascia

TH E N ER V O U S SYSTE M .

M e dulla Sp ina lis . Sp in al Co r d .

Fasc iculus an te rio r pro p riu s ( F le ch An te rio r g ro u n d o r basis bun dl e

sis )
F asciculu s late ralis p ro p riu s L ate ral g ro un d bun dle
N u cle u s do rsa lis C l k ’
ar e s co lu mn
P ars tho racalis D o rsal p art o f spin al c o rd
S ulcu s in te rm e diu s p o ste rio r Parame dian fu rro w

C o lu m n ae an te rio re s, e tc . An te rio r g re y co lu mn
F ascicu lu s ce re bro Sp in a is an te rio r-
l D irect py ramidal tract
F ascicu lu s ce re bro sp in a is ate ra is -
l l l C ro sse d py ramida t rac t l
( py ramidalis)
Fascicu lu s ce re be llo spin a is -
l D ire ct c e re be ll ar t ract
F asciculus an te ro late ralis sup e r G o w e rs ’
t rac t
ficialis
G L OSSAR Y XX I

A a c e
o o f . a

v
o
w
m

z
w 2 2 i
m m
m m
m
u
x x ii G L OSSARY

B ra in .

B N A . . . TER MIN O L O Y G . OL D TER MIN OL OG Y .

R h o mbencep h alo n
Emin e n tia m e dia is l Emin e n tia te re s
Ala c in e re a Trig o n u m v agi
Ala ac ustica Trig o n u m acu sticu m
l
N u c e u s n e rvi abduce n t is l
N u c e us o f 6 th n e rv e
l
N u c e i n acu stic i . Au dito ry n u cle u s
l
F ascic ulus o ng itu din a is m e dialis l Po st e rio r lo n g it u din al bu n d e l
C o rp u s trap e o ide u m z C o rp us t rap e o ide s z
I n cisu ra ce re be li an te rio r l l
Se m i u n ar n o tch ( o f ce re be u m ) ll
I nc isu ra ce re be i p o ste rio r ll M arsup ial n o tch
z
S u lcu s h o ri o n talis ce re be l i l G re at h o riz o n tal fissu re
L o bulu s ce n tra li
s L o bus ce n tralis
F o l ium v e rm is F o liu m cacu minis
Tu be r v e rm is Tu be r v a v u ae l l
L o bu l u s q u adran g u l aris Q uadrate lo bu e l
B rac h iu m c o nj u n ct iv um c e re be ll i Su p e rio r ce re be llar p e du n cle
L o bu l u s se l
m i u n aris su p e rio r P o st e ro su e rio r lo bu le
p
-

L o bu l us se m ilu n aris in fe rio r P o ste ro in fe rio r lo bu le


-

Ce r ebrum
Pd l
e u n cu u s c e re bri C rus ce re bri
C ll i l
o c u u s su p e rio r A n te rio r co rp u s q u adrig e min u m
C ll i l
o in fe rio r
cu u s P o ste rio r co r u s q u adrig e minu m
p
A q u e du ct us c e re bri I te r e te rtio ad q u artum v e n tri
o n lu m , o r a u e d O f Sy lv iu s
q .

F o rame n in te rv e n tricu l are F o ram e n o f M o n ro


H yp o thalamu s Su bth alm ic re gio n
S u l cu s hy p o th alam icu s Su lcu s o f M o n ro
M assa in te rm e dia l
M idd e co mmissu re
Fascicu lus th alamo m am m illaris -
B u ndle o f V ic q d Az y r

P ars o p e rcu laris P ars basilaris

Th alamus O p tic th alam u s


P ll
a iu m x
C o rte ce re bri
G y ri tran sitiv i Ann e ctan t gy ri
F issu ra ce re bri l at e ral is F issu re o f Sylv iu s
G yru s te mp o ral is su p e rio r t
F irst e mp o ral gy rus
Gyru s te mp o ral is m e diu s Se co n d t e mp o ral gy rus
G yru s te mp o ral is in fe rio r Th ird te mp o ral gy rus
Su lcu s ce n t ra is ( K o lan di) l F issu re f R o lan do
o

S ulcu s t e mp o ralis su p e rio r Paralle l su lcu s

Su lcu s te m p o ralis m e diu s Se co n d te mp o ral su cus l


S ulcu s circularis L im itin g su cu s o f R e i l l
Su lcu s t e m p o ralis infe rio r O ccip ito te mpo ral su lc us
-

G yru s fusifo rm is O ccip ito te mp o ral c o n vo lu t io n


-

S u lcu s in te rp arie ta is l I n trap arie tal sulcus


l
Su cu s co rp o ris ca o si ll C allo sal su lcu s
l
S u c u s cing u li C allo so m argin al fissu re
-

F issu ra h ipp o camp i D e n tate fissu re


G y rus cing u l i C all o sal co n v o lu tio n
GL OSSARY xx iii

B N A. . . TER M IN O L OG Y . OL D TER MIN O L OG Y .

St ria t e rm ina is l Tae n ia se m icircii laris


Trig o n u m c o llate rale Trig o n um v e n tricu li
H ipp o cam pus H ip p o campu s m aj o r
D ig itatio n e s h ippo cam p i P e s h ippo campi
F ascia de n tata h ippo cam pi G yru s de n tatus
C o lu mna fo rn icis An t e rio r p illar o f fo rn i x
Se p tu m p e llu cidum S e p tum lu cidu m
I n fe rio r co rn u D e sce n din g h o rn o f l at e ral v e n tricle
C o mm issu ra h ip p o cam p i L y ra
l
N u c e us le n tif o rmis L e n ticu lar n u cle u s
P ars fro n ta is cap su ae in te rn ae l l An te rio r lim b ( o f in e rnal capsu le )t
P ars o cc i italis cap su lae in te rnae
p Po ste rio r limb ( o f in te rnal ca su le )
p
R adiatio o ccip ito th alam ica -
O p tic radiatio n
R adiatio co rpo ris ca o si ll R adiatio n o f c o rp us callo su m
P
ars fro n talis F o rce ps min o r
P
ars o cci ita is
p l F o rce ps maj o r

M e mbran es o f B rain .

C iste rn a ce re be llo me dullaris -


t
C is e rn a mag n a
C iste rna in te rp e du n cularis C iste rn a basalis
G ran u latio n e s arachn o ide ale s Pacch io n ian bo die s

Te la c h o rio ide a v e n tricu li te rti I V e lum in te rpo situ m


Te la ch o rio ide a e n tricu li q uarti v Te la ch o ro ide a infe rio r

Cerebral N erv es .

N . o cu lo mo to riu s Th ird ner ev


N . t ro c h le aris F o u rth ne rv e
N . ge min us
tri F ifth n e rve
G ang l io n se milunare ( C asse ri) G asse rian g anglio n
N . n as o -
ciliaris N asal n e rv e
N ma illaris
. x Sup e rio r m ax il lary n e rv e
N m e n in g e us ( m e diu s)
. R e cu rre n t m e n in ge al n e rv e
N yg o maticu s
. z Te mp o ro malar n e rv e
-

R ami alv e o lare s su p e rio re s po s P o ste rio r su


p e rio r de n tal
te rio re s
R am i v
al e o lare s su pe rio re s me du M iddle su p e rio r
de n ta l
R am i al e o v lare s su
p e rio re s an An te rio r su p e rio r de n ta l
te rio re s

G an g lio n Sp h e no -

p alatinum M e ck e l s ’
gang l io n
N .
p alatin u s me diu s x
E te rn al p alatin e v
ne r e

N man dibularis
. I n fe rio r m a i lary xl n e rv e

N e rvu s spin o sus R e cu rre n t ne r e v


N alv e o laris in fe rio r
. I n fe rio r de n ta l
N . abdu ce n s x
S i th n e rv e
N . facialis Se v e n th n e rv e
N . in te rm e dius P ars in te rm e dia o f W risbe rg

N . acu s icu s t Eigh th o r au dit o ry n e rv e


xx iv G L OSSARY

B N A. . . TER M I N O L OG Y . OL D TER MI N O L OG Y .

G anglio n su p e rius j guu lar g an g l io n o f


9 th n e rv e
N . re c u rre n s R e cu rre n t laryn g e al n e rv e
G ang l io n j u gu l are G ang lio n o f ro o t
O f v ag u s
G ang l io n n o do su m G ang l io n o f tru n k
Pl x e u s o eso
p hage u s an te rio r
P le x us gulae
Pl x phage u s p o st e rio
e u s o eso r

N e rv u s acce sso riu s Sp inal acce sso ry


R am us in te rn u s Acce sso ry p o rtio n o f S
p in a l
acce sso r y ner e v
R amu s e xt e rn u s Sp in a p o rtio l n

Sp i nal N erv es .

R am i p o ste rio re s P o st e rio r y divisio n s


p rimar

R am i an te rio re s An te rio r p rimary div isio n s


N . cu tan e u s co ll i Sup e rfi cial ce rvic al n e rv e
Nn . su p rac a l vi lc u a re s an te rio re s Su p raste rn al n e rve s
Nn . v icu lare s me dii
su p racla Supraclav icu lar n e rv e s
Nn . su raclav icu lare s p o st e rio re s
p Su p ra acro m ial n e rv e s
-

N . do rsalis scap u ae l N e rv e to th e rh o mbo ids


N n in te rc o sto brach iale s
.
-
I n te rco st o h u m e ral n e rv e
-

N th o racalis lo n g us
. N e rv e o f B e ll
N . do rsa is th o raco -
l L o ng subscap ular n e rv e
N c u tan e u s brach ii m e dia is
. l L e sse r in te rn al c u tan e o u s n e r e v
N cu tan e u s brachn ate ra is
. l l C u tan e o u s bran ch o f circu m fl e x
ner ev
F ascicu lus late ralis O u te r co rd ( o f p le x us )
F ascicu lus m e dialis I nn e r co rd
N . cu tan e u s an tibrach n late ra is l C u tan e o us bran ch o f m u scu lo -
cu ta

n e o us n e r e v
N . c u tan e u s an t ibrachn me dialis I n te rn al cu tan e o u s n e r e v
R am u s vo laris An te rio r branch
R amu s u ln aris P
o ste rio r bran c h

N . cu tan e u s an tibrach n do rsalis x


E te rn al cu tan eo u s bran c h o f m u s
c u lo sp iral
-

N . a x il l aris C ircu m fl e x n e rv e
N in te ro sse us v o aris
. l An te rio r in te ro sse o u s
R amu s palm aris N m e dian i . Palmar cu tan e o us bran ch o f the
m e dian n e rv e
N n dig itale s . v o lare s p ro p ru l
C o late ral p almar dig ital bran ch e s
o f m e dian n e rv e

R amus do rsalis m an us D o rsal c u tan e o u s bran ch o f u ln ar


v
ner e

R am us cu tan e us p maris
al P alm ar cu tan e o u s bran ch o f u ln ar

v
n er e

N . radialis M u scu lo -
Sp iral n e r e v
N . cu tan e u s brach n p o ste rio r I n te rn al cu tan e o u s bran ch . o f
m uscu lo -
sp ira l ner ev
N . cu tan e us an t ibrach u do rsalis x
E te rn a l cu tan e o us bran ch e s o f
I n u sculo -
Sp ira l ner ev
GL OSSARY XXV

B N A . . . TER MI N O L OG Y . TER MIN OLOG Y


OL D

N . radialis ( co n t a

. M u scu lo sp iral n e rve ( co n tra)
-

R amu s su p e rficialis R adial n e rv e


in te ro sse u s do rsa is
N . l P o ste rio r in te ro sse o u s n e r e v
N n dig it ales do rsale s
. Do rsal digita l v
ne r es

l
i io hyp o gas tricu s-
I iol hyp g -
o astric n e r e v
R amus cu tan e us late ralis I liac bran ch o f ilio -
hyp o gastric
v ne r e

R amus cu tan e u s an te rio r H ypo gastric bran ch o f il io


hypo gastric n e rv e
N . ge n ito fe mo ralis
-
G e n ito cru ral n e rve
-

N . lu mbo ing u in a is -
l C ru ral bran ch o f g e n ito cru ral -

n e rv e

N . S
p e rmaticus e xt e rn us G e n ital bran ch o f ge n ito cru ral -

n e rve

N . cu tan e u s fe m o ris late ralis Ex te rn al c u t an e o us n e rv e


N . fe m o ralis An te rio r c ru ral n e rv e
sap h e nus L o n g saph e n o u s n e rv e
R amu s in frap ate llaris P ate llar branch o f lo ng sap h
e n o u s ne rv e

isch iadicus G re at sc iatic n e rv e


p e ro n ae us com m u nis Ex te rnal p o p lite al n e rve
R amu s anasto mo tic u s p e ro N e rvu s co mm unicans fibu laris
nae us

N .
p e ro nae u s s u p e rfic ialis M u scu lo -
cu tan e o us n e r e v
p e ro n ae u s p ro fu ndus
N . An te rio r tibial n e rv e
tibialis I n te rn al p o p lite al n e rv e
N . cu tan e u s su rae me dialis N e rvu s co m m u n ican s t ibialis
N . su ralis Sh o rt saph e n o u s n e rv e
p lan taris m e dia is l I n te rn al p lan tar
p lan taris late ralis x
E te rnal p lan tar
p u de ndu s Pu dic n e rv e

TH E H EART AN D BL OO D V ESSE L S .

H e a rt .

At riu m Au ricle
Au ricu la co rdis Au ricu lar ap p e n di x
I n cisu ra c o rdis N o tch at ap e o f x h e art
Trabe culae c arn e ae C o lum nae carn e ae
Tu be rcu lum in t e rv e no su m I n t e rv e n o ns tu be rc le o f L o w e r
Su lcus lo ngi tu dinalis an te rio r An te rio r in te rve n t ric u lar g ro o v e
l
Su cus co ro n ariu s Au ricu lo ve n tricu lar g ro o
-
ve
L imbus fo ssae o va is l l
Ann u u s o v alis
l
Valvu a v e nae cavae Eustachian v alv e
l l
V a vu a Sinus c o ro n aru Valve o f Th ebe siu s
xx vi GL OSSARY

Art erie s .

B N A . . . TER MIN OL OG Y . TER MIN O L OG Y


OL D .

Sin us ao rtae Sin u se s o f V alsalva


A p ro fu n da in gu ae
. l R an in e arte ry
A ma i aris e te rn a
. x ll x F acial arte ry
A alv e o laris in fe rio r
. I n fe rio r de n tal arte ry
R am u s me ninge u s acce sso riu s Sm al l m e n in g e al arte ry
A bu ccin ato ria
. B u ccal art e ry
l
A a v e o laris su p e rio r p o ste rio r
. P o ste rio r de ntal arte ry
Aa alv e o lare s sup e rio re s an te rio
. re s An te rio r su p e rio r de n tal arte rie s
R amus c aro tic o tym p an icu s -
Ty m pan ic bran ch o f in t caro tid .

A c h o rio ide a
. An te rio r ch o ro idal arte ry
A au ditiva in te rn a
. Au dito ry arte ry
R am i ad p o n te m Tran sv e rse arte rie s ( bran ch e s
B asi l ar arte r y)
A p e ricardiaco p h re n ica
.
-
Arte ria co m e s n e rv i ph re n ici
R ami in te rco sta e s ( A m amm aria l . An te rio r in te rco stal arte rie s
in te rn a)
Tru ncu s thyre o ce rv icalis -
Thy ro id a is x
t ran sv e rsa scap u lae Su p rascap u lar arte ry
in t e rco st a is su p re ma l Su p e rio r inte rco stal
t ran sve rsa co l i
0 l Tran sv e rsalis c o lli
tho racalis su pre m a Su p e rio r th o racic arte ry
th o raco ac ro m ia is -
l A c ro mio th o rac ic arte ry
-

th o racalis late ralis L o n g th o racic arte ry


circ um fl e x a scap u la e Do rsalis sca u la
p e
p ro fu n da brach ii Sup e rio r p ro fu n da
l
co lat e ralis radialis An te rio r bran ch o f su p e rio r p ro fun da
t
co lla e ralis u ln aris su p e rio r I n fe rio r p ro fu n da
l
A c o l ate ralis u lnaris infe rio r
. An asto mo tica m agn a
R am u s carp e us v o laris A n te rio r radial carpal
R am us carp eu s do rsalis P o st e rio r radial car al
p
Aa m e tacarp e ae do rsale s
. D o rsal in te ro sse o u s arte rie s
A . v
o laris indicis radia is l l
R adia is in dicis
Arcu s v o laris su p e rficialis Su p e rficial p almar arch
Arcus v o laris p ro fu n du s D e e p p almar arch
A in te ro sse a do rsalis
. P o ste rio r in te ro sseo u s arte ry

t
A in e ro sse a re cu rre n s
. P o ste rio r in e ro sse o u s t re cu rre n t

a rte r y
A in te ro sse a v o laris
. An te rio r in te ro sse o u s arte ry
R am u s c arp e u s do rsalis P o ste rio r u lnar car al
p
R am u s carp e u s v o laris An te rio r u ln ar carp al
Aa dig itale s v o lare s co mmu n e s
. Palm ar dig it al arte rie s

Aa dig itale s v o lare s p ro p riae


. C o llate ral digital arte rie s
A rte riae in te stin ale s I n te stinal bran ch e s o f su p . m e se n
te ric
A su p rare n alis m e dia
. M iddle c ap su lar arte r y
A hyp o gastrica
. I n te rn al i iac l y
arte r

A u mbi ica is
. l l t
O blite ra e d hyp o g astric
A p u de nda in te rna
. t
I n e rn al p u dic arte ry
A e p ig astrica in fe rio r
. D e e p e p igastric arte ry
xx v iii G L OSSARY

Ly mp hat ics .

E N A
. . . TER MIN O L OG Y . TER MIN O L OG Y
OL D .

C iste rn a c hyl i R e ce p tacu lu m chy li

TH E V I S C ERA .

Digest iv e A p p arat u s .

Arcu s g lo sso p alatin u s -


An te rio r p il ar o f fau ce s l
Arcu s ph ary n g o palatin u s -
Po ste rio r p illar o f fau ce s

G l lin gu alis an te rio r


. G l an d o f N u hn
D u ctus su bma illaris x W h arto n s duc t ’

Gl p aro tis acc e sso ria


. So cia p aro tidis

D u ctus p aro tide u s ( Ste n o n is ) Ste n so n s du ct
D e n te s p raem o lare s B icu spid e e th t
D e n s se ro tinu s W isdo m to o th
Pa illae v allata
p e C ircu m v allate pap i lae l
R e ce ssu s ph ary n g e u s L ate ral re ce ss o f p h aryn x
Te la su bmu co sa P h ary ng e al ap o n e u ro sis
P li a c e c ircu lare s l
Valvu ae co nn ive n te s
Gl in te stin ale s
. C ry p ts o f L ie be rk u h n
V alv u la co li I le o cae cal valv e
-

C o lumnae re ctale s l
C o u mn s o f M o rgag n i
Pli a t v l
c e ran s e rsa e s re ct i V alv e s o f H o u sto n
V l v l p i li
a u a s ra s V alve s o f H e ist e r
N d l i l y m p h ati i gg re gat i Py p atch e s

o u c a e er s

( P e y e ri)
I n te stin u m j ej u n u m Je j un u m
I n te stinu m ile um I le um
N o du li lym ph atici lie nale s l
M a p igh ian co rp u sc e s l
( M alp ighii)

R e sp ira t o ry A p p ara t us .

La r y nx
P mi
ro n e n tia laryn g e a Adam s ap p le

I n cisu ra thy re o ide a su p e rio r Su p e rio r thy ro id n o tch


M ary e p iglo t ticu s
.
-
Ary te n o e pig lo ttidean m uscle
-

M v o calis
. I n te rn al thy ro ary te n o id m u scle -

M tlI y re o e p iglo tticu s


.
-
Thy ro e pig o t tide an m u scle
-
l
x
Ap pe n di v e n tricu li lary n g is L aryn g e a l sac

Pl ica v o ca is l Tru e v o cal co rd


P lica v e n tricu laris F alse v o cal co rd
L ig ame n tum v e n t ricu lare Su pe rio r thyro ary te n o id ligam e n t -

L igame n tu m v o cale I n fe rio r thyro ary te n o id lig am e n t -

G l o ttis G l o t t is v e ra
R im a v e st ibu li G l o t tis spu ria
C artil ago thyre o ide a ,
Thy ro id cart il age
G L OSSARY i
xx x

B N A
.TER MIN O L OG Y
. . . OLD TER MIN O L OG Y .

M e mbrana hy o thy re o ide a -


Thy ro hy o id m e m bran e
-

C artilag o co rn icu l ata ( San t o rin i) l


C arti ag e o f San to rin i
Tu be rcu lu m e p ig l o tticu m C u sh io n o f e p ig o ttis l
P in te rme mbranace a ( rim ae
ars G o ttis v o ca is
l l
glo ttidis)
arsP in te rcartilagin e a G lo ttis re spirato ria
l
g o ttidis)
C o n us e lasticu s ( m e m bran ae C rico -
t hy ro id me mbran e
e last icae lary n g e s)
G lan du la thyre o ide a Thy ro id glan d
G lo mus caro ticu m I n te rcaro tid g l an d o r bo dy
N o se
C o nch a n asalis su p re ma ( San to rin i) H igh e st tu rbinate bo n e
C o n ch a n asalis su p e rio r Su p e rio r u rbinate bo n et
C o n ch a n asalis m e dia M iddle tu rbin ate bo n e
C o n ch a n asa is in fe rio r l I nfe rio r tu rbin ate bo n e

U ro ge nit a l App a rat u s .

C o rp usc ula re n is M alp igh ian p co r u scle s

Paradidy m is O rgan o f G iraldés


Ap pe ndi t e st is x H ydatid o f M o rgag ni ( ma e ) l
D uctu s de fe re ns V as de fe re ns
Gl u re thrale s
. G ands o f L ittré
l
G lan du la bulbo u re th ralis ( C o wp e ri)-
C o w p e r s g lan d

F o llicu li o o pho ri ve sicu lo si G raafian fo llicle s


C u mulu s O o ph o ru s D iscu s p ro ig e ru s l
Tu ba u te rin a F allo p ian tu be
Ep o o p h o ro n P aro v a riu m

Ap pe n dice s v e sicu lo si H y datids o f M o rgagn i ( fe m a l e )


D uc tu s e po o ph o ri lo n gitu dinalis G artne r s duct

O rificiu m in te rn u m u te ri I n te rnal 0 5 ( o f u te rus)


O rificiu m e te rnu m x x
E te rn al o s
P ro ce ssu s v ag in alis C an al o f N uck
G andu la m agn a ve stibu i
l l Barth o in s g an d

l l
P erit o n e um .

B u rsa m e n talis
o L e sse r p e rito ne a l sac

F o rame n e p ip lo icu m F o rame n W in sl o w o f


L ig p h re n ico co licu m
.
-
C o sto co lic ligam e n t
-

x
E cavatio re cto u te rin a ( cav u m -
P o uch o f D o ug l as
D o ug asi) l
L ig gastro lie n ale
.
-
G astro s ple n ic o me n tu m

S E N SE OR G A N S .

Th e Ey e .

S c e ral Sc le ro t ic co at
L am in a e last ica an te rio r ( B o wm an i) B o w man s m e m bran e

x xx GL OS SARY

B N A
. . . TER MIN O L OG Y . OL D TER MIN O L OG Y .

L am in a p o ste rio D e sce me t m e mbran e



e last ica r (Des s

ce m e ti )
Spatia an g u i iridis l Space s o f F o n tan a
A n g u lu s iridis I rido co rn e al j u n c tio n
-

Zo n u la c iliaris Z o nu e o fl in n Z
Se p tu m o rbitale P alp e bral lig am e n t

F ascia bu lbi C ap su le o f Te n o n
C o m m issu ra palp e braru m la e ralis t x
E te rnal c an th us
C o mmissu ra p alp e braru m m e dialis I n te rnal can th u s
Tarsus su p e rio r Su p e rio r tarsal p ate l
Tarsus in fe rio r I n fe rio r tarsal p ate l
L ig p alpe bra e m e diale
. l I n te rn al tarsal igam e n t l
l
R ap h e p a p e bra is late ra is l l x
E te rn al tarsal ligam e n t
Tarsal glan ds M e ibo mian glands

Th e Ear .

C analis se m icirc ularis la te ra is l x


E te rnal se micircu ar can al l
D uctus re u n ie n s C an alis re u n ie n s
D uc tu s co ch le aris M e m bran o us co ch le a
R e ce ssu s sp h e ricu s Fo v e a h e m isph e rica
R e ce ssus e lip ticu sl F o ve a h e mi e llip tica -

Pa rie s j u g ularis F lo o r o f tymp an u m


Parie s laby rin t hica I nne r w all

F e n e stra v e stibu li F e n e stra o valis


F e ne stra co ch le ae F e n e stra ro tu nda
Pa rie s m asto ide a Po ste rio r wal l
An trum tym p an ic u m M asto id an t ru m
Parie s caro t ica An te rio r w all
P ro c e ssu s ate ralisl P ro c e ssu s bre v is ( o f malle us )
P ro ce ssus an t e rio r P ro ce ssu s gracilis
MANUAL

P RAC TI CA L A N A TO M Y .

TH E S U P E R I O R EX T R E M I TY .

I nt ro duc io n t — Th e su p e r ior e x tr e mity co n sist s o f th e


brat /zinm o r arm , wh ich e x t e n d s fro m t h e shou ld e r to t h e
e lbow ; t h e a n tiorat /zin m or f or e ar m, wh ich lie s be tw e e n th e

e lbow an d th e wr ist ; th e wrist, wh ich co n n e ct s th e f or e ar m

w ith the ha n d ; an d th e man ti s or ha n d B e lo n g in g to it.

a lso are th e bo n e s o f the shou ld e r g ird le , the clavic le an d


sca p u la , by me a n s o f wh ich it is art icu lat e d w ith th e sk e le to n

o f th e tru n k ; it is a lso attach e d to t he tru n k by me a n s o f a

n u mbe r o f m u sc le s . The a n g le wh ich lie s be tw e e n the arm


an d t he u p p e r p art o f t he tru n k is th e a x illa or arm p it .

Surf ace An at o my . B e for e co m me n c in g t h e actua l dis


-

se ct io n o i an y r e g io n o f t he body t he stud e n t shou ld be

qu it e fa miliar w ith th e bo n e s o f t he r e g io n , fo r th e y are th e


la n d m ark s by me a n s o f wh ich the p o sit io n s o f t h e so ft p art s
wh ich lie be n e ath the sk in c an be d e fi n e d , both in t h e d e ad
an d in t h e livin g body . Th e out lin e s o f ma n y o f t h e bo n e s
an d t h e p r o j e ct in g p art s o f oth e r s can be se e n , fo r th e y cau se

p ro m in e n c e s o n t h e s ur fac.e M a n y p o rt io n s o f bo n e wh ich
ca n n o t be se e n can be felt qu it e e a sily wh e n th e fi n ge r is
p a ss e d light ly o v e r t h e p lac e s wh e r e th e y l ie s light p r e ssur e

m u st be u se d in oth e r p lac e s wh e r e th e bo n e s lie m o r e


d e e ply So me p art s o f the sk e le to n, how e ve r, c an be n e ith e r
.

se e n n o r fe lt u n t il t h e so ft p art s hav e be e n r e m ov e d .

V OL . I— l
THE S U P ER I OR E X TRE M I TY
I t is e sse n t ia l th e r e for e that t he stud e n t shou ld train his
, ,

e y e s to se e all that c an be se e n an d his fi n g e r s to fe e l all ,

that can be fe lt an d he mu st r e m e mbe r that a n yth in g wh ich


,

h e can se e or fe e l in th e ca se o f th e body o f a n o th e r p e r so n
h e c an a lmo st e qua lly w e ll se e an d fe e l in t h e ca se o f h is
o wn body .

Th e bo n e s o f t he su p e r io r e x tr e mity are th e clavicle ( co llar


bo n e ) an d t h e scap u la ( shou ld e r blad e ) t h e nu meru s t h e , ,

radiu s an d th e u ln a eiglzt carp al bo n es fi ve met acar


,
pal ao n es , ,

an d fo u rteen p lz alanges ( F ig s 1 z .
, ,

Th e sca p u la an d c lav ic le tog e th e r for m th e shou ld e r gird le


, , ,

by me a n s o f wh ich th e arm is art icu lat e d w ith th e sk e le to n o f


t he tru n k .

Th e c lav ic le can be se e n an d fe lt at th e low e r p art o f th e


fro n t o f the n e ck I t e x t e n d s fro m th e shou ld e r to th e u p p e r
.

e n d o f th e st e r n u m ( br e a st bo n e ) wh ich lie s in th e m idd le ,

p art o f t h e f ro nt o f t h e ch e st B e low t h e j u n ct io n o f.

its in t e r me d iat e an d lat e ra l th ird s is a d e p r e ssio n o f th e


sur fac e t he aelto p ecto ral triangle The so ft p ro min e n c e to

-
.
,

t h e m e d ia l sid e o f t h e de lto p e ctora l tr ia n g le is cau se d by th e


-

p o rt io n o f t h e p e ctora l is m ajor mu sc le wh ich is attach e d to

t h e fro n t o f t h e m e d ial ha lf o f the c lav ic le an d t h e p ro min e n c e ,

o n th e lat e ra l sid e o f th e tr ia n g le is due to t h e a n t e r ior p art

o f t h e d e lto id m u sc le wh ich sp r in g s f ro m t h e fro n t o f th e

lat e ra l th ird o f th e c lav ic le I f t he fi n g e r is p r e sse d u p ward s


.

an d backward s at t h e u p p e r p art o f t h e lat e ra l m arg in o f

th e de lt o p e ctora l tr ia n g le a p ro min e n c e o f bo n e ca lle d t h e


-

co raco ia p ro cess o f t he sca p u la w ill be fe lt I t lie s u n d e r cov e r



.

o f th e m e d ia l e dg e o f th e d e lto id m u sc le an d is an imp orta n t ,

la n d mark ( F ig s 1 2 5 5 5 6.
, , , ,

B e yo n d an d be h in d t h e lat e ra l e n d o f t h e c lav ic le a m or e
o r le ss quadra n gu lar p lat e o f bo n e c an be fe lt I t is t h e .

acro mio n o f t h e sca p u la I t s me d ia l m arg in art icu lat e s w ith


.

t h e lat e ra l e n d o f th e c lav ic le at t h e acro mio clavicu lar j o in t ,


-
.

I t s lat e ra l m arg in lie s at t he tip of the slzo u laer an d it is t h e



,

u pp e r p o in t fr o m wh ich the le n gth o f the su p e r ior e x tr e mity


is me a sur e d .

O n th e p o st e r ior a sp e ct o f th e body ru n n in g m e d ia lly , ,

backward s an d slight ly dow n ward s fro m th e acro mio n is a ,

p ro m in e n t an d e a sily fe lt r idg e o f bo n e I t is t h e p o st e r ior .

bord e r or crest of tlz e spin e of the scap u la .

I n the arm th e r e is o n e bo n e the lzu merus I t exte nd s ,


.
P LA TE I
C LA I L E
V C Sp i ne
C LA I L E
V C
Acro m i o n
e dia l a n gl e

Med a i l gl
an e

Ac ro m i o n

SC A ULAP

SC A ULA
P

I n t e rt u be r

l
.

c u la r su c u s

I i
n fe r o r a n g le

I i
n fe r o r a n gl e

H U ER U
M S H U M ERU g Su l cu s fo r rad a i
~

ne r e v

M e dial su p ra
La t e ra l e p ic o n d
y
e
p i co nd yl i dg
ar r e
il p
M ed a
la r r d ig e
pi dy l i dg
su ra

di l p i dy l
e co n ar r
Me a e co n e
e

M di l p i dy l
Ol e c ra n o n
e a e co n e

hl
Co ro n o id p ro c e s s
T ro c ea

C id p
o ro n o ro c e ss

Vl o ar bo ide r'

~
O bli q ue li ne

Vl o ar s urfac e
R A IU D S U LN A
U LNA R A IU D S

D o rsa lb o rde r
D o rsa lb o rde r
.I n t e ro sse o u s c re s t s I n t e ro sse o u s c re s ts

Vl o ar bo rde r
O bli q ue li ne Vl o ar su rfac e

Vl o ar bo rde r
H e a d\

St yl i
o d p ro c e ss
A St yl i d p
o ro c es s St yl id
o

CAR U P S St yl i d po ro c e ss

M e ta c a rp a

M e ta c a rp a l
I ST P H ALA N X

2 N l) P H ALA N X
I St p ha l x
an

FI G . L — B o ne s o f U p per L mb i . FI G . 2 .
— Bo ne s o f U pper L m b i .

P o ste ri o r v i e w .

A n te r o i r V e iw .
P LA TE II

R dia us

St yl id p
o ro
ce ss o f l
u na

Di l st a ep
ii
p hy
sis o f rad u s

L u n at u m

P i sI fo rm
St y l id p
o ro
c e ss o f radi u s

Na vi l
c u ar

Tr iq u e t ru m
Mu l gl
tan u u m
In a u s j
H am a t u m

C ap i tat u m

FI G .
3 .
— An te ro p o ste r o
-
i r R dia o grap h o f th e Wri st o f a p e rso n o f
1 9 ye ars .

N o te (I ) i li
Th e e p p hyse al n e s o f th e rad u s an d u n a i l .

(2 ) i l l
Th e d ffe re n ce in e ve o f th e sty o id pro ce ss l o f t he l
u na as co n
t raste d w i th th e st yl o i d p ro c e ss o f th e radi u s .

Th e ve rl ap sh ado w s o f adj ac e n t bo n e s
(3) o o f th e .
4 TH E S U P ER I O R E X TRE M I TY

j u st lat e ra l t o t h e sty lo id p roc e ss an d slight ly p r o x im a l t o

it th e r e is a rou n d e d p ie c e o f bo n e ca lle d th e bead of tbe u ln a .

I t is be st se e n an d fe lt wh e n t h e p a lm o f t h e ha n d is tur n e d
dow n ward s .

The rad iu s is m o r e de e p ly bur ie d tha n th e u ln a bu t th e r e ,

is n o d ifficu lty in lo cat in g it s p r o x im a l an d d ista l e n d s Th e .

p r o x im a l e n d ca lle d t h e li co d of ta
, e radiu s lie s a sh o rt d ista n c e
,

d ista l t o the lat e ra l e p ic o n dy le o f the hu me ru s I ts p o sit io n .

is m ark e d o n t h e back o f t h e fo r e ar m by a d imp le o f t h e


sk in . I f a fi n g e r is p lac e d in t h e d imp le t he h e ad o f t h e
rad iu s can be fe lt rotat in g wh e n the p a lm o f t he ha n d is
tur n e d a lt e r n at e ly u p ward s an d d o w n ward s .

Th e d ista l e n d o f t h e rad iu s is t h e quadra n gu lar m a ss o f


bo n e wh ich c an be fe lt at t h e lat e ra l sid e an d t he back o f th e
wr ist I t lie s lat e ra l to th e h e ad o f the u ln a an d it t e rmin at e s
.

o n th e lat e ra l Sid e in a p o in t e d p roc e ss t h e sty lo id p ro cess of


,

The eigbt p bo nes o f the wrist lie in th e in t e rva l


car al

be tw e e n th e sty lo id p roc e sse s o f t h e rad iu s an d u ln a be y o n d ,

wh ich th e y e x t e n d d ista lly fo r a short d ista n c e ( F ig s 3 6 7 .


