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Upper Limbs 1 Surgical Society | Junior Anatomy Series 16/01/2023 Presented By Phase1c StudentThe pectoral region What are the muscles of the pectoral region and their function? Pectoralis major • Adducts, internal rotation and flexion of the arm • Innervated by lateral and medial pectoral nerves Pectoralis minor • Limited function (depress shoulder/elevated ribs 3-5) • Innervated by lateral and medial pectoral nerves Subclavius • Stabilizes clavicle during movements of shoulder • Innervated by nerve to subclavius (from brachial plexus) Serratus anterior • Holds scapula against the chest wall • Innervated by long thoracic nerve Surgical Society | Junior Anatomy SeriesThe pectoral region Clinical Relevance: Winging of the Scapula One of the actions of the serratus anterior is to ‘hold’ the scapula against the ribcage. If the long thoracic nerve is damaged (and the serratus anterior therefore paralysed), protrudes out of the back. It is said to have a ‘winged’ appearance. Surgical Society | Junior Anatomy SeriesThe shoulder joint Surgical Society | Junior Anatomy SeriesThe shoulder joint Surgical Society | Junior Anatomy SeriesQuestion: What nerve innervates the serratus anterior? Surgical Society | Junior Anatomy SeriesAnswer: Long thoracic nerve Surgical Society | Junior Anatomy SeriesThe (upper) arm Surgical Society | Junior Anatomy SeriesBrachial Plexus Anterior Rami • The brachial plexus is a network of nerve fibres that supplies Spinal the skin and musculature of the upper limb. It begins in the Cord root of the neck, passes through the axilla, and runs through the entire upper extremity. • The plexus is formed by the anterior rami of cervical spinal Posterior Rami nerves C5, C6, C7 and C8, and the first thoracic spinal nerve, T1. • Function: Provide motor & sensory innervation of upper limbs. However, there are EXCEPTIONS of Trapezius muscle Spinal cord in transverse/horizontal plane Surgical Society | Junior Anatomy Series Brachial Plexus C5 C6 Anatomy C7 C8 T1 REVISION TIP ROOTS Read Roots That Trunks TRUNKS Damn Divisions Cadaver Cords Book Branches DIVISIONS CORDS t r DCB- reverse- alphabetical order xa A Think of a TREE! BRANCHES Brachial plexus of the right arm Surgical Society | Junior Anatomy SeriesBrachial Plexus Anatomy REVISION TIP The ‘M’ shape of the brachial plexus, formed by the Musculocutaneous, Median and Ulnar nerves. If you find this, you’ll be able to identify the rest of the features of the Brachial Plexus. Anterior view of Brachial Plexus Surgical Society | Junior Anatomy SeriesThe (upper) arm Surgical Society | Junior Anatomy SeriesBrachial Plexus Anatomy are:2 main groups of nerve branches from the Brachial Plexus • Supraclavicular: from the roots and trunks e.g. Dorsal Scapular nerve, long thoracic nerve • Infraclavicular: from the cords & terminal branches e.g. superior scapular nerve, thoracodorsal nerve, medial pectoral and the 5 peripheral/terminal nerves Surgical Society | Junior Anatomy Series Medial Cord Posterior Cord Lateral Cord Trunks Roots Medial Pectoral N Superior Lateral Pectoral N (C) Subclavian N Dorsal scapular (C) Subscapular N (C) (T) nerve (R) Cutaneous N of Thoracodorsal N Musculocutaneous N Suprascapular Long thoracic Arm (C) (C) (TB) N (T) nerve (R) Cutaneous N of Inferior Forearm (C) Subscapular N (C) Axillary N (C) Radial N (TB) Surgical Society | Junior Anatomy SeriesQuestion: What comes after trunks in the anatomy of brachial plexus? SurgicalSocii ty| Junior A natom y Se riesAnswer: Cords SurgicalSocii ty| J unior Anatom y SeriesQuestion: What nerve innervates the anterior compartment of the arm? SurgicalSocii ty| Junior A natom y Se riesAnswer: The musculocutaneous nerve SurgicalSocii ty| Junior A natom y Se riesArterial Supply Surgical Society | Junior Anatomy Series Right subclavian Right and left a. common carotids Arterial Supply First rib Left subclavian a. LEFT: Aorta Axillary a. (Inferior border) RIGHT: