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Regional Anatomy of the Upper Limb
山东大学医学院 解剖教研室李振华
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Parts and regions of upper limb
Shoulder region - junction of arm and trunk
Arm - between should and elbow Elbow - bend of arm, joint between
arm and forearm Forearm - between elbow and hand Hand
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Surface anatomy of upper limb
Shoulder region: Acromion Spine of scapula Coracoid process Greater tubercle Anterior and posterior axillary folds
Arm
Medial and lateral biceps brachii furrow
Deltoid tuberosity Elbow
Medial and lateral epicondyles Head of radius Olecranon Tendon of biceps brachii
Wrist and hand Styloid process Head of ulna Dorsal tubercle Proximal wrist crease Middle wrist crease Distal wrist crease Tendon of palmaris Tendon of flexor carpi ulnaris Tendon of carpi ulnaris Radial longitudinal crease Proximal palmar crease Distal palmar crease
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In extension, the medial and lateral epicondyles and the top of the olecranon process are in a straight line; in flexion, the bony point form the boundaries of an equilateral triangle.
The acromion, the greater tubercle and coracoid process form the boundaries of an equilateral triangle.
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1650 ~ 1700
Carring angle 提携角
The carrying angle, which opens laterally, is seen when the elbow joint is extended and lies between the arm and forearm. The angel is 1700 in males and 1670 in females. The angle disappears when the elbow joint is flexed.
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The Pectoral Region and the Axilla
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Mamma 乳房Position Lie in superficial fascia over
the pectorals major and pectoral fascia
Extend from 3rd to 7th ribs vertically, and from parasternal line to midaxillary line transversally
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Mamma 乳房Structures Contains skin, mammary glan
ds and adipose tissue Consists of 15 to 20 Lobes o
f mammary gland 乳腺小叶 that radiate outward from the nipple
lactiferous duct 输乳管 lactiferous sinuse 输乳管窦 Suspensory ligaments of br
east 乳房悬韧带 (cooper’s ligaments): connective tissue septa that extend from the skin to the deep fascia
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Pectoral Region
Superficial structures Superficial nn.
Supraclavicular n. 锁骨上神经 Anterior cutaneous branches of inter
costal n. 肋间神经前皮支 lateral cutaneous branches of interco
stal n. 肋间神经外侧皮支
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Superficial veins of the upper limb
Cephalic vein 头静脉 Arises from the lateral side of the dorsal ve
nous rete on the back of hand Winds around the lateral border of the fore
arm; it then ascends into the cubital fossa and up the front of the arm on the lateral side of the biceps.
It continues up in the deltopectoral groove and then to the infraclavicular fossa, where it pierces clavipectoral fascia to drain into axillary vein.
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Superficial veins of the upper limb
Basilic vein 贵要静脉 Arises from the medial side of the dorsal v
enous rete of hand Winds around the medial border of the for
earm Then ascends into the cubital fossa and u
p the front of the arm on the medial side of the biceps to middle of the arm where it pierces the deep fascia and joins the brachial vein or axillary vein
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Superficial veins of the upper limb
Median cubital vein 肘正中静脉 Links cephalic vein and basilic vein in
the cubital fossa It is a frequent site for venipuncture to
remove a sample of blood or add fluid to the blood
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Pectoral Region
Deep structures Deep fascia
Superficial layer Deep layer—clavipectoral fascia
锁胸筋膜 The deep fascia which extends be
tween subclavius, coracoid process and pectoralis minor muscles The structures pass through th
e clavipectoral fascia Cephalic v. Thoracoacromial a. Lateral pectoral n.