, ,

The fi ve metacarp al bo n es o f tbc band o n e fo r e ach d ig it , ,

e x t e n d fro m t h e car p u s to t h e p ha la n g e s .

Th e y are n u mbe r e d o n e to fiv e fr o m th e thu mb to the


litt le fi n g e r sid e an d all are e a sily fe lt at th e back o f t he
,

ha n d wh e r e the h e ad s o r d ista l e n d s for m t he p ro min e n c e s


,

k n o w n as th e k n uckle s “
.
!

Th e fo u rteen p /zalanges are in t he fr e e p art s o f th e d ig it s :


t wo in t he thu mb first o r p ro x im a l an d seco n d or d ista l
'

t hr e e in e ach fi n g e r p r o xima l o r first m idd le o r seco nd an d


, , ,

d ista l or tlzird The se co n d p ha la nx o f th e thu m b an d th e


.

th ird p ha la n g e s o f the fi n g e r s are fre qu e n t ly ca lle d t e r min a l


p ha la n ge s .

Th e structur e s co n n e ct e d an d a sso c iat e d w ith all th e


bo n e s m e n t io n e d h av e t o be e x a min e d by th e d isse ct o r o f
th e su p e r io r e x tr e m ity an d wh ilst wa it in g t o c o m m e n c e t h e
,

disse ct io n t h e d isse ctor sh o u ld v e r ify all th e p o in t s a bo v e


m e n t io n e d u p o n h is o wn body w ith th e aid o f h is fi n g e r s an d
a lo o k in g gla ss
-
.

Sin c e m a n y stud e n t s co m me n c e d isse ct in g be fo r e th e y


hav e att e n d e d e ith e r le cture s o r d e m o n strat io n s o n An at o my ,

th e y are u n acqua in t e d w ith t e r m s wh ich m u st be u se d in th e


in struct io n s g iv e n r e gard in g th e d isse ct io n s wh ich are to be
P E C TORA L RE G I O N 5

mad e F ortu n at e ly m o st o f th e t e r ms u se d , lik e tho se a lr e ady


.

me n t io n e d, r e fe r t o th in g s wh ich can be se e n an d fe lt ; th e y,
th e r e fo r e are e a sily u n d e r st o o d Th e re are how e v e r c e rta in
, .
, ,

t e r ms u se d wh e n bra n ch e s o f Sp in a l n e rv e s are u n d e r c o n
,

sid e rat io n wh ich are n o t se lf e x p la n atory an d it is n e c e ssary


,
-

, ,

th e re for e that the stud e n t shou ld p o sse ss a k n ow le dg e o f the


,

te rms u se d in co n n e ct io n w ith sp in a l n e rve s an d th e ir bra n ch e s


'

be for e th e actu al w o rk o f d isse ct io n is c o mm e n c e d Th e .

fo llo w in g p o in t s shou ld be n ot e d : ( 1 ) Ev e ry sp in a l n e rv e is
attach e d to th e sp in a l m e du lla ( sp in a l c o rd ) by two root s an ,

a n terio r ro o t an d a p o sterio r ro o t Th e a n t e r ior ro o t is n o n .

n lio n ated an d t he p o st e r ior r o ot is


a
g g a
g gn lio n ated
( )
2 A s t h e <
r
é
f
.

root s are le av in g th e v e rt e bra l ca n a l thr o ugh an in t e rv e rt e bra l ,

fo ra me n th e y u n it e to fo r m a tru n k
, (3) I m m e d iat e ly a f t e r .

its e x it fro m t h e in t e rv e rt e bra l fo ra me n th e tru n k d iv id e s in to


a p o sterio r ramus an d an an terio r ramus o f wh ich the a n t e rior
ra m u s is w ith fe w e x c e p t io n s m uch the larg e r ( 4 ) Each
, , .

p o st e r ior ra m u s d iv id e s in t o a medial branc/z an d a lateral


branc/z (5 ). Each a n t e r io r ra mu s d iv id e s in t o a latera l bran ca

an d an an terio r brancti ( F ig .

Ev e ry a n t e r ior r o o t c o n sist s o f n e rve fi br e s wh ich Sp rin g


fr o m n e rv e c e lls in t he sp in a l me du lla an d p a ss to th e m u sc le
fi bre s o f variou s mu sc le s Th e y carry motor imp u lse s t o the .

mu sc le s Each p o st e rio r root co n sist s o f n e rv e fi bre s p a ssin g


.

to an d fro m the n e rv e c e lls o f the ga n glio n o f the p o st e r ior


ro o t The p o st e r io r root fi br e s carry se n so ry imp u lse s such
.
,

as c o ld h e at a in e t c T h e se n so ry im p u lse s p a ss through
p , , ,
.

th e c e lls o f th e ga n g lio n o f th e p o st e r io r root an d th e n o n ward s


to the sp in a l m e dulla .

The tru n k o f e v e ry Sp in a l n e rv e th e r e fo r e co n ta in s both , ,

mo to r
'

o r e fi erent an d sen so r
y o r a fi eren t n erve fibres ,
an d t h e

p o st e r io r an d a n t e r ior ra m i in to wh ich it d iv id e s a ls o co n ta in

both se t s o f fi br e s Th e bra n ch e s o f th e ra mi may co n ta in


.

e ith e r both se t s o f fi br e s o r o n ly o n e o r th e oth e r se t .

Ev e n tua lly h o we v e r th e p e rip h e ra l p art s o f the fi br e s c o n


, ,

v e yin
g im p u lse s f r o m an d tho s e co n v e y in g im p u lse s t o t h e

sp in a l me du lla se p arat e fro m o n e a n oth e r The fi br e s wh ich .

co n v e y imp u lse s fro m the Sp in al me du lla be co m e th e mo t o r


n e rv e s wh ich e n d in t h e mu sc le fi br e s wh ilst t h e fi br e s w h ich ,

1
Th is div isio n is no w ay s o bvi o us and in ce rtain
t al ,
situ at io n s the
lat e ra l an d an te rio r bran ch e s are calle d re sp e ctiv e ly , , po ste ri o r an d
an t e rio r bran ch e s .

1— 16
TH E S U P ER I O R E X TRE M I TY
co n v e y se n so ry im p u lse s o n ly are ory n e rv e fi br e s
th e se n s .

The se n so ry n e rv e fi br e s wh ich c o n v e y se n so ry imp u lse s fr o m


th e sk in a re t e r m e d cu ta n eo u s n erves .

Th e d isse ctor o f th e upp e r ex tr e mity m u st be g in work o n

Me d i al c u t an e o u s b ran c h o f me di l di a ii
v s o n o f p o st e r o i r ramus

L ate ral c u tan e o us b ra n c h o f me di l d i


a ii
v s o n o f p o st e r o i r ram u s Me d ld
ia im
i v si o n o f
p o st e ri o r ra us

L ate ral d ii i
iv s o n O f
n to
i
p o st e r o r
t e rm i nal m u
P o st e r o i g gi
r an l o n at e d
ro o t
c u lu s o f
i
P o st e r o r ramu s me d u lla

te n o r g y lum n
A
re co
n t e ri o r ra m us

M u sc u la r b ran c h es

A i
nt e r o r ro o t

l [ R e c urre n t b ran c h
L ate ral d
an t e ri o r ra
iim
iv s o n o
us
f 1
y
S m p at h e ti c g gl
an io n

A n t e ri o r di ii
v s o n o f i
an t e r o r ram u s

M us cu la r b ra n c h es

Me
dm
d i al c u t an e o u s
sr
o n o f
b ran c
an t e ri o r ram us
h o f an t e r o r i
I
L at e ral c ut ane o b us ra nc h o f ant e r o r i d ii iv s o n o f an te r o i r ramu s

FIG .
4 .
— Di g
a ram o f a na N er e Spi l
N o t e t a t th e m e d a d s v . h i l i vi i o ns o f
i
t he p o ste r o r ram u s is re p re se n te d as d s tr bu te d t o sk n st t h e i i i wh il ,l ate ra l
ivi i i
d s o n t e rm n ate s at a de e p e r e e in m usc e I n so m e s t u at o lvl l . i i n s t he

re ve rse co n di t i o n o c c u rs , an d th e me d a i l an d l t l div i i
a e ra s o ns o f all

p o st e r o i r ra mi su p p ly m l
u sc e s .

th e urth day a ft e r t he su bj e ct has be e n plac e d in t he


fo
d isse ct in g ro o m H e w ill fin d the body ly in g u p o n its back
-
. .

Th e thora x w ill be ra ise d to a co n v e n ie n t h e ight by m e a n s o f


blo ck s an d a lo n g bo ard w ill be p lac e d u n d e r the sh o u ld e r s
,

fer t he p ur p o se o f su pp ort in g th e ar ms wh e n th e y are a bduct e d


fro m the sid e s .
P E C TORA L RE G I O N 7

U ntil the disse ctio n o f the axilla is co mple te d the disse cto rs o f the arm
an d o f th e h e ad an d n e ck w ill fin d it adv an tag e o u s t o arran g e t o w o rk
at diffe re n t h o u rs Th e disse cto r o f the h e ad an d n e ck at th is stag e is
.
, ,

e n g ag e d o n t h e p o st e rio r t rian g le o f th e n e ck an d t h e disse ctio n o f the


,

triang le can n o t be w e ll do n e u n le ss the arm is p lac e d c lo se t o the Side


an d the sh o u lde r de p re sse d F o r t he disse ct io n o f the ax illa th e arm Sh o u ld
.

be stre tch e d o u t at righ t an g le s t o the th o rax A co m pro m ise be t w e e n


.

t h e se t wo p o sit io n s alw ay s re su lts in disco m fo rt t o bo th disse c to rs .

F iv e day s are a llo w e d fo r th e e x a min at io n o f the a xilla


an d t he mu sc le s wh ich p a ss t o t h e u p p e r e x tr e mity fro m t h e

a n t e rior p ort io n o f the thorac ic r e g io n o f th e body The .

fo llow in g ta ble w ill be fou n d u se fu l in r e gu lat in g th e a mou n t


o f w o rk wh ich sh o u ld be carr ie d o u t o n e ach day

First Day .
— m y ( b) re fl e ctio n o f the skin ( c) cu tan e
( a ) Su rface anato
l
o us v e sse s an d n e rv e s o f th e an t e rio r an d late ral asp e ct s o f the th o ra ; x
x
( d) e am in atio n o f the fascia o f the p ecto ralis m aj o r an d the a illary fasc ia x
( c) the c le an ing o f the p e c to ralis m aj o r ( f ) the re fl e ctio n o f the p e ct o ralis
m aj o r .

S eco n d Day . x
—a The e am in atio n o f the c o sto co raco id m e m bran e an d
( ) -

the stru ctu re s p ie rcin g it ( b) the re m o v al o f the co sto co raco id m e m bran e


-

x
an d th e e amin at io n o f th e st ru ctu re s p o ste rio r to it .

T h irdD y a .

( a ) The cle an in g o f the p e cto ralis m ino r ( b) the c le an in g
x
o f th e c o n t e n ts o f th e a illa be lo w t h e p ec to ralis m in o r .

F o u rt h Day — ( a ) The re fle ctio n o f the p e cto ralis m in o r ; ( b) the co m


.

p le t io n o f t h e c le an in g o f th e co n t e n t s o f th e a i laxl
( c) the c le an in g o f the
se rratu s an te rio r ; ( d) t h e c le an in g o f th e po ste rio r w all o f t he a i a (e) x ll
th e re fl e ctio n o f t he su bc av iu s ; l x
( f ) the e amin atio n o f the st e rn o
c lav icu lar articu latio n an d t he disarticu latio n o f the c lav icle at t he ste rn o

c lav icu lar j o in t .

x
Fift h Day — ( a ) The brach ial p le u s an d a g e n e ral re v ie w o f the a illa
. x
an d its co n te n ts .

B e for e co mme n c in g t he d isse ct io n o f the a xillary r e g io n


draw your fi n g e r alo n g the clavicle fro m its st e rn a l to its ‘

acro mia l e n d N ot e that in the m e d ia l two th ird s o f its


.
-

le n gth th e bo n e curv e s fo rward s to g iv e r o o m fo r th e p a ssag e


o f v e sse ls an d n e rv e s fro m t h e n e ck t o the a x illa Th e lat e ra l .

th ird is curv e d backward s P lac e your fi n g e r in the de lto


.

p e ct o ra l tr ia n g le b e low t h e ju n ct io n o f t h e in t e r m e d iat e an d

lat e ra l th ird s o f t he c lav ic le an d n o t e that t he gr e at p e ctora l


,

mu scle lie s to it s m e d ia l Sid e an d th e d e lto id mu sc le to its


lat e ra l sid e ; both m u sc le s sp r in g fro m t h e a n t e r io r a sp e ct
o f t h e c lav ic le Pu sh y o ur fi n g e r u ward s an d
( se e F ig

p
backward s in t h e tr ia n g le u n d e r t h e m e d ia l bord e r o f t h e
d e lt o id u n t il the coraco id p roc e ss is d ist in ct ly fe lt N e x t .

e x a min e t h e art icu lat io n s o f th e c lav ic le L itt le o r n o .

p ro min e n c e is for m e d by th e lat e ra l e x tr e mity o f th e bo n e


its su p e r ior sur fac e lie s in the sa m e p la n e as th e su p e r ior
I— lc
8 TH E S U P ER I OR E X TRE M I TY
s urfac e o acro mio n o f t h e sca p u la Wh e n t he u p p e r
f th e .

lim b is m ov e d h o w e v e r th e j o in t c an e a sily be d e t e ct e d
, ,
.

I n stro n g c o n tra st t o t he in c o n sp icu o u s acr o m io c lav icu lar -

j o in t is t h e st e r n o c lav icu lar j o in t wh e r e t he me d ia l e n d o f t h e


-

c lav ic le can be fe lt as a mark e d p r o j e ct io n a lt hough it is ,

m a sk e d to the e ye by t h e st e r n a l p art o f th e st e r n o c le ido


, ,
-

m a st o id mu sc le wh ich cau se s the r idg e lik e p ro m in e n c e at th e -

sid e o f t h e n e ck as it e x t e n d s fro m th e st e r n u m an d c lav ic le t o

t h e sku ll be h in d th e e ar P lac e th e in d e x fi n g e r in the j ugu lar


.

n o tclt o n th e u p p e r bord e r o f th e m a n u br iu m st e r n i be tw e e n ,

t h e c lav ic le s an d carry it d o w n ward s a lo n g th e m idd le o f


, ,

t h e st e r n u m in t h e in t e rva l be tw e e n t h e attach m e n t s o f t h e
,

gr e at p e ctora l m u sc le s Th e p ort io n o f the st e r n u m u n.

cov e r e d by th e t wo gr e at e r p e ctoral m u sc le s is n arrow a bov e ,

bu t it w id e n s o u t be low an d as t he fi n g e r p a sse s a lo n g it a ,

p r o m in e n t r idg e w ill be fe lt T h e r idg e m ark s t he j u n ct io n


.

o f t h e m a n u br iu m st e r n i w ith t h e bo dy o f t h e st e r n u m an d ,

a lso th e le v e l at wh ich t he co sta l cart ilag e s o f the se c o n d


r ibs j o in th e st e r n u m I t is e a sily felt an d can o ft e n be se e n
. .

I t is th e r e for e an e x c e lle n t la n d m ark in d icat in g th e p o sit io n s


, , ,

o f t h e se c o n d p a ir o f r ibs f ro m wh ich t he cou n t in g o f t h e oth e r


,

r ibs Sh o u ld a lway s co m me n c e At th e low e r e n d o f th e body o f .

t h e st e r n u m t h e fi n g e r as it is carr ie d dow n ward s w ill sin k


, , ,

sudd e n ly in to a d e p r e ssio n be tw e e n th e cart ilag e s o f t he ,

se v e n th p a ir o f r ibs an d r e st aga in st t h e x ip h o id p r o c e ss o f
,

t h e st e r n u m Th e d e p r e ssio n is t e r m e d t h e inf rastern alf o ssa


.
,

or p it o f th e sto m ach Th e c o sta l arch e s be low th e first.


, ,

are e a sily r e cog n ise d bu t t h e fir st rib lie s d e e p ly u n d e r th e


,

clavicle an d can be fe lt o n ly in fr o n t at its ju n ct io n w ith


'

, ,

th e m a n u br iu m st e r n i The arm shou ld n o w be a bduct e d


.

a carr ie d lat e ra lly fro m t h e tru n k ) wh e n t he h o llow o f


( i . .
,

th e a x illa an d th e two rou n d e d fo ld s wh ich bou n d it ,

in fro n t an d be h in d w ill be brought in to v ie w , Th e .

a n t e r ior fo ld o f the a x illa is for me d by th e low e r bord e r o f


t h e p e ct o ra lis m aj or an d t o a sm a ll e x t e n t a lso by th e low e r
,

bo rd e r o f th e p e ctora lis min or The p o st e r ior fo ld wh ich is .


,

for me d by th e lat issimu s d o r si as it w in d s rou n d th e t e r e s


major mu sc le is carr ie d dow n ward s to a low e r le v e l tha n the
,

a n t e r io r fo ld Th is as w ill be se e n lat e r is an imp orta n t


.
, ,

p o in t in co n n e ct io n w ith the a n at o m y o f th e a x illa I f t h e .

fi n g e r is p u sh e d u p ward s in to the a x illa the glo bu lar h e ad o f


th e hu m e ru s w ill be fe lt wh e n th e arm is rotat e d , O n e oth e r .
P E C TOR A L RE G I O N 9

p o in t d e m a n d s t h e att e n t io n o f t h e stud e n t be for e t h e dis

se ct io n is c o mm e n c e d an d that is t h e p o sit io n o f the n ipp le


,
.

As a ru le it lie s su p e rfic ia l to t h e in t e r sp ac e be tw e e n th e
fourth an d fi fth r ibs an d it is situat e d rath e r m or e tha n four
,

in ch e s fro m t he me d ia n lin e .

Th e stud e n t shou ld e x a min e th e se var iou s la n d m ark s n o t ,

o n ly u p o n th e d e a d bo dy bu t a lso u p o n h imse lf an d h is
fr ie n d s u n t il h e is p e rfe ct ly fa m iliar w ith th e m both by touch
, ,

an d Sight an d c an at o n c e p u t h is fi n g e r o n an y g iv e n p o in t
, ,

what e v e r th e p o sit io n o f th e limb may be .

Dis s e c tio n — R e fl e ct io n o f t he Sk in — I n cisio n s z— ( I ) Alo n g .

t h e m iddle lin e o f t h e bo dy f ro m t h e u p p e m arg in o f t h e m an u r


t
briu m s e rn i t o t h e tip o f t h e x ip h o id p ro ce ss ( 2 ) U p ards . w
t
an d la e rally f ro m t h e t ip o f t h e x ip h o id p ro ce ss t o t h e n ip p le .

At th e n ip p le th e in c isio n m u s bifu rca e , t o e n circle t h e dark t t


p a tc h o f s k in a ro u n d t h e n ipp le h ic h is calle d t h e are o la, w
t t t
h e n it m u s be co n in u e d alo n g t h e an e rio r fo ld o f th e ax illa t
t o t h e arm As so o n as it re ac h e s t h e arm it m u s be c arrie d
. t
t
do w n w ards f o r abo u 6 3 mm ( t wo in c h e s an d a h alf ) , an d h e n . t
t v
ra n s e rse ly t o t h e la e ral bo rde r o f t h e arm t (3 ) F ro m t h e t ip .

o f t h e x ip h o id p ro ce ss t ran s e rse ly a c ro ss t h e f ro n v
an d side o f t
t
t h e c h e s t o t h e p lan e o f t h e p o s e rio r f o ld o f t h e ax illa (F ig t .

To m ak e a c le an in cisio n in t h e sk in p lac e t h e p o in o f t h e t
scalp e l o n o n e e n d o f t h e lin e o f in cisio n , an d, h o ldin g t h e sc alp e l
at righ t
an g le s t o t h e su rf ace t o be in cise d, f o rce t h e p o in t
t t
h ro u gh th e Sk in ill it e n e rs t h e so f su p e rfi cial fas cia h ic h t t w
lie s be n e a h t
Th e n in clin e t h e blade t o an an g le o f 4 5 t o
.
°

t h e su rfa ce o f th e sk in , an d, p re ssin g fi rm ly o n t h e back o f t h e


blade wt
i h t h e f o re fi n g e r, c arry it s e adily t o t h e o pp o si e e n d t t
o f t h e lin e o f in cisio n , bu t as t h e e n d o f t h e lin e is app ro a c h e d
brin g t h e blade ag ain t o a righ an g le w i h t h e su rf ace , an d so t t
wt i h dra w it f ro m t h e in cisio n .

t t
To re fl e c t h e S k in ak e h o ld o f o n e o f t h e an g le s o f th e fl ap
r n ark e d o u t by t h e in cisio n s i h t h e f o rce p s ; in t h e c ase o f wt
th e u pp e r fl ap ( 1 , F ig w
h ic h sh o u ld be de al i h fi rs , t h e
. t wt t
su p e rio r m e dial an g le o n t h e righ side an d t h e in fe rio r m e dial t
an g le o n t h e le f S ide , an d t wt
i h t h e e dg e o f t h e scalp e l de ac h it t
f ro m th e so f f at be n e a h t t .

As so o n as t h e an g le se le c e d is su ffi cie n ly de ac h e d disca d t t t r


th e f o rce p s , an d, h o ldin g t h e de ac h e d an g le o f sk in be een t tw
t
th e h u m b an d f o re fi n g e r o f t h e le f h an d, k e e p it e n se an d t t
draw th e e dg e o f th e s calp e l acro ss t h e sk in at its j u n c io n i h t wt
t h e f at f ro m o n e e dg e o f th e fl ap t o th e o h e r, al ay s k e e p in g t w
t h e e dg e o f t h e k n ife a g ain s t h e sk in B e c are fu l n o t t o ak e t . t
an y f at a ay w
i h t h e sk in wt Co n in u e t h e re fl e c io n u n il th e. t t t
t
la e ral bo rde r o f t h e sh o u lde r re g io n is re ac h e d Le a e t h e . v
fl ap h an g in g alo n g t h a bo rde r an d u rn t o fl ap 2 , F ig 5 t Co m t . .

m e n ce at t h e m e dial an g le , p ro ce e d as i h fl ap I , an d c o n wt
t t t
in n e t h e re fl e c io n u n il t h e p o s e rio r f o ld o f t h e ax illa is re ac h e d t .

As t h e S k in fl ap s are re fl e c e d o ards t h e arm an d t h e side t t w


o f th e ch e s t
t h e sm all p a c h aro u n d th e n ipp le m u s be le f

t t t
t
u n o u ch e d .
THE SUPER I O R EXTRE M I TY
As t h at re fl e ctio n p ro ce e ds n o t t h at
e th e co n n e ct io n be tw een

th e su p e rfi cral f as cia an d t h e sk in is t
s ro n ge r in so m e p laces
t h an in o th e rs . I n th e fe m ale de fi n i te fi bro u s strands w ill be

Ju n c t i o n o f man u br u m i
St e rn a l end o f l vi l
c a c e
W i t h bo d y O f s t e rn u m

Acro m il
a e nd o f c a l vi l c e

H e ad o f h u me ru s

N pp i l e

L o we r e n d o f bo d y o f st e rn u m

L a t e ra l pi e co nd yl e

Me di l p i
a e co n dy l e

An t . su p . i
sp n e o f iliu n

G re a t e r t ro ch an t e r

St yl id p
o ro c e ss o f ra d u si
y l id p
St o ro c e ss o f ul

M ed a il yl f f m
co nd e o e ur

L at e ra l dy l
co n f f m e o e ur
P t ll a e a

L at e ra l dyl f t i bi
co n
e ad o
e o
f fibu l
a
H a

i l ll l
M e d a ma eo us

l
L at e ra m alle o lu L at e ra l m ll l
a eo us

FIG .
5 ,
— Su rface vie w sh o w i n g I ii
n c s o n s an d Bo n y P o i n ts .
1 2 TH E SUPER I OR EXTRE M I TY
be e n t e d the n e rve s an d v e sse ls wh ich p a ss through
no it t o
th e sk in m u st be so ught fo r Th e y are .

N e rv i C u tan e i .

l
Su prac lav icu ar, fro m th e c e rv ical p e u s l x .

An te rio r c u tan e o u s ] fro m th e an te rio r ( in te rco sta ) rami o f th e th o racic l


l
L ate ra cu tan e o u s n e rv e s .

A rte riae C u tan e ae .

C u tan e o u s t w igs fro m th e bran ch e s o f th e th o raco ac ro m ial arte ry -

F ro m the c av icu ar bran ch l l .

F ro m the ac ro m ia bran ch l .

F ro m the de lto id branch .

P e rfo ratin g bran c h e s o f t h e in te rna m a mm ary arte ry l .

B ran ch e s fo rm t h e ate ral th o racic arte ry l


Bran ch e s fo rm t he tran sv e rse sc ap u ar arte ry l .

t
D is s e c t i o n — Cu t h ro u gh t h e su p e rfi c ial f ascia t o t h e de e p
.

f as cia alo n g t h e la e al m arg in o f t h e s e rn u m t r Th e le e l o f t . v


t h e de e p f ascia w ill be re co g n ise d by t h e in cre ase d re sis an ce t
o ffe re d t o t h e k n if e , an d by its blu is h wh i e c o lo u r h e n it is -
t w
e x p o se d As re g ards t h e diff e re n ce o f re sis an ce t h e disse c o r
. t t
t t
mu s e du ca e h is fi n g e rs t o re co g n ise t h e diffe re n “
fe e l o f th e
!
t
v ario u s s ru c u re s t t
As t h e e dg e o f t h e k n ife o u c h e s h e m ,
. t t
su p e rfi c ial f ascia, de e p f asc ia, n e r e s, e sse ls, m u scle s , t h e y all v v
c au se a diffe re n se n sa io n , t t
e co g n isable by t h e e du ca e d o u c h , r t t
w h ic h can o n ly be ac q u ire d by a t e n io n an d p rac ice t t t .

v
As so o n as t h e le e l o f t h e de e p f ascia is re ach e d raise t h e
cu t m arg in o f t h e su p e rfi cial f ascia w i h t h e f o rc e p s o r fi n g e rs t
an d, wt
i h t h e e dg e o f t h e scalp e l, se e r t h e s ran ds h ich a t ac h v t w t
t h e de e p su rf ace o f t h e su p e rfi cial f as cia t o t h e de e p f as cia ,
cu tt t
in g ag ain s th e de e p f asc ia an d re m o in g t h e h o le o f th e v w
su p e rfi cial f ascia As t h e se p ara io n p ro ce e ds p u ll t h e de ac h e d
. t t
su p e rfi c ial f as cia a w ay f ro m t h e s e rn u m , an d as so o n a s t h e t
t t
an e rio r e n ds o f t h e in e rc o s al sp ace s are re ac h e d lo o k f o r t h e t
an te rio r cu tan eo us n e rv es an d t h e p er f o rati ng bran che s of the
i n tern al mamm ary artery , h ic h p ie rce t h e de e p fascia n e ar t h e w
m arg in o f t h e s e rn u m t
I f t h e ar e rie s are w e ll in j e c e d o n e
. t t
s h o u ld be f o u n d in e ac h o f t h e u pp e r six in e rco s al sp ace s It t t .

is n o t p ro bable h a a n e e t t
ill be f o u n d in t h e fi rs sp ace , bu t rv w t
o n e sh o u ld be fo u n d in e a c h o f t h e o h e r fi v e sp a ce s Th e t .

art e rie s w
ill be re co g n ise d by t h e re d in j e c io n h ic h h e y t w t
t
co n ain ; e ac h is a cco m p an ie d by a sm all e in Th e n e r e s v . v
a re w t t
h i ish h re ads, n o t u n lik e h in h i e h re ad Th e y are t w t t .

t
m u c h fi rm e r t o th e o u c h , an d m u c h s ro n g e r h an t h e blo o d t t
v e sse ls .

t v
Trac e bo h th e e sse ls an d n e r e s as far la e rally as p o ssible v t .

t
W h e n th e an e rio r cu an e o u s n e r e s an d t h e a cc o mp an y in g t v
v e sse ls h aV e be e n se cu re d lo o k f o r t h e sup raclavi cu lar n erves ;
t t
t o fi n d h e m cu t h ro u gh t h e fi bre s o f t h e p la y sm a alo n g t h e t
u p p e r bo rde r o f t h e cla icle f ro m t h e s e rn u m t o t h e s h o u lde r, v t
t
an d u rn t h e lo w e r p ar o f th e se e re d m u scle a n d f ascia do t n v w
w t
ards, de a c h in g it f ro m t h e f ascia be n e a h i h t h e e dg e o f t wt
t h e scalp e l . t
As h is is do n e lo o k f o r t h e n e r e s h ic h app e ar v w
as w t t
h i ish s ran ds r n n in g do n ards acro ss th e cla icle an d u w w v
p a ssi n g f ro m t h e de e p e in o t h e m o e s u p e rfi c i r
al lay e r Tw o t r .

t
o r h re e s h o u ld be f o u n d abo u th e middle o f the c la ic le , o n e t v
PE C TOR AL RE G I O N I 3

n e ar its t it s acro m ial e n d de sce n din g in


s e rn al e n d, an d o n e n e ar
v
t h e f as c ia o e r t h e an e rio r p ar o f t h e de l o id m u scle t F o llo t t . w
v w
t h e n e r e s do w n ards h ro u gh t h e su p e rfi c ial f asc ia as far as t
p o ssibl e ; h e y d e sce n d t ott h e le e l o f t h e se co n d o r h ird rib, v t
t
an d are so m e im e s a cco m p an ie d by sm all bran ches o f the tran s
verse scap u lar artery w h ic h p ie rce t h e de e p f asc ia abo e t h e v
c la iclev t
N e ar t h e s e rn al e n d o f t h e c la icle sm all w i g s o f
. v t
t h e clavicu lar branch o f the tho raco acro m ial artery m ay be -

se e n N e ar t h e a cro m io n
. ig s o f t h e acro mi al bran ch o f t h e tw
t
sam e ar e ry m ay be f o u n d ; an d in t h e de l a p e c o ral

rian g le t -
t t
t wig s o f t h e de lto i d bran ch are o cc asio n ally i si ble V .

t
A f e r t h e su p racla icu lar n e r e s h a e be e n f o u n d an d v v v
w t t
f o llo e d t o h e ir e rm in a io n s cu t h ro u gh t h e su p e rfi c ral f as ci a t t
alo n g t h e lin e o f t h e an e rio r f o ld o f t h e ax illa an d t h e lo w e r t
t
m arg in o f t h e p e c o ralis m aj o r As so o n as t h e le e l o f t h e . v
de e p f ascia is re ac h e d u rn t h e an e ri o r p ar o f t h e su p e rfi cral t t .

t
t
f asc ia o w ards t h e m e dian p lan e , an d lo o k f o r t h e an te ri o r
bran ches o f the la te ral cu tan eo us n erves, as h e y u rn ro u n d t h e t t
t
bo rde r o f t h e p e c o ralis m aj o r, p ie rce t h e de e p f asci a, an d ru n
m e dially in th e su p e rfi c ial fascia .

N er v u s c u t an e u s
Acc e s so r y n e rv e C O lll

L e v at o r sc a p u a: l
i l
M dd e su p ra c la v ic u la

P i
o s t e r o r su ra c
p

Sca l e nu s me

FIG . 6 .
-
The S u p ra c l vi l
a cu ar B ran c he s o f the C e r v i c al P l e x u s .

N erv i up raclavic ula re s The supraclavicu lar n erves arise


s —

in the n e ck fr o m t h e th ird an d fourt h c e rv ica l n e rv e s


, Th e y .

sp r e ad o u t as th e y d e sc e n d i rc h d fa c ia ck
p e e t e e e p s o f t h e n e ,
,
an d th e y cro ss t h e c lav ic le u n d e r cov e r o f t h e aty a
p l sm .

Th e y are c la ssifi e d accord in g to th e ir p o sit io n s in t o the


, ,

a n t e r ior the midd le an d the p o st e rior bra n ch e s ( F ig


, , Th e .

a nterio r are t h e sm a lle st o f th e se r ie s


; th e y cro ss t h e m e d ia l
p art o f t h e c lav ic le to e n d in t h e sk in im m e d iat e ly be low .

The middle bran ches p a ss ov e r the midd le o f th e c lav ic le an d


e x t e n d dow n ward s in t he su e rfic ia l fa sc ia ov e r t h e ctora
p ,
p e lis
maj or as far as th e th ird rib
, Th e po sterio r cr o ss the lat e ra l .
1 4 TH E SU PER I OR EXT R E M I TY
th ird o f the c lav ic le an d w ill be a ft e rward s fo llo w e d t o th e
,

sk in o f t h e sh o u ld e r Th e y are fr e qu e n t ly acc o mp an ie d by
.

cu ta n e ou s bra n ch e s o f the tra n sv e r se sca p u lar art e ry .

N e rv i Cu t an ei A n t e ri o res Th e anterio r cu tan eo u s n er ves


.

are t h e min ut e t e r m in a l tw ig s o f t h e a n t e r io r ra m i o f t h e

th o rac ic n e rve s Th e y be c o me su p e rfic ial by p ie rc in g th e


.

p e ct o ra lis m ajor m u sc le an d t h e d e e p fa sc ia c lo se t o t h e ,

m arg in o f t h e st e r n u m O n e w ill be f ou n d in e ach in t e r


.

co sta l in t e rva l e x c e p t th e first ; an d th e y are acc o mp a n ie d by


t he cu tan eo u s p er fo rating branches o f the in t e rn a l ma mm ary
art e ry wh ich se rv e as the be st gu id e s to th e n e rv e s The
, .

n e rv e s an d t h e art e r ie s g iv e sle n d e r tw ig s to t h e sk in ov e r

th e st e r n u m an d larg e r bra n ch e s wh ich ru n lat e ra lly an d


,

m ay be trac e d as far as th e a n t e r ior fo ld o f th e a x illa Th e .

cuta n e ou s p e r fo rat in g art e ry wh ich a pp e ars through the th ird


in t e rc o sta l sp ac e is u sua lly t h e larg e st o f t h e se r ie s e sp e c ia lly ,

in th e fe ma le .

N e rv i Cut an e i L a t erales — Th e lateral cu tan eo u s n erves.


,

m uch larg e r tha n th e a n t e r ior ar ise fro m t h e a n t e r io r ra mi o f


,

t he thorac ic n e rv e s an d a p p e ar o n th e sid e o f t h e th o ra x
, , ,

a lo n g a lin e situat e d a litt le be h in d th e a n t e rior fold o f th e


a xilla Th e y p ie rc e th e wa ll o f th e thora x in the in t e r sp ac e s
.

be tw e e n th e r ibs an d d iv id e in to a n t e r io r an d p o st e r ior
,

bra n ch e s u n d e r cov e r o f th e se rratu s a n t e r ior m u sc le At a .

lat e r stag e th e bra n ch e s w ill be fou n d a p p e ar in g be tw e e n t h e


d ig itat io n s o f the se rratu s a n t e r io r Th e an terio r branches .

a pp e ar as a ru le abo u t an in ch in fro n t o f th e corr e sp o n d in g


'

, ,

p o s t e r ior bra n ch e s an d th e n p a ss fo rward s o v e r the lo w e r


,

bo rd e r o f t h e p e ct o ra lis m aj o r m u sc le F r o m t he lo w e r .

m e mbe r s o f th is se r ie s so m e m in ut e tw ig s are g iv e n o ff wh ich ,

e n t e r t h e su p e rfic ia l sur fac e s o f t h e d ig itat io n s o f t h e e x t e r n a l

o bliqu e m u sc le o f th e a bd o m e n wh ich w ill be e x p o se d by

t he d isse ct io n o f t h e a bd o me n Th e po sterio r bra nches ru n .

backward s t o th e dor sa l a sp e ct o f the tru n k o v e r th e a n t e r io r


, ,

bo rd e r o f th e lat issim u s d o r si mu scle ( F ig .