Right Brachiocephalic a. ➢Subclavian a. Profunda ➢Axillary a. bracchi a. Brachial a. ➢Brachial a. Elbow ➢Profunda Brachii ➢Ulnar & Radial a. Radial a. Ulnar a. ➢Deep & Superficial Palmar Arches arches & Dorsal ➢Dorsal Carpal Arch Surgical Society | Junior Anatomy Series Colour Atlas of Anatomy A Photographic Study of the Human Body Rohen et al. Surgical Society | Junior Anatomy Series Arterial Pulse BRACHIAL With an extended elbow, place your fingers medial to biceps tendon in the cubital fossa AXILLARY SUBCLAVIAN Along the middle third of the On the medial side of humerus, humerus, place fingers against posterior to the tendon of short Just above and behind the medial head of biceps end of the clavicle humerus in the medial bicipital groove shaft Surgical Society | Junior Anatomy Series Venous Drainage • DEEP Veins of the upper limb are named the same as arteries but they’re just changed to ‘vein’ i.e. Subclavian Artery -> Subclavian Vein DEEP VEIN RETURN SUPERFICIAL VEIN RETURN • Pass through upper limb alongside arteries (but opposite blood flow direction) • Deep Veins not always singular => venae comitantes (groups of 2-4 smaller veins) Surgical Society | Junior Anatomy Series Venous Drainage • DEEP Veins of the upper limb are named the same as arteries but they’re just changed to ‘vein’ i.e. Subclavian Artery -> Subclavian Vein One-way drainage DEEP VEIN RETURN SUPERFICIAL VEIN RETURN • Small veins in digits drain into superficial • Pass through upper limb network on dorsal of hand alongside arteries (but • Cephalic (lateral) & Basilic (medial) veins opposite blood flow direction) run proximally from wrist to arm • Deep Veins not always singular • Median Cubital Vein connects C & B veins => venae comitantes (groups together -> used for blood test of 2-4 smaller veins) • Venae comitantes increase • Basilic = deep to join venae comitantes of venous flow & heat exchange Brachial veins • Cephalic = passes between deltoid & pectoral muscles to drain into axillary Surgical Society | Junior Anatomy SeriesSurgical Society | Junior Anatomy SeriesSurgical Society | Junior Anatomy SeriesLymphatic Drainage DEEP DRAINAGE • Lymph nodes running deep alongside the deep veins SUPERFICIAL DRAINAGE Cubital lymph nodes • Within cubital fossa • Drains distal limb (hands & forearm) Delto-pectoral lymph nodes • Within groove where deltoid & pectoralis major muscles meet Surgical Society | Junior Anatomy SeriesSurgical Society | Junior Anatomy SeriesLymphatic Drainage DEEP DRAINAGE • lymph nodes running deep alongside the deep veins AXILLARY LYMPH NODE • Both superficial and deep SUPERFICIAL DRAINAGE drain into the axillary lymph nodes Cubital lymph nodes • Within cubital fossa • drain most of the limb and • Drains distal limb (hands & the breast forearm) Delto-pectoral lymph nodes • Within groove where deltoid & pectoralis major muscles meet Surgical Society | Junior Anatomy SeriesSurgical Society | Junior Anatomy SeriesLymphatic Drainage DEEP DRAINAGE • lymph nodes running deep alongside the deep veins EXTRA MATERIAL AXILLARY LYMPH NODE Clinically relevant in spread of • Both superficial and deep metastatic breast cancer SUPERFICIAL DRAINAGE drain into the axillary lymph nodes Removal of axillary lymph Cubital lymph nodes nodes can risk nerves in close • Within cubital fossa relation: • Drains distal limb (hands & • drain most of the limb and forearm) the breast • Long Thoracic nerve => serratus anterior muscle Delto-pectoral lymph nodes • Thoracodorsal nerve => • Within groove where deltoid latissimus dorsi muscle & pectoralis major muscles meet = winging of scapula Surgical Society | Junior Anatomy SeriesSurgical Society | Junior Anatomy Series Emma Marchong JAS LEADS Contact em1020@ic.ac.uk Phase 1b: Chirag Goyalneni CPA: Kavyesh Vivek Please fill out the following feedback form in order Feedback to receive a copy of the slides via email, along with bonus SBAs to aid your revision! 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