upper limb/extremity 申新华

Transcription

1 upper limb/extremity 申新华 1

2 Parts and regions of upper limb Shoulder Arm Elbow Forearm Wrist Hand 2

3 Surface anatomy Shoulder region clavicle spine of scapula acromion coracoid process deltoid anterior & posterior axillary fold Arm biceps brachii medial & lateral bicipital groove 3

4 Carring angle 提携角 肱骨与尺骨夹角的补角 正常 >20 外翻 0-10 直肘 <0 内翻 165 o ~170 o 4

5 The acromion, greater tubercle and coracoid process form the boundaries of an equilateral triangle. In extension, the medial & lateral epicondyles and the top of the olecranon are in a straight line; In flexion, the bony points form the boundaries of an equilateral triangle posterior cubital triangle. 5

6 Superficial veins of the upper limb Cephalic vein Arises from lateral side of dorsal venous rete of hand. Ascends on radial side of forearm to the cubital fossa and then in the lateral bicipital groove. It continues up the arm in the deltopectoral groove and then to the infraclavicular fossa, where it pierces clavipectoral fascia to drain into axillary v. or subclavian v. Note: it may be absent at arm. Basilic vein Arises from medial side of dorsal venous rete. Ascends on ulnar side of forearm to the cubital fossa and then in the medial bicipital groove to middle of the arm where it pierces the deep fascia and joins the brachial v. or axillary v. Median cubital vein Links cephalic v. & basilic v. It is a frequent site for venipuncture. 6

7 Muscles connecting the upper limb to the thoracic wall Anterior group( 胸上肢肌 ) Pectoralis major 胸大肌 Subclevius 锁骨下肌 Pectoralis minor 胸小肌 Serratus anterior 前锯肌 7

8 Muscles connecting the upper limb to the thoracic wall Posterior group( 背肌浅群 ) Trapezius Levator scapulae Rhomboid minor Rhomboid major Latissimus dorsi 8

9 Deltoid Muscles connecting the scapula to the humerus( 上肢带肌 ) Supraspinatus Infraspinatus Teres minor Teres major Subscapularis 9

10 10

11 Trilateral foramen/space Quadrilateral foramen/space 11

12 Myotendinous cuff (rotator cuff) The name given to the tendons of subscapularis, supraspinatus, infraspinatus, and teres minor, which are fused to the underlying capsule of the shoulder joint. The cuff is important in stabilizing the shoulder joint. 肌腱袖 12

13 MISS teres Minor Infraspinatus Supraspinatus Subscapularis 13

14 Skin incisions 14

15 Thoracic wall Superficial fascia Supraclavicular n. Anterior and lateral cutan br. of intercostal n. a. & v. 2nd intercostobrachial n. ( 胸大肌深面 ) 15

16 Mamma 乳房 position structure suspensory lig. of breast /Cooper lig. 16

17 17

18 Axillary region/fossa 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. 18

19 Boundaries of 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, superficial fascia and axillary fascia. 19

20 Boundaries of the axillary fossa Anterior wall ( 三肌一膜 ) pectoralis major, pectoralis minor and subclavius Clavipectoral fascia 锁胸筋膜 The deep fascia which extends between subclavius, coracoid process and pectoralis minor. narrow sense broad sense 20

21 The structures pass through the clavipectoral fascia, include: Cephalic v. thoracoacromial vessels lateral pectoral n. Lateral pectoral n. 21

22 Cut and reflect the pectoralis major Clean the pectoralis major. Indentify the deltopectoral groove and the cephalic v., which drains blood into the axillary v. The pectoralis major forms the anterior axillary fold. 22

23 Detach the pectoralis minor Cut and reflect the pectoralis major close to its attachment. When reflecting, look for the lateral & medial pectoral n. on its underside. Identify and clean the thoracoacromial a. Next, detach the pectoralis minor from the costal cartilages of ribs 3, 4, 5, and reflect it toward the shoulder. 23