I t is v isable to atte m p t to se cu re
no t ad th e p o ste rio r bran ch e s o f th e
l ate ral cu tan e o u s n e rv e s in the m e antim e . Th e y are be st disse c t e d a o n g l
w ith the o th e r co n te n ts o f the ax ill a .

Th e M a mma ( M a mmar y Glan d o r B r e a st ) I n th e fe m a le .


t h e m a m m a fo r m s a r o u n d e d p r o min e n c e o n t h e fr o n t an d
a lso to so me e x t e n t o n the lat e ra l a sp e ct o f the thora x I t
, , , .
PE C TOR AL RE G I O N 1 5

lie s in the su p e rfic ia l fa sc ia, an d its sm ooth co n tour is larg e ly


du e to th e in va sio n o f its su bsta n c e by th e fatty t issu e o f that
fa sc ia .

A litt le below its mid p o in t , an d at a le v e l wh ich u sua lly -

corr e sp o n d s to the fourth in t e rco stal sp ac e , the ma mma is


sur m ou n t e d by a co n ica l e le vat io n t e r me d t h e papilla mo mma

o r n ipp le The n ipp le sta n d s in th e midd le o f a c ircu lar


.

p atch o f co lour e d sk in wh ich is ca lle d th e m amma .

L at iss mu s i
P e c to rali

L o bu l es

A mp u ll i
a: o r s n u se s o fd
Se rrat u s an t e

i
F bro u s t rabe cu l a o f the gl an d

FIG .
7 .
— Di i
ssec t o n o f the M amm a
.

W ith in th e a lso subjac e n t to the ar e o la th e r e is


n ip p le , an d ,

n o fat A cur iou s cha n g e o f co lour occur s in th is r e g io n in


.

t h e fe ma le durin g t h e se co n d m o n th o f p r e g n a n cy At that .

t ime th e d e licat e p in k co lour o f t h e sk in o f t he n ip ple an d


ar e o la wh ich was p re se n t in the v irgin be co me s co n v e rt e d to ,

brow n by t h e d e p o sit io n o f p ig m e n t an d it n e v e r aga in


, ,

r e su me s its orig in a l a p p e ara n c e .

Th e m a mm a e x t e n d s in a hor iz o n ta l d ir e ct io n fro m , ,

t h e sid e o f th e st e r n u m a lm o st t o t he m id a x illary lin e o n -

th e sid e o f t he thora x an d in a v e rt ica l d ir e ct io n fro m , , ,

th e se co n d co sta l arch a bov e to t he six th co sta l cart ilag e


1 6 TH E SUPER I O R EXTRE M I TY
be low About two th ird s o f the gla n d are plac e d u p o n t h e
.
-

p e ctora lis m ajor m u sc le ,


wh ilst t h e r e m a in in g p art ,
wh ich
corr e sp o n d s to its in fe r ior an d lat e ra l th ird, e x t e n d s be yo n d
t h e a n t e rior fo ld o f the a x illa, an d lie s u p o n t h e se rratu s
a n t e rior mu scle F ro m the p art wh ich lie s in r e lat io n to th e
.

low e r bord e r o f t he p e ctoralis major a p ro lo n gat io n e x t e n d s


u p ward s in to the a x illa, an d r e ach e s as h igh as the th ird rib .

Pr o ce sse s ra d at n i ig o ut
fro m t h e c o rp us mam mae

P e ct o ra li s j
ma o r

S i n us lac t ife ru
D uc t u s l if i
ac t er

F at l o bu l e

F IG . 8 — Se c t
. i o n t h ro u gh a M am m ary G l an d p re p are d by th e m e th o d
re co mm e n de d by S ir H aro d St l il es .

The m a mm a is n o t e n c lo se d in a ca p su le , an d in that
r e sp e ct it d iffe r s fro m m a n y oth e r gla n d s I ts lo bu le s an d .

lo be s are e mbe dd e d be tw e e n stra n d s o f fi brou s t issu e wh ich


p a ss through t h e su p e rfic ia l fa sc ia fro m t h e sk in to t h e d eep

fa sc ia . Th e stra n d s for m th e stro ma or fra me work o f th e


gla n d Th e y su pp o rt an d bin d tog e th e r the vario u s p art s o f
.
PE C TOR AL RE G I O N 1 7

the tru e gla n du lar t issu e wh ich co n sist s o f c e ll lin e d tu be s


,
-
,

an d th e y attach th e g land both t o t he sk in an d to t h e d e e p

fa sc ia . Th e stra n d s wh ich p a ss to t h e sk in hav e be e n ca lle d


th e ligaments of C o op er .

The stro ma an d th e g la n d t issu e tog e th e r for m a co n ica l


m a ss ca lle d the co rp u s mamma F ro m th e sur fac e s an d bo rd e r s
.

o f t he g e n e ra l ma ss o f t h e cor p u s m a mm a e m a n y p r o c e sse s

o f stro m a an d g la n d su bsta n c e p roj e ct an d in t h e ho llo w s ,

be tw e e n th e p roj e ct io n s is d e p o sit e d th e fat u p o n wh ich th e


sm o oth an d rou n d e d co n tour o f t h e orga n d e p e n d s .

Th e p o rt io n s o f th e tu be s o f t h e g la n d wh ich for m th e
se cr e t io n ca lle d m ilk are grou p e d t o g e th e r in sm a lle r an d

larg e r m a sse s ca lle d lo bu le s an d lo be s in the in t e r st ic e s o f


, ,

the fi brou s stro m a o f th e g la n d Th e p ort io n s o f the tu be s


.

wh ich carry th e se cr e t io n toward s the n ip p le are ca lle d duct s:


The sma lle r duct s fu se w ith oth e r s to for m larg e r duct s u n t il
fi n a lly so m e fi ft e e n o r m or e t e r min a l duct s ca lle d lactifero us ,

ducts co n v e rg e toward s t he ba se o f th e n ip p le
, Su bjac e n t to .

the ar e o la e ach duct e x p a n d s in to a fu sifor m d ilatat io n ca lle d


a lactifero u s sinu s th e n it co n tract s trav e r se s the su bsta n c e
, ,

o f th e n i p le an d O e n s o n it s a p e x g
p p , ( F i s 7 a n d .

I n a w e ll inj e ct e d su bj e ct tw ig s fro m t h e in terco stal arteries


-

an d a lso fro m t h e p er fo rating branches Of the intern al mammary


artery ,
may be trac e d in to th e ma mma an d oth e r v e sse ls ,

calle d the ex ternal mammary branches Of th e lateral tho racic


arter y ,
m a y b e se e n w in d in g rou n d t h e e dg e o f t h e p e ctora lis

maj or or p ie rc in g it s low e r fi br e s to r e ach t he gla n d


, ,
.

B y me a n s o f ly m p h v e sse ls wh ich issu e fro m it in t h e


n e igh bourhood o f t h e ar e o la an d fro m its bord e r s an d its ,

d e e p sur fac e the m a mmae is co n n e ct e d w ith the a x illary the


, ,

st e r n a l an d t h e in frac lav icu lar ly mp h g la n d s an d w ith t h e ,

ly mp h v e sse ls o f th e a bdo me n ( F ig s 9 Th e ly mp h v e sse ls


.
,

are n o t as a ru le
,
visible in an ord in ary d isse ct in g roo m
,
-

su bj e ct fo r Sp e c ia l me thod s o f p r e p arat io n are n e c e ssary fo r


,

th e ir p ro p e r d isplay bu t th e y m u st be r e me mbe r e d be cau se


, ,

th e y are o f th e gre at e st imp orta n c e in co n ne ct io n w ith th e


sp r e ad o f an y m a lig n a n t d ise a se wh ich h as co mm e n c e d in

t h e m a m ma .

I n th e m ale th e m a mm a ( ma mm a vir ilis) is qu it e rud i


m e n tary Th e n ipp le is sma ll an d p o in t e d an d the ar e o la
.
,

is surrou n d e d by Sp ar se ha ir s wh ich are n e v e r p r e se n t in th e


,

fe m a le .

V OL . 1— 2
1 8 TH E SUPER I O R EXTRE M I TY
D i s s e c t io n — t
I f th e su bj e c is a fe m ale th e disse c o r sh o u ld
. t
e n de a o v u
r t o m ak e o u t so m e o f th e de ails de scribe d abo e t v .

t
Th e s ran ds calle d th e lig am e n s o f Co o p e r e re n o e d, as t h e t w t
sk in w as re m o v
e d f ro m t h e su rf ace o f t h e g lan d (p No w .

t h e sk in o f t h e are o la m u s be de ac h e d f ro m t h e su rf ace o f t t
t h e glan d, an d re fl e c e d t o ards t h e n ip p le t w
As h a is do n e . t t
t ry t o m ak e o u t t h e la ct ife ro u s sin u se s (F ig 7 ) an d th e e rm in al . t
t t t t t
,

du c s . I f p o ssible p ass a bris le in o o n e o r o h e r o f t h e du c s


at t h e ap e x o f t h e n ip p le an d race t h e du c t o a lac ife ro u s t t t
t
sin u s, an d f ro m t h e sin u s ra ce t h e de e p e r p art o f t h e du c in o t t
t
t h e su bs an ce o f th e g lan d N ex t , i h t h e aid o f th e scalp e l,
. wt
t
g radu ally de ach the glan d f ro m th e de ep f ascia B e g in at .

r
t h e u pp e bo rde r, an d, as th e g lan d is disp lace d, n o e t h e s ran ds t t
o f t h e s ro m a t w
h ic h co n n e c its de e p su rface wi h th e de e pt t
f ascia t t
I t is alo n g h o se s ran ds h a blo o d e sse ls an d ly m p h
. t t -
v
v e sse ls, w h ich p ie rce t h e su bs an ce o f t h e p e c o ralis m aj o r, t t
t
e n e r an d le a e v
t h e g lan d Trace a p ro ce ss o f th e la e ral
. t
t
m arg in o f th e g lan d in o th e ax illa be h in d t he an e rio r ax illary t
f o ld . v
F in ally , re m o e th e g lan d by cu in g t h e m amm ary tt
t t
bran ch e s o f t h e la e ral h o racic art e ry at th e la e al m arg in , t r
a n d t h e m amm ary bran ch es o f t h e an e rio r p e f o a in g a e rie s t r r t rt
at t h e m e dial m arg in , t
h e n ex am in e th e de e p f ascia o f th e
p e c otr a l a n d ax illa ry re g io ns .

De e p F ascia — The d e e p fa sc ia o f the p e ctora l r e g io n is


a th in me mbra n e wh ich c lo sely in v e st s th e p e ctoralis m aj or .

I t is attach e d a bov e to t he c lav ic le , an d me d ia lly to t he


fro n t o f t h e st e r n u m B e low, it is co n t in uou s w ith th e d e e p
.

fa sc ia cov e r in g th e a bdo min a l m u sc le s, an d, at t he low e r


bord e r o f t he p e ctoralis m aj or m u sc le , it is co n t in uou s w ith
t h e a x illary fa sc ia At th e de lto p e ctora l tr ia n g le a p roc e ss
.
-

fro m it s d e e p sur fac e d ip s in , be tw e e n t h e d e lto id an d


p e ctora lis major m u sc le s, to j o in t h e co sto coraco id m e mbra n e , -

wh ilst , furth e r lat e rally, it be co me s co n tin uou s w ith the fa sc ia


cov e r in g th e d e lto id m u sc le Th e co sto coraco id me mbra n e .
-

w ill be d e scr ibe d lat e r ( p .

F ascia A x ill a ri s — Th e a x illary fa sc ia is a d e n se fe lt e d


.

m e mbra n e wh ich e x t e n d s acro ss the ba se o f t he a x illa It .

is co n t in uou s a n t e r ior ly w ith th e d e e p fa sc ia ov e r th e


p e ctora lis m aj or , p o st e r ior ly w ith t he f a sc ia ] sh e ath s o f t he

lat issim u s dor si an d th e t e r e s m aj or m u sc le s, m e d ia lly w ith


th e d e e p fa sc ia o n th e sur fac e o f th e se rratu s a n t e r ior,
wh ilst lat e ra lly it is co n tin uou s w ith t he d e e p fa sc ia o n
th e me d ial sur fac e o f th e p ro x im a l p art o f t h e arm I t is .

draw n u p toward s th e ho llow o f th e a xilla , an d th e


e le vat io n is du e ch ie fly to t h e c o n n e ct io n o f it s d e e p sur fac e
w ith the fa sc ial sh e ath o f the p e ctora lis min or, an d p art ly
to its attach me n t to t h e ar e o lar tissu e wh ich fi lls th e a xillary
TH E SUPER I OR EXTRE M I TY
an d fro m t he
hou ld e r by ly mp h v e sse ls wh ich acc o mp a n y
s

t h e c e p ha lic v e in an d th e y tra n sm it it to ly mp h v e sse ls wh ich


,

c o n n e ct th e de lto p e ct o ra l gla n d s w ith th e in fraclav icu lar -

gla n d s ( se e F ig s 9
.

.
,

M P e ct o ra lis M ado n — Th e p ow e r fu l p e ctora lis m aj o r


.

m u sc le e x t e n d s fro m th e a n t e r io r a sp e ct o f t h e th o ra x t o th e
hu me ru s I t is d iv id e d by a d e e p fi ssur e in to a c lav icu lar an d
.

li v i
C e p ha c e n
l xill y g l
I C e n t ra a ar an ds
gl an d
gl an ds
c ial to co st o -
co ra co id in e mbrai
c t o ra l gl a n ds
h v e sse s l p ig
a ss n to
s t e rna l gl an ds

y v
L m p h e sse s fro m l m ar

l xill y g l d
"
L a t e ra a ar an s

o s t e rio r o r su bsc a p l xill y g l d


u ar a ar an s

i
An t e r o r o r p l xill y g l d
e c t o ra a ar an s

y
L mph v e sse s l fro m de e p p arts o f m am ma
p a ss i gt
n o i l
n t e rp e c t o ra , i n fra c a i c u ar lv l
a nd a l so t o s u p rac a cu ar l vi l gl
an ds

y
L mp h v e sse s l p ass ig j i n to o n o t he r l ymp h
ve sse s l i x p n e
.

t ra e ri t o n e a l t i ssu e

FI G .
9 .
— The L y mp h G l an ds an d Ve sse l s o f the xill
A a an d M amm a .

a st e r n oco sta l p ort i o n Th e fi ssur e p e n e trat e s through the .

e n t ir e th ick n e ss o f th e m u sc le the c lav icu lar an d st e r n oc o sta l ,

p o rt i o n s be in g d ist in ct e x c e p t c lo se to th e ir in se rt io n s T h e ,
.

clavicu lar po rtio n ar ise s by short t e n d in o u s an d m u scu lar fi br e s

fro m an im p r e ssio n o n t h e m e d ia l ha lf o f th e a n t e r ior sur fac e


o f t h e c lav ic le Th e su p e rfic ia l p art o f th e stern o co stal p o rtio n
.

tak e s orig in by fl e shy fi br e s ( r) fro m th e a n t e rio r sur fac e o f


, ,

t h e st e r n u m ( 2 ) fro m th e a p o n e uro sis o f th e e x t e r n a l o bliqu e


,

m u sc le an d ( 3 ) o cca sio n a lly fro m th e six th rib n e ar it s


,
AX I L LARY SP AC E 2 r

cart ilag e Th e d e e p e r p art ar ise s by a var ia ble n u mbe r o f


.

m u scu lar slip s fr o m th e cart ilag e s O f the u


pp e r six r ibs .

Th e m u sc le is in se rt e d , by a flatt e n e d bila min ar t e n do n ,


in to th e lat e ral lip o f t h e in t e rtu be rcu lar su lcu s o f t h e
hu me ru s, an d the fi br e s o f th e m u sc le u n d e rgo a r e arra n g e
me n t as th e y c o n v e rg e u p o n t h e t e n do n Th e gr e at e r .

p art o f t h e c lav icu lar p ort io n j o in s the a n t e r ior la min a o f the


co mm o n t e n do n ; so m e o f the m o st me d ia l c lav icu lar fi br e s,
how e v e r, are in se rt e d d ir e ct ly in to the hu me ru s, d ista l to -

t h e t e n do n , wh ilst a fe w ga in attach m e n t to t h e d e e fa sc ia
p
o f th e arm, an d oth e rs be co m e adh e r e n t to t h e adj ac e n t

p art o f t he d e lto id .

The fi br e s o f t h e ste r n oco sta l p ortio n o f th e m u sc le d o


n o t all p a ss in th e sa m e d ir e ct io n bu t t h e y all j o in t h e la min a e

C o st o -
l vi l li g
c a c u ar a me n t
Co no i d li g ame n t

FIG . I o .
-
I n fe rio r Surface o f t he C l v i l w i th th
a c e e Attach me n ts o f t he
M u sc l es m ap p e d o ut .

o f th e t e n do n o f in se rt io n
u p e r ior fi br e s d e sc e n d . Th e s

slight ly t h e in t e r me d iat e fi br e s p a ss horiz o n ta lly wh ilst th e


, ,

in fe r io r fi br e s a sc e n d an d at t h e sa m e t ime ga in th e d e e p
, , ,

sur fac e o f t h e r e st o f t h e m u sc le A smooth fu ll an d rou n d e d .


, ,

low e r bord e r o f t he m u sc le is thu s for me d ; it co n st itut e s t he


a n t e r ior fo ld o f t h e a xilla Th e attach me n t s o f th e m u scle .

to the hu me ru s w ill be stud ie d in d e ta il at a lat e r stag e


o f t he d isse ct io n ( p .

Th e p e ct o ra lis m aj or is su pp lie d by th e medial an d la teral


a nterio r tho racic nerves I t is an adductor o f t h e su p e r io r
.

e x tr e mity an d a m e d ia l rotator o f t h e hu m e ru s .

Axilla — The a xilla is th e ho llow o r r e c e ss be tw e e n t h e


u p p e r p art o f t he sid e o f th e thora x an d th e p ro xima l p art
o f t h e arm W h e n th e arm is a bduct e d fro m th e tru n k
.
,

an d th e are o lo fatty t issu e wh ich occu p ie s the a x illa is


-

r e m ov e d th e sp ac e d isc lo se d has th e for m o f a four sid e d


,
-

p yra m id T. h e a p e x o r n arrow p art o f


,
t h e s p ac e lie s ,
2 2 TH E SUPER I O R EXTRE M I TY
imme d iat ely to th e me d ia l sid e o f th e coraco id p roc e ss, an d
is d ir e ct e d u p ward s toward s t h e root o f the n e ck , wh ilst the
w id e r p art or ba se o f the sp ac e look s dow n ward s Th e .

me d ia l wa ll, fo r m e d by t h e thora x, is o f gr e at e r e x t e n t tha n


th e lat e ra l
wa ll wh ich is for m e d by t h e arm I t fo llow s .
,

th e r e fo r e that the a n t e r ior an d p o st e rior wa lls c o n v e rg e as


,

th e y p roc e e d lat e ra lly an d be cau se the p o st e rior wa ll is


, ,

lo n g e r fro m a bov e d o w n ward s tha n t h e a n t e r ior t h e p o st e r ior


, , ,

bord e r o f th e ba se is low e r tha n th e a n t e r ior .

B e fo be g in n in g the disse ctio n o f th e sp ac e , th e disse cto r sh o u ld h av e


re
a g e n e ral k n o w le dg e o f its bo u n darie s an d o f th e man n e r in wh ich th e
co p l
n te n ts are dis o se d in re at io n t o th e bo u n darie s .

B o un daries o f t h e Axilla — The fo ur wa lls o f the a x illa are


( ) a
i n t e r ior , ( )
2
p o st e r ior , (3) m e d ia l,
an d ( )
4 lat e ra l Th e .

a nterio r w all is for m e d by th e two p e ctora l mu sc le s, t h e


su bc lav iu s an d th e fa sc ia wh ich surrou n d s t he p e ctora lis
min or an d attach e s its u p p e r bord e r to th e c lav ic le an d it s
lo w e r bord e r to the fl o or o f the axilla an d to th e d e e p fa sc ia ,

o n th e m e d ia l sid e o f t h e arm Th e p e ct o ra lis maj o r fo r m s


.

t h e su p e rfic ia l stratu m an d is sp r e ad o u t ov e r th e e n t ir e
,

e x t en t o f t h e a n t e r io r wa ll Th e p e ctora lis m in or lie s


.

p o st e r ior t o th e p e ct o ra lis major an d tak e s p art in th e ,

for mat io n o f th e midd le th ird o f th e a n t e r io r bou n dary Th e .

fa sc ia wh ich fi lls t h e gap be tw e e n th e p e ct o ra lis min o r an d


th e c lav ic le is ca lle d t he co st o corac o id me m bra n e ; it sp lit s -

a bov e to e n c lo se t he su bc lav iu s m u sc le an d a lo n g th e lo w e r ,

bord e r o f that mu sc le it is str o n g e r tha n e lse wh e r e Th e .

lo w e r bo rd e r o f t h e a n t e r io r wa ll is th e an terio r fo ld o f th e
a xilla I t is for me d by th e low e r bo rd e r o f the p e ctora lis
.

m aj or str e n gth e n e d m e d ia lly by t h e low e r bord e r o f th e


, , ,

p e ctora lis m in or wh ich p


,
roj e ct s be yo n d t h e m ajor n e ar t h e

sid e o f th e thora x .

Th e p o sterio r wall o f th e a x illa is for me d by th e lat e ra l


p art o f t h e s u b sca p u lar is m u sc le b a
y p o rt io n o f t h e lat
,
issi m u s

dor si an d its t e n d o n an d by th e t e r e s m ajor m u scle Th e


,
.

su bsca p u lar is cov e r s th e co sta l sur fac e o f th e sca p u la Th e .

lat issim u s dor si w in d s fro m t h e back rou n d t h e m e d ia l p art ,

o f t h e lo w e r bord e r o f t h e t e r e s m aj o r to ga in its a n t e r ior

s ur fac e ; thu s t he low e r bord e r o f th e p o st e r io r wa ll wh ich ,

co n st itut e s th e p o sterio r fo ld o f th e a xilla is fo r me d in its ,

me d ia l p art by t he lat issimu s dor si an d lat e ra lly by t h e ,

in fe r ior marg in o f th e t e r e s maj or .


AX I L L ARY SP AC E 2 3

I n the medial wall are p art s o f t he u p p e r fiv e r ibs w ith


th e in t e rv e n ing in t e rco sta l m u sc le s th e y are cov e r e d by th e
corr e sp o n d in g d ig itat io n s o f th e se rratu s a n t e r ior mu sc le .

The lateral wall is for me d by t h e hu me ru s an d th e co nj o ine d


p ro x ima l p art s o f th e coraco brach ia lis an d t h e short h e ad o f -

the bic e p s brach ii m u sc le s .

At the apex o f the sp ac e is t h e n arrow tr ia n gu lar in t e rva l


through wh ich the a x illa co mm u n icat e s w ith th e n e ck ; it is
fr e qu e n t ly ca lle d th e cervico ax illary canal I t is bou n d e d -
.

a n t e r ior ly by t he c lav ic le, m e d ia lly by t he out e r bord e r O f


t h e fir st rib, an d p o st e r ior ly by th e su p e rior m argin o f t h e
sca p u la ; through it p a ss the a x illary v e sse ls an d th e big
n e rv e cord s o f th e brach ia l p le x u s o n th e ir way fro m t h e

i . P ro x ima l e nd o f
3 . A xill ary arte r y .

ll u mc ru s .

9 . Lo n gh e ad o fb i ce p s .

2 . 5 0 13 0 15“
3 10 . Co n o j i ne d o r ig i n o f
i
i fiég
he ad o f b ce p s
sh o rt
i mu o s ma j o r
an d c o raco - brach i
5 . Se rrat u s an t e r o r i .

a s li .

l l scap ll laf ls

ii
6
f 1 3 B rachialn e rv e s
v
. .

7 . i llary ein .

FIG . I r .
— Di g a ram o f i
se c t o n t hro u gh t he A xill a o f th e L e ft S de i .

ne ck to the arm The w id e base o r floor o f th e Sp ac e is


.

c lo se d by the vau lt e d a xillary fa sc ia .

Co nt e nt s o f t h e Axilla — Th e a x illary art e ry an d v e in .


,

w ith th e larg e brach ial n e rv e s wh ich su pp ly th e su p e r ior ,

e x tr e mity an d t h e a ,
x illary ly m p h v e sse ls an d ly m h g la n d s
p ,

are t h e m o st imp orta n t co n t e n t s o f t h e a x illa Th e y are .

all e mbe dd e d in th e so ft a x illa ry fat E x c e p t at th e a p ex .

o f t h e sp ac e th e gr e at v e sse ls an d n e rv e s lie c lo se to th e
,

lat e ra l wa ll an d fo llow it in all th e m ov e me n t s o f the arm


, .

D ss e c t o
i i n — C t t h r u gh t h lav ic lar fi bre o f t h p e ct o ralis
u o e c u s e
m aj o r im m e diat e ly b lo w t h ir att ac h m e n t t t h e clav icl an d
,
e e o e,
t rn t h e m t o w ard t h ir in se rtio n At th sam e t im s re t h e
u s e . e e, e cu
bran ch e f t h lat r al an t rio r t h o racic n rv e w h i h p ass in t o
s o e e e e c
t h e d e p s rf ac o f t h e m scle
e u F o ll w t h
e p h alic v e in an d u . o e ce
t h e de lt o id bran c h o f t h e t h o ra o acro m ial a rt ry m dially u n de r c -
e e ,

ve r o f th clavic lar p art o f th p ct o rali m aj o r an d se r th e


co e u e e s ,
cu e
a r m ial an d p
c o t ral bran ch s f th latt r art e ry Cl an t h
ec o e o e e . e o se
ve s ls an d dir ctly b lo w t h lavi l disp lay t h co sto
se ,
e e e c c e, e
co raco id membrane an d m o re in f e r io rly an d lat e rally t h e f as cia
, , ,
2 4 TH E SUP ER I OR EXTRE M I TY
o n t h e la t e ral p art
f th e p e c o ralis m in o r o Cu t h ro u gh t h e t . t
t
s e rn o c o s o t al p art f
t h e p e c o ralis m aj o r abo u t wo in c h es f ro m t t
t
t h e la e ral bo rde r o f t h e s e rn u m t
Tu rn t h e m e dial p ar o ards . tt w
t h e m e dian p lan e e rify it s a ac h m e n v
t o t h e co s al c a ilag e s tt t t rt
t
an d t o t h e s e rn u m an d t o t h e ap o n e u ro sis o f t h e e x e rn al o bliq u e t
m u scle o f t h e abdo m e n Tu n t h e la e ral p ar o f t h e m u scle
. r t t
t w
o ards t h e arm w
h ils do in g h a , se cu e th e m e dial an e io t t t r t r r
t v
h o racic n e r e , w h ic h p e rfo ra e s th e p e c o alis m in o an d e n ds t t r r
in t h e p e c o ralis m aj o r t Ex am in e t h e in se rt io n o f t h e p e c o ralis
. t
t t t t
m aj o r N o e h a t h e e n do n o f in se rt io n co n sis s o f tw o lam in a
. t
w t t
h ic h are u n i e d o g e h e be lo t r
in o h e r o rds, th e e n do n is w t w t
f o lde d o n i se lf t an d be tw
e e n t h e tw o lam in a a mu co us bu rsa
t
is f re qu e n ly in e rp o se d t Th e c la icu lar fi bre s an d t h e u pp e r
. v
t t tt
s e rn o c o s al fi bre s are a ac h e d t o t h e an e rio r lam in a, t h e lo er t w
t t r
s e rn o co s al fi b e s t o t h e p o s e rio r lam in a B o h lam in a are t . t
t t
a t ac h e d t o t h e la e ral lip o f t h e in e r u be rcu lar su lcu s o f t h e t t
r
h u m e u s, bu t t he de e p lam in a asce n ds to a m o re p ro x im al le e l, v
t
an d be co m e s co n in u o u s w i h a lay e r o f f as cia w h ic h is a ac h e d t tt
t
t o t h e le sse r u be rcle o f t h e h u m e ru s Th e in f e rio r bo rde o f t h e . r
t t
e n do n o f in se r io n is c o n in u o u s t
i h th e de e p f as c ia o f th e arm wt .

t
W h e n t h e p e c o ralis m aj o r is co m p le e ly re fl e c e d a c o n in u o u s t t t
sh e e t
o f f ascia is e xp o se d, h ic h ex e n ds f ro m th e cla icle w t v
r
su p erio ly t o t h e ax illary f asc ia in f e rio rly , an d f ro m t h e all o f w
t
t h e h o rax m e dially t o t h e arm la e rally t h e sh e e o f f ascia is t t
t h e so calle d clavip ecto ral f asci a o r susp e nso ry ligamen t of the
-

axi lla I t is be cau se o f th e a t ac h m e n o f h a f asc ial s h e e t o


. t t t t t
v
t h e c la icle su p e rio rly an d t o t h e ax illary f ascia in fe rio rly h a t t
t h e fl o o r o f t h e ax illa is raise d as t h e a rm is abd ct e d f ro m th e u
side an d t h e cla icle is e le a e d vTh e p e c o ralis m in o r m u scle , v t . t
p assin g o bliq u e ly f ro m its o rig in o n t h e h o racic all t o its t w
t r
in se rt io n in o t h e c o ac o id p ro ce ss o f t h e sc ap u la, ru n s h ro u gh t
t
t h e su bs an ce o f t h e cla ip e c o al f asc ia an d di ides it in o h re e v t r v t t
p ar s t v
( 1 ) t h e p art abo e t h e m scle , (2 ) th e p ar h ic h e n clo se s u tw
t h e m u scle , an d (3 ) t h e p art be lo w t h e m u scle Th e u pp e rm o s . t
p a rt i s t h e c o s o t
- co raco id m e m bran e
,
t h e in e rm e dia e p art is t h e t t
t
s h e a h o f t h e p e c o ralis m in o r t
No sp e cial t e rm is app lie d t o .

w t
t h e lo e s p art , bu t it s h o u ld be n o e d h a it lie s p o s e io r t o t h e t t t t r
w t t
lo e r p ar o f t h e p e c o ralis m aj o r, an d h a it co e rs t h e dis al t t v t
rt
p o io n s o f t h e ax illary e sse ls an d n e r e s v v .

M embran a Co st o co raco ide a co sto coraco id me m .


-
Th e -

bra n e occu p ie s the gap be tw e e n th e c lav ic le an d th e p e ctora lis


min or I t e x t e n d s fro m th e fir st rib m e d ia lly t o the corac o id
.

p roc e ss lat e ra lly a n d f ro m t h e c lav ic le


,
a bo v e to t h e p e ctora lis
m in or be low I t s u pp e r p art is sp lit in to t wo lay e r s an
.
,

a n t e r ior an d a p o st e rio r wh ich are attach e d to th e c o rr e ,

sp o n din g bord e r s o f t h e c lav ic le E n c lo se d be tw e e n th e m is .

t h e su bc lav iu s m u sc le Th e stro n g e st p art o f t h e m e mbra n e


.

is that wh ich e x t e n d s a lo n g t h e low e r bord e r o f t h e su b


c laviu s fro m th e fir st rib to the c o raco id p roc e ss that p ort io n
,

is fr e qu e n t ly ca lle d th e co sto co raco id ligamen t Th e m e mbra n e -


.

is co n t in uou s be low w ith th e fa sc ia l sh e ath o f the p e ctora lis


AX I L L A RY SP A C E 2 5

m in or p o st e r ior ly w ith th e fa sc ia l S h e ath o f t he a x illary


an d

v e sse ls ( F ig . I t is p e r fo rat e d , a bov e the u p p e r bo rd e r


o f the
p ctora lis m in or, by the c e p ha lic v e in , t h e thoraco
e

acro mia l v e sse ls, an d the lat e ra l a n t e r ior thorac ic n e rv e .

N ot e ( I ) that the fibres of the membran e ru n medio laterally, -

( )
2 t hat th
ey a re pu t o n the stretch w hen the arm is a bdu cted
,
an d 3 ) that they are relax ed w hen the a rm is by the side Th e .

s urg e o n tak e s adva ntag e o f th e se fact s wh e n he is ligatur in g


t h e fir st p art O f th e a x illary art e ry .

C l vi l
a c e

S u bc l vi
a us

Tho raco ac ro
-
m il
a a rte r y
Fi rst rib

Co sto -
co raco id
m e mbran e

A xill y ar art e r y

A xill y
ar sh e a th

ary fasc i a

FIG . 1 2 .
— Di g
a ra m o f th e C o sto -
co raco id M e m bran e .

t r u
D is s e c ti o n — Cu t h o gh t h e an e rio lay e r o f t h e u p p e r p ar t r t
o f th e t
co s o c o raco id m e m bran e
-
an d e x p o se t h e su bcla iu s v
m u scle P
ass t h e h an dle o f a k n ife be lo
. t h e lo e r bo rde o f w w r
v w r
t h e su bcla iu s an d u p a ds be h in d t h e m u scle an d de m o n s ra e t t
t
t h e p o s e rio r lay e r o f t h e u pp e r p art o f t h e m e m bran e Cle ar a w ay .

r
t h e e m ain s o f t h e m e m bran e an d f o llo t h e ce p h alic e in t o it s w v
t wt v
j u n c io n i h th e ax illary e in , th e h o raco acro m ial art e ry t o t -

t t
t h e ax illary ru n k , an d t h e la e ral an e rio r h o rac ic n e r e t o t h e t t v
t r
la e al co rd o f t h e brac h ial p le xu s Cle an t h e p ro x im al p art s o f .

t v
t h e ax illary ar e ry an d e in an d t h e la e ral co rd o f t h e bra c h ia l t
p lex u s t t t
N o e h a th e ax illary e in lie s t o t h e m e dial side o f t h e
. v
t t
ar e ry , o n a so m e wh a an e rio r p lan e , an d h a a s t h e arm is t t t
t
abdu c e d f ro m t h e side t h e v
e in p asse s m o re an d m o re in f ro n t
o f t h e art e ry t r
Th e la e ral co d o f t h e p le xu s lie s t o t h e la e ral
. t
side o f t h e art e ry an d o n a p o s e rio r p lan e t
B e h in d t h e u p p e r .

t
bo rde r o f t h e p e c o ralis m in o r fi n d t h e m e dial an e rio r h o rac ic t t
v
n e r e , an d n o e t t t
h a a co mm u n ica io n is f o rm e d be t e e n th e t w
t t
m e dial an d la e ral an e rio r h o acic n e r e s , acro ss t h e f ro n o f t r v t
t
t h e ax illary ar e ry an d be h in d th e co s o co raco id m e m bran e t - .
2 6 TH E SUPER I OR EXTRE M I TY
t r
Cle an t he p e c o alis m in o r m scle i h o u u wt t inj urin g th e m e dial
an t t
e rio r h o racic n e e, hich p ie rce s it rv w .