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Muscles connecting the upper limb to the thoracic wall
Pectoralis major 胸大肌 Subclevius 锁骨下肌
Pectoralis minor 胸小肌
Serratus anterior 前锯肌
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Muscles connecting the upper limb to the thoracic wall
Posterior group Trapezius Levator scapulae Rhomboid minor Rhomboid major Latissimus dorsi
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Muscles connecting the scapula to the humerus
Deltoid Supraspinatus Infraspinatus Teres minor Teres major Subscapularis
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Myotendionous cuff (rotator cuff) 肌腱袖
The name given to the tendons of the subscapularis, the supraspinatus, the infraspinatus, and the teres minor muscles, which are fused to the underlying capsule of the shoulder joint.
The cuff is important in stabilizing the shoulder joint.
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Axillary region 腋区
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The Axillary fossa 腋窝
A pyramid-shaped space between the upper part of the arm and the side of the chest
through which major neurovascular structures pass between the thorax and upper extremity
Axillary fossa has an apex, a base and four walls
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Boundaries of the axillary fossa
Apex is bounded by Middle 1/3 of clavicle Lateral border of first rib Upper border of the scapula
Base is formed by the skin stretching between the anterior and posterior walls
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Boundaries of the axillary fossa
Anterior wall Formed by pectoralis major, pectoralis
minor and subclavius muscles Clavipectoral fascia 锁胸筋膜
The deep fascia which extends between subclavius, coracoid process and pectoralis minor muscles
The structures pass through the clavipectoral fascia Cephalic v. Thoracoacromial a. Lateral pectoral n.
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Boundaries of the axillary fossa
The posterior wall latissimus dorsi teres major subscapularis and scapula
Trilateral and quadrilateral foramina 三边孔和四边孔 The posterior humeral circumflex a. an
d axillary n. pass through the quadrilateral foramen.
The circumflex scapular a. passes through the triangular space to reach the dorsum of the scapula.
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Boundaries of the axillary fossa
The medial wall serratus anterior Upper four ribs Intercostal muscles
The lateral wall Coracobrachialis Biceps brachii Intertubercular groove
Biceps brachii (long head)
Biceps brachii (short head)
Coracobrachialis
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Contents of axillary fossa
Brachial plexus and branches Axillary a. and principal branch
es Axillary v. and tributaries Axillary lymph nodes Loose connective tissue
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Axillary artery 腋动脉
Begins at the at lateral border of first
rib as a continuation of subclavian ar
tery At the lower border of teres major it
becomes the brachial artery. Divided into three parts by overlying
pectoralis minor
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Branches of axillary artery First part gives off
thoracoacromial a. 胸肩峰动脉 Second part gives off
lateral thoracic a. 胸外侧动脉 Third part gives off
subscapular a. 肩胛下动脉 Throcodorsal a. 胸背动脉 Circumflex scapular a. 旋肩胛动脉
Anterior humeral circumflex a. 旋肱前动脉 Posterior humeral circumflex a. 旋肱后动脉
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Axillary vein 腋静脉
Formed at the lower border of the teres major by the union the brachial vein and the basilic vein
Runs upward on the medial side of the axillary artery
Ends at the lateral border of the first rib by becoming the subclavian vein
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Brachial plexus 臂丛Formation Five roots: formed by anterior ra
mi of C5-C8 and T1 spinal nerves
Three trunks (upper, middle and lower)
Six divisions Three cords
Lateral cord Medial cord Posterior cord
C5
C6
C7
C8T1
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Brachial plexus 臂丛Position: Passes through the scalene fissu
re to posterosuperior of subclavian artery
Then enters the axilla to form lateral, medial and posterior cords
Supraclavicular part Long thoracic n. 胸长神经 compa
nies with the lateral thoracic a., supplies serratus anterior
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Paralysis of the serratus anterior
When the serratus anterior paralyzed because of injury to the long thoracic nerve, the medial border of the scapula moves laterally and posteriorly away from the thoracic wall, giving the scapula the appearance of a wing.
Winged scapula 翼状肩
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Main branches of infraclavicular part
1. Lateral cord Musculocutaneous n. 肌皮神经 Lateral root of median n. 正中神经外侧根
2. Medial cord Medial root of median n. 正中神经内侧根 Ulnar n. 尺神经 Medial brachial cutaneous n. 臂内侧皮神经 Medial antebrachial cutaneous n.