M P ect o ra lis M in o r The p e ctora lis m in or mu sc le is


. .
-

tria n gular in out lin e I t arise s ( 1 ) fro m th e a n t e rior e n d s .

o f t he th ird fourth an d fi fth r ibs c lo se to th e ir ju n ct io n s


, , ,

w ith th e ir cart ilage s an d ( 2 ) fro m the fa sc ia cov e rin g the ,

in t e rco stal m u sc le s in th e in t e rv e n ing sp ac e s I t s fi br e s p a ss .

u p ward s an d lat e ra lly an d its t e n do n o f i n se rt i o n i s attach e d ,

to t he u p p e r sur fac e an d the a n t e ro m e d ia l bord e r o f th e -

horiz o n tal p art o f the coraco id p roc e ss n e ar its lat e ra l ,

e x tr e mity W h e n the mu sc le is in act io n it draw s th e sca p u la


.

dow n ward s an d forward s an d d e p r e sse s th e shou ld e r It , .

is su p p lie d by t he medial an terio r tho racic n erve Th e gr e at e r .

p ort io n o f t h e p e ctora lis m in or is co n c e a le d by t h e p e ctora lis


m ajor bu t th e low e r an d me d ia l p art o f its in fe r ior bord e r
,

a pp e ar s o n the lat e ra l wa ll o f the thora x be lo w the pe ctora lis


major ; its in se rt io n is co n c e a le d by th e a n t e r ior fi br e s o f the
d e lto id .

D is s e c t i o n — Cle a a ay t h e cla ip e c o al f ascia be lo


. r w th e v t r w
v t r
le e l o f t h e p e c o alis m in o r an d o p e n u p t h e lo e r p ar o f t h e w t
ax illa v
re m o e also t h e de e p f ascia o f t h e arm in t h e e g io n o f r
t
t h e la e ral bo u n dary o f t h e ax illa .

Co mm e n ce at t h e la e ral p art o f t h e are a be lo t


t h e p e c o ralis w t
m in o r an d cle an t h e c o raco b ac h ialis an d t he s h o h e ad o f th e -
r rt
t
bic e p s, as h e y de sce n d in o t h e arm f ro m th e t ip o f t h e c o rac o id t
p ro c e ss t
F in d t h e dis al p ar o f th e ax illary ar e ry at t h e m e dial
. t t
bo rde r o f t he co raco brac h ialis Th e ru n k o f th e m e dian n e r e
-
. t v
lie s be tw t
e e n t h e a r e ry an d t h e m u scle , an d at t h e lo e r bo rde r w
t
o f t h e p e c o ralis m in o r t h e m e dial h e ad o f t h e n e r e c ro sse s t h e v
r t
f o n o f t h e ar e ry t
P u ll t h e co rac o brac h ialis la e rally an d fi n d
.
-
t
t
t h e m u scu lo cu an e o u s n e r e e n e rin g its de e p su rf ace , j u s
-
v t t
be lo w
t h e p e c o ralis m in o r t Abo e an d t o t h e la e ral side o f t h e . v t
t ru n k o f t h e m u scu lo cu an e o u s n e r e fi n d t h e bran c h f ro m it -
t v
w h ic h su p p lie s t h e c o raco brac h ialis Th e ax illary e in lie s alo n g -
. v
t h e m e dial side o f t h e ar e ry , an d in t h e in e r al be w e e n t h e t t v t
t v t
ar e ry an d e in , an e rio rly , is t h e m e dial cu an e o u s n e r e o f t h e t v
f o re arm ( O T in e rn al cu an e o u s)
. . t
R u n n in g alo n g t h e m e dial t .

s ide o f t h e v
e in is t h e m e dial cu an e o u s n e e o f t h e arm ( O T t rv . .

t r
le sse r in e n al cu an e o u s n e r e ) t
se cu re it an d f o llo it u p w a ds v w r
t
t o th e co m m u n ic a io n w h ic h it re ce i e s f ro m t h e in te rco st o v
brac h ial n e r e (F ig I v At t h e sam e t im e ide n if y an d
. t
v t
p re se r e t h e la e ral g ro u p o f ax illary ly m p h g lan ds, h ic h lie w
alo n g t h e m e dial side o f t h e ax illary e in Se cu re th e in t e rco st o v .

brac h ial n e r e an d f o llo v it m e dially , t o t h e p o in w h e re it w t


e m e rg e s f ro m t h e se co n d in e rco s al sp ace , an d la e rally t o t h e t t t
m e dial an d p o s e rio r asp e c o f t h e arm , t h e re it is dis ribu e d t w t t .

I n o rde r t o disp lay t h e dis ribu io n o f t h e in te rco st o brac h ial t t -

v v
n e r e , an d t o g i e be e r a c ce ss t o t h e m e dial an d p o s e rio r tt alls t w
o f t h e ax illa, t h e ax illa y fascia m s be se p ara e d f o m t h e f as cia r ut t r
2 8 TH E SUPER I O R EXTRE M I TY
o t
f t h e p e c o ralis m in o r, fi n d t h e la e ral h o rac ic ar e ry cle an t h e t t t
art e ry an d t h e m e dial g ro u p o f ax illary ly m p h g lan ds, h ich lie w
alo n g its c o u rse .

t
At t h e j u n c io n o f t h e p o s e rio r h ird an d an e rio r tw o h irds t t t t -

o f t h e m e dial w
all o f t h e ax illa fi n d t h e lo n g h o ra cic n e r e , h ic h t v w
t
su p p lie s t h e se rra u s an e rio r an d de s ce n ds alo n g it s la e ral t t
su rf a ce , f ro m t h e ap e x t o t h e base o f t h e ax illa Af e t h e n e r e . t r v
h as be e n se cu re d t h e se rra u s an e rio r m u s be cle an e d t
W hen t t .

t t
h a h as be e n do n e t h e disse c o r sh o u ld cle an t h e dis al p ar s o f t t t
v
t h e larg e e sse ls an d n e r e s an d h e ir bran c h e s an d ribu arie s v t t t .

t
W i h c h ain an d h o o k s p u ll t h e ax illary ar e ry an d t h e m e dial t
t
cu an e o u s n e r e o f t h e f o re arm v o w ards t h e a rm an d disp lace t
v
t h e ax illary e in in t h e o pp o si e dire c io n t h e n fi n d t h e u ln ar t t
ne r e v w h ic h lie s in t h e p o s e rio r p ar o f th e in e r al be e e n t h e t t t v tw
art e ry an d v
e in ; p u ll t h e u ln ar n e r e la e rally , an d be h in d t h e v t
t
a r e ry fi n d t h e larg e radial n e r e ( O T m u scu lo sp iral
) u ll it v . .
-
. P
m e dially an d f o llo w it s la e ral bo rde r u p ards At t h e lo e rt w . w
bo rde r o f t h e su bsc ap u laris m u scle o n t h e la e ral side o f t h e t
v
radial n e r e se cu re t h e ax illary n e r e as it u rn s back ards in o v t w t
t
t h e p o s e rio r all o f t h e ax illa w N e ar t h e ax illary n e r e is t h e . v
larg e su bscap u lar bran c h o f t h e ax illary ar e ry a cc o m p an ie d by t
t h e co rre sp o n din g e in v
Th e su bscap u lar ar e ry sp rin g s f ro m
. t
t h e m e dial side o f t h e ax illary ar e ry A sh o rt dis an ce be lo its t . t w
v t
o rig in it di ide s in o tw o bran c h e s, t h e c i cu m fl ex s cap u lar an d r
t r
t h e h o aco do rsal Th e circu m fl e x sc ap u lar p asse s back ards
-
. w
t t
in o t h e p o s e rio r all o f t h e ax illa wTh e h o raco do rsal ar e ry . t -
t
de s ce n ds alo n g t h e lo w e r bo rde r o f t h e su bscap u laris m u scle t o
t h e an g le w h e re t h e p o s e rio r t
all j o in s t h e m e dial w all o f t h e w
ax illa w
F o llo th e art e ry do n ards , ak in g c are n o t t o in j u re
. w w t
t h e in t e rco st o brac h ial n e r e an d t h e p o s e rio r bran c h e s o f t h e
-
v t
t
la e ral ram i o f t he 3 rd, 4 th , an d sth in e co s al n e r e s h ic h c ro ss t r t v w
in f ro n o f it t t
N o e t h e p o s e rio r g ro u p o f ax illary ly m p h g lan ds
. t
w h ic h lie alo n g it s co u rse , an d n e ar its lo e r e n d se cu re t h e w
t r v w
h o aco do rsal n e r e , h ic h cro sse s in f ro n o f th e art e ry , o n it s
-
t
w ay t o t h e la issim u s do rsi, t h ich it su pp lie s R e u n t o th e w . t r
v
di isio n o f t h e su bscap u lar ar e ry D isse c in t h e an g le be w e e n t . t t
it s c ircu m fl e x s cap u lar an d its h o ac o do rsal bran c h e s an d t r -

se cu re t h e se co n d su bsc ap u lar n e r e , h ic h su pp lie s t h e e re s v w t


m aj o r m u scle f o llo w it t o th e m u scle .

t
R e u rn t o t h e radial n e r e an d fi n d sp rin g in g f ro m its m e dial v
bo rde r n e ar t h e lo w e r m arg in o f t h e su bs cap u laris t h e p o s e rio r t
t v
brac h ial c u an e o u s n e r e , an d bran ch e s t o t h e lo n g an d m e dial
t
h e ads o f t h e rice p s m u scle No t u n co mm o n ly all h o se bran ch e s . t
are co n j o in e d at t
h e ir o rig in , an d se p ara e as h e y p ass t o h e ir t t t
t
de s in at io n s t
Th e p o s e rio r brac h ial cu an e o u s n e r e , o n its
. t v
w ay t o t h e m iddle o f t h e p o s e rio r asp e c o f t h e arm , p asse s t t
be h in d t h e in te rc o st o brac h ial n e r e Th e n e r e t o t h e lo n g
- v . v
h e ad o f th e t rice p s e n e rs t h e p ro x im al p ar o f h a m u scle t t t t .

Th e re are u su ally tw o bran c h e s t o t h e m e dial h e ad o f t h e rice p s t


t
o n e e n e rs t h e p ro x im al p ar o f t h e m u scle , an d t h e o h e r, k n o t n t w
as t h e u ln ar co llateral, bec au se it ru n s by t h e side o f t h e u ln ar
v
n e r e , p asse s t o t h e dis al art
p I t ill be r a c e t
d t o it s e rm in a . w t t
t io n at a la e r p e rio d t .

Th e an e rio t r t
an d p o s e rio r h u m e ral c ircu m fl e x bran c h e s o f
t h e ax illary ar e ry t w
ill be f o u n d sp rin g in g f ro m t h e ar e ry a t
sh o r t t t
dis an ce dis al t o t h e su bscap u lar bran c h , t h e f o m e r r
AX I LLA RY SP AC E 2
9

arisin g f ro m t h e an t e rio r , an d t h e t
la t e r f ro m t h e p o t r io r a
s e sp e c t
o f t h e ax illary ru n k t .

t w
Af e r t h e lo e r p art o f th e ax illa h as be e n h o ro u gh ly cle an e d, t
t
t h e p e c o ralis m in o r m u s be di ide d, abo u m id ay be t
e e n it s v t w tw
t
o rig in an d in se r io n , a n d t h e tw o p art s m u s be u n e d aside t t r .

t t
W h e n h a h as be e n do n e t h e u pp e r su bscap u lar n e r e m u s be v t
t
f o u n d as it e n e rs t h e u p p e r p ar o f th e su bsc ap u laris , an d h e n t t
t
t h e re m ain in g are o lar issu e m u s be re m o e d f ro m t h e ax illary t v
t
sp ace , t h e ru n k s an d bran c h e s o f t h e ax illary e sse ls an d n e r e s v v
t t r
mu s be h o o u gh ly cle an e d, an d t h e co n e n s o f t h e sp ace m u s t t t
t
be s u die d in de ail t .

R lgh t j u u 1ar
'

g I f i d
n er o r e e p cer vi ca l
ly
mp h t ru n k l y mp h g l an ds

I l v i l l y mp h
n fra c a c u ar
gl an ds

i
Su p e r o r a n t e rio r
i i l ly
m e d as t na mp h an ds gl I n t e rpe c t o ra l l y mp h
gl a nd

Tho rac i c du c t

S t e rn a l l y mp h g l d an s

f i gh id ‘
o r t s e

l l y mph gl
St e rn a an ds o f l e ft s id

i l
N pp e

mamma
Are o l a

y
L mp h v e sse s l gig ji
o n to o n
ly
mp h v e sse s o l f abdo me n

FI G . I 4 .
— Di g a ram o f the C o n n e c t o ns i o f th e L y m p h Ve sse l s O f
t h e M am m a .

Ly mp h o glan dula Ax illa res ( Axillary Ly mp h Glan ds) .

The ly mp h gla n d s in th e a x illary r e g io n are sp ok e n o f,


co lle ct iv e ly, as the a x illary gla n d s, bu t fo r co n v e n ie n c e o f
d e scr ip t io n , an d to fac ilitat e a m or e p r e c ise k n ow le dg e o f
th e ir co n ne ct io n s an d a ssoc iat io n s, th e y are su bd ivid e d in to
se v e ra l su bord in at e grou p s So m e o f th e g la n d s hav e be e n .

r e mov e d as th e d isse ct io n p roc e e d e d, an d oth e r s are so sm a ll


that th e y m ay have e sca p e d the att e n t io n o f the d isse ct o r ;
bu t if h e h as fo llow e d th e d ir e ct io n s g iv e n a bov e h e w ill
hav e n ot e d at le a st four grou p s o f gla n d s ( 1 ) A lat e r al o r .

brach ia l gro u p co n sist in g o f six o r m or e gla n d s, wh ich lie


3 0 TH E SUPER I O R EXTRE M I TY
a lo n g the a x illary v e sse ls Th e y r e c e iv e the ly mp h v e sse ls
.

fro m th e gr e at e r p art Of th e u pp e r e x tr e mity an d tho se at t h e ,

u p p e r p art o f the cha in also r e c e iv e ly mp h fro m th e d e e p


p art o f t h e m a m ma
'

( ) p
2 A e.ctora l gr o u p o r a n t e r ior grou p , ,

wh ich lie s in the a n gle be tw e e n th e a n t e r ior an d me d ial wa lls


O f t h e a x illa Th is is su bd iv isible in to two p art s : ( a) an
.

u pp e r grou p o f two or thre e sm a ll gla n d s wh ich lie be h in d


th e p e ctora lis m ajor in th e r e g io n o f th e se co n d an d th ird
in t e rco sta l sp ac e s th e se r e c e iv e ly mp h fro m the a n t e r io r wa ll

o f t h e thora x an d fro m the lat e ra l two th ird s o f th e m a m m a -

n in fe r ior grou p wh ich lie s a lo n g th e p o st e r ior bord e r o f


( )
b a

th e lat e ra l thorac ic art e ry an d r e c e iv e s ly m p h fro m t h e lat e r al


,

wa ll o f the thora x ( 3 ) A p o st e r ior o r su bsca p u lar gr o u p


.
,

wh ich lie s a lo n g the su bsca p u lar art e ry o n the p o st e r ior wa ll o f


th e a x illa an d r e c e iv e s ly mp h v e sse ls fro m the back
, ( )
4 T h e .

de lto p e ctora l g la n d s a grou p o f two o r thr e e sma ll g la n d s


-
,

wh ich lie in t he de ltO p e ctoral tr ia n gle an d r e c e iv e ly mp h


-

fro m t he p ro x ima l an d lat e ra l p art s o f t he arm .

I n add it io n to th e ly mp h g la n d s wh ich are u sua lly se e n in


an ord in ary d isse ct io n th e r e are thr e e o th e r grou p s o f g la n d s
,
.

nterp ecto ral gla n ds fr o m o n e to thr e e or four wh ich lie


( )
a I -

, ,

o n th e a n t e r io r sur fac e o f th e e ct o ra lis m in or ; th e y r e c e iv e


p
ly mp h fro m t h e d e e p p art o f th e m a mm a by ly m p h v e sse ls
wh ich pie rc e the p e ctora lis m aj o r ( b) Th e central glands .
,

wh ich are v e ry varia ble th e y lie e ith e r o n the surfac e o f th e


a x illary fa sc ia in a p ock e t o f its su bsta n c e o r d e e p to it
, ,

in th e fat o f t h e midd le p art o f th e a x illa th e y hav e n o


a ff e r e n t s fro m an y d e fin it e r e g io n bu t are co n n e ct e d w ith
,

t he oth e r grou p s ()
c .Th e infraclavicu lar gla n ds wh ich lie ,

in th e a p e x o f th e a x illa be h in d t h e co sto c o raco id me mbra n e -


.

Th e y r e c e iv e e ffe re n t s fro m all the low e r grou p s an d th e ir ,

e ffe r e n t s u n it e to for m a su bc lavia n ly mp h tru n k wh ich


t e r min at e s o n th e le ft sid e in the tho racic du ct an d o n th e ,

right sid e in t he right ly mph du ct ( F ig .

R ami Lat era les ( O T Lat eral Cut an e o u s Bran ch e s) o f t he


. .

Ant erio r Bran ch es o f t he Seco n d an d Third Th o racic N erv es .

— As a ru le th e fir st thorac ic n e rv e do e s n o t g iv e o ff a lat e ra l
,

bra n ch . That wh ich sp rin g s fro m the se co n d th o rac ic n e rv e


is th e larg e st o f th e se r ie s an d d iffe r s fro m th e oth e r s in n o t
,

d ivid in g in to an a n t e r ior an d a p o st e rior bra n ch I t is t e r me d .

th e interco sto brachial n erve o n accou n t o f its be in g d istr ibut e d


-

to the sk in o n the me d ial an d dor sa l a sp e ct s o f the p ro x ima l


AX I L L ARY SP AC E

p art o f t h e arm To r e ach th is d e st in at io n it cro sse s th e


.

ax illa an d p ie rc e s the d e e p fa sc ia B ut be for e p ie rc in g the .

fa sc ia it e sta blish e s co m mu n icat io n s an d f or m s a p le x ifor m


arra n g e me n t in the a xilla w ith the m e d ia l cuta n e ou s n e rv e o f
t he arm an d th e lat e ra l bra n ch o f th e th ird thorac ic n e rv e
, .

The p le x u s so for me d may be j o in e d by a n oth e r tw ig wh ich


D id b h h mi y e lt o f t al arte r
A i ran c o o ra co - ac ro
y lla r
A
arte
C hm i m
O laCO ld

y p ro ce ss
x
n t e ri o r u e ral c rc u fle x art e r
A mi b h
c ro al ran c o f th o

T h o raco - ac ro i
m al art e r y
t h
C lavic u la r
o rac o - ac ro
b
mi
ran c
al art e r
h o
y
f

e ral
C i rc u m tle x a rt e r y
Su b sca p u lar a rt e r y
C i rc um fl e x y
sc ap u lar art e r

Su b i
c lav u s

o rac o -
d o rsal a rt e r y
S e rrat u s ant e r o i r

L a te ral t h i
o rac c art e r y

FIG . 1 5 .
— Di i
sse c t o n o f the A i x ll y A t y
ar r er and its B ran ch e s .

is occa o a
si n lly p r e se n t viz th e m in ut e lat e ra l cuta
,
n e ou s .
,

bra n ch o f th e fir st thorac ic n e r ve .

Th e lateral branch o f the th ird thorac ic n e rv e d iv i d e s i n to


a t r
n e i or o
an d p s e t r ior art wh ich a re d i s tr ib ut e d in th e
an p ,

ordin ary way F ro m the p o st e r ior bran ch tw ig s are giv e n to


.

k a
th e s in o f the x ill a a dn t h e t e r m in a l tw ig s a r e d is tr ib ut e d
,

to the in t e gu me n t o n the p ro x imal p art o f the me d ial a sp e ct


'

o f th e arm .

Art eria Ax illaris .


— Th e a x illary art e ry is th e ch ie f art e ry
TH E SUPER I O R EXT R E M I TY
Of u p p e r limb I t e n t e r s th e ax illa at its a p e x at the
the .
,

out e r bord e r o f the first rib co mme n c in g as th e c o n t in ua ,

t io n o f th e su bclav ia n art e ry I t lie s fo r a short d ista n c e .


, ,

P i i mfl x y A i i mfl x y o s t e r o r c rcu e art e r n t e r o r c rcu e arte r

S b p l y li m j to ta s a o r
h l
u sc a u ar art e r
M C u sc
b o ra c o -
rac ia is

Axill y (O ar n e rv e .

C ph e

A mi l c ro a ar
L l i h i
a t e ra an t e r o r t o ra c c n e rv e

L l
at e ra d fb
co r h o ra c
Th mi l
o rac o -
a c ro a
Axill yar ya rt e r ,
1

i
M e d al a n t e r o r i
t ho rac c i

ial cu tan e o us ne r e o v f the a

n e rv e ( O T m u s cu lo
.
-
sp rai l
ap u a l (O T . .

n o f a l at e ra l cu t ane o u s n e r e v

I
v
er e ( O T m dd e
. . i l su bscap u lar )

Lo ng t h o rac c ne r i ve
I n te rco st o brach a n e r e
-
il v
An te ri o r li f afl Ch Of a l
L at e ra tho rac c art e r i y
l a t e ra l c u t an e o u s n e r e v l g
( O T o n t ho rac i c)
. .

FI G . 1 6 — The
. f the A
co n te n ts o xill
ary S p ace e p o se d by t h e re fl e c t o n o f th e x i
li j j
P e ct o ra s M a o r an d t he su b ace n t fasc a, an d t he re mo va o f the fat an i l
l
t h e y m p h g an ds l
P art o f t he a ary v e n h as be e n re m o ve d to e p o se
. xill i x
i l
t h e me d a c u tan e o u s ne rve o f th e fo re arm an d th e u n ar n e rve l .

o n me d ia l wa ll o f th e a x illa , cro sse s th e fat in th e a n g le


th e
be tw e e n th e me d ia l an d p o st e r ior wa lls, an d th e n ru n s a lo n g
the lat e ra l wa ll t o th e low e r bord e r o f th e t e r e s m aj or th e r e it
AX I L L ARY SP AC E 33

le av e s th e a xilla an d p a sse s in to the arm wh e r e it be co me s th e ,

brach ia l art e ry F o r co n v e n ie n c e o f d e scr ip t io n it is u sua lly


.

d ivid e d in to thr e e p art th e p art a bov e t he p art be h in d an d


s—
, ,

t h e p art be low t h e p e ctora lis min or wh ich are k n ow n ,

r e sp e ct iv e ly as the first se co n d an d th ird p art s , Th e , .

d ir e ct io n wh ich the ar te ry tak e s varie s w ith the p o sit io n o f


th e limb Wh e n th e arm is at a right a n gle w ith th e body
.
,

th e d ir e ct io n is that o f a stra ight lin e fro m t he c e n tr e o f t h e


c lav ic le to the midd le o f the be n d o f t he e lbo w Wh e n t h e .

arm is by th e sid e th e art e ry d e scr ibe s a curv e w ith th e


,

co n v e xity d ir e ct e d lat e ra lly ; an d if the arm is ra ise d a bo v e


t h e h e ad th e curv e fo r m e d by th e art e ry is co n v e x in th e
r e v e r se d ir e ct io n .

The first part o f th e a xillary art e ry lie s v e ry d e e p ly I t is .

cov e r e d a n t e r ior ly by th e skin su p e rfic ia l fa sc ia d e e p fa scia


, , , , ,

th e c lav icu lar p art o f t he p e ctora lis maj or t h e co sto coraco id ,


-

m e mbra n e an d the v e sse ls an d n e rv e s su p e rfic ia l to it


,
Ev e n .

wh en tho se are r e mov e d the v e sse l is n o t co mp le t e ly e x p o se d ,

be cau se it is e n v e lo p e d a lo n g w ith th e a x illary v e in an d gr e at


,

n e rv e s by a fu nn e l sha p e d Sh e ath wh ich is p ro lo n g e d u p o n


,
-

th e m fro m th e d e e p c e rv ical fa sc ia ( F ig an d it is .

cr o sse d by the I oo p o f co mmu n icat io n be tw e e n th e two


a n t e r ior thorac ic n e rv e s wh ich lie s in fro n t O f the sh e ath .

B ehin d th is p art o f the v e sse l are t h e fir st in t e rco sta l sp ac e


an d th e fir st d ig itat io n o f t h e se rratu s a n t e r ior m u sc le ; th e

lo n g thorac ic n e rv e an d th e me d ia l cord o f t h e brach ia l


p le x u s a lso cro s s b e h in d it To it s m edia l s ide a n d s o. m e ,

what ov e rla pp in g it is th e a x illary v e in wh ilst abo ve an d to


, ,

it s lateral side are th e lat e ra l an d p o st e r ior cord s o f t h e


brach ia l p le x u s .

Th e seco nd p art o f th e a x illary art e ry is p lac e d be h in d


th e two p e ctora l mu sc le s an d has th e thr e e cord s o f th e ,

brach ial p le x u s d isp o se d arou n d it The me d ia l cord lie s .

u p o n its me d ia l sid e th e lat e ra l cord u p o n its lat e ra l sid e


, ,

an d t he p o st e r ior cord be h in d it Th e a x illary v e in is st ill .

u p o n its me d ia l sid e bu t is se p arat e d fro m the art e ry by th e


,

me d ia l n e rv e cord -
Str ict ly sp e ak in g it is n o t in a pp o sit io n
.
,

w ith any mu scle p o st e r iorly be in g se p arat e d fro m t h e su b ,

sca p u lar is m u sc le by are o lo fatty t issu e -


.

The third an d lo ngest part o f th e a x illary art e ry is su p e rfic ial


in its d ista l ha lf be cau se th e a n t e r ior wa ll o f t h e a x illa d o e s
,

n o t e x t e n d so far dow n as th e p o st e r ior wa ll Th e r e for e .


,


V OL . 1 3
34 TH E SUPER I O R EXTRE M I TY
wh ilst the th ird p art o f th e a xillary art e ry is cov e re d in its ,

p ro x ima l ha lf by the p e ctora lis m ajor its d ista l ha lf is c o v e r e d


, ,

o n ly by th e sk in an d fa sc ia B e h in d it p r o x imo d ista lly are .


,
-

,
th e su bsca p u lar is the t e n do n o f the lat issim u s d r i
, o s an d ,
th e t e r e s m aj or
; bu t it is se p arat e d fr o m th e su bsca p u lar is
m u sc le by the a x illary O T c ircu m fl n d rad ia l
( e x
) a
( O T . .
.

mu scu lo sp ira l) n e rv e s an d fr o m the lat issim u s dor si an d t h e


-

t e re s maj or by the rad ia l n e rve To its lat e ra l sid e is the .

L a t e ra l c o rd

P i
o st e r o r c o rd o f brac h i l pl
a exus

Med a il c o rd

M u sc u lo -
c u t an e o u s n e r e v

M e d an i ne r e v ( l a te ra lh e ad )

d ani n e rv e ( me d a i lh e ad )

M ed a il c u t an e o u s n e r e o v f t h e fo re arm

M ed ail c u t an e o u s n e r e o v f the arm

M e d an i v
ne r e

Ul nar n e r e v
R di l i l)
l

a (O T m
a n c rv e . . u sc u lo -
sp ra

FI G . 1 7 .
-
Di g m t h w l t i
a ra o s o re a o ns o f Axill y Var e sse ls an d N e rv e s .

coraco brach ia lis mu sc le bu t be tw e e n th e m u scle an d th e art e ry


-

are t h e m u sc u lo cuta n e ou s an d t h e m e d ia n n e rv e s
-
To th e .

me d ia l sid e o f th e art e ry is th e v e in w ith th e m e d ia l ,

cuta n e ou s n e rv e o f th e for e ar m in th e a n t e r io r a n g le be tw e e n
th e art e ry an d v e in an d t h e u ln ar n e rv e in t h e p o st e r io r a n g le
,

be tw e e n t h e art e ry an d v e in The m e d ia l cuta n e ou s n e rv e .

o f th e arm lie s a lo n g t h e m e d ia l Sid e o f t h e v e in


( g
F i .

The branch es o f t h e ax illa ry art e ry hav e be e n see n at


d iffe r e n t stage s o f the d isse ct io n Th e y shou ld n o w be e x .

amin e d m or e fu lly ( F ig Th e y are .


3 6 T H E SU PER I O R EXTRE M I TY
Alar Th o racic .
-
Th is sm all arte r y su pp lie s ly m ph g lan ds
th e fat an d

in the a i la, xl bu t it is rare ly pre se n t as a se p arate bran ch , an d its p ace is l


l
u su a ly t ak e n by t w ig s fro m th e su bscap u lar an d lat e ral th o racic arte rie s .

Art e ria Subsca p ulari s — Th e su bsca p u lar bra n ch o f th e


.

a x illary is a r e lat iv e ly larg e an d co mp arat iv e ly short bra n ch


wh ich sp rin gs fro m th e p ar e n t tru n k at th e low e r bord e r o f
t h e su bsca p u lar is m u sc le I t d e sc e n d s, fo r a bout o n e in ch ,
.

a lo n g the lo w e r bo rd e r o f the su bsca p u lar is, an d th e n d iv id e s


in to two t e r m in a l bra n ch e s, t h e a circu m fl e x a sca p u la , an d.

t h e a thorac o dor sa lis


.
-
Th e circu mflex scap u lar branch turn s
.

rou n d t he a x illary bo rd e r o f th e sca p u la o n it s way t o the


in fra sp in ou s fo ssa o f that bo n e , wh e r e it a n a sto m o se s w ith
bra n ch e s O f th e tra n sv e r se c e rv ica l an d tra n sv e r se sca p u lar
art e r ie s . I t g iv e s n u m e rou s bra n ch e s to t h e adjac e n t
m u sc le s Th e tho raco do rsal branch d e sc e n d s a lo n g th e lo w e r
.
-

bord e r o f t h e su bsca p u lar is t o t h e in fe rior a n g le o f t h e


sca p u la .I t g iv e s bra n ch e s t o t h e adjac e n t m u sc le s an d
a n a sto m o se s w ith the lat e ra l thorac ic art e ry an d w ith
bra n ch e s fro m t h e in t e rc o sta l art e r ie s I t se n d s bra n ch e s
.

a lso in to the su bsca p u lar fo ssa wh ich a n a sto m o se w ith tw ig s


o f th e tra n sv e r se an d c ircu m fl e x sca p u lar art e r ie s, an d
w ith bra n ch e s o f th e d e sc e n d in g bra n ch o f the tra nsv e r se
c e rv ica l art e ry .

Aa Circumfl ex a H u meri, An t erio r et P o st e rio r ( O T


. . .

Ant e rio r a n d P o st e ri o r i
C c r um fl ex Art e e s)
ri — Th e a n t e r ior .

an d th e p o st e r ior hu m e ra l c ircu m fl e x art e r ie s both ar ise fro m

th e a x illary at th e sa m e le v e l, a short d ista n c e d ista l to th e


orig in o f the su bscap u lar art e ry The po sterio r hu meral cir .

cu mfl ex ar t ery is m uch th e larg e r o f the two O n ly a sma ll .

p ort io n o f it c a n b e se e n at t h e p r ese n t stag e I t sp r in g s .

fro m th e p o st e r ior a sp e ct o f t h e a x illary art e ry, an d at o n c e


p a sse s b ackward s ,
w i th t h e a x illary n e rv e , in t h e in t e rva l
be tw e e n th e su bsca p u laris an d t e r e s m ajor m u sc le s o n th e
m e d ia l sid e o f t he surg ica l n e ck o f th e hu m e ru s The .

sma lle r anterio r hu meral circu m flex artery tak e s orig in fro m th e
lat e ral a sp e c t o f th e a x illary art e ry, an d ru n s lat e ra lly , in fro n t
o f t h e surg ica l n e ck o f th e hu me ru s, u n d e r cov e r o f th e
coraco brach ia lis an d short h e ad o f the bic e p s brach ii
-
.

R e ach in g the in t e rtu be rcu lar sulcu s, it d ivid e s in to two


bra n ch e s O n e o f th e two is d ir e ct e d p ro x ima lly , a lo n g th e
.

lo n g h e ad o f th e bic e p s brach ii, to th e sh o u ld e r j o in t ; t h e -

oth e r p a sse s lat e ra lly, to th e d e e p surfac e o f the d e lto id , an d


AX I L L ARY SP AC E 37

fi n a lly a n a sto mo se s w ith so m e o f the t e r min a l tw igs o f th e


p o st e r io r c ircu m fl e x art e ry o f t h e hu m e ru s .

V e n a Axillaris — The a xillary v e in has the sa m e e x t e n t


.

as t h e art e ry I t be g in s at t h e low e r bord e r o f t h e t e r e s


.

m ajor as t h e p ro x ima l cont in uat io n o f the ba silic v e in o f th e


,

arm an d it be co mes th e su bc lav ia n v e in at the out e r marg in


,

o f t he fir st rib At th e low e r m arg in o f t he su bsca p u lar is


.

it r e c e iv e s the two vena co mites o f the brach ia l art e ry an d ,

abov e the le v e l o f t h e p e ctora lis m in or it is jo in e d by the


c e p ha lic v e in I ts oth e r tr ibutar ie s corr e sp o n d m or e o r
.
,

le ss c lo se ly to th e bra n ch e s o f th e a x illary art e ry


, .

M Subclav ius
. Th e su bc lav iu s is a sm a ll m u sc le wh ich
.

lie s imm e d iat e ly be low t h e c lav ic le e n c lo se d be tw e e n t h e ,

two lay e r s o f th e co sto coraco id m e mbra n e I t take s or ig in -


.
,

by a short r o u n d e d t e n do n fro m the su p e r ior sur fac e o f ,

t h e fir st co sta l arch at th e ju n ct io n o f t h e bo n e w ith th e


,

cart ilag e an d the fl e shy be lly is in se rt e d in to th e sha llow


,

groov e o n the in fe rior sur fac e o f th e c lav ic le The n e rv e o f .

su p p ly is d e r iv e d fro m t h e fi fth an d six th c e rv ica l n e rv e s an d

e n t e r s the p o st e r ior sur fac e o f t h e m u sc le W h e n th e mu sc le .

co n tract s it d e p r e sse s t he c lav ic le an d draw s it Slight ly


forward s .

D is s e c t i o n — W h e n t h e su b lav iu s h as be n
. am in d it m st c e ex e u
be di id d h riz o n t lly an d w h n t h at h as b n do n e t h e c st
v e o a ,
e ee o o
clav i lar lig am e t w ill be f o n d be h in d t h m e dial n d o f t h e
cu n u e e
m u scle .

t
At h is s ag e , t wt t
i h t h e assis an ce o f t h e disse c o r o f t h e h e ad t
v
an d n e ck , t h e cla icu la r p art o f t h e s e rn o cle ido m as o id m u scle t - - t
t t
m u s be de ac h e d f ro m t h e su p e rio r bo rde r o f t h e cla icle an d v
t
t li e s e rn al p art o f t h e m u scle m u s be p u lle d o ards t h e m e dian t t w
p lan e .

Art icula t io St ern o clavic ula ris — Th e st e r n o c lav icu lar j o in t .


-

is a d iarthrod ia l jo in t , for m e d by th e st e r n a l e n d o f th e
c lavic le , the lat e ra l p art o f th e su p e rior bord e r o f th e
m a n u br iu m st e r n i, an d th e su p e r ior sur fac e o f th e st e r n a l
e n d o f t h e cart ilag e o f th e fir st rib I t h e lp s to in cr e a se .

th e ra n g e o f th e f orward , backward , an d u p ward m ov e m e n t s


o f th e arm The c lav ic le is attach e d to the st e r n u m an d t h e
.

first rib by a stro n g fi brou s ca p su le W ith in th e ca p su le is an .

art icu lar d isc wh ich se p arat e s t he j o in t cav ity in to two p art s .

I t is attach e d to t h e su p e r ior bord e r o f t h e st e r n a l e n d o f t h e


c lav ic le , t o th e su p e rior sur fac e o f th e fir st c o sta l cart ilag e , an d
to the a n t e rior an d p o st e rior p art s o f the ca p su le On th e .
38 TH E SU PE R I OR EXTRE M I TY
lat e ra l a sp e ct o f the ca p su le th e r e is a str o n g acc e sso ry
liga m e n t t h e co sto clavicu lar ligament wh ich lie s be h in d t h e
,

,

o r ig in o f t h e su bc lav iu s m u sc le an d a sse s u p ward s back


p ,

ward s an d lat e ra lly fro m the fir st rib to th e c o sta l tu be rc le o n


,

the low e r sur fac e o f t he c lav ic le I n th e ca p su le it se lf th e r e .

are thr e e th ick e n e d ba n d s an a n t e r io r a p o st e rior an d a , , ,

su p e r io r an d as so m e o f t h e fi br e s o f th e latt e r p a ss fr o m
,

o ne c lav ic le to the oth e r it is ca lle d th e in terclavicu lar ,

Jo i n t c ap su

Jo i n t ca vi t y

I n t e rart ic u la
lg
i a me n t

Jo i n t ca vi t y An t e r o i h d
rC o n ro
s t e rn a l li g m a e nt

FI G . 1 8 — S te rn o
.
-
l vi l
c a cu ar an d C o s to -
s te rn a lj i o n ts .

D is s e c t i o n — t P u ll th t
le id e s e rn al h e ad o f the s e rn o -
c o
m a t id m s l
s o m dian p lan
u c e t o w ard t h
C t t h r gh t h s e e e . u o u e
an t ri r p rt
e f t h c ap s l
o f th j i t l
a o t th t r m e u e o e o n c o se o e s e nu .

P a s t h k if b h i d t h cap l av idin g t h e a t ri r j g lar


s e n e e n e su e , o n e o u u
v in w h i h r n lat rally b h i d t h pp r b rd r f t h j i t
e ,
c u s e e n e u e o e o e o n ,

an d de t a h t h fi br f rig in f t h st rn hy id m s l w h i h
c e es o o o e e o -
o u c e c
sp rin g f ro m t h ba k o f t h ap s l C t t h r gh t h p t ri r
e c e c u e . u o u e o s e o
lig am e t a d p ll t h n lav i l lat rally
n Th art i lar di c i
u e c c e e . e cu s s
no w p d D t ac h it f r m t h fi r t rib
ex o se . t h n rry th k if
e o e s e ca e n e

lat rally b l w t h
e lav i l a d e o t t h r gh t h l w r p art e f c c e n cu o u e o e o
th e ap l an d t h
c t lavi lar lig am n t Th lavi l
su e e co s o -
c cu e . e c c e
can n o w be di p la d ffi i n t ly p w ard a d l t rally t bri g
s ce su c e u s n a e o n
th ew h l o f t h bra h ial p l
o e i t Vie w B f r t dy i g
e c ex u s n o . e o e s u n

th epl s th di t r h o u ld n o t e t h at b h i d t h t rn o
exu ,
e sse c o s e n e s e
AX I L L ARY SP AC E
39
clavi lar j i t t h r ar t h l w r fi br f th t r hy o id
cu o n e e e e o e es o e s e no -

an d t rn t hyr id m l w h i h i t rv righ t
s e o n th eo id u sc e s
-
c n e ene, o e s e,
b tw n t h
e ee c ap l f t h e j in t a d t h
e bif r at i f th
su e o o n e u c o n o e
inn m at
o art ry in t
in it righ t emm o n ar t id an d s b lav ian
e o s co c o u c
bran h a d
c t h l f t ide b tw n t h j o in t an d t h l f t
e s, n , o n e e s e ee e e e
mm n ar t id art ry
,
co o c o e .

P lex us B rach ialis ( Brachia l Plex us) .


— Th is imp o rta n t

gcAvut n n ew !

A N N R I OR

u r e a“
n annc cc “ N i

U S n e rv e

l
L a t e ra cu t a n e o u s n e r ve
M ED I AN N ER

S u bsc ap u l ar n e rv e I
I n t e rc o st o bra c h i a n e r e
-
l v
Ul n ar n e rv e M e di a l c u t a n e o u s n e rv e o f arm
M e di a l c u t a n e o u s n e rv e o f fo re arm

FIG . 1 9 .
— Di agra m o f B rac h i a l P l e x u s an d its B ran c he s .

le xus is for m e d by t he a n t e r io r ra mi o f th e lo w e r fo ur
p
c e rv ica l n e rv e s an d th e gr e at e r p art o f t h e a n t e r io r
ra mu s o f th e fir st thorac ic n e rv e Th e p le x u s is furth e r .

r e in fo rc e d a bov e by a sm a ll tw ig o f c o m mu n icat io n wh ich


, ,

p a sse s f ro m t h e f ourth t o t h e fi fth c e rv ica l n e rv e wh i lst b e low , , ,

a similar c o n n e ct in g tw ig n o t in fr e qu e n t ly p a sse s u p ward s in ,

fro n t o f t h e n e ck o f t h e se co n d rib fr o m the se co n d to ,


4 0 TH E SUPER I O R EXT R E M I TY
th e fir st thorac ic n e rv e The ma n n e r in wh ich the n e rv e s
.

j o in to fo r m the p le x u s is v e ry co n sta n t The fif th an d six th .

cervical n erv es u n it e t o for m an upper tra nh th e seventh r e m a in s


sin g le an d p roc e e d s d ista lly as a tranh ; wh ilst the

U pp er t ru nk

Sca l i
e n u s a n t e r o r an d o n l g u s co lli
Sca l e nu s me diu s an d i
p o st e r o r

P hr i
e n c ne r e v
l i
Sc a an t e r o r an d o n u s co l g lli
l i i
.

S c a me d u s an d p o st e r o r
i l
.

M dd e t ru nk

N Tno aA C A u s A fl fl i mo
.

i n AN S
Sc al i l g
an t e r o r an d o n u s co lli
l i
.

Sc a . me di u s an d p o st e r o r

Sca l e n u s an t e r o r an d i l g
o n u s co lli
Sc a l e nu s m e di u s an d p o st e r o i r

L o we r t ru nk

N I N T£ R C O $ TA U 3
.

F IG . 20 .
— Di g
a ram o f t h e B rac h i al P l e x u s . P ate rso n .

an d first jo in to co n st itut e a third O r


tho racic n erves ,

lo wer tran h A Short d ista n c e a bo v e th e c lav ic le e ach o f th e


.

thr e e tru n k s sp lit s in to an anterio r an d a po sterio r divisio n .

W h e n t he thr e e a n t e rior d iv isio n s are ra ise d o n th e ha n d le


o f a k n ife t h e thr e e p o st e r ior d iv isio n s w ill be se e n u n it in g to
,

for m t h e po sterio r co rd o f th e p le x u s I t shou ld be n o t e d that


.

t he low e st o r m o st m e d ia l o f t h e p o st e r ior d iv isio n s is m uch


AX I LL ARY SP AC E 4 1

s ma lle r tha n th e oth e r two Of th e thr e e a n t e r ior d iv isio n s


.

th e two upper j o in to c o n st itut e t h e lateral co rd wh ilst t h e ,

lo wer p a sse s d ista lly by it se lf as t h e medial co rd o f t h e p le x u s


,
.

F ro m th e thr e e cord s o f th e p le x u s t h e bra n ch e s are giv e n


o ff wh ich su p p ly t h e su p e rio r e x tr e m ity g
( F i s 1 9 20 .
, ,

F ro m th e a bov e d e scr ip t io n it w ill be se e n that t he p le x u s


may be d iv id e d in to four stag e s

F iv e se parate n e rve s ( v iz lo w e r fo u r ce rv ical an d fi rst.


,

th o racic ) .

Th re e n e rv e tru nk s ( v iz an u pp e r middle an d lo w e r)
-
.
, , , .

Th re e an te rio r div isio n s an d th re e po st e rio r div isio n s .

Th re e n e rv e co rds ( v iz a lat e ral a m e dial


-
an d a
.
, , ,

po s t e rio r ) .

Th e p le x u s t d s fro m the lat e ra l bord e r o f th e sca le n u s


ex e n

a n t e r ior to th e low e r bord e r o f the p e ctora lis m in or an d it ,

lies in th e low e r an d me d ia l p art o f t h e p o st e r ior tr ia n g le o f


t he n e ck be h in d t he midd le th ird o f t h e c lav ic le an d in t h e
, ,

a x illa As a ru le the fir st two stag e s are in the n e ck the


.
, ,

th ird stag e is be h in d th e c lav ic le an d th e la st stage is in the ,

a x illa ( F ig s 2 1 .
,

I t h as be e n cu sto mary to d iv id e t h e bra n ch e s o f the


p l e x u s in to su p rac lav icu lar a n d in frac lav icu l ar grou p s b u t ,

such a d iv isio n is n e ith e r sc ie n t ifica lly accurat e n o r O f p ract ica l

imp orta n c e Th e bra n ch e s o f t he p le x u s sp r in g e ith e r fro m


.

it s root s or its tru n k s or it s cord s


, ,
.

Th p t
e f th pl x
ar s o e b v th
e l vi l
us a d th b
o eh g iv e c a ff i c e , an e ranc es en o n

th e v icu lar re gio n mu st be fo u n d an d cle an e d by the disse cto r o f


su p racla ,

t he h e ad and n eck ; the re m ainin g p arts o f th e p le x u s an d its bran ch e s


sh o u ld be dis lay e d b
p y th e disse c t o r o f th e u pp e r e x t re m ity bu t the t wo ,

disse cto rs m u st co mbin e to e x am in e th o ro u gh l y th e g e n e ral re latio n s an d


the bran ch e s o f th e p le x u s .

The R elat io n s o P le x u s Sup erfi cial to the c e rv ica l


f the —

p art o f t h e p le x u s lie t h e Sk in t h e su p e rfic ia l f


,
a sc ia t h e ,

p laty sm a t h e, d e e p fa s c ia t h e e x t e,
r n a l jugu lar v e in t h e tra n s ,

v e r se c e rvica l an d tra n sv e r se sc ap u lar v e in s th e p o st e rior ,

be lly o f t h e o mo hyo id m u scle an d th e tra n sv e r se c e rv ica l


-

art e ry B ehin d it is the scale n u s m e d iu s m u sc le ( F ig


. .

I n th e in t e rva l be tw e e n th e n e ck an d t h e a x illa t h e c lav ic le ,

an d th e tra n sv e r se sca u lar art e ry an d v e in are in fro n t o f


p
it an d t he th ird art o f t h u b c lav i a n art e ry is a n t e r ior to
p e s

its low e st tru n k .The sca le n u s m e d iu s is st ill be h in d it .

I n t h e a x illa it h as in fro nt of it th e in t e gu me n t th e fa sc ia , ,
4 2 TH E SUPER I OR EXTR E M I TY
th e pl aty sma th e p e ct o ra lis m ajor th e p e ct o ra lis m in or the
, , ,

co st o coraco id me mbra n e the c e p ha lic v e in an d t he a x illary


-
, ,

art e ry ; behind it lie the u p p e r se rrat io n o f th e se rratu s


a n t e rior th e fa sc ia fille d in t e rva l be tw e e n th e me d ia l an d
,
-

p o s t e r io r wa lls o f th e a x illa an d th e su bsca p u lar is m u sc le ,

( g
F i .

Th e B ranch es
P le x u s — The bra n ch e s fr o m th e
o f the
root s o f the p le x u s are ( I ) B ra n ch e s t o th e sca le n u s
a n t e rior th e lo n gu s co lli the sca le n u s m e d iu s an d th e
, , ,

sca le n u s p o st e r ior ( fro m C v VI VII ( )


2 A co m . .
,
.
,
.
,

m u n ic at io n to th e p hr e n ic n e rv e ( fro m C v o r v an d . .
,
.

L e v at o r scap u la

S t e rn o hy i d m
-
o usc le

D o rsal scap u lar n e rv e

E x t e rnal ju g u la r v e n i
S cale n u s me d ius S t e rn o q n as t o id
i i i u sc le

T ran s v e rse c e rv i
c al art e r

lav i au
S u p rasc ap u l

FI G . an —
c Di i
sse c t o n O f th e l o we r p art P o ste ri o r Tri angl e o f
o f t he th e N e ck ,

ho w i n g
s the S u p rac l av i c u l ar P art o f the B rac h i al P l e x u s .

3) dor
Th e sa lis sca p u la n e rv e wh ich su
pp l ie s t h e rho m b o id ,

mu sc le s ( fr o m C ( )
4 T h e lo n g th o rac ic n e rv e wh ich
.
,

su pp lie s t h e se rratu s a n t e r ior ro m


( f C v VI . .
, .
,

Th e bra n ch e s fro m t h e tru n k s o f the p le x u s are : ( I ) Th e


n e rv e to th e su bc laviu s fro m t h e u p p e r tru n k fr o m C v
( ,
. .
,

I t h as a lr e ady be e n se e n p ie rc in g t he p o st e r io r sur fac e o f t he


co sto coraco id me mbra n e an d e n t e r in g the p o st e rio r a sp e ct
-

o f t h e su bc lav iu s ( p ( )
2 T h e su p ra sca p u lar
. n e rv e ,

fro m t h e u p p e r tru n k ( fro m C v I t w ill be fou n d . .


,

cr o ssin g the lo w e r p art o f the p o st e rio r tria n g le d e e p t o ,

t h e p o st e r io r be lly o f t he o m o hy o id m u sc le an d d isa p p e ar -

in g through th e sca p u lar n otch o n its way to th e dor su m


sca p u la
( g
F i .
44 TH E SUPER I O R EXTRE M I TY

p a sse s d o w n ward s a n d lat e ra lly g iv e s bra n ch e s to ,


the low e r
p art O f t h e su bsca p u lar is th e n p a sse s thr o ugh ,
t he a ngle
23 24 25

FI G . 1 6 .
— Di sse c t o n i to s o h w t h e G e n e ra l R l ti
e a o ns o f t he B rac h i al P l e x u s .

1 Acce sso ry n e rv e M di l
e a cu t an e o u s n e r e o v f a rm .
lv l il
. .

v
N e r e t o e at o r sc ap u a I n t e rc o s t o bra c h a n e r
-
v e.
l L i im i
.

v
L e a t o r sca p u a a t ss u s do rs
D l l l
. .

o rsa sc a p u a r n e r e . v Tho rac o -


do rsa n e r e v
i i
.

g
L o n t ho rac c n e r e v Lo n g th o ra c c n e r e v
l i I lj g l
. .

Sca e n u s me d u s n t e rn a u u ar ve in.
l S p i id y
.

Su p ras cap u ar n e r e v u hy
er o r t re o a rt e r
i S bm xill y g l d
. .

Se rra t u s a n t e r o r u a ar an
l Ex lj g l v i
. .

U p p e r su bsc a p u ar n e rv e t e rn a u u ar e n

l i S l
. .

S u bsc ap u ar s m d
c a e nu s e i u s.
li m i hi l pl x
.

P e c t o ra s no r Up p k fb
er t ru n o rac a e us.
i li M i ddl hi l p l x
.

N er v e t o c o raco -
brach a s. k f b
e t ru n o rac a e u s.
Axill y ar n e rv e E igh h ti l v c e rv c a ne r e .
Om hy id
.

M l
u sc u O - c u t an e o u s n e r e v o -
o
Rd l v b l vi
. .

a ia ne r e N e rv e t o su c a us

M di l i h i v
. .

e a n n e rv e . L at e ra ante r o r t o rac c n e r e
M di l M di l i h i v
.

e a cu t ane o us n e r e o v f fo re arm
. e a an t e r o r t o rac c n e r e .

be tw e e n th e thoraco dor sa l -
an d c ircu mfl e x sca p u la art e r ie s
an d e n d s in t he t e r e s m ajor, wh ich it su p plie s .
AX I L L ARY SP AC E 45

N . Th o ra co do rsa li s ( O T L o ng Su bsca p ular N erv e)


. . Th e .
-

thoraco dor sa l n e rv e sp rin g s fro m the p o st e rior c o rd o f th e


-

le x u s, a sse s o bliqu e ly dow n ward s a d lat ra lly through t h


p p n e , e

a x illa, an d jo in s the thoraco dor sa l art e ry n e ar the low e r p art


-

O f t h e lat e ra l bo rd e r o f t h e su bsca p u lar is mu sc le Aft e r cro ss .

Scal e n us i
me d u s
l
Sc a e n u s an t e r o r i
p a rt o f Se rrat u s

i l
M dd e p o rt i o n o f
Se rrat u s a n t e ri o r

FIG . 2 3 .
—Se rratu s i
An te r o r m u sc l e an d o r g n o i i f the E te rn a O b q u ex l li
m u sc l e the l
sc ap u a is draw n away fro i
m th e s de o f the ch e st .

in g in fro n t f t h e art e ry it t e r min at e s in th e lat issim u s dor si,


o

wh ich it su p plie s .

N Tho racalis Lo ngu s ( O T P o st e rio r Tho racic o r Ex


. . .

t er na l i
R sp a o ry
e r t N e rv e o f B e ll) — T h e lo n g thorac ic .

n e rv e m ay n o w be studie d in its who le le n gth I t p a sse s .

dow n ward s o n th e lat e ra l surfac e o f the se rratu s a n t e rior, an d


is th e n e rv e o f su pp ly to that m u sc le I t ar ise s, in the ro o t o f .
TH E S UPER I OR EXTRE M I TY
th e n eck fro m th e brach ial ple x u s by thr e e root s The u pp e r
, , .

two ro o t s ( o n e fro m th e fi fth c e rvica l an d th e oth e r fr o m the


six th c e rv ica l n e rv e rc ca u d u u t g
) p ie e t h e s le n s m e i s an d n i in , ,

C o ra co
brac hi a l i s and

P e c t o ra li s m i no r

O mo h
-
y id
o

2 4 .
— C o sta l asp e c t o f t he Scap u l w ith th
a e At tach m e n ts
o f M u sc l es m ap p e d o ut .

in t o o ne t
s em, g iv e o ff bra n ch e s t o
u p p e r p art o f th e the
se rratu s a n t e r ior Th e th ird root tak e s or ig in fro m t he se v e n th
.

c e rv ical n e rv e p a sse s in fr o n t o f th e sca le n u s me d iu s an d ru n s


, ,

dow n ward s fo r a co n sid e ra ble d ista n ce o n t he Surfac e o f


AX I L L A RY SP AC E 47

th e rratu s a n t e rior be for e it u n it e s w ith the oth e r p art o f


se ,

th e n e rv e The e n t ir e n e rv e can be fo llo w e d to th e lo w e r


.

p art o f t he se rratu s a n t e r ior g iv ing tw ig s to e ach o f it s ,

d igitat io n s .

M Serra t us An t erio r ( O T Serrat u s M agnu s) — Th e


. . . .

se rratu s a n t e r ior ar ise s by fl e shy d ig itat io n s fro m t h e u p p e r

e ight r ibs a bout m idway be tw ee n th e ir a n g le s an d cart ilag e s


, .

The slip s are arra n ge d o n th e ch e st wa ll so as to p r e se n t a


g e n t le curv e co nv e x fo rward s The low e r thre e in t e rd ig itat e .

w ith the e x t e rn al o bliqu e mu scle o f the a bdo m e n The .

se rratu s a n t e r ior is in se rt e d in to t he e n t ir e le n gth o f t h e

a n t e rior lip o f th e v e rt e bra l m arg in o f the sca p u la an d it fa lls ,

n atura lly in t o thr e e p art s ( a) The upp er part co m p o se d o f .


,

t h e larg e fir st d ig itat io n a lo n e ar ise s fro m th e fir st an d se co n d ,

r ibs an d fro m a t e n d in ou s arch be twe e n th e m Th e fi br e s


, .

co n v e rg e to be in se rt e d in to a so me what tria n gu lar surfac e o n


,

th e co sta l a sp e ct o f th e m e d ia l a n g le o f t h e sca p u la ( )
b T h e .

middle part co n sist s o f two d ig itat io n s wh ich tak e or ig in fro m


th e se c o n d an d th ird r ibs The u pp e r Slip is v e ry broad an d
.
,

sp r in g s fro m th e low e r bord e r o f th e se co n d rib Th e fi bre s .

o f t h e m idd le p art d iv e rg e to for m a th in m u scu lar sh e e t ,

wh ich is in se rt e d in to th e a n t e rior lip o f the v e rt e bra l m arg in


o f th e sca p u la be tw e e n th e in se rt io n s o f t h e u p p e r an d low e r
,

p o rt io n s
()
c .T h e lo w er p art is for m e d b
y t h e r e m a in in g

d igitat io n s o f the m u scle Th e y co n v e rg e to fo r m a th ick .

m a ss wh ich is in se rt e d in t o a r o ugh sur fac e u p o n t h e c o sta l


,

a sp e ct o f the in fe rior a n gle o f the sca p u la The d e e p surfac e .

o f th e se rratu s a n t e r ior is in co n tact w ith th e ch e st wa ll .

I t is th e m o st p ow e r fu l p rotract o r o f th e wh o le u p p e r
e x tr e m ity .

D I SSE C T I ON OF TH E B AC K .

D i s s e c t i o n — At t h e e n d o f t h e fi f h day , af e r t he disse c o r t t t
t
h as e x am in e d t h e se rra u s an e rio r an d c are fu lly re ise d t h e t v
t t
co n e n s o f t h e ax illa, h e m u s re p lace t h e cla icle , p ack t h e t v
ax illa wt i h t o w o r rag s s e e p e d t
i h p re se r a i e so lu io n an d wt v tv t
fi x t h e sk in fl ap s t o t h e all o f th e w
h o rax i h a f e w s it c h e s t wt t .

t
W h e n h e re u rn s o n t h e sixt h day h e ill fi n d h a t h e bo dy h as w t t
be e n p lace d u p o n it s f ace , wt
i h blo ck s su pp o r in g th e c h e s an d t t
t h e p e l is v
I t w ill re m ain in h a p o si io n f o r fi v e day s , an d
. t t t
t t
du rin g th e fi rs tw o o f h o se t h e disse c o r o f t h e u pp e r e xt re m i y t t
t t t
mu s e x am in e t h e s ru c u re s h ic h co n n e c t h e lim b w i h t h e w t t
t
p o s e rio r asp e c o f t h e ru n k t t .
48 TH E SU PER I O R EXTRE M I TY
Surf ace An at o my — I n th e me d ia n lin e o f the back th e r e

i
S u p e r o r n u c ha l li ne

M ast o i d p ro ce ss
x t e rn al o c c ipi l p
ta ro t u be ran c e

Sp i ne o f l
sc a p u a
e o f se v
e n th ce r vi ca lve rt e bra

Ac ro m i o n

I i
nfe r o r an gl e o f sc ap u a l

M ed a i l pi
e co n d yl e
Ol e c ran o n

e ad o f i
rad us

P i
o st e r o r su p e r o r i
sp i n e o f 1 1mm

St yl i d p
o ro ce ss o f u na l
G re at e r t ro c h an t e r
St yl i d p
o ro ce ss o f rad u s i
Tu be ro s i y f i hi
t o sc u m

Med a il yl
co n d
f fe mu r e o
l
L at e ra co n dy l
e o f fe m u r
L at e ra c o nl dy l
e o f t b a ii
H e ad o f fibu a l

e dial ma e o ll l us
L a t e ra ma l ll l eo us

FIG . 2 5 .
— Surface V i e w sh o w i n g I nc ii
s o n s an d Bo n y P o i n ts .

is litt le d iffi cu lty in r e cognisin g th e t ip s o f the Sp inou s p roc e sse s


D I SSE C T I ON O F TH E B AC K 49

o f t he v e rt e br a ( F ig Th e y fo llow e ach oth e r in co n


.

se cu t ive ord e r an d it may be n ot e d wh e n th e fi n g e r is p a sse d


, ,

ov e r th e m that all o f th e m do n o t lie in t h e m e d ia n p la n e ;


,

so m e m ay be d e fl e ct e d in a slight d e gr e e t o o n e S id e o r th e
, ,

oth e r The spin e s o f the v e rt e br a are the o n ly p art s o f


.

th e sp in a l c o lu m n wh ich co m e to t h e sur fac e ; th e y a lo n e


y ie ld d ir e ct in fo r m at io n by touch to the surg e o n as to th e
, ,

c o n d it io n o f th e Sp in e At the low e r e n d o f t he n e ck th e
.
,

Sp in e o f t h e se v e n th c e rv ica l v e rt e bra ( vertebra p ro min ens)


mak e s a v isible p roj e ct io n ; an d th e sp in e s o f the fir st
two thorac ic v e rt e bra lik e w ise are v e ry p ro min e n t AS .

a ru le the m o st e v id e n t o f the thr e e is that o f the fir st


,

th o rac ic v e rt e bra At a lo w e r le v e l in su bj e ct s o f g o od
.
,

mu scu lar d e v e lo p me n t a me d ia n furrow is p roduc e d by th e


,

p ro m in e n c e o f t h e sacro sp in a lis m u sc le o n e ach s id e an d ,

t h e sp in e s o f t h e v e rt e br ae m ay be fe lt at t h e bott o m O f
t h e gr o o v e Th e furrow atta in s its gr e at e st d e p th in t h e
.

u pp e r p art o f t he lu mbar r e g io n an d it fad e s away be low , , ,

at the le v e l o f the Sp in e o f t he th ird sacra l v e rt e bra The .

fi n ge r shou ld n e x t be p a sse d d o w n ward s fro m th e th ird sacra l


sp in e be tw e e n t h e buttock s a lo n g t h e low e r p art o f th e tu be r
, ,

c u lat e d p o st e r io r sur fac e o f t h e sacru m an d a lo n g t h e p o st e r ior ,

sur fac e o f t h e coccy x t o th e t ip o f t he coccy x wh ich is t he ,

in fe r ior e x tr e m ity o f t h e v e rt e bra l c o lu m n A ft e rward s the .

fi n g e r should be carr ie d a lo n g the cr e st o f t h e iliu m I t .

co mme n c e s at th e p o st e r io r su p e r ior sp in e o f th e iliu m wh ich


can e a sily be d e t e ct e d be cau se it s p o sit io n is in d icat e d by

a small bu t d istin ct d imple wh ich lie s at th e le v e l o f th e


se co n d sacra l sp in e F ro m the p o st e r ior su p e r ior sp in e t h e
.

cr e st o f the iliu m p ursu e s a sig m o id course lat e ra lly an d ,

fo rward s .Th e h igh e st p o in t it r e ach e s is o n a le v e l w ith


t h e sp in e o f t h e fo urth lu mbar v e rt e bra an d it t e r m in at e s ,

in fr o n t in a p ro min e n c e ca lle d th e a n t e r ior su p e r ior


sp in e .

ca p u la o r shou ld e r blad e is fo r the m o st p art th ick ly


Th e s , , , ,

cov e re d by mu sc le s ; bu t in sp it e o f that its g e n e ra l out lin e


, ,

c an be m ad e o u t F ig I cov e r s a co n sid e ra ble ar e a o f


( t .

th e u pp e r p o rt io n o f t h e p o s t e r ior a sp e ct o f t h e th o ra x W ith .

t h e ha n d by th e sid e it s m e d ia l a n gle lie s o v e r t h e se c o n d


rib t h e r o o t o f its sp in e is p lac e d o p p o sit e t h e sp in e O f t h e
,

th ird thorac ic v e rt e bra wh ilst it s in fe r io r a n gle r e ach e s


,

down as far as th e se v e n th o r e v e n the e ighth rib Th e , ,


.

V OL . 1— 4
50 TH E SUPE R I OR EXTRE M I TY
sca p u la is v e r y m o bile an d move s t o a gr e at e r or le ss
,

d e gr e e w ith e v e ry m ov e me n t o f th e limb Th e sp in e an d .

acro mio n o f the sca p u la are su bcuta n e ou s thr o ugh o ut


B e lo w t he sca p u la th e low e r five r ibs c an be d ist in gu ish e d ,

an d t h e tip o f t h e la st rib c an be fe lt at a p o in t a bo ut t wo

in ch e s o r le ss a bo v e th e iliac cr e st .

As th e back is d isse ct e d th e fo llow in g are the p art s wh ich


mu st be e x a m in e d .

The cu tan e o u s v e sse ls an d n e rv e s o f the back .

The trape iu s mu sclez . I st day .

The latissim u s do rsi mu scle .

The rh o m bo id m u scle s an d th e ir n e rv e .

l
The e v ato r sc apu la m u scle .

The ac c e sso ry n e rv e an d th e n e rv e s fro m the ce r v ical p l e x u s


wh ich su p p l y the trap e iu s z . 2 n d day .

The tran sv e rse c e rv ic al arte ry an d its t wo t e rmin al bran ch e s .

The p o ste rio r be lly o f the o m o hyo id m u scle -


.

The tran sv e rse scapu lar arte ry an d the su p rascapu lar n e rv e .

Th is d isse ct io n m u st be co mp le t e d in two day s in o rd e r that ,

t h e d isse ctor o f t he h e ad an d n e ck m ay be e n a ble d t o c o n


t in u e t h e d e e p e r d isse ct io n o f the back Th e first day s w o rb ’
.

sh o u ld co mp r ise ( I ) the r e fl e ct io n O f the sk in ( 2 ) th e


d isse ct io n o f the cuta n e ou s n e rv e s an d v e sse ls ; an d ( 3 ) the


c le a n in g o f the lat issimu s dorsi an d tra p e z iu s m u sc le s The .

r e ma in d e r o f th e d isse ct io n can be u n d e rtak e n o n the seco nd


day .

D is s e c ti o n —
. f t h e Sk im— Th e f o llo in g in c isio n s
R e fl e ct io n o w
are n e ce ssary — 1 F ro m t h e t ip o f th e c o ccyx , at t he lo e r e n d
. w
o f the v
e rt e bral co lu m n , u p w ards , alo n g t h e m e dian lin e o f t h e
bo dy , t o t h e sp in e o f t h e se e n h c e rv ic al e rt e bra v t
2 F ro m v . .

t v
t h e u p p e r e n d o f 1 ran s e rse ly , t o t h e t ip o f th e a c ro m io n o f t h e
scap u la 3 F ro m t h e lo w e r e x re m i y o f t h e m e dian in cisio n
. . t t
v t t
in a cu r e d dire c io n la e rally an d f o rw ards, alo n g t h e cre s o f t
t h e iliu m , t o wt
i h in tw o in c h e s o f t h e an e rio r su p e rio r iliac sp in e t .

4 An o bliq u e in c isio n f ro m t h e sp in e o f t h e fi rs lu m bar e rt e bra,


. t v
t t
u p w ards an d la e rally , t o t h e p o s e rio r f o ld o f t h e ax illa , an d a lo n g
t
t h e la t e r t o t h e arm Th e tw o larg e fl ap s ( 1 7 an d 1 8 , F ig 2 5 )
. .

w h ic h are n o w m app e d o u t u p o n t h e back m u s be care fu lly t


raise d f ro m t h e su bj ac e n fa y issu e Re fle c t tt
t h e u pp e r t . t
t rian gu lar fl ap fi rs , an d h e n t h e lo t e r fl ap t w .

P anniculus A dip o sus ( Sup erficial P ascia) I n su bj e ct s .


-

wh ich hav e be e n a llow e d to lie fo r so m e t im e o n the back


th e su p e rfic ia l fa sc ia is u sua lly m or e o r le ss in fi ltrat e d w ith
flu id wh ich has grav itat e d in to it s m e sh e s ; oth e rw ise it has
t h e ord in ary charact e r s o f su p e rfic ia l fa sc ia ( p I I ) . .
TH E SUPER I OR EXTRE M I TY
m arg in o f the acro sp in a lis m u sc le a short d istan c e a bove th e
s ,

iliu m . Th e y are t he t e r min a l tw i g s o f th e lat e ra l d i vi si o n s


o f t he p o st e r ior ra m i o f th e u p p e r thr e e lu mbar sp i n a l n e rv e s

G re a t e r o c c ip i lta n er e v m isp in alis c ap t s ii (O T . . co mp lxe us )

Th rd o cci ip i lta ne r e v
St e rn o mast o d
-
i S t o t rap e z m s

ner e v
L e sse r o cc ip i lta n e r e v in gb r o . f t ra n s ve rse c e r i ca v l art

Trap e z i us

us m i no r

D l id
e to

e re s ma j o r

Te re s m a j o r

Se rra t u s an t e r o r i

Se rra t u s p o s t e r o r i i n fe r o r i
Lat i ssi mu s do rSI L at i im
ss us do rs i ( c u t)

Ex t e rn a l bli q m l
o ue u sc e

L a te ra d l iii v s o ns o f
p o st e ri o r ra m i o f T ig
r o nu m l mb l ( P i i ) et t
l u mba r n e r v es
u a e

G lu t a u s me d u s i
G lu ta u s ma xi m us

F IG . 2 6 .
— Di i
sse c t o n o f t he Su p e rfic i l
a M usc l e s an d N er v e s o f t he B ack .

an d th e y d iff e r fro m the n e rve s a bov e in a sm uch as th e y turn ,

dow n ward s ov e r the cre st o f the iliu m to su p ply the sk in o f


th e g lut e a l r e g io n ( F ig .

Th e cutaneo us arteries wh ich acco mp a n y th e cuta n e ou s


n e rv e s o f t h e back are d e r iv e d fro m th e o st e r ior bra n ch e s
p
o f th e in t e rco sta l an d lu mbar art e r ie s .
D I SS ECTI ON O F TH E B AC K 53

M uscle s c o nn ect ing t h e Limb t o t h e Do r sal Asp e ct o f t he


Trunk — Th is grou p c o n sist s O f fiv e m u sc le s an d th e y are ,

arra n g e d in two strata Two fo r m th e superficial stratu m v iz .


, .
,

t h e tra p e z iu s an d th e lat issim u s d o r si B oth are broad flat .


,

m u sc le s wh ich c o v e r th e gr e at e r p art o f th e d o r sa l a sp e ct o f
the tru n k fr o m t h e occ ip ut a bo v e to t h e iliu m be lo w
,
Th e .

tra p e z iu s lie s ov e r th e back o f the n e ck an d th e thora x .

Th e lat issim u s d o r si is p lac e d lo we r dow n The deep er .

stratu m o f m u sc le s co mp o se d o f t h e le vat o r sca p u la an d t h e


,

t wo rho mbo id m u sc le s is u n d e r cov e r o f t h e tra p e z iu s , .

Se m s p i i li na s c ap t s ii
R e c t u s c ap ii t s p o st e r i
R ii
e c t us c ap t s i
p o st e r o r m aj

S t e rn ol id m id
-
c e o -
ast o

Sp l i pi i
e n u s ca t s

O bli q ii
u u s c ap t s s u e r o r
p i

R e c t u s ca
p ii l t s a t e ra li s

R e c t u s ca
p t s an t e ii
Lo n g us
Su p e ri o r c o nstr cto r o i f p har) r
I lX

FIG . 2 7 .
— M usc l e - At t ac h m e n ts to the O cc p i it l a Bo ne .