前臂内侧皮神经
3. Posterior cord Radial n. 桡神经 Axillary n. 腋神经 Thoracodorsal n. 胸背神经 companies with the throcodorsal a., supplies l
atissimus dorsi
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Main branches of infraclavicular part
Axillary n. 腋神经
Radial n. 桡神经
Thoracodorsal n.胸背神经
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Axillary 腋神经 Origin: Arises from the posterior cord
of the brachial plexus in the axilla. Course: Passes backward and enters t
he quadrangular space with the posterior circumflex humeral artery.
Distribution: Deltoid and teres minor muscle; shoulder joint; skin over deltoid and upper posterior aspect of arm
Injury: result in deltoid and teres minor paralysis (loss of shoulder abdcution and weak external rotation) with loss of sensation over the deltoid
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Axillary lymph nodes
Axillary lymph nodes vary in s
ize from a pin-head to a large
bean. They are arranged in fi
ve groups.
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Axillary lymph nodes
Pectoral lymph nodes 胸肌淋巴结
Lying along the lower border of pectoralis minor behind the pectoralis major
Receive lymph vessels from the lateral quadrants of the breast and superficial vessels from the anterolateral abdominal wall above the level of the umbilicus
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Axillary lymph nodes
Lateral lymph nodes 外侧淋巴结
Along medial side distal part axillary vein
Receives lymph from upper limb
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Axillary lymph nodes
Subscapular lymph node 肩胛下淋巴结
Lying along subscapular vessels, in front of the subscapularis
Receive superficial lymph vessels from the back, down as far as the level of the iliac crests
Efferents above three groups pass to central lymph node
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Axillary lymph nodes
Central lymph node 中央淋巴结
Lying in the center of the axilla in the axillary fat
Receive lymph from the above three nodes
Efferents pass to apical lymph node
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Axillary lymph nodes
Apical lymph node 尖淋巴结
Lying at the apex of the axilla at the lateral border of the fist rib
Receive lymph the efferent lymph vessels from all the other axillary nodes
The efferents of the apical nodes form the subclavian trunk
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Axillary lymph nodes
Lateral ln.
Pectoral ln.
Subscapular ln.
Central ln.
Apical ln.
Efferents form subclavian trunk, the right subclavian trunk joints the right lymphatic duct; left usually drains directly into thoracic duct
Subclavian trunk
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Breast cancer
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pulmonary metastasis
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Axillary sheath 腋鞘
Extension of deep cervical fascia of the neck, forming a tubular sheath that surrounds axillary a. and v., and brachial plexus
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The anterior brachial region 臂前区
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Deep fascia
Encloses the arm sends septa between the various groups of muscles to allow them to slide on each other and to give an increased area of origin for their fibers.
The lateral and medial intermuscular septa divide the distal part of the arm into anterior and posterior osseofascial compartments .
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Contents of anterior osseofascial compartment of the arm
Muscles: biceps brachii 肱二头肌 Coracobrachialis 喙肱肌 Brachialis 肱肌
Blood supply: brachial artery 肱动脉
Nerve supply to the muscles: musculocutaneous nerve 肌皮神经
Structures passing through the compartment:
musculocutaneous nerve 肌皮神经 median nerve 正中神经 ulnar nerve 尺神经 brachial artery 肱动脉 medial antebrachial cutaneous nerve 前臂内侧皮神经
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Muscles of anterior osseofascial sheath of the arm
Biceps brachii 肱二头肌 Coracobrachialis 喙肱肌
Brachialis 肱肌
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Brachial artery 肱动脉 Begins at the lower border of the teres m
ajor as a continuation of axillary artery Terminates opposite the neck of radius
by dividing into radial and ulnar arteries Branches
Deep brachial a. 肱深动脉 follows the radial nerve into the spinal groove of the humerus
Superior ulnar collaeral a. 尺侧上副动脉 follows the ulnar nerve
Inferior ulnar collateral a. 尺侧下副动脉 takes part in the anastomosis around the elbow joint.
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Musculocutaneous nerve 肌皮神经
Distribution: Biceps brachii Brachalis Coracobrachialis
At the lateral margin of biceps tendon it pierces the deep fascia just above the elbow. It runs down the lateral aspect of the forearm as the lateral antebrachial cutaneous n. which supply skin on anterior aspect of forearm.
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Median nerve 正中神经
Origin: arises from the medial and lateral cord of the brachial plexus.
Course: Descends on the lateral side of
brachial artery. Halfway down the arm, it
crosses the brachial artery to reach its medial side.
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Ulnar nerve 尺神经
Origin: arises from the medial cord of the brachial plexus.
Course: Descends on the medial side of brachial ar
tery. At the middle of the arm, it pierces the me
dial intermuscular septum and passes down behind the medial epicondyle of the humerus.
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Cubital fossa 肘窝Boundaries Base - line drawn through epicondyle
s of humerus Laterally - brachioradialis Medially - pronator teres Roof - skin, superficial facia, deep fa
scia and aponeurosis of biceps Floor - brachialis, supinator and caps
ule of elbow joint
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Contents of the cubital fossa
Medial to biceps brachii tendon Brachial a. 肱动脉- divides into radial and
ulnar a., usually at apex of fossa Median n. 正中神经
Lateral to the biceps brachii tendon Radial n. 桡神经 Lateral antebrachial cutaneous n.
前臂外侧皮神经
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Contents of anterior osseofascial sheath of the forearm
Muscle (9) Blood supply to the muscles:
ulnar and radial arteries. Nerve supply to the muscles:
median nerve and ulnar nerve
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Muscles of anterior osseofascial sheath of the forearm
Superficial layer Brachioradialis 肱桡肌 Pronator teres 旋前圆肌 Flexor carpi radialis 桡侧腕屈肌 Palmaris longus 掌长肌 Flexor carpi ulnaris 尺侧腕屈肌
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Muscles of anterior osseofascial sheath of the forearm
Second layer Flexor digitorum superficialis 指浅屈
肌
Third layer Flexor digitorum profundus 指深屈肌 Flexor pollicis longus 拇长屈肌
Fourth layer Pronator quadratus 旋前方肌
Action: flex radiocarpal joint and fingers, pronate forearm
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Radial artery 桡动脉
Begins: in the cubital fossa at the neck of the radius.
Course: passes downward and laterally Branches
Radial recurrent a. 桡侧返动脉 Superfical palmar branch 掌浅支 Principal artery of thumb 拇主要动脉
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Ulnar artery 尺动脉 Begins in the cubital fossa at the
neck of the radius. Course: passes downward and m
edially Branches
Ulnar recurrent a. 尺侧返动脉 Common interosseous artery
骨间总动脉 Anterior interossous a.
骨间前动脉 Posterior interosseous a.
骨间后动脉 Deep palmar branch 掌深支
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Superficial palmar arch 掌浅弓 Formed by ulnar artery and superfici
al palmar branch of radial artery The curve of arch lies across the pal
m, level with the distal border of fully extended thumb
Gives rise to three common palmar digital arteries each then divides into two proper palmar digital arteries
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Deep palmar arch 掌深弓 Formed by radial artery and deep pa
lmar branch of ulnar artery The curve of arch lies across upper
part of palmar at level with proximal border of extended thumb
Gives rise to three palmar metacarpal arteries
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Median 正中神经
Course: Passes between the two heads of the pronat
or teres. It continues downward behind the flexor digit
orum superficialis. At the wrist, it enters the palm by passing be
hind the flexor retinaculum.Distribution: Flexor of forearm except brachioradialis, flex
or carpi ulnaris and ulnar half of flexor digitorum profundus
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Ulnar nerve 尺神经 Course
Passes from behind the medial epicondyle of the humerus, and enters the front of the forearm by passing between the two heads of the flexor capi ulnaris.