D is s e c ti o n — . Af t t
e rt h e cu an e o u s n e r e s an d v v e sse ls h ave be e n
disp lay e d an d f o llo w e d t o h e ir e rm in a io n s, cle an t t t a w ay t h e
tt
re m ain s o f t h e f a y su p e rfi c ial f ascia in t h e a re a o f t h e rap e iu s , t z
bu t do n o t in j u re t h e de e p f as c ia o r t h e c u an e o u s n e r e s ; h e n t v t
p ro ce e d t o c le an t h e rap e iu s, w h ic h is t h e m o s su p e rfi c ial t z t
m u scle o f t h e bac k Th e rap e iu s be lo n g s o n ly in p ar t o t h e
. t z t
t
disse c o r o f t h e u pp e r e xt re m i y Th e p o r io n o f it wh ic h lie s t . t
v t
abo e t h e p ro m in e n sp in e o f t h e se e n h ce r ical e r e bra is t h e v t v v t
t
p ro p e r y o f t h e disse c o r o f t h e h e ad a n d n e ck , an d m u s be t t
t
disse c e d by h im Th e tw o disse c o rs sh o u ld o rk in c o n ju n c
. t w
t io n wt
i h e ac h o h e r ; an d t
h e n t h e e n ire m u scle is e x p o se d, w t
v
e ac h s h o u ld g i e t h e o h e r an o pp o r u n i y o f s u dy in g it in it s t t t t
t t
e n ire y .

t
I f t h e disse c io n is be in g m ade o n t h e righ s ide , p lace t h e arm t
clo se t o t h e t
ru n k an d dra g t h e s cap u la f o r a rds o e r t h e e n d o f w v
t h e blo ck w h ic h su p p o r s t h e h o rax Cu t h ro u gh t h e de e p t t . t
1— 4b
54 TH E SUPER I OR EXTRE M I TY
v t v
f asc ia f ro m th e s e e n h c e r ical sp in e t o t h e ac ro m io n ; t h e
in c isio n w
ill c o rre sp o n d wt
i h t h e dire c io n o f t h e fi bre s o f th e t
v t
m u scle at t h e le e l se le c e d W o rk g radu ally do w n w ards, raisin g
.

t
t h e f ascia in a c o n in u o u s lay e r f ro m t h e su rf a ce o f th e m u scle .

w
Al ay s c arry t h e s calp e l in t h e dire c io n o f t h e m u s cle fi bre s , t
t v
an d ak e c a re t o le a e n o n e o f t h e f as c ia o n t h e su rf ace o f t h e
m u scle t
As t h e dire c io n o f t h e m u scle fi bre s c h an g e s , al e r t h e
. t
t
p o si io n o f t h e a rm t o k e e p t h e fi bre s wh ic h are be in g cle an e d o n
t h e s re c ht t I n th e c ase o f t h e lef t trap ez i u s t h e p re lim in ary
. ,

t t
in c isio n h ro u gh th e f ascia m u s be m ade alo n g t h e lo w e r m arg in
o f t h e m u scle , an d t h e su rf a ce o f t h e m u scle m u s be cle an e d, t
w v
f ro m be lo w u p ards, t o t h e le e l o f t h e se e n h ce r ical e rt e bra v t v v .

v
As t h e de e p f asc ia is re m o e d f ro m t h e rap e iu s, an d in de e d t z
t t w t
h ro u gh o u t h e h o le disse c io n o f t h e back , t h e cu an e o u s t
v
ner e s mu s t v
be c are fu lly p re se r e d, in o rde r h a t h e disse c o r t t t
v
o f t h e h e ad an d n e ck m ay h a e an O p p o rt u n i y o f e s ablish in g t t
t r t t wt t
h e i co n in u i y i h t h e ru n k s f ro m h ich h e y arise w t .

M Tra p ez ius — Th e
. . tra p e z iu s i s a flat tria n gu lar m u sc le
, ,

wh ich lie s, in its e n t ir e e x t e n t imm e d iat e ly su bjac e n t to t he


,

S t e rn o h -
y ido

FIG . 2 8 — U p p e r Su rface
. o f th e R ight C l v i l
a c e.

d e e p fa sc ia I t has a v e ry lo n g orig in wh ich e x t e n d s a lo n g


.
,

th e m e d ia n p la n e fro m th e o cc ip ut a bov e to th e le v e l o f th e
,

la st thorac ic v e rt e bra be low I t ar ise s fro m . the m e d ia l


th ird or le ss o f th e su p e r ior n ucha l lin e o f th e occ ipita l bo n e
an d th e e x t e r n a l occ i ita l rotu ra c ga m tu m
p p b e n e ( )
2 t h e li e n

n uch a an d t h e sp in e o f t h e se v e n th c e rv ica l v e rt e bra ; 3 ) th e


t ip s o f the Sp in e s o f all th e thorac ic v e rt e bra as w e ll as th e ,

s u p ra sp in ou s liga m e n t s wh ich br idg e acro ss th e in t e rva ls


be tw e e n th e m ( F ig s 2 6 .
,

I n th e lo w e r ce rv ical an d u p p e r th o racic re gio n s th e t e n din o u s fibre s by


wh ich the mu scle arise s le n g th e n o u t so as to fo rm a fl at te n do n , wh ich ,
t ak e n in co nj u n ctio n w ith th e co rre sp o n din g ap o n e u ro sis o f the o pp o sit e
x
side , e h ibits an o v al o u tlin e .

As th e fi br e s o f th e tra p e z iu s p a ss lat e ra lly t h e y co n v e rg e


t o th e ir in se rt io n s in t o th e two bo n e s o f th e sh o u ld e r g ird le -
.

Th e o ccipital an d upper cerv ical fibres in clin e dow n ward s, an d,


D I SSE C T I O N O F TH E B AC K 55

turn in g forward s o v e r the sh o u ld e r are in se rt e d in to th e ,

p o st e r ior b ord e r o f t h e lat e ra l th ird o f t h e c lav ic le ( F ig .

t he lo wer cervical an d upper tho racic fibres p a ss m or e o r le ss


tra n sv e r se ly to ga in an in se rt io n in to the me d ia l bord e r o f
t h e acr o m io n an d the u pp e r m arg in o f t h e p o st e r ior bord e r
o f t h e sp in e o f t h e sca p u la wh ile the lo w er tho racic fibres are
dir e ct e d u p ward s an d at the v e rt e bra l bo rd e r o f t h e sca p u la
, ,

e n d in a flat tr ia n gu lar t e n do n wh ich p lay s ov e r th e sm ooth


, ,

sur fac e at t h e a p e x o f t h e sca p u lar s in e an d is in se rt e d


p ,

in t o a rough tu be rc le o n t h e sp in e im me d iat e ly be yo n d that


sur fac e To ac tat m ov m t
( g 3 p
F i 8 . f ,ili e t.h e e e n o f t h e

t e n do n u po n the bo n e a sma ll bursa m uco sa is in t e rp o se d


be tw e en th e m .

The tra p e z iu s is su p plie d by the accesso ry nerv e an d by


twig s fro m t he third an d fo urth cervical nerves I t is an .

e le vator an d d e p r e ssor o f t h e sh o u ld e r ; an d a rotator an d

adductor o f the sca p u la .

i
D s e c tio n
s — Th lat i im u s do r i is n o w t o b di
. ect d It ss s e sse e .

is a diffi c lt m cl t u le an n t n ly n a c
us nt e f t h v ary i g
o c ,
o o o c o u o e n
dir ct i n o f it fi bre b t al o b a e its pp r p art is g
e o s s, rallyu s ec us u e ene
v ry t h i an d it u pp r b rd r ill d fi d N ar t h p i
e n, s ef o e -
e ne . e e s nes o
t h v rt bra it u pp r p rt i n is v e rlapp d by t h t rap z i
e e e s e b t o o o e e e u s, u
in it g r at r p art t h e m
s e ecle i bcu t an e s B t h th p r us s su o u . o e su e
fi ial a d t h de p f a ia sh o u ld b rai e d at t h sam t im f ro m
c n e e sc e s e e e
it s r f ace a d it s fi br s m ay b st re t h d by rai in g t h arm
s u ,
n e e c e s e
an d f o ldin g it u n de r t h e n e c k .

On t h e right s i de cu t h ro u gh t h e f as cia alo n g t h e u p p e r bo rde r t


o f t h e m u s cle f ro m t h e p o in h e re h a m arg in disapp e ars u n de r tw t t
t z
t h e rap e iu s t o t h e p o s e rio r f o ld o f t h e ax illa , an d w o rk do n t w
w ards D e fi n e c are fu lly t h e a t ac h m e n t o t h e su p e rfi c ial lay e r
. t t
o f t h e lu m bo do rs al f asc ia Cle an h a f ascia, bu t do n o t in j u re it
-
. t t
it is t h e p ro p e rt y o f t h e disse ct o r o f t h e h e ad an d n e ck Nex . t
tt t
de fi n e t h e a ac h m e n o f t h e lo w e r e n d o f t h e m u scle t o t h e c re s t
o f t h e iliu m ; an d wh e n t h e lo e r p art o f t h e la e ral bo rde r o f t h e w t
m u scle is re ac h e d, c le an t h e slip s o f t h e la issim u s h ic h are t w
t
a t ac h e d t o t h e lo w e s tt
h re e o r fo u r ribs, an d cle an also t h e slip s
o f t h e e x t e rn al o bliq u e m u scle o f t h e abdo m e n w h ic h in e r t
dig i a e t t wt
i h t h e co s al slip s o f t h e la issim u s do rsi t t .

On t h e lef t s i de cu t h ro u gh t h e f as c ia f ro m t h e c re s o f t h e t t
t
iliu m t o t he p o s e rio r f o ld o f t h e ax illa, an d w o rk m e dially an d
u p w ards an d w
h e n t h e m ain p art o f t h e m u scle h as be e n cle an e d,
re tu
rn t o t h e lo w e r p art o f t h e la e ral bo rde r an d disp lay t h e t
t t t
co s al a t ac h m e n s o f t h e m u s cle an d t h e in e rdig i a io n s o f t h e t t t
e xt e rn al o bliq u e .

t t
Af e r t h e co s al slip s o f t h e m u scle h a e be e n de fi n e d, e e r v v t
t h e u pp e r m arg in o f t h e m u sc le , a s it c ro ss e s t h e in f e rio r a n g le o f
t h e sc ap u la , t o disp lay t h e slip o f fi bre s w h ic h sp rin g s f ro m h a t t
a n g le an d j o in s t h e de e p asp e c o f t h e u p p e r bo rde r o f t h e m u scle t
t
it is ap t t o be m is ak e n f o r a p ie c e o f t h e e re s m aj o r u p o n w h ic h t
it lie s .

1— 4 0
56 THE SUPER I OR EXTRE M I TY
M L at issimus Do rsi — Th e lat issimu s
. dor si is a w id e flat ,

mu sc le wh ich cov e r s th e back fro m the le v e l o f th e Six th


,

th o rac ic v e rt e bra d o w n to the cre st o f t he iliu m ( F ig 2 6 p .


,
.

I t ar ise s— ( I ) fro m th e t ip s o f th e Sp in ou s p roc e sse s o f th e


low e r six thorac ic v e rt e br a an d t h e su p ra sp in ou s liga me n t s in
co n n e ct io n w ith th e m ( 2 ) fro m th e su p e rfic ial la me lla o f
t h e lu mbo dor sa l fa sc ia F ig 2 6 )
-

( 3) yb a th in t e n d in ou s or ig in .

fro m a sma ll e x t e n t o f th e out e r lip o f th e cr e st o f t he iliu m in ,

FIG 9 . Di g
2 .
— a ram o f t h e L u m bo do -
rsa lF asc a i .

1 . S e rra t u s
p i if i
o st e r o r n e r o r. 6 . F i a sc a t ran s e rsa v li s.

2 . L i im
at ss d i
us o rs .
7 . Sac ro sp n a i li s.

3 . T v
ra n s bd m i i
e rsu s a o n s. 8 .
Q uadrat u s l u mbo ru m .

4 . O bli q i u us n t e rn u s .
9 . P so a s ma j o r.

5 . O bli q x
uus e t e rnu s .

fro n t o f t h e lu mbo
dor sa l fa sc ia ( F ig 2 6 p 5 2 ) ( 4 ) by thr e e
-
.
,
.

o r four d ig itat io n s fro m the lo w e r thre e o r fo ur r ibs ; an d 5 )


by a fl e shy slip fro m t h e d o r sa l a sp e ct o f t he in fe r ior a n g le
o f t he sca p u la m a or g r
( F ig 3 8 p B y e n
. s o f it s i in f
, o m
.

t he p o st e r ior la me lla o f lu mbo d o r sa l fa sc ia it atta in s an in -

d ir e ct attach m e n t to th e spin e s O f the lu mbar an d u p p e r sacra l


v e rt e br a an d a lso to the p o st e rior p art o f t h e cre st o f the
,

iliu m . Th e c o sta l Slip s o f or ig in in t e rd ig itat e w ith t h e low e r


d ig itat io n s o f the e x t e r n a l o bliqu e mu sc le o f t he a bdo min a l
wa ll.

Th e fi br e s o f th e lat issim u s d o r si co n v e rg e ra p id ly as
D I SSE C T I O N O F TH E B AC K 57

th e y a pp roach the low e r p art o f th e sca p u la The h igh e st .

fi bre s p a ss a lm o st h o riz o n ta lly toward s that p o in t the lo w e st


fi br e s a sc e n d a lmo st v e rt ica lly ; wh ilst t he in t e r me d iat e
fi br e s Show vary in g d e gr e e s o f o bliqu ity As a r e su lt Of th e .

c o n v e rg e n c e o f fi bre s t he m u sc le is gre at ly r e duc e d in w idth


,

an d it sw e e p s ov e r th e in fe r io r a n g le o f th e sca u la in th e
p
for m o f a th ick fl e shy ba n d wh ich w in d s rou n d t h e low e r
, ,

marg in o f t he t e r e s m ajor mu sc le an d t e r m in at e s in a
'

n arr o w ,flat t e n d o n wh ich is in se rt e d in to the fl o or o f th e


,

in t e rtu be rcu lar su lcu s o f t he hu m e ru s ( F ig 4 5 p The .


,
.

in se rt io n ca n n ot be stud ie d at p r e se n t bu t w ill be se e n lat e r ,


.

With the t e r e s major m u sc le t he lat issim u s dor si for m s the,

p o st e r ior fo ld o f t he a xilla At first it is p lac e d o n the dor sa l


.

a sp e ct o f t he t e re s m aj o r th e n it is fo ld e d rou n d its low e r


,

bo rd e r an d fi n a lly it is in se rt e d in fro n t o f it
, To the .

p e cu liar r e lat io n sh ip o f the two m u sc le s is du e th e fu ll ,

rou n d e d a pp e ara n c e o f t he p o st e r ior ax illary fo ld .

The lat issim u s d o r si is su pp lie d by the tho raco do rsal n erv e -


.

I t is an adduct o r r e tract o r an d m e d ia l r o tator o f th e u p p e r


, ,

e x tr e m ity .

Tw o I nt e rmuscular Sp aces ( )
I A tr ia n gu lar
— sp ac e

m a pp e d o u t by t h e in fe r ior bord e r o f the tra p e z iu s the su p e r ior ,

bord e r o f t h e lat issim u s d o r si an d th e ba se o f the sca p u la, ,

Shou ld n o w be n ot ic e d i W ith i im i t
( g
F 2 6 p . n ,
t h e .l s Of

that tr ia n g le a sma ll p ort io n o f t he rho mbo id e u s major c an be


se e n an d a lso a vary in g a m o u n t o f t he wa ll o f th e thora x — a
,

p art o f t h e s ix th in t e rc o sta l S p ac e an d t h e b ord e r s o f t h e r ib s

wh ich bo u n d it a bo v e an d be lo w I t is w e ll to n ot e that .

th is is th e o n ly p art o f the th o rac ic wa ll o n the p o st e r io r


a sp e ct o f t h e tru n k wh ich is n o t cov e re d by mu sc le s ( 2 ) .

B e t we e n th e la st rib an d t h e cr e st O f t h e iliu m th e a n t e r io r
bo rd e r o f t h e lat issim u s d o r si g e n e ra lly ov e r la p s t h e
p o st e r ior bord e r o f th e e x t e r n a l O bliqu e m u sc le o f t he
a bd o min a l wa ll So me t ime s how e v e r a n arrow tria n gu lar
.
, ,

in t e rva l e x ist s be tw e e n th e t wo m u sc le s in wh ich is se e n a ,

sm a ll p art o f t h e in t e r n a l o bliqu e m u sc le That Sp ac e is .

t e r me d the trrgo nu m lu mbale ( P etiti) ( F ig 2 6 p I t is a .


, .

w e ak p art o f the wa ll o f th e a bd o me n an d occa sio n a lly so m e ,

O f t h e c o n t e n t s O f t h e a bdo me n are r o trud e d thr o ugh it


p ,

fo r min g a lu mbar hern ia .

D is s e c t i o n — R e fl e ct io n
. of t h e Trap e z m s —On t h e seco n d day
t
t h e disse c o r m u s be g in by t re fl e c in g t h e t
rap e iu s , t z w ki g
o r n ,
it
5 8 TH E SU PER I OR EXTRE M I TY
p o ssible , in c o n j u n c io n t wt
i h t h e disse c o r o f t h e h e ad an d n e ck t .

v t
D i ide t h e m u scle abo u t w o in c h e s f ro m t h e sp in e s o f t h e e rt e v
t t
bra , an d h ro w it la e rally , t o w ards it s in se rt io n Th e rap e iu s . t z
v t
is e ry h in at its o rig in , an d t h e g re a e s c are m u s h e re f o re be t t tt
tak e n n o t t o in j u re t h e su bj a ce n rh o m bo id m u s cle s Th e sm all t .

t
bu rsa be tw e e n t h e e n do n o f in se r io n o f t h e lo e r p ar o f t h e t w t
t z tt
rap e iu s an d t h e fl a e n e d ap e x o f t h e sp in e o f t h e s c ap u la m u s t
v
n o t be o e rlo o k e d, an d t h e n e r e s an d e sse ls o n t h e de e p su rf ace v v
o f t h e m u scle m u s t
be cle an e d an d p re se r e d Th e y are t h e v .

v
a c ce sso ry n e r e an d branc h e s o f t h e h ird an d f o u r h ce r ical t t v
v
n e r e s, t h e as ce n din g bran c h o f t h e ran s e rse ce r ical ar e ry , t v v t
an d bran c h e s o f t h e de s c e n din g bran c h o f t h e ran s e rse c e r ic al t v v
ar e ry t tt
Th e la e r p ass in o t h e rap e iu s f ro m be w e e n t h e
. t t z t
m u scle s o f t h e se co n d lay e r .

N e rv e s an d V e sse lsf Su p p ly t o t h e Trap e z i us — A dis


o .

se ct io n o f the d e e p sur fac e o f the r e fl e ct e d m u sc le w ill r e ve a l


t h e fo llo w in g structur e s

a The acce sso ry n e rv e


. .

b Two o r th re e n e rv e s fro m the c e rv ical ple u s


. x .

c The asce ndin g bran ch o f the t ran sv e rse ce rv ical arte ry


. .

d Tw ig s o f the de sc e n ding bran ch o f the tran sv e rse ce rv ic al


.

arte r y .

Th e se co n st itut e th e n e rvou s an d va scular su p ply o f th e


tra p e z iu s .

The n e rv e s hav e alr e ady be e n d isplay e d by the d isse ctor o f


t h e h e ad an d n e ck as th e y cro ss th e p o st e rior tr ia n g le o f th e
,

n e ck .Th e bra n ch e s fr o m th e c e rvica l p le x u s co me fro m th e


third an d fo urth cerv ical nerves On th e d e e p sur fac e o f th e .

tra p e z iu s th e y j o in w ith bra n ch e s Of the acc e ssory n e rv e to


for m t he su btrap ez ial plex u s fro m wh ich tw ig s p roc e e d in to t h e ,

su bsta n c e O f t h e m u sc le Th e t e r min a l tw ig o f th e accesso ry


.

nerve c an be trac e d n e arly to the low e r margin o f the


tra p e z iu s .

Th e ascen ding branch of the transverse cervical artery wh ich ,

acco mp a n ie s the acc e ssory n e rv e m u st be fo llow e d to the ,

a n t e rior bord e r o f the tra p e z iu s wh e r e it will be se e n t o ,

sp r in g fro m th e tru n k o f t he art e ry at t h e p o in t wh e r e it

d iv id e s in t o it s a sc e n d in g an d d e sc e n d in g bra n ch e s .

Th e t wigs fro m the descen ding branch of the transverse


cerv ical a rter y p ie rc e th e m u sc le s o f t h e se co n d lay e r or p a ss
be tw e e n th e m c lo se t o th e v e rt e bra l bo rd e r o f th e sca p u la
,
.

D is s e c t i o n — t
Th e p o s e rio r be lly o f t h e o m o hy o id, t h e ran s -
t
ve rse s cap u lar art e ry , an d su p ras c ap u lar n e r e m u s n o w be v t
v
disp lay e d, an d t h e cla icu lar an d sc ap u lar in se rt io n s o f t h e
t z
rap e iu s m u s be e x am in e d t
D i ide t h e rap e iu s in o an u p p e r . v t z t
60 THE S U P ER I O R EXTRE M I TY
ba n d wh ich ru n s p ara lle l to the u p p e r bo rd e r o f th e m ajor
rho mbo id I t sp rin g s fro m the lo w e r p art O f th e liga me n tu m
.

n uch a the Sp in e o f t h e se v e n th c e rv ica l v e rt e bra an d fr e qu e n t ly


, ,

a lso fro m th e sp in e o f t he fir st th o rac ic v e rt e br a I t is .

in se rt e d in t o t h e v e rt e bra l m arg in o f t h e sca p u la o p p o sit e


t h e tr ia n gu lar sur fac e at t h e flatt e n e d a p e x o f it s sp in e

( g 3 p
F i . 8 8 ,
I t is e.n t ir e l y cov e r e d b y t h e tra p e z iu s .

Th e rho mbo ideu s maj o r arise s fro m th e u pp e r fo ur o r fiv e


thorac ic sp in e s an d the corr e sp o n d in g p art s o f the su p ra spin ou s
,

liga m e n t s I t s fi br e s ru n o bliqu e ly d o w n ward s an d lat e rally


.
,

an d e n d in a t e n d in ou s arch wh ich is attach e d to th e ,

v e rt e bra l marg in o f the sca p u la fro m th e in fe rior a n gle to ,

t h e a p e x o f t h e sp in e Th e m a in attach m en t o f t he fi brou s .

arch is to th e in fe r ior a n gle bu t it is bou n d t o th e v e rt e bra l ,

bo rd e r fro m that p o in t to t h e sp in e by fa ir ly fi rm ar e o lar


t issu e ( F ig 3 8 p 8 . Th e gr e at e r p art o f th e rho mbo id e u s
,
.

m ajor is cov e r e d by t h e tra p e z iu s o n ly a sma ll p ort io n n e ar


th e in fe r ior a n g le o f t he sca p u la lie s im m e d iat e ly su bjac e n t
to th e d e e p fa scia .

M L ev at o r Sc ap ula — Th e le vator sca p u la is an e lo n


.

gat e d mu sc le wh ich ar ise s by four m o r e or le ss t e n d in ou s , ,

slip s fro m t h e p o st e r ior tu be rc le s o f t h e tra n sv e r se p roc e sse s

o f t h e u p p e r four c e rv ica l v e rt e br a I t p a sse s dow n ward s .

an d backward s to be in se rt e d in to t h e v e rt e bra l m arg i n O f

th e sca p u la fro m t h e m e d ia l a n g le to th e sp in e
,
I t is su pp lie d .

by bra n ch e s fro m th e third an d fo u rth cervical n erves .

D is s e c t i o n — Cl an t h l v at r s ap la t k in g ar n o t t o e e e o c u ,
a c e
in j r t h
u e rv w h ich s p p ly it Th m u cl b l n g p art ly to
e ne es u . e s e e o s
t h di e t r f th h e ad a d n k n d p a tly t th di ct r o f
sse c o o e n ec a r o e sse o
the p ri rsu t r m it y W h n b t h f t h m h av st di d its
e o ex e . e o o e e u e
att a h m n t an d n rv
c e pp ly t h m s l m u t b div id d at
e e - Su ,
e u c e s e e
th e m iddl f it l g t h Th l w r h alf i t h n t b t rn e d
e o s en . e o e s e o e u
do w w rd a d lat rally t o it i
n a s rt i
n a d th d rsalis cap la
e s n se o n, n e o s u
n rve a d th
e d di g bra h
n ef th t ra v r c rvical
e sce n n nc o e ns e se e
art ry w h i h li
e , d p to th m c l ar to b p r
e ee rv d a d e u sc e , e e e se e n
f ll w d t t h
o o pp r m rg i o f t h rh m b ide s m i
e o e u e r a n e o o u no .

N t t t h r u gh t h rh m b id fr m b v do w n w ard
ex cu o e o o s, o a o e s,
m idw ay b tw e th s ap la a d t h
e pi
en f t h v rt bra ;
e c u n e s nes o e e e
r m m b r t h at t h y ar v ry t h i
e e e n d t ak ar e t t i j u r th e e n, a e c e no o n e e
s rrat
e p st ri r us p rio r wh i h i imm di t ly s bj a
o e o su t to
e ,
c s e a e u ce n
t h m Tu r th m dial p rt f h m s l t w ards th v rt bral
e . n e e a o e ac u c e o e e e

sp in a d v rify it
e att a h m
n t T r t h lat ral p art t o w ards
e s c en . u n e e s
th c ap u la an d f ll w t h
e s d r alis ap la n rv o n d tho e o s sc u e e a e

de din g bra c h
sc e n f th t ra v rs rv i al art ry t
n ot h ir e ns e e ce c e o e
t rm in at i n s Th n rv g iv bran h t o th l v t r ap la
e o . e e e es c es e e a o sc u

an d t b t h t h rh m b id m
o o l an d t h art ry
e oo t n ly p p li
o u sc e s , e e n o su es

t h e rh o m bo id b t al t h adj a n t m s cl un th s ap la so e ce us es o e c u .
D I SSE C T I ON OF TH E B AC K 61

N e rvu s Do rs a li s Sca p ula ( O T N e rv e t o t h e Rh o mbo ids) . . .

Th is lo n g sle n d e r n e rv e arise s, in th e n e ck, fro m the fi fth


c e rv ica l n e rv e , u sua lly in co mm o n w ith t he u p p e r r o ot o f
th e lo g thorac ic n e rv e
n I t p ie rc e s th e sca le n u s m e d iu s
.
,

an d p a sse s dow n ward s u n d e r c o v e r o f the le vator sca p u la


, ,

to th e d e e p surfac e o f the rho mbo id e i mu sc le s I t e n d s in .

tho se mu sc le s bu t it su pp lie s a lso o n e or two tw ig s to the


, , ,

le vator sca p u la .

Th e root tw ig s o f o r ig in o f t h e d o r sa lis sca p u la n e rv e


so m e t ime s p ie r ce t he le vator sca u la se p arat e ly a n d th e n
p ,

u n ite in a ple x ifor m m a n n e r .

R amus Desc en de n s o f t h e Art Tran sv e rsa Co lli ( O T . . .

P o st erio r Sca p ular Art e ry ) — The d e sc e n d in g bra n ch o f the .

tra n sv e r se c e rv ica l art e ry tak e s or ig in in the low e r p art o f


t h e n e ck c lo se to t h e lat e ra l m arg in o f t h e le vator sca p u la .

At fir st it ru n s m e d ia lly u n d e r cov e r o f th e le v at o r sca p u la


.
,

bu t it so o n cha n g e s it s d ir e ct io n an d th e n ru n s dow n ward s


a lo n g th e v e rt e bra l bord e r o f the sca p u la u n d e r cov e r o f the ,

rh o mbo id mu sc le s ( F ig 2 6 p I t g iv e s n u me r o u s bra n ch e s
.
,
.

t o bo th t h e c o sta l an d dor sa l a sp e ct s o f th e sca p u la an d it s ,

t e r min a l tw ig s m ay e n t e r the lat issim u s dor si O n e larg e .

bra n ch u sua lly p a sse s backward s in th e in t e rva l be tw e e n t he ,

rho mbo id mu sc le s o r through th e gr e at e r rho mbo id to r e ach ,

th e tra p e z iu s m u sc le ; an d a n oth e r bra n c h t he sup rasp z n al


, ,

is g iv e n to t h e su p ra sp in atu s m u sc le an d t h e stru ctur e s


su p e rfic ia l t o it .

D is s e c ti o n — R e fl e ct io n o f t h e L a issim u s D o rsi an d t h e t
v
re m o al o f t h e Su p e rio r Ex t re m i y —D iv ide t h e la issim u s do rs i t . t .

v
Co mm e n ce t h e di isio n at t h e u p p e r bo rde r h re e in c h e s f ro m t h e t
v e rt e bral sp in e , an d c arry t h e k n ife o bliq u e ly do w n ards an d w
t
la e rally t o a p o in j u s be lo t t
w h e re t h e las dig i a io n o f t h e w t t t
m u scle sp rin g s f ro m t h e las rib t
R e m e m be r h a t h e m u s cle is . t t
t h in an d do n o t in j u re t h e p art s su bj ace n t o it Tu rn t h e t .

t
m e di al p o rt io n o w ards t h e e rt e bral sp in e s, ak in g c are n o t t o v t
t t
in j u re t h e se rra u s p o s e rio r in f e rio r in t h e re g io n o f th e lo w e r
v
f o u r ribs , an d e rif y th e o rig in o f t h e m u scle f ro m t h e sp in e s
an d s u p rasp in o u s lig am e n s , lu m bar f ascia an d iliac c re s t t .

Th ro w t t
t h e la e ral p ar o f t h e m u s cle la e rally an d f o r ards , t w
cle an t h e de e p su rfa ce s o f t h e slip s a a c h e d t o t h e lo w e r h re e tt t
o r f o u r ribs, an d n o t e t t t
h a h e y in e rdig i a e w i h t h e e x t t t t
t e rn al o bliq u e m u scle o f t h e abdo m e n At t h e in f e rio r an g le .

o f t h e s cap u la fi n d t h e t
h o raco do rsal n e r e an d t h e h o raco -
v t
do rs al a r e ryt Th e y su pp ly t h e m u s cle an d e n e r its de e p
. t
su rf ac e .

v
Th e R e m o al o f t h e Su p e rio r Ext re m i y D i ide t h e t v
v
t ran s e rse scap u lar a rt e ry an d t h e su p rascap u lar n e r e an d t h e v
62 THE SUP ER I OR EXTRE M I TY
t
p o s e rio r be lly o f the o mo -
hy o id at th e u pp e r bo rde r o f th e
scap u la .

( ) 2 D i id e t h e v d o r s a l s c a p u la r n e r e a n d t h e d e s ce n d in g v
t v
bran c h o f th e ran s e rse ce r ic al ar e ry n e ar t h e m e dial an g le o f v t
t h e s cap u la .

P v
(3 ) u ll th e e rt e bral bo rde r o f t h e scap u la a w ay f ro m t h e
t
ribs t o e x p o se t h e p o s e rio r p ar o f t h e se rra u s an e rio r o n t h e t t t
t
c o s al su rf a ce o f t h e s c ap u la .

(4 ) C u t h r o u gh t t
h e p o s e ri o r p a r o f t h e se rra u s a nt e r io r f ro m t t t
its u pp e r t o its lo w e r bo rde r abo u o n e in c h f ro m t h e e rt e bral t v
m arg in o f t h e s cap u la .

( 5 ) P u ll th e scap u la s ill fu r h e r a ay f ro m th e h o rax an d t t w t


v v
di ide t h e ax illary e sse ls an d n e r e s at t h e o u e r bo rde r o f t h e v t
t
fi rs rib .

( 6 ) D e a c h t h e t a n e r i o r s k i t
n fl ap p re io u sly s i c h e d t o t h e v tt
t
an e rio r all o f t h ew t
h o rax , an d ak e t h e lim b to th e able t t
p r ov id e d ,
h e re t hwe f u r t h e r di sse c io n is t o b e c o m p le ed t t .

v
Tie th e di ide d ax illary e sse ls an d n e r e s t o a p ie ce o f o o d, v v w
abo u t m m ( 1 5 in c h e s) lo n g , in h e ir p ro p e r o rde r ( a p ie ce o f
. t
a bro k e n p e n h o lde r w ill se r e t h e p u rp o se ) , an d h e n by m e an s v t
o f a lo o p fi x t h e w
o o d t o t h e co ra co id p ro c e ss ; by h a m e an s t t
v
t h e e sse ls an d n e r e s v w
ill be re aine d in h e ir p ro p e r re la io n t t t
s h ip s du rin g t h e fu rt h e r s ag e s o f disse c io n , an d t
h e y can be t t
re le ase d f ro m t h e c o raco id p ro c e ss w h e n it is n e ce ssary t o
e x am in e an y h in g t
h ic h lie s be h in d h e m w t .

t
A f e r t h e su p e rio r e xt re m i y h as be e n se p ara e d p ro ce e d t o t t
v
re m o e t h e w h o le o f t h e sk in h ic h co e rs it h ils t h e su b w v w t
t t
cu an e o u s issu e s are s ill in g o o d co n di io n , an d in o rde r h a t a t t t
v
g e n e ral ie w o f th e cu an e o u s e in s an d n e r e s m ay be o b ain e d t v v t .

t
Th e m ain cu an e o u s e in s c arry blo o d t o t h e ax illary e in , an d v v
t v
t h e cu an e o u s n e r e s are e i h e r dire c bran c h e s o f t h e brac h ial t t
p le xu s o r h e y sp r t
in g f r o m t h e m a in e rm in al bran c h e s o f t h e t
p le x u s Th e fo llo win g s e p s m u s be ak e n t
( I ) p lac e t h e lim b t t

"
.

t t
o n it s p o s e rio r asp e c ; ( 2 ) m ak e an in cisio n alo n g t h e an e rio r t
asp e c t
f ro m t h e re g io n alre ady de n u de d t o t h e t ip o f t h e m iddle
fi n g e r (F ig ( 3 ) m ak e a ran s e rse in cisio n at th e
. ris t v w t
t v
(4 ) a ran s e rse in c isio n at t h e p ro x im al e n ds o f t h e fi n g e rs ;
.

( 5 ) an o bliq u e in cisio n f ro m t h e m iddle o f w ris to t h e t ip t


o f the t
h u m b ; ( 6 ) in cisio n s alo n g t h e m iddle o f th e in dex ,
t h e rin g , an d t h e li le fi n g e r tt
Tu rn t h e la e ral fl ap s 3 an d 5 . t
t
(F ig 5 ) la e rally , t h e m e dial fl ap s 4 an d 6 m e dially ro u n d t h e
.

tv
re sp e c i e m arg in s o f t h e lim b, an d h e n disse c h e m fro m t h e t tt
do rsal asp e c t t
Tre a t h e fl ap s 5 an d 7 an d h o se o f t h e fi n g e rs
. t
in t h e sam e w ay , an d disse c fl ap 6 dis ally t o t h e an g le be tw e e n t t
t
th e h u m b an d t h e in de x fi n g e r .

Tak e g re a c are t w
h ils re m o in g the fl ap s n o t to in j u re t h et v
t
cu an e o u s v
e sse ls an d n e r e s v
h ic h lie in th e su p e rfi cial f ascia w
t
im m e dia e ly su bj ac e n t o t h e sk in t .

t t
N o e t h a t h e sk in is re adily se p ara e d f ro m th e su p e rfi c ial t
f asc ia in t h e arm an d f o re arm an d o n t h e do rsal asp e c o f t h e t
t
h an d I t is sligh ly m o re adh e re n o e r t h e e p ico n dy le s o f th e
. t v
h u m e ru s an d t h e O le cran o n I n t h e re g io n s o f t h e p alm an d th e .

v t
o lar asp e c s o f t h e dig i s. t h e sk in t
an d su p e rfi c ial f asc ia are
'

t t
c lo se ly adh e re n , f o r h e re t h e sk in is bo u n d t o t h e de e p f ascia
t w
by fi bro u s s ran ds h ic h p ass h ro u gh t h e su p e rfi c ial f ascia t
In .

th e u ln ar p art o f th e p alm , abo 2 5 mm dis al t o t h e ris , ut . t w t


D I SSE C T I O N O F SU PER F I C I AL STRU C T U RE S 63

so m e m u scle fi bre s w ill be bro u gh t in t o v ie w ; t h e y co n n e ct the


s k in o n t he u ln ar m arg in o f t h e p alm w it h t h e de e p f as cia ,

an d co n st it t e th p almaris bre is m uscle


u e v .

W h n t h e k in i
e m p l t ly r m v d it m u t n t be t h r wn
s s co e e e o e s o o
aw ay b t m st b u k p t to be w rapp d r n d th p art wh r e t he
u e e e o u e e
dis ct io n i n o t p r o
se di g
s ce e n .

Cu t a e o u s V e in s o f t h Su p rio r Ext re m it y — Af t r t he sk in
n e e . e
h as b n r m o v d p r c d t o di p lay t h
ee e e t an o s v in s be a
o ee s e cu e u e ,
c u se
t h y ar
e p t h r an d t h r t h m st s p e rfi cial st ru ctu re
e, e x ce e e e e, e o u s,
b t b car f l t p r s rv an y n e rv s m e t w it h as t h e v i
u e e u o e e a re e e e ns
be in g cle an e d (F ig s 3 1 , .

t v
Co mm e n ce at t h e in e r al be tw e e n t h e p e c o ralis m aj o r an d t
t
t h e de l o id an d f o llo w
t h e ce p h alic e in dis ally , be in g care fu l t o v t
v t
p re se r e t h e ribu arie s w h ic h j o in it t At t h e be n d o f t h e e lbo . w
se cu re a larg e c o m m u n ica in g bran c h calle d t h e me di an cu bi tal t
ve i n ; it ru n s o bliq u e ly , p ro x im ally , an d m e dially , an d j o in s th e
t
bas i li c ve i n , abo u 3 0 mm p ro x im al t o t h e le e l o f th e m e dial . v
e p ico n dy le Th e m e dian cu bi al e in is j o in e d at its dis al
. t v t
bo rde r by a e in v w
h ic h p ie rce s t h e de e p fascia an d co n n e c s t h e t
t v wt
m e dian cu bi al e in i h t h e de e p e in s o f t h e f o re arm Af e r v . t
t v
t h e m e dian cu bi al e in an d its co n n e c io n s h a e be e n disp lay e d, t v
v
f o llo w t h e ce p h alic e in dis ally , alo n g t h e f o re a m an d ro u n d its t r
radial m arg in , t o t h e do rsu m o f t h e h an d h e re it co m me n ce s, w
t t
do rsal t o t h e fi rs m e acarp al bo n e , in t h e radial e xt re m i y o f t h e t
do rsal ven o us arch Th e do rsal e n o u s arc h c o sse s t h e do rsu m
. v r
o f t h e h an d, f ro m t h e r
adial t o t h e u ln ar side , an d at its u ln a r
e n d, w t
h ic h lie s Opp o si e th e in e rsp ace be e e n t h e f o u rt h an d t tw
t t
fi f h m e acarp al bo n e s, t h e basi li c vei n co mm e n ce s F o llo . w
t h e bas ilic e in p ro x im allyv I t p asse s at fi rs alo n g t h e do rsal . t
t
asp e c o f t h e u ln ar bo rde r o f t h e f o re arm , h e n u rn s ro u n d t h e t t
u ln ar bo rde r t o th e fro n , an d asce n ds t o t h e arm , t
h e re it is w
j o in e d by th e m e dian cu bit al e in alre ady disse c e d F o llo t h e v t . w
bas ilic v
e in p ro x im ally be y o n d its j u n c io n i h t h e m e dian t wt
cu bi al t v
e in t o t h e m iddle o f t h e a rm h e re it p ie rces t h e w
v
de e p f ascia, at t h e le e l o f th e in se rt io n o f t h e c o raco - brac h ialis
m u scle As y o u cle an it , in t h e lo e r p art o f t h e arm , lo o k f o r
. w
so m e su p e rfi cial cu bi al lym p h g lan ds t
h ic h lie in th e su p e rfi cial w
t
f ascia ; a li t le p ro x im al t o t h e e lbo w h e y re ce i e lymp h f ro m th e t v
t r
fi n ge rs, p alm , an d t h e an e io r asp e c o f th e f o re arm , an d are ap t t
t o be co m e in flam e d an d p ain fu l h e n o u n ds o f h o se p art s w w t
be co m e se p ic t
Th e ce p h alic an d t h e basilic e in s re ce i e ribu
. v v t
t arie s , w v
h ic h ary in n u m be r an d si e , bo h fro m the do rsal an d z t
v
t h e o lar su rf ace s o f t h e f o re arm an d h an d .

W h e n t h e ce p h alic an d basilic e in s an d h e ir m ain ribu arie s v t t t


v r t
h a e be e n cle an e d, e u rn to th e do rsu m o f th e h an d, cle an th e
v
do rsal e n o u s arc h an d t h e ribu arie s h ic h p as s t o it f ro m t h e t t w
t t
dig i s ; h e y are ( I ) three do rsal m e tacarp al vei n s , o n e o pp o si e t
e ac h o f t h e t
h re e m e dial in e rdig i al cle f s ; (2 ) t h e h radial do rsal t t t
t v
dig i al e in f ro m t h e in de x fi n g e r On t h e do rsu m o f e ac h dig i . t
lo o k f o r t wo do rsal digi tal vei ns , o n e alo n g t h e radial an d o n e
alo n g t h e u ln a r bo rde r Th e do rsal dig i al e in s o f t h e h u m b
. t v t
v
j o in t h e ce p h alic e in t h e u ln ar do rsal dig i al e in o f t h e li t le t v t
fi n ge r u su ally j o in s th e basilic e in ; t h e o t h e r do rsal digi al v t
v t t
e in s e rm in a e in t h e do rs al m e acarp al e in s Th e tw o do rsal t v .

t v
dig i al e in s o n e ac h fi n g e r are u n i e d by m an y c h an n e ls h ic h t w
f o rm a se rie s o f arc ades, t h e do rsal digi tal ven o u s arche s Th e .
TH E SUPER I OR EXTRE M I TY
su p e r c ial fi v t h e do rsu m o f th e h an d c o m m u n ica e h ro u gh
e in s o n t t
t h e in t t t
e rdig i al c le ft s w i h t h e de e p an d su p e rfi cial e in s o f t h e v
p alm .

The su p e rfic ial v e in s o n t he v o ar aspe c ts o f the fin g e rs an d in the p alm l


are sm a ll
a n d c an n o t as a ru le be disp ay e d in an o rdin ary disse c tio n , bu t ,
, l
sprin gin g fro m a n e t w o rk in th e su p e rfi cia fascia o f th e p a m , o r ap p e arin g l l
in the s u p e rfic ial fascia of t he v o lar asp e c t o f the w rist , t h e re is o cc asio n a y ll
a m edia n a n tebrac/z z a / v e in wh ic h p asse s p ro im al y , a o n g t he m iddle

x l l
o f t h e v o lar as pe c t o f t he fo re arm , t o w ards t h e e lbo w A sh o rt distan c e .

l l
dista to t he e bo w it e ith e r j o in s the m e dian c ubital v e in o r it div ide s
in to t wo bran ch e s, the m e dian basi ic an d the m e dian ce p h alic , wh ich l
t e rm in at e re spe c tiv e ly in th e basilic an d c e ph alic v e in s .

Acco m p any ing t he v ario u s su pe rfi cial v e in s o f the su pe rio r e t re m ity x


t h e re are n u me ro u s ly m ph v e sse s wh ic h co le c t ly mp h fro m t he re g io n s l l
drain e d by t he v e in s Th o se wh ich ac co mp an y the p ro im al part o f the
. x
c e p h alic v e in , an d wh ich are de riv e d p art y fro m the do rsu m o f th e l
l
fo re arm an d p art y fro m t he do rsu m o f t he arm an d the late ral part o f
th e sh o u lde r, p ass to the de lto p e c to ral an d in fraclav icu lar ly m ph g lan ds ;
-

l
so m e o f th e y m ph v e sse ls wh ic h acco m pany the basi ic v e in e n d in the l
su p e rfic ial c u bital g lan ds, abo v e the m e dial e p ico n dy le t h e re m ain de r, an d
t h e e ffe re n ts o f t h e su p e rfi cial c u bital g lan ds, ac co m p an y t he pro im a p art x l
l
o f the basi ic v e in , an d, afte r p ie rc in g t he de e p fasc ia , th e y te rm in at e e it h e r

l
in the brach ial g an ds o r the a te ra g ro u p o f a il ary g lan ds ( F ig l l x l .

l
The su pe rfic ia ly m ph g lan ds c an o fte n be fo u n d by a c are fu l disse cto r,
ll
bu t t h e su p e rfic ia y mp h v e sse ls are diffic u lt t o de m o n strat e in an o rdin ary
disse c tin g ro o m T h e y app e ar as fi n e wh it e stran ds, an d are m o st

art
p
-
.

l
e asi y distin g u ish e d as th e y e n te r o r le av e th e g an ds l .

V ena Ce p h a lic a
c e p ha lic v e in co mme n c e s at t he
.
— Th e
rad ia l e n d o f th e v e n ou s arch o n t he dorsu m o f th e ha n d .

I t r e c e iv e s th e t wo dor sa l d ig ita l v e in s fr o m the thu mb an d ,

th e n tur n s rou n d the rad ia l bo rd e r o f the d ista l p art o f the


fo r e ar m an d a sc e n d s to t he r e g io n o f th e e lbo w ; th e r e t h e
gre at e r p art o f t he blo od wh ich it carr ie s is tra n sm itt e d to the
ba silic v e in by t h e larg e m e d ia n cu bita l v e in Pro x ima l to .

t h e le v e l o f th e m e d ia n cu bita l v e in th e c e p ha lic v e in a sc e n d s ,

e ith e r a lo n g t h e lat e ra l p art o f t h e bic e p s o r in t h e gr o o v e ,

at the lat e ral bord e r o f the bi c e p s t o the low e r bo rd e r o f th e ,

p e ct o ra lis m ajor ; th e r e it p ie rc e s t h e d e e p fa sc ia F ig
( an d .

th e n co n t in u e s p ro x imally in the gr o ove be tw e e n the p e ct o ra lis


major an d th e d e lto id t o the de lto p e ct o ra l tr ia n g le I n t he -
.

de lto p e ctora l tr ia n g le it cr o sse s the lat e ra l p art o f th e p e ctora lis


-

min o r an d tur n s me d ia lly be tw e e n th e clav icu lar p art o f the


,

p e ct o ra lis m aj or an d t h e co sto corac o id me m bra n e I n th is -


.

t e r min a l p art o f its c o ur se it lie s a n t e r io r to th e a x illary art e ry ,

bu t is se p arat e d fro m the art e ry by t he c o st o coraco id me m -

bra n e F in a lly it p ie rc e s t h e c o sto corac o id m e m bra n e an d


.
-

j o in s the a xillary v e in I t r e c e iv e s ( r) th e dor sal d ig ita l v e in s


.
D I SSE C T I O N O F SU PER F I C I A L STR U C TU R E S 65

f th e thu mb, ( 2 ) t ribu tarie s f ro m th e vo lar an d d o r sa l a sp e ct s


o f t h e fo r e ar m, tr utar ro m at ra dor a
(3 ) ib ie s f t h e l e l an d s l
a sp e ct s o f the arm, ( 4 ) a tributary fro m t he sid e o f the shou ld e r,
an d imm e d iat e ly be fo r e it p ie rc e s th e co sto c o rac o id -

me mbra n e , it is j o in e d by t he v e n a c o mit e s o f th e d e lto id an d


acro mia l bra n ch e s o f th e thoraco acr o mia l art e ry I t is -
.

acc o mp a n ie d by ly mp h v e sse ls fro m t h e dor su m o f the ha n d ,


an d t h e lat e ra l an d d o r sa l sid e s o f t h e for e ar m an d arm ;

tho se v e sse ls t e r min at e in th e de lt o p e ct o ral ly mp h gla n d s


-
.

Ve na B asili ca — Th e ba silic
v e in c o mme n c e s at th e u ln ar
e n d o f th e dor sa l v e n ou s arch o f t h e ha n d I t r e c e iv e s t h e
.

dor sal d ig ita l v e in fro m th e u ln ar sid e o f the lit t le fi n g e r an d


th e n a sc e n d s o n the u ln ar p art o f t he dorsa l sur fac e o f t he
fo r e ar m B e low th e e lbow it tur n s rou n d th e u ln ar bo rd e r
.

o f t he for e ar m an d a s c e n d s t o t h e gro o v e a lo n g t h e m e d ia l

bord e r o f t h e bic e p s brachn Abo ut 3 0 mm a bov e t h e


. .

m e d ia l e p ico n dy le it is jo in e d by th e m e d ia n cu bita l v e in ,

th e n it co n tin u e s p ro xima lly to the le ve l o f t he midd le o f t he


arm wh e r e it p ie rc e s t h e d e e p fa sc ia
, Aft e r it has p ie rc e d
.

t h e d e e p f a sc ia it ru n s a lo n g t he m e d ia l sid e o f t h e brach ia l
,

art e ry to the low e r bord e r o f the t e r e s major wh e r e it be co me s ,

t h e a x illary v e in ; o n ly t he t e r m in at io n o f th is p art o f t h e
v e in can be se e n at p r e se n t the r e ma in d e r w ill be dis
,

p l ay e d in a lat e r d is se ct io n T h e
. tr ibutar ie s o f t h e ba silic

v e in are ( I ) the u ln ar dor sa l d ig ita l v e in o f th e litt le fi n g e r ,

( )
2 tr ib utar ie s fro m t h e vo la r an d d o r sa l a sp e ct s o f t h e fo r e

arm , (3) t h e m e d ia n cu b ita l v e in


( )
4 tr
, ib utar ie s f r o m t h e

m e d ia l an d p o st e r ior p art s o f th e arm I t is acco mp a n ie d


.

by ly mp h v e sse ls fro m th e d o r su m an d pa lm o f t h e ha n d
an d t h e vo lar an d dor sa l a sp e ct s o f th e for e ar m So me .

o f t h e acco m p a n y in g ly m h v e sse ls e n d in t h e su p e rfic ia l


p
cu bita l g la n d s wh ich lie p ro x ima l t o the me d ia l e p ico n dy le
,
.

O th e r s p a ss d ir e ct ly to the brach ia l an d the lat e ra l a x illary


gla n d s .

V e n a M e dian a Cubit i — The m e d ia n cu bita l v e in is a


. .

larg e co m mu nicat in g v e in wh ich sp r in g s fro m t he c e p ha lic


v e in a bout 2 5 mm be low th e be n d o f the e lbo w an d
.
,

t e r min at e s in the ba silic v e in 3 0 mm a bov e the m e d ia l .

e p ico n dy le As it cr o sse s fro m t h e c e p ha lic t o t h e ba silic


.

v e in it r e c e iv e s tr ibutar ie s fro m th e vo lar a sp e ct o f t h e


fo r e ar m it is se p arat e d fro m t h e d ista l p art o f th e brach ia l
,

art e ry by a th ick e n e d p ort io n o f d e e p fa sc ia ca lle d the


V OL . 1— 5
66 TH E SU P ER I O R EXTRE M I TY
lacertu s fi bro su s,
1
an d it is cr o sse d th e r d e e p ly o r su p e r
ei

fi cially by th e v o lar bra n ch o f t he m e d ia l cuta n e ou s n e rv e o f


t h e for e ar m ( F ig .

Th e Ly mp h V e sse ls an d L y mp h Glands o f t h e Su p e rio r Ex t re mit y .

x
W ith the e ce p tio n o f a fe w ym p h v e sse s wh ic h the disse cto r m ay h av e l l
Ju g u l l y mp h
ar

l vi l
S u bc a an
I n frac a l v i l l y mp h g ]
cu ar '
I n t e rn a lj g l v i
u u ar e n

S u bc lav ia n v e in

I i
nn o m n a t e v e n i
l l y mp h g l di as t m a l
gfigi p

h

D e lt o p e c t o
-
ra an ds,
r

y
L mp h v e sse s l i
wh ch ac c o m p a n y
t he ce p h a c e n

li v i

A xill y l y mp h gl
ar a n ds

L y mp h v l whi
e sse s c h ac c o mp a n y
h b ili v i
t e as c e n

l y mp h gl an ds

FIG .
3o .

Di agra m o i l
f th e S u p e rfic a L ym p h Ve sse s l an d L ym ph G l an ds o f
t he Ri i
gh t Su p e r o r E tre m ty x i .

fo und
p assin g t o an d fro m th e a il ary lym p h g lan ds ( p x l . th e l m p y
h
v e sse ls o f the su p e rio r e tre m ity can n o t be di sp ay e d in x l an o rdin ary
disse c tin g ro o m
p t,
a r
!
an d it is o n ly o cc asio n al y in th e
-
l h o spital , th e
p o st -
mo rte m ro o ll
m , an d in sp e cia y p re p are d su bj e c t s th at an o
pp o rt u n ity
fo r se e in g t he l ym ph v e sse ls w ill o ccu r I t is u n fo rtu n ate th at th is sh o u d
. l
1
Th e st re n gt he n i ng fi bre s f theo l ace rt u s fibro su s are de r iv ed fro m t h e
t e n do n o f i i
n se rt o n o f th e i
b ce p s brac h ii .
68 TH E SU PER I OR EXTRE M I TY
The sup erfi cia l ly ncp /z gla n ds are t he su pe rficial cu bital glan ds wh ich lie
in the fat o f the fro n t o f t he m e dia side o f th e arm imm e diate ly p ro im al l x
l
to the m e dia e pico n dy le ( se e p .

The lym ph fro m the sk in an d su bcu t an e o u s tissu e s o f the su p e rio r


x
e t re m ity fo rm s t w o m ain stre am s ( ) F ro m the pa m , the u n ar bo rde r . I l l
an d the u ln ar art o f the do rsal su rface o f the h an d, the g re ate r art o f th e
p p
fro n t , the u ln ar bo rde r, an d th e u nar p art o f the do rsa su rfac e o f the fo re l l
arm , it fl o w s th ro u gh a se rie s o f su e rficia
p y m p h v e sse ls wh ich acco m p an y ll
th e tribu tarie s an d t he dist a part o f the tru n k o f the basi ic v e in t o the l l
l
su p e rfic ia c u bital g lan ds The e ffe re n t v e sse ls fro m the su pe rfi cial cu bital
.

g lan ds, re in fo rce d by ym ph v e sse s fro m the m e dia part o f the arm , l l l
ac c o m an y the
p p ro im a p a x l
rt o f th e basilic v e in t h ro u gh the de e p fascia ;

so m e o f th e m e n d in the brach ia g an ds, bu t th e m aj o rity pass to the l l


x l
late ral a il ary g an ds l
( 2 ) The se co n d st re am flo w s fro m the radial part
.

o f th e do rsal as e ct o f t he h an d, t he radial bo rde r, an d th e radial


p p art o f
t he p o ste rio r su rfac e o f th e fo re arm an d the lat e ra p art o f the arm , th ro u gh l
p l
a se rie s o f y m h v e sse ls wh ic h ac co m any th e ce ph a ic v e in
p T h ey e n d l .

l
in the de lto pe c to ral g an ds, wh ic h re ce iv e lym ph a so fro m the re g io n
-
l
o f the sh o u lde r Th e lym p h fro m the late ral a illary g lands an d the
. x
de lto pec to ral g lan ds p asse s t o th e in fraclav icu lar g lan ds , an d th e n ce o n the
-

p l
righ t side t o t he righ t y m h du c t , an d o n th e le ft side to t he th o racic du ct .

The ly mph fro m th e de e p an d su pe rficial p arts o f the scapu ar re g io n l


flo w s mainly to the po ste rio r a i ary g lan ds, an d th ro ugh th e m to the in fra x ll
c lav ic u la r g lan ds Th e su p e rficia an d de e p ly m ph v e sse ls o f the an te rio r
. l
x l
a il ary re gio n h av e a re ady be e n trac e d l
Th e y c arry ly m ph p artly to the .

x
an t e rio r a illary a n d in t e r e c to ral g an ds, wh e n ce it p asse s t o t he in fra
p l
c lav icu lar g lan ds , an d
p l
art y dire c t y to th e in frac lav icu lar g lands, bu t th e y l
also co n v e y it t o the st e rn a ly m h g lan ds, an d th e y co mm u n ic ate w ith th e
p l
l
ly mph v e sse s o f t he u pp e r an d an te rio r p art o f the abdo m e n ( se e p 1 7 .

an d F ig .

Wh en u p e rfic ia l v e in s an d th e ir co n n e ct io n s hav e
the s

be e n c le a n e d an d stud ie d th e cuta n e o u s n e rv e s o f th e ,

su p e r ior e x tr e m ity m u st be fo u n d an d c le an e d ; th e y are


'

v
- The po ste rio v icu lar n e rv e s
r su prac la .

p The in te rco sto brach ial n e rv e -


.

o
a The m e dial cu tan e o u s n e rv e o f the arm
To th e sk in o f the arm
g
.

-
The late ra l brach ial cu t an e o u s n e rv e
.

F- .

n
L
Th e po ste rio r c u t an e o u s n e rv e o f t h e
arm .

The m e dial cu t an e o u s n e rv e
\
0 o f th e
fo re arm . To th e sk in o f th e arm an d

v The do rsal cu tan e o u s n e rv e o f t he t h e fo re arm .

fo re arm .

8 Th e late ral c u tan e o u s n e rv e


. o f th e To the fo re arm an d ba l l o f
fo re arm . th e t h u mb .

9 The p almar c u tan e o u s bran ch


. o f th e
m e dian n e rv e
To sk in o f the p alm
.

the
The palm ar cu tan e o us bran ch f the
.

10 . o

u ln ar n e r e v .

11 . The dig ital bran ch e s o f the m e dian n e rv e .

12 . The dig ital bran ch e s o f t he u lnar n e rv e .

13 . The su pe rficia l bran ch o f the radial n e rv e an d its do rsal dig ital


bran ch e s .

14 . The do rsa branc h l o f t he ulnar n e r e an d v it s do rsal dig it al bran ch e s .


D I SSE C T I ON O F SU PER F I C I AL STR U C T U R E S 6 9

i
D se ct o n
s i — Tu rn t o t h e p ro x im al e n d o f t h e limb an d co m
m e n ce wt
i h t h e i n terco sto brachial n erve , w h ic h w as se e re d v
w h e n th e su p e rio r e xt re m i y w as re m o e d f ro m th e ru n k I t t v t .

t
lie s in t h e p o s e rio r p art o f t h e m e dial side o f t h e arm , an d is at
t
fi rs de e p t o th e de e p fascia N o e th e p o in at h ic h it p ie rce s . t t w
t h e de e p f as cia ( F ig s 3 1 , 3 2 ) an d race it t o its e rm in a io n n e ar
. t t t
t h e e lbo w B y m e an s o f its ario u s bran c h e s it su p p lie s th e sk in
. v
o n t h e m e dial s ide o f t h e p o s e rio r p art o f t h e arm ( F ig s 3 1 , t .

F in d, n e xt , th e me di al cu tane o u s ne rve of the arm I t p ie rce s .

t h e de e p o f t h e fas c ia p ro x im al h ird o f t h e arm o n t h e m e dia l t


side , an d its bran c h e s su p p ly t h e sk in as f ar as t h e e lbo w in an
are a an e rio r t o t t t
h a su p p lie d by t h e in te rco sto brac h ial n e r e -
v .

t t
Af e r t h e m e dial cu an e o u s n e r e o f t h e arm h as be e n cle an e d, v
lo o k f o r t h e bran c h e s o f t h e me di al cu taneo us nerve of the f o re
arm , w
h ic h su p ply th e m e dial p art o f th e sk in o f t h e arm Th e y .

v ary in n u m be r an d si e , bu t z
h e y u su ally p ie rce th e de e p fas cia t
alo n g t h e lin e o f t h e me dial bo de r o f t h e bic e p s brac h ii an d h e y r t
co mm u n ica e t wt
i h o n e an o h e r (F ig t .

t
Th e ru n k o f t h e m e dial cu an e o u s n e r e o f t h e f o re arm t v
t
e i h e r p ie rce s t h e de e p f asc ia clo se t o t h e bas ilic e in , o r it p asse s v
t h ro u gh th e s am e o p e n in g as th e e in , an d di ide s in o its vo lar v v t
an d u lnar te rmma l bran ches Th e o lar bran c h p as se s e i h e r . v t
de e p o r su p e rfi c ial t o t h e m e dian cu bi al e in an d h e n de sce n ds t v t
t o t h e w ris t
I t su p p lie s t h e sk in o f t h e u ln ar h alf o f t h e o lar
. v
asp e ct o f t h e f o re arm Th e u ln ar bran c h p asse s e i h e r an e rio r
. t t
t
o r p o s e rio r t o t h e m e dial e p ic o n dy le an d h e n alo n g t h e u ln ar t
m arg in o f t h e f o re arm I t su p p lie s t h e sk in o f t h e u ln ar m arg in
.

r t
an d o f t h e u ln a p ar o f t h e do rsu m o f t h e f o re arm as f ar as t h e
w t ris .

t t
Af e r t h e m e dial cu an e o u s n e r e o f t h e f o re arm h as be e n v
t
disse ct e d, race t h e re m ain s o f t h e p o s e rio r su p racla icu lar n e r e s t v v
t v
h ro u gh t he f at o e r th e p ro x im al p art o f t h e de l o id h e y su p p ly t t
v
t h e sk in o e r t h e p ro x im al h alf o f t h e de l o id m u scle W he n t .

t v t
h e y h a e be e n race d t o h e ir e rm in a io n s m ak e an in cisio n t t t
t h ro u gh th e f at alo n g t h e dis al h alf o f t h e p o s e rio r bo rde r o f t het t
t
de l o id an d se cu re t h e la teral cu tan eo u s n erve o f th e arm I t is a .

v
bran c h o f t h e ax illary n e r e an d w ill be f o u n d u rn in g ro u n d t h e t
p o s e t
r io r b o d e r o f t h r
e d e l o id a t t h e j u n t
c io n o f t h e p ro x im al t
tw o t h irds
-
wt t t
i h t h e dis al h ird o f th e m u scle ( F ig s 3 1 , 3 2 ,
-
.

w
I t ru n s f o r ards a cro ss t h e m u s cle an d su pp lie s t h e sk in o e r it s v
t
dis al h alf .

To fi n d t h e p ro ximal an d dis tal branc hes o f t h e do rsal cu tane


o us n erve of the f o rearm disse c in t h e f at be w e e n t h e la e ral t t t
e p ico n dy le o f t h e h u m e ru s an d t h e in se rt io n o f t h e de l o id t .

Th e y are bran c h e s o f t h e radial n e r e an d bo h are o ccasio n ally v t


diffi cu l t o fi n d t Th e p ro x im al bran c h u su ally p ie rc es t h e de e p
.

tt t
f ascia a li le dis al t o t h e in se rt io n o f th e de l o id ( F ig s 3 1 , t .

I t su p p lie s t h e sk in o f t h e la e al p art o f t h e an e rio r asp e c o f t r t t


t h e arm as f ar as th e e lbo Th e dis al bran c h w ill be f o u n d
. t w
abo u t
o n e in c h n e are r t h e la e ral e p ico n dy le t
I t p asse s be h in d .

t
t h e la e ral e p ico n dyle an d h e n de sce n ds alo n g t h e do rsal asp e c t t
o f t h e f o re arm t o t h e w ris t .

t t
Af e r t h e dis al bran c h o f th e do rsal cu t an e o u s n e rv e o f t h e
f o re arm h as be e n t race d t o it s e rm in a io n , fi n d t h e late ral t t
cu tan eo u s nerve o
f t he f o r e a r m I t is t h e c o n inu a io n o f t h e . t t
m u scu lo cu an e o u s n e r e
- t v
I t app e ars at t he late ral; bo rde r o f
. , ,

1— 5 6
70 TH E SU PER I OR EXTRE M I TY
the bic e p s u n de r co e r O f t h e ce p h alic v
e in , abo u 2 5 mm v t .

v
abo e t h e p o in tw
h e re th e m e dial cu bi al e in le a e s t h e c e p h alic t v v
v e in . t
So o n af e r it e n e rs t h e su p e rfi c ial f ascia it di ide s in o t v t
a v o lar an d a do rsal bran c h Th e o lar bran c h de sce n ds alo n g . v
v
t h e radial p art o f t h e o lar asp e c o f t h e f o re arm t o th e ball o f t h e t
t h u m b, an d th e do rsal bran c h m ay be t race d dis ally o n t h e do rsal t
t
asp e c o f t h e radial s ide o f t h e f o re arm as f ar as t h e ris w t .

Th e p o steri o r cu tan eo us n erve o f the arm w as fo u n d du rin g


t
t h e disse c io n o f th e ax illa sp rin g in g f ro m t h e p ro x im al p art o f
t h e radial n e r e v
No w it m u s be race d alo n g th e do rsal asp e c
. t t t
o f t h e arm t o t h e e lbo w
I t su p p lie s t h e sk in O f t h e do rsu m o f
.

t h e arm f ro m th e ax illa t o t h e e lbo w (F ig .

t t
Af e r t h e p o s e rio r cu an e o u s n e r e O f t h e arm h as be e n t v
c le an e d, p lace t h e lim b o n it s do rs al su rf ace an d lo o k f o r t h e
t
p alm ar c u an e o u s bran c h e s o f t h e m e dian an d u ln ar n e r e s v .

t
Th e y bo h p ie rce th e de e p f as cia o f t h e f o re arm abo u 3 0 t
m m p ro x im al t o t h e w ris
. Th e p alm ar cu tane o u s bran ch o f t .

the m edi an n erve lie s in t h e lin e o f t h e m e dial bo rde r o f t h e


p ro x im al e n d o f t h e ball o f th e h u m b ( h e n a e m in e n ce ) an d it t t r
e x t e n ds t o t h e m iddle o f t h e p alm Th e p almar cu tan eo u s .

bran ch of the u ln ar n erve lie s in t h e lin e o f t h e m iddle o f t h e


t
ball o f th e li t le fi n g e r ( hyp o h e n ar e m in e n ce ) it also e x t e n ds t o t
v
t h e le e l o f t h e m iddle o f t h e p alm (F ig .

t t t
A f e r t h e dis ribu io n o f t h e p alm ar cu an e o u s n e r e s h as t v
w
be e n se e n cle ar a ay t h e su p e rfi cial f asc ia o f t h e p alm f ro m t h e
t v
in e r al be e e n the tw t
h e n ar an d hyp o h e n ar e m in e n ce s t o th e t
t
base s o f t h e dig i s t o e xp o se t h e in e rm e dia e p ar o f t h e p almar t t t
ap o neu ro sis ,
t t
h a is, th e de e p fascia o f t h e p alm N o e h a t h e . t t t
su p e rfi c ial f asc ia in t h e are a u n de r c o n side ra io n is de n se I t is t .

v t
di ide d in o sm all lo bu le s by fi bro u s se p a h ic h p ass f ro m th e t w
sk in t o t h e p alm ar ap o n e u ro sis W h e n t h e in e rm e dia e p art O f . t t
t h e p alm ar ap o n e u ro sis is ex p o se d it w ill be f o u n d t o be rian gu lar t
in o u lin e tTh e ap ex lie s at th e ris
. h e re it is co n in u o u s i h w tw t wt
t h e de e p f ascia o f t h e f o e a m The base is at t h e le e l o f t h e r r . v
t t
dis al e n ds o f t h e m e acarp al bo n e s, an d it di ide s in o fi v e p ie ce s, v t
o n e f o r e a c h fi n g e r an d a le ss de fi n i e slip f o r t h e hu mb A t t .

bu n dle o f t ran s e rse fi bre s w ill be m e t v i h in t h e f o ld O f sk in wt


w h ic h c ro sse s th e p ro x im al e n ds o f th e in e rdig i al cle f s I t is t t t .

t h e sup erfi ci al tran sverse ligame n t o f t h e h an d, an d it m u s be t


v t
di ide d Opp o si e t h e cle f s in o de r h a t h e o lar dig i al n e r e s t r t t v t v
w h ic h su pp ly t h e adj ace n side s o f the cle f s m ay be f o llo e d t t w .

v t
Th e o lar dig i al n e r e s are se e n in n u m be r Th e fi rs an d v v . t
se c o n d p ass t o t h e t
h u mb, o n e to its radial an d o n e t o its u ln ar
side Th e y are a c co m p an ie d by b an c h e s o f th e p rin ce p s p o llic is
. r
t
ar e ry w
Th e y ill be f o u n d at t h e m e dial m arg in o f t h e h e n ar
. t
e m in e n ce an d m u s be race d t o t h e e n d o f t h e h u m b t t
Th e h ird t . t
t
app e ars at th e la e ral m arg in o f t h e slip o f t h e p alm ar ap o n e u ro sis
t o t h e in de x - fi n ge r I t ru n s alo n g t h e radial side o f t h e fi n g e r
.

acco m p an ie d by t h e o lar radialis in dic is art e ry v


Th e fo u r h , . t
t w
fi f h , an d sixt h ill be fo u n d be e e n t he slip s o f t h e in e r tw t
t t
m e dia e p ar o f t h e p alm ar ap o n e u ro sis in lin e w i h t h e fi rs , t t
t
se co n d, an d h ird in e rdi g i al c le f s re sp e c i e ly t
Eac h is ac t t tv .

co m p an ie d by a v
o lar dig i al art e ry , an d lik e t h e a r e ry it di ide s t t v
t
t o su p p ly t h e adj a ce n side s o f t h e fi n g e rs wh ic h bo u n d t h e cle f t
t
O p p o si e w h ic h it lie s Th e se e n h su pp lie s th e u ln ar s ide o f
. v t
tt
th e li le fi n g e r I t app e ars at th e dis al bo rde r o f t h e p alm aris
. t
P L ATE IV

Nn . su p ra c a l vi l c u a re s

N . c u t an e u s brach n l a t e ra li s

N . c u ta n e u s brac h ii
p o st e ri o ri s

N . in t e rco st o brach ia lis

N c u t a n e u s a n t ibra c h i i do rsa li s ram u s su p e r o r i


N . c u t a n e u s a n t ibrach ii do rsa li s, ra mu s i n fe r o r i
c u t a ne u s bra c h n m e d a i li s

N cu t an e u s an t ibra c h i i me d a i li s,
4
l
.

ra m u s u n ari s

c u t a n e u s a n t ibra c h ii l a t e ra li s

V . bas ili c

V . bas ili c

rad a i li s su p e rfi c al s i i

c e p ha li ca

l i
u n a r s , ra m us do rsa l si man u s

FIG .
32 .
— i
Su p e rfic ial V e n s an d N e rve s o f t h e P o ste ri o r Asp e ct
o f th e S u p e r o r E tre m ty i x i .
D I SSE C T I ON O F SU PER F I C I AL STR U C TURE S 7 1

v
bre is m u scle an d is ac co m p an ie d by a dig i al art e ry Th e fi v e t .

t t t v
m o s la e ral dig i al n e r e s are bran c h e s o f t h e m e dian n e r e , t h e v
t
t w o m o s m e dial a re bran c h e s o f t h e u ln ar n e r e , h e re f o re t h e v t
v t
m e dian n e r e su pp lie s h re e an d a h alf dig i s , t h e h u m b, th e t t
in de x , t h e m iddle an d h alf t h e rin g dig i , an d t h e u ln ar su pp lie s t
t h e re m ain in g o n e an d a h alf , v iz , t h e li le fi n g e r an d h alf t h e . tt
rin g fi n g e r .