In the distal two-third of the forearm, the ulnar artery lies on the lateral side of the ulnar nerve.
Enters the palm of the hand b passing in front of the flexor retinaculum and lateral to the pisiform bone.
Distribution: flexor carpi ulnaris and ulnar half of flexor digitorum profundus
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Superficial branch of the radial nerve桡神经浅支
Course Runs down on the lateral side of th
e radial artery. In the distal part of the forearm, it le
aves the artery and passes backward, reaches the posterior surface of the wrist and hand.
Distribution: brachioradialis
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Skin incisions
Make the skin incisions indicated in figure and reflect the skin flaps.
Be careful not to cut too deep. As you remove the skin, look for the cephalic v., basilic v. and median cubital v.
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Cut and reflect the pectoralis major
Clean the pectoralis major m.. Indentify the deltopectoral groove and the cephalic vein, which drains blood into the axillary v.
The pectoralis major m. forms the anterior axillary fold.
Cut and partlly reflect the pectoralis majorm. Close to its attachment to the clavicle. Look for the lateral pectoral n. on its underside.
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Detach the pectoralis minor
Identify and clean the thoracoacromial artery medial to the pectoralis minor.
Next, detach the pectoralis minor from the costal cartilages of ribs 3, 4, and 5, and reflect it toward the should.
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Axillary a.
Thoracoacromial a.
Musculocutaneous n.
Median n.
Medial antebrachial cutaneous n.
Ulnar n.
Medial brachial cutaneous n.
Intercostobrachial n.Thoracodorsal n. & a.
Long thoracic n. & lateral thoracic a.
Lateral pectoral n.
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Posterior humeral circumflex a. & axillary n.
Radial n.
Circumflex scapular a.
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Musculocutaneous n.
Median n.Medial brachial cutaneous n.
Ulnar n.
Medial antebrachial cutaneous n.
Superior ulnar coleteral a.
Brachial a.
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Musculocutaneous n.
Median n.
Axillary a.
Brachial a.
Medial antebrachial cutaneous n.
Medial brachial cutaneous n.
Deep brachial a.
Superior ulnar coleteral a.& Ulnar n.
Inferior ulnar coleteral a.
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Muscolocutaneous n.
Brachial a.
Radial n.
Radial recurrent a.
Radial a.
Median n.
Ulnar recurrent a.
Common interosseous a.
Ulnar a., v. & n.
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Radial recurrent a.
Radial a.
Radial n.
Median n.
Ulnar n.
Ulnar a.
Ulnar recurrent a.
Ulnar n.
Brachial a.
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Palmar aponeurosis
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Superficial palmar a.
recurrent n.
Ulnar a.
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You must identify follow structures !
Pectoral region and Axilla Muscles
Pectoralis major Pectoralis minor Serratus anterior
Arteries and veins Axillary artery thoracoacromial a. lateral thoracic a. subscapular a. Throcodorsal a. Circumflex scapular a. Posterior humeral circumflex a. Axillary vein
Nerves Long thoracic n. Lateral cord musculocutaneous n. lateral root of median n. Medial cord Medial root of median n. Ulnar n. Posterior cord Radial n. Axillary n. Thoracodorsal n.
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You must identify follow structures ! Superficial vv.
Cephalic v. Basilic v. Median cubital v.
Arm Biceps brachii Coracobrachilis Bracialis Musculocutaneous n. Median n. Ulnar n. Brachial a. Profunda brachii a.
Forearm Brachioradialis Pronator teres Flexor carpi radialis Palmaris longus Flexor carpi ulnaris Flexor digitorum superficialis Flexor digitorum profundus Flexor pollicis longus Pronator quadratus Ulnar n. Radial n. Median n. Ulnar a. Radial a.