As t h e bran ch e s o f t h e m edian n e r e t o t h e fi n g e rs are f o llo w e d v


t
alo n g t h e fi n g e rs h e y w ill be f o u n d t o se n d bran c h e s n o t o n ly t o
v
t h e o lar su rf ace s bu t a lso t o t h e do rs al su rf ace s in t h e re g io n s
o f t h e se co n d an d e rm in al p h alan g e s t .

The c are fu l disse cto r w ill n o te th at so m e o f the fi n e r bran ch e s o f th e


digital ne r e s v t e rmin at e in m inu te o v o id bo die s e m be dde d in the fat .

Th e y a re the P ac in ian to u ch c o r u sc le s an d are asso ciate d w ith th e se n se


p
o f to u ch .

Tw o h e r cu t an e o u s n e rve s h av e st ill t o be disse ct e d ; t h e y are


o t

t h e do rsal bran c h o f t h e u ln a r n e rv e an d t h e su p e rfi cial div isio n


o f t h e radial n e rv e B o t h are dist ribu t e d t o t h e do rsu m o f t h e
.

h an d an d t o th e do rs al asp e ct s o f t h e dig it s .

Th e do rsal bran ch of the u ln ar n erve m u st be s o u gh t f o r as


it t u rn s ro u n d t h e u ln ar bo rde r o f t h e w rist im m e diat e ly dist al
t o t h e st y lo id p ro ce ss o f t h e u ln a I t g iv e s a bran c h t o t h e u ln ar.

s ide o f t h e litt le fi n g e r an d a bran c h t o su pp ly t h e a dj ace n t s ide s


o f t h e rin g an d litt le fi n g e rs ; t h e latt e r co m m u n icat e s w it h t h e
m o st m e dial bran c h o f t h e su p e rfi c ial div is io n o f t h e radial n e rv e .

Th e sup erfi ci al bran ch of the radi al n erve w ill be f o u n d at


t h e radial bo rde r o f t h e f o re arm I t ap p e ars f ro m u n de r co e r . v
o f th e t
e n do n o f th e bra c h io radialis abo u 8 cm (3 1 in c h e s) -
t .

abo e t h e v w t
ris , an d, as it de s ce n ds t o t h e h an d, it bre ak s u p
t
in o fi v e bran c h e s — o n e t o e ac h s ide o f t h e h u m b, o n e t o t h e t
radial s ide o f t h e in de x - fi n ge r, o n e t o t h e adj ace n side s o f t h e t
in de x an d m iddle fi n g e rs, an d o n e t o t h e adj ace n side s o f t h e t
m iddle an d rin g fi n g e rs Th e las bran c h is co n n e c e d w i h t h e
. t t t
j
ad a ce n t ram u s o
f t h e do rsal bran c h o f t h e u ln ar n e r e by a v
co m m u n ica in g ig t tw
A p alm ar cu an e o u s bran c h is dis ribu e d
. t t t
t t
t o t h e ball o f t h e h u m b e i h e r f ro m t h e ru n k o f t h e su p e rfi c ial t
p a r o t
f t h e ra dial n e r e o r f ro m t h e bra n c h t v
o t h e radia l s id e

o f th e t
h u m b Th e do rsal dig i al n e r e s o f t h e h u m b can be
. t v t
t race d t o t h e e n d o f t h e t
h u m b, h o se o f t h e in de x dig i t o th e t t
p ro x im al e n d o f t h e se co n d p h alanx , h o se o f t h e m iddle fi n g e r t
t o t h e m iddle o f t h e se co n d p h alan x a n d h o se o f t h e rin g an d t
tt
li le fi n g e rs t o t h e p ro x im al e n d o f t h e e rm in al p h alan x Th e t .

t
re m ain in g p ar s o f t h e do rsal asp e c s o f t h e fi n g e rs a re su p p lie d t
by t h e v
o lar dig i al n e r e s t v
Th e im p o rt an p rac ic al p o in is
. t t t
t t
h a p art s O f t h e do rsal su rface o f th e in de x , m iddle , an d rin g
t
dig i s are su p p lie d n o t by t h e radial bu t by t h e m e dian n e r e v .

The g e m e n t o f the n e rv e s o n the do rsu m o f the h an d is v e ry


arran

v ariable Th at de scribe d abo v e is u su ally m e t w ith bu t n o t u n co m mo n l y


.
,

th e u lnar n e rv e su pp l ie s a larg e r an d the radial n e rv e a sm all e r are a .

The re v e rse arran g e m e n t is also fo u n d .

W hen t h e disse c iot n o f th e t


cu an e o u s n e r e s o v f th e su p e r o r
i
e x t re m ity is co mpl t e e d re m o ve t h e re m a in s o f th e f a t y t su p e rfi c ral
f asc ia an d p ro ce e d t o th e s udt y o f the de e p f ascia.
1— 5 a
72 TH E SU PER I OR EXTRE M I TY
D ee p F a sc ia — Th e d e e p fa sc ia o f the su p e rio r e x tre mity
c o n sist s ch ie fly o f tra n sv e r se fi br e s wh ich are bo u n d t o g e th e r
,

by o bliqu e an d lo n g itud in a l fi br e s The o bliqu e an d lo n g i


.

tu din al fi br e s be co me sp e c ia lly d e v e lo p e d in c e rta in situat io n s


wh ich w ill be n o t e d lat e r The d e e p fa sc ia is fa irly str o n g in
.

th e r e g io n o f t h e sh o u ld e r ov e r t h e d e lt o id m u sc le Ov e r .

t h e p o st e r io r p art o f th e d e lt o id an d t h e adj o in in g p art o f t h e


in fra sp in atu s wh ich c o v e r s th e low e r p art o f t h e back o f t h e
,

sca p u la it be c o m e s d e n se an d it is c lo se ly attach e d by d e e p
, ,

p r o c e ss e s t o t h e a x illary bo rd e r o f t h e sca p u la Ov e r t h e .

fr o n t o f th e arm wh e r e it c o v e r s t h e bic e p s m u sc le it is th in
, , ,

bu t it is m uch str o n g e r at t h e back o f th e arm o v e r t h e tr ic e p s , .

O n e ach sid e e x t e n d in g p ro x im a lly fr o m th e lat e ra l an d the


,

m e d ia l e p ico n dy le s d e e p e x p a n sio n s bin d it to th e lat e r al


an d m e d ia l su p ra e p ic o n dy lar r idg e s o f t h e h u m e ru s
-
Th e .

e x p a n sio n s are k n o w n as the latera l an d medial in termu scu lar

sep ta be cau se th e y se p arat e t h e m u sc le s o n t h e fr o n t f r o m


,

th o se at th e back o f t h e arm At the e lbo w it is th ick e n e d.

an d str e n gth e n e d by t e n d in o u s fi br e s wh ich p a ss t o it fr o m ,

t h e bic e p s an d tr ic e p s m u sc le s an d it is c lo se ly attach e d to
,

t h e lat e ra l an d m e d ia l e p ic o n dy le s o f t h e hu me ru s an d t o
t h e O le cra n o n o f t h e u ln a A sp e c ia l th ick e n in g ca lle d th e
.

lacertu s fibro su s ( F ig 3 1 ) is fou n d at t h e fr o n t o f t h e e lbo w


. .

I t e x t e n d s fro m th e m e d ia l bo rd e r o f t h e p r o x im a l p art o f
t h e bic e p s t e n do n an d th e adjac e n t p art o f t he m u sc le to t h e
m e d ia l sid e o f th e p r o x ima l p art o f t he for e ar m I t se p arat e s .

t h e m e d ia n cu bita l v e in wh ich lie s su p e rfic ia l t o it fro m t h e


,
.
,

brach ia l art e ry wh ich is d e e p t o it


, Th e v o lar bra n ch o f .

t h e m e d ia l cuta n e o u s n e rv e o f t h e fo r e ar m u sua lly p a sse s


be tw e e n th e lac e rtu s fibro su s an d t h e m e d ia n cu bita l v e in .

I n t h e fo r e ar m t h e d e e p fa sc ia is stro n g ov e r t h e p r o x im a l
p art s o f t h e m u sc le s wh ich sp r in g fr o m t h e m e d ial an d th e

lat e ra l e p ic o n dy le Th e n it be c o me s th in e sp e c ia lly o n the


.
,

v o lar a sp e ct O n th e d o r sa l a sp e ct it is bou n d t o the wh o le


.

le n gth o f t he p o st e r io r bo rd e r o f t h e u ln a by a d e e p
e x t e n sio n wh ich in t e rv e n e s be tw e e n the m u sc le s o n t he
dorsa l an d vo lar p art s Of the m e d ia l sid e o f the fo r e ar m .

A t the wr ist t he tra n sv e r se fi br e s o f th e d e e p fa sc ia


be c o me v e ry o bv iou s an d th e y fo r m t wo m ark e d tra n sv e r se
,

ba n d s ; o n e o n t he v o lar a sp e ct ca lle d t he transverse carp al


liga men t an d o n e o n th e dor sa l a sp e ct ca lle d t h e do rsal carp al
liga ment .
74 TH E SUPER I OR EXTRE M I TY
o f the p a lm Th e d ista l m arg in o r ba se lie s at th e le v e l o f
.

t h e h e ad s o f th e me tacar p a l bo n e s, an d it d iv id e s in t o fiv e
r
p c o e ss e s o,
n e fo r e ach fi n g e r a n d a m o r e sle n d e r p r o c e ss fo r

t h e thu m b Each p r o c e ss p a sse s to the c o rr e sp o n d in g d ig it


.

wh e r e it ble n d s w ith t he vo lar surfac e o f the sh e ath o f th e


fl e x o r t e n d o n s an d it se n d s a p roc e ss o n e ach sid e o f th e
,

d igit wh ich j o in the d e e p fa sc ia o n the d o r sa l sur fac e .

Th e do rsal carpal ligamen t is attach e d o n t h e rad ia l sid e


to th e vo lar m arg in o f t h e sty lo id p roc e ss o f t h e rad iu s an d
o n t h e u ln ar sid e t o t he fa sc ia o n th e m e d ia l sid e o f th e
wrist Th e sp ac e be tw e e n it an d th e d ista l e n d s o f th e
.

rad iu s an d u ln a is d iv id e d in t o six c o mp art m e n t s by se p ta ,

wh ich p a ss fr o m its d e e p sur fac e t o the r idg e s o n t he rad iu s


an d t o t h e h e ad an d s ty lo id p roc e ss o f the u ln a .Th e co m
p a rt m e n t s tra n s m it t h e t e n do n s wh ich p a ss f r o m t h e d o r su m
o f t h e for e ar m t o t h e dor su m o f t h e ha n d an d t o t h e dor sa l

a sp e ct s o f t he fi n ge r s I ts su p e rfic ia l sur fac e is cro sse d by


.

th e t e r min a l bra n ch e s o f t h e S U p e rfic ial d iv isio n o f t h e


rad ia l n e rv e an d by the c e p ha lic an d ba silic v e in s The .

d ista l bord e r o f t he d o r sa l carp a l liga me n t is c o n t inuou s


w ith th e th in d e e p fasc ia o f t he ha n d wh ich is p ro lo n g e d
,

in t o t h e d o r sa l a sp e ct s o f t h e d ig it s .

Wh e n th e study o f the d e e p fa sc ia o f the su p e rio r


e x tr e mity has be e n c o mp le t e d r e tur n t o t h e sh o u ld e r r e g io n ;

v e r ify aga in the attach me n t s o f th e m u sc le s wh ich c o n n e ct e d


th e sca p u la an d th e c lav ic le w ith t he tru n k ; a ft e rward s cut
away th e su p e r flu o u s p art s o f t h e m u scle s le av in g a bo ut o n e
,

in ch o f e ach fo r r e v isio n . Th e n p roc e e d t o th e g e n e ra l


study o f th e sh o u ld e r r e g io n .

M u scle s in se rt e d int o t h e Cla i cle v


Scap u la — The in se rtio n s o f
an d
t h e m u scle s wh ic h h av e alre ady be e n div ide d m u st fi rst e n g ag e the
atte n tio n o f th e stu de n t . l
Th e y sh o u ld be c are fu ly de fin e d an d th e
p re c ise e x
t e nt o f e ac h stu die d B e gin
. w it h th e o mo hy d, wh ich
o i -

sp rin g s fro m th e su p e rio r bo rde r o f th e scap u la ; th e n de al in th e sam e

way w ith th e lev ato r scap u la , rho m bo ideu s m in o r an d m aj o r, wh ich


are att ach e d to th e v
e rte bral bo rde r o f th e bo n e , an d th e serrat u s an te rio r,

wh ich is in se rte d in to the co stal asp e ct o f the m e dial an d in fe rio r an gle s,


an d th e in te rv e n in g p o rtio n o f the v e rt e bral bo rde r o f the sc ap u a Thel .

in se rtio n o f the pecto ralis m ino r in to th e co raco id p ro ce ss, an d o f the


t rap ez i u s in to bo th clav icle an d sc ap u la, sh o u ld also be th o ro u gh ly re
x
e am in e d .
S HO U L D ER — SC APU L AR RE G I O N 75

SH O U L ER
D — SC A PU L AR RE GI O N .

I n t he d isse ct io n o f th is r e g io n th e fo llow in g p art s m u st be


s tud ie d :
H C u tan e o u s n e rv e s o f the sh o u lde r .

N D e e p fascia .

C
O l
N D e to id mu scle .

P- Su b acro m ial bu rsa


-
.

L
F An te rio r an d po st e rio r circu m fl e v e sse ls o f the h u me ru s x .

xl
Q A i lary ( circu m fl e ) n e rv e x .

V C ircu m fl e x scapu ar art e ry l .

O
O Subscapu aris m u scle l .

S i t i fra i tu s, t e re s min o r, an d t e re s m aj o r m u scle s


O u
p r asp n a u s, n sp n a .

10 B u rsa in c o nn e c tio n with the sh o u lde r j o in t


.
-
.

11 Su p rascapu lar n e rv e an d tran sv e rse scapu lar arte ry


. .

I 2 Acro mio clavicu lar j o in t , an d the co raco acro mial arch


.
- -
.

N e rv i C u t an e i ( Cu t an e o us N e rv es) — The n e rv e s wh ich lie .

in t he su p e rfic ia l fa sc ia o f the shou ld e r r e g io n are d e r iv e d


fro m two d iffe r e n t sou rc e s Th e y are : .

I P t i
.
p l vi l
o s e r o r su rv f m th th ird a d f
rac a th
cu ar n e vi l es ro e n o ur ce r ca
v
ner e s .

2 . C u tan e o u s bran ch e s fro m the x ill y v ( i mfl x ) a ar ner e c rcu e .

Th e y hav e a lre ady be e n se cur e d an d c le a n e d .

The po sterio r sup raclavicu lar n erves cro ss the lat e ra l th ird
o f th e c lavic le an d th e in se rt io n o f t h e tra p e z iu s u n d e r cov e r ,

o f t h e p laty s ma Th e y w e r e d iv id e d wh e n the lim b was


.

r e mov e d an d t he d ista l e n d s have be e n f o llow e d ov e r the


,

p ro x im a l h a lf o f t h e d e lt o id .

Th e cu taneo u s bran ches o f t he ax illary n erve co n sist


a ) o f a larg e bra n ch th e lateral cu tan eo u s n erve of the a rm
( , ,

wh ich tur n s rou n d th e p o st e r ior bord e r o f the d e lto id m u scle ,

an d ( h) o f se v e ra l fin e fi la m e n t s wh ich p ie rc e t he su bsta n c e

o f t he d e lto id m u sc le an d a p p e ar at irr e gu lar in t e rva ls o n


,

it s sur fac e ( F ig The latt e r are difli cu lt to se cur e bu t th e


.
,

lat e ra l brach ia l cuta n e ou s n e rv e h as a lr e ady be e n fo u n d an d


c le a n e d ( se e p I t tur n s rou n d t h e p o st e r ior bord e r
.
,

an d is d istr ibut e d ov e r t h e d ista l p art o f t h e d e lt o id r e g io n .

De ep F ascia — I t h as a lr e ady be e n n ot e d that t he d e e p


fa sc ia ov e r t he d e lto id is fa ir ly stro n g an d that as it p a sse s ,

fro m t h e d e lt o id to t he mu sc le s wh ich sp rin g fr o m t h e low e r


p art o f t h e p o st e r ior a sp e ct o f t h e sca p u la i t be co m es stro n g ,

an d d e nse ov e r th e in f ra sp in atu s t he t e r e s m in or an d th e ,

t e re s m aj or I n the lo w e r sca p u lar r e g io n it is fir mly attach e d


.

to the limit s o f the in fra sp in ou s fo ssa in wh ich the in fra


76 TH E SUPER I O R EXTRE M I TY
sp in atu s tak e s or ig in an d it , p r e se n t s oth e r v e ry a p p ar e n t

co n n e ctio n s . Thu s a stro n g


,
se p tu m p r o c e e d in g fr o m its
,

ral e n d o f c a l vi l c e

M ar gi n o f a c ro m i o n

t o ralis ma j o r

C e p ha li v i c e n

D l id
e to

C u t an e o us bra n c he s oxill y
f a ar

(O T c i rcu m fl x) e v pi i g
ne r e e rc n

l i
. .

de t o d

L at e ra bra ch l il a c u tane o u s

bran c h o f a i x ll y ar v
ner e

B i ce p s

L at e ra he ad l Of i
t r ce p s

i li
B ra ch a s

P xi m l b
ro a ra n c h o f do rsa l
c u t an e o u s n e rv e o f fo re arm

C p h li v i
e a c e n

Di l b hs ta ra n c o f do rsa l c u t an e o u s
ne r e o v f fo re a rm

B rac h i o -
rad a i li s

Te n do n o f tr ce i p s

Ol e c rano n

E x t e nso r carp i rad a i li l gs o n us

FIG .
33 .
—The D l t id M
e o l
u sc e an d th e l at al
er asp e c t o f the Arm .

d e e p sur fac e w ill be n ot ic e d to dip in b e tw e e n the in fra


,

sp in atu s an d t e r e s mino r m u sc le s an d th en as it p r o c e e d s
, ,

forward s it g iv e s a th in
, minor t e r e s ,

majo r an d th e d e lto id
, ,
I n dee du i t may ibfe sa id t o sp lit in to
.
78 TH E SUPER I O R EXTRE M I TY
an d Sp in e o f the sc ap u la, an d tu rn it t w ard
o s its in se rt io n in to
th e h u m e ru s , t ak in g
t t o in j u re t h e c ircu m fl e x h u m e ral
c are no
t
a r e rie s an d t h e ax illary n e rv e N o e t h e e n din o u s in e rse c io n s . t t t t
w t r
h ic h ru n h o u gh th e su bs an ce o f th e mu scle , h e n cle an t he t t
ve s se ls an d n e r es v w h ich are ex p o se d. Th e ax illar y ne r e v
ent t h e ba ck p art o f t h e sh o u lde r re g io n h ro u gh t h e p o s e rio r
e rs t t
p art o f t h e u adran g u lar sp ac e , ac co m p an ie d by th e p o s e rio r
q t
h u m e ral circu m fl e x e sse ls, an d at o n ce di ide s in o an an e rio rv v t t
an d a p o s e rio r di is io n tB e f o re it di ide s , v
h ils it is in t h e . v w t
q u adran gu la r sp ace , im m e dia e ly be lo w t h e s h o u lde r j o in , it t -
t
v t
g i e s o ff an ar icu lar ig t o th e j o in , h ic h sh o u ld be se cu re d tw t w .

t v
Th e an e rio r di isio n acco mp an ie s t h e p o s e rio r h u m e ral c ir t
t
cu m fl ex ar e ry ro u n d t h e su rg ical n e c k o f t h e h u m e ru s It .

t
su pp lie s t h e de l o id an d se n ds bran c h e s h ro u gh it t o t h e s k in o n t
its su p e rfi c ial su rf ace Cle an bo h t h e n e r e an d t h e e sse l ; . t v v
t t
h e n u rn t o th e p o s e rio r bran ch an d se cu re th e ig to the e re st tw t
m in o r up o n w h i h t h e re is a gan glif rm e n larg m t
m u scle , c o e en .

Th p o t rio r bran c h t rm in at
e s e as t h lat e ral c t an o u rv o f
e es e u e s ne e

t h arm w h ic h t r
e r
, d t h p o t rio r b rd r f t h d lt o id
u ns o un e s e o e o e e

t o g ain its s p r fi ial s rfa I t h as alr ady b e n disse t d


u e c u ce . e e c e

( s ee p Cl.a n t h e t r s m aj o r a d m ei r m le w h i h e e n no u sc s c

s p rin g f ro m t h e p o t ri r s r fa f t h a illary bo rd r f t h
s e o u ce o e x e o e

s ap la an d p as
c u t ,
th h u m r an d n o t t he t r g
s o pt m e e u s, e s o n se u

o f d p f asc ia w h i h s p arat e s t h m
ee Cle an t h l n g h ad f
c e e . e o e o

t h e t ri e p s w h i h ari
c f r m t h u p p r p art o f t h a illary
c se s o e e e x
bo rde r o f t h e scap u la Th e n ex am in e t h e su bacro m ial bu rsa,
.

w t
h ic h lie s dire c ly be lo t h e acro m io n , o n th e in se r io n o f t h e w t
su p rasp in a u s t
I f t h e w all O f t h e bu rsa is q u i e e n ire a blo
. t t w
p pi e m ay b e h r u s in o it t
I t c a n h e n t b e dis e ntd e d ,
a n d if . t t
u n ilo c u lar it m ay be in fl a e d t o abo u t h e a e rag e s i e o f a h e n s t ’
t v z
e gg It
. v
aries m u c h in si e , h o e e r, in diffe re n su bj e c s z wv t t .

Op e n t h e bu rsa an d ex am in e its e xt e n i h the fi n g e r o r a t wt


blu n
p t
ro be t
I ts in e rio r is so m e im e s di ide d by fi bro u s p art i
. t v
t t
io ns i n o two o r m o re lo cu li No w u rn th e lim b o n t o its . t
p o s e rit
o r a sp e c an d c le an t h e p r t
o x im a l p a r s o f t h e c o ra c o t
r
b ac h ialis an d t h e sh o r h e ad o f th e bice p s brac h ii w h ic h sp rin g , t
t
by a co mm o n e n do n , f ro m t he t ip o f t h e c o raco id p ro ce ss o f t h e
s cap u la P u ll t h e sh o r h e ad o f t he bice p s an d t h e co rac o
. t
brac h ialis m e dially an d e x p o se th e e n do n o f t h e lo n g h e ad o f th e t
t rt
bice p s ly in g i n t h e in e u be rcu lar su lcu s o f t h e h u m e ru s, bu t do
n o t disp lace it at p re se n t
No w p u ll t h e s h o rt h e ad o f t h e bice p s
.

an d t h e c o raco brac h ialis la e rally an d cle an t h e in se r io n o f t h e


-
t t
s u b s ca p u la i s — it is inrse r e d in o t h e le ss e r u b e rcle o f t h t
e t t
h u m e ru s o n th e m e dial side o f th e in e r u be rcu lar su lcu s Cle an t t .

t
also t h e an e rio r h u m e ral c ircu m fl e x art e ry , race it t o its di isio n t v
t
in o an asce n din g bran c h , h ic h ru n s t o th e s h o u lde r j o in w t
t t
alo n g t h e in e r u be rcu lar su lcu s, an d a ran s e rse bran c h , h ic h t v w
an as o m o ses t wt
i h t h e p o s e rio r h u m e ral c ircu m fl e x art e ry , an d t
t h e n re ex am in e t h e s ru c u re s h ic h lie dire c ly u n de r co e r o f t t w t v
t
t t t
t h e de l o id an d n o e h e ir re la i e p o si io n s tv .

P A RTS U N D ER C O V ER O F TH E D ELTO ID The d e lto id .


c o v e r s t h e p ro x ima l p art o f the hu me ru s an d e n v e lo p s t h e ,

r e g io n o f th e sh o u ld e r j o in t be h in d lat e ra lly an d in fr o n t -

, ,
.

I t a lso cov e r s th e coraco id p roc e ss o f th e sca p u la I t is .


S HO U L D ER — SC A P U L A R RE G I O N 79

se p arat e d fr o m t h e sh o u ld e r j o in t by th e m u sc le s wh ich are


-

attach e d to t he p r o x im a l e n d o f t he hu m e ru s an d by t h e
su bacro m ia l bur sa The fu ll r o u n d e d ap p e ara n c e o f the
.
,

shou ld e r is du e to t h e d e lt o id p a ssin g ov e r t h e p ro x im a l e n d

o f t h e hu m e ru s an d th e m u sc le s attach e d t o it Wh e n t h e .

h e ad o f the hu me ru s is d islo cat e d the mu sc le p a sse s v e rt ica lly


D di g b h f v vi l
e sc e n y n ra n c o t ra n s e rs e c e r ca a rt e r
S p p l v d v u ra sca u ar ne r e an t ran s e rse
p l y sca u a r a rt e r

C p l f h ld j i a su e o s o u e r- o nt

d f p pi o n o su ras nat u s

T d f i f en o n o n ra
i na t u s

Su bsc
I l
n fra sc a p u a r bra n ch

C irc u mfl e x l sc ap u a arte

P i i mfl x
o s t e r o r c rc u y d e a rt e r an
v
xill y v a ar ne r e
N er e t o t e re s m i no r

F G 34
I Di t i
. .
— sse c o n o f th e P o ste ri o r Scap u l ar R e g i o n .

fro m it s or ig in t o it s in se rt io
d islocat io n is n, an d th e
r e cog n ise d by the s uar e n e ss o r flat n e ss o f t h e shou ld e r
q .

U n d e r cov e r o f the p o st e r io r p art o f the d e lto id are p o rt io n s


o f t he m u sc le s wh ich s rin g fro m t h e p o st e r io r sur fac e o f t he
p
sca p u la v iz,
t h e in fra sp in atu s t e re s m ajor an d t e r e s m in or
.
, , , ,

an d t he p ro x im a l art o f th e lo n g h e ad o f t h e tr ic e p s wh ich
p ,

arise s fro m t he u p p e r p art o f the a x illary bord e r o f the


sca p u la U n d e r it s m idd le p art lie th e in se rt io n o f th e
.
TH E SUPER I OR EXTRE M I TY
su pra sp in atu s c o v e r e d by t h e su bacro mia l bursa an d th e
, ,

u pp e r p ort io n o f the lat e ra l a sp e ct o f t he bo dy o f t he .

hu me ru s I ts a n t e rio r p art c o v e rs t he c o rac o id p roc e ss an d


.

Sp i f p l S p p l v ne o s ca u a u rasca u ar n e r e
T v ra n sp l y e rse s c a u ar art e r

(O T p p l )
. . su ra sca u ar
S u p ra s

m ial bu rsa
'

u ba c ro

I i
n fras p n at u s mu sc l e

Su bsca p u l i ar s

L a t e ra brac h l il a

c u t an e o u s n e r e v
Tri
Qu adra ng u l a r sp ace

i
Tr c e p s , o n h e ad l g La t e ra he ad 0 f l
R di l i l t r1c e p s
.

a a ne r e v ( O T m usc u lo sp ra )
. .
-

i rac h ia l art e ry R di l
a a ne r e v (O T . .

m u sc u lo sp t ral
-
)
i
Tr ce p s, l lh
a t e ra e ad

N . i
t o t r ce p s, m di l h
e a e ad
brfi
fiiéls
r
an
m
d p ro fu n da

N . t o an c o n a u s
P o stbran ch o f p ro fu n da
.

art e r o f a rmy
i
Tr ce p s, me d h e ad D l
o rsa an t i brach i a l
.

cu t a ne o u s n e r e v
B rac h i lia s

Ul n ar n e r e v
M ed a i l pi e co n dy l e

N . to fl e x . c a rp . u lm
.

Ol e cran o n

35 .
— Di i
sse c t o n o f t h e do rsa asp e c t o f t he Arm l . Th e l ate ra lh e ad o f
t he Tric e p s h as be e n d de d an d tu rn e d as de t o ivi i e xp o se t h e l
su c u s o n

th e H u me ru s fo r th e ra d a n e r e i l v .

the m u sc le s an d liga m e n t s
wh ich are attach e d to it t he lo n g ,

h e ad o f the bic e p s mu sc le d e sc e n d in g in the in t e rtu be rcu lar


su lcu s an d t h e in se rt io n o f t h e su bsca p u lar is in to t h e le sse r
,

tu be rc le o f th e hu me ru s The m u sc le a lso cov e r s th e gre at e r .


82 THE SUPE R I OR EXTRE M I TY
bord e r o f th e sca p u la, a n t e r ior to the t e r e s m in or, an d e n t e r s
t h e in fra sp in o u s fo ssa .

Th e bo u n dar ie s o f th e quadra n gu lar sp ac e , as se e n fro m


th e fro n t , are t he su bsca p u lar is a bov e , t h e t e r e s major
be lo w, t h e lo n g h e ad o f t h e tric e p s m e d ia lly, an d t he
surg ica l n e ck o f th e hu me ru s lat e ra lly A t t h e back th e .

t e re s min or r e p lac e s t he su bsca p u lar is as the u p p e r bou n d ary .

B e tw e e n t h e su bsca p u lar is a n t e r ior ly , an d t he t e r e s min or


p o st e r io r ly ,
t h e in fe r ior surfac e o f t he ca p su le o f th e shou ld e r
j o in t fo r ms the u pp e r bo u n dary o f the sp ac e , an d through the
sp ac e , d ir e ct ly be low t h e ca p su le , a ss t h a illary rv e an d
p e x n e

t he p o st e r ior hu m e ra l c ircu m fl e x v e sse ls .

A rt eria Circumfl ex a H u meri ( O T Circumfl e x Art eries) . . .

Th e po steri o r hu meral circu mflex artery has be e n a lr e ady

H . Tran sve rse se c t o n i o f t he


i
hu me ru s m me d at e i l y di l s ta

t o t he t u be rc l e s.

A A . . A xill y ar y art e r .

P C . . P i i mfl x
o ste r o r c rc u e art e r y
of h h m
t e u e ru s .

A C . . A i i mfl x
n t e r o r c rc u e art e r y o f
th h m
e u e rus.

CJ V . Axill y v
ar ne r e .

a . A i l b
rt cu ar h ran c .

TM
. . B h
ran c mi
t o t e re s n o r.

C . C u tan e o u s bran che s .

F IG .
37 .
— Di g a ram o f th e C ircu mfl e x Ve sse l s an d the A xill y N v
ar er e .

o bse rv e d to ar ise w ith in the ax illa fro m the p o st e rior a sp e ct


, ,

o f th e a x illary art e ry a short d ista n c e d ista l to th e su bsca p u lar


,

bra n ch I t at o n c e p a sse s backward s through th e quadr i


.
,

lat e ra l sp ac e an d w in d in g rou n d th e surg ica l n e ck o f t he


, ,

hu me ru s it is d istribut e d in n u m e rou s bra n ch e s to the d e e p


,

sur fac e o f th e d e lto id mu sc le Se v e ra l tw ig s are g iv e n a lso t o


.

th e shou ld e r jo in t an d th e in t e gu m e n t
-
I t a n a sto mo se s w ith .

t h e acro mia l bra n ch o f t h e th oraco acro mia l art e ry an d w ith -

th e a n t e r ior hu m e ra l c ircu m fl e x art e ry an d a lso by o n e o r , ,

m or e tw ig s wh ich it se n d s d istally to th e lo n g h e ad o f the


,

tric e p s w ith th e p ro fu n da bra n ch o f the brach ia l art e ry


,
.

Th e t e r min at io n o f th e anterio r hu meral circu mflex artery


c an n o w be m or e sat isfactor ily stud ie d an d its a n a sto m o sis ,
S HOU L D ER — SC AP U L AR RE G I O N 83

w ith th e p o st e r ior hu me ra l c ircu m fl e x art e ry e stablish e d if th e ,

inj e ct io n h as flow e d w e ll B y th e a n a sto m o sis th e art e ria l


.

rin g wh ich e n circ le s th e p r o xima l p art o f the hu me ru s is


co mple t e d .

N e rvus Axillaris ( O T Circumfl e x N e rv e ) — Th e a x illary


. . .

M i
tr c e p s
l gh
.

( o n e ad )

G ro o v
fo r c rc u m
e i flx e

a rt e r y
o f sc a p u a l
( O T do rsa s li
l
. .

sc ap u a )

l i im
at ss us do rs i( scap u ar s l li p)
F IG .
3 8
.
— D o rsu m o f Sc ap u l w i th t h
a e A tt ach m e nt s o f th e M u sc l es m app e d o u t .

ne rv e acco mp a n ie s the p o st e rior hu me ral c ircu m fl e x art e ry .

I t su p p lie s : ( 1 ) an articu lar twig to th e shou ld e r jo in t ( 2 ) -

mu scu lar branches to th e d e lto id an d t e r e s min o r ; an d ( 3 )


cu taneo u s branches to t he sk in ov e r t h e d ista l p art o f th e
84 TH E SUPER I OR EXTRE M I TY
d e lto id I t sp r in g s fro m the p o st e r ior cord o f the brach ia l
.

p l e x u s , tur n s rou n d t h e lo w e r bord e r o f th e su bsca u lar is


p ,

an d p a sse s backward s w ith t he o st e r i r hu m ra l c ircu m fl


p
, o e ex

art e ry thr o ugh the quadrilat e ra l sp ac e t o the back o f the limb


, .

Th e r e it d ivid e s in t o an a n t e r io r an d a p o st e rio r d ivisio n


Th e articu lar bran ch tak e s or ig in fro m the tru n k o f th e n e rv e


in t h e quadr ilat e ra l sp ac e an d e n t e r s th e jo in t fro m be low
, .

Th e po sterio r divisio n g iv e s o ff the bra n ch to th e t e r e s min or ,

an d a ft e r fur n ish in g a fe w tw ig s to t h e o st e r i r art f t h


, p o p o e

d e lto id is c o n t in u e d o n ward s as th e lateral cu taneo u s nerve


, ,

of the arm wh ich has a lr e ady be e n d isse ct e d in th e su e rfic ia l


, p
fa sc ia ov e r t h e d ista l p art o f th e d e lto id ( F ig s 3 1 3 2