24 Boundaries of axillary fossa posterior wall ( 三肌一骨 ) latissimus dorsi teres major subscapularis scapula Trilateral foramen 三边孔 circumflex scapular vessels. Quadrilateral foramen 四边孔 posterior humeral circumflex vessels. axillary n. 24

25 posterior wall Anterior wall subclavius pectoralis minor subscapularis pectoralis major teres major latissimus dorsi 25

26 Boundaries of axillary fossa Medial wall serratus anterior upper four ribs intercostal muscles Lateral wall coracobrachialis biceps brachii intertubercular groove biceps brachii (long head) biceps brachii (short head) coracobrachialis 26

27 胸长神经, 唯一行于支配肌浅面, 易受损 27

28 Paralysis of the serratus anterior When the serratus anterior paralyzed because of injury to the long thoracic n., the medial border of the scapula moves laterally and posteriorly away from the thoracic wall, giving the scapula the appearance of a wing. 推墙实验 : 当患者用手支撑或用力推墙时, 臂上 举, 肩胛骨的内侧缘和下角明显地远离胸后壁 致使臂不能外展至水平位置以上 ( 生活中的表现 以不能梳头为标志 ) 28

29 Contents of axillary fossa Axillary a. and brs Axillary v. and tributaries Brachial plexus and brs Axillary lymph nodes Loose connective tissue 29

30 Axillary a. and brs First part gives off superior thoracic a. 胸上动脉 thoracoacromial a. 胸肩峰动脉 ( 胸肌肩峰三角肌锁骨 ) Second part gives off lateral thoracic a. 胸外侧动脉 ( 与胸长神经伴行, 胸小肌后面 下缘 ) Third part gives off Begins at lateral border of 1st rib as a continuation of subclavian a. Becomes brachial a. at lower border of teres major. Divided into 3 parts by overlying pectoralis minor. subscapular a. 肩胛下动脉 thoracodorsal a. 胸背动脉 circumflex scapular a. 旋肩胛动脉 anterior humeral circumflex a. posterior humeral circumflex a. 30

31 Note: There is no one which is the same as textbooks described. 腋动脉分支变异较多, 应根据走行 分布综合判断 31

32 Axillary v. Formed at the lower border of teres major Runs upward on the medial side of the axillary a. Ends at the lateral border of the first rib by becoming subclavian v. Tributaries accompany branches Receives cephalic v. 32

33 Formation Brachial plexus 臂丛 3 trunks 6 divisions 5 roots 3 cords branches 支 束 股 干 第一肋 根 33

34 Position: Brachial plexus 臂丛 Passes through the scalene fissure to posterosuperior of subclavian a. Then enters the axilla to form lateral, medial and posterior cords. Supraclavicular part Long thoracic n. 胸长神经 companies with the lateral thoracic a., supplies serratus anterior. Dorsal scapular n. 肩胛背 ( 菱形肌 ) Suprascapular n. 肩胛上 ( 冈上冈下肌 ) 颈根部 root of neck 34

35 Main brs of infraclavicular part 1. Lateral cord Musculocutaneous n. 肌皮神经 ( 穿喙肱肌 ) Lateral root of median n. 正中神经外侧根 Lateral pectoral n. 胸外侧神经 ( 胸大肌 ) 2. Medial cord Medial root of median n. 正中神经内侧根 Ulnar n. 尺神经 Medial antebrachial cutaneous n. 前臂内侧皮神经 ( 伴行贵要 V) Medial brachial cutaneous n. 臂内侧皮神经 ( 与肋间臂神经有吻合 ) Medial pectoral n. 胸内侧神经 ( 胸小肌胸大肌 ) 3. Posterior cord Radial n. 桡神经 Axillary n. 腋神经 山外有山 (3), 山后有寺 (4), 寺内有 5 神 Thoracodorsal n. 胸背神经 ( 背阔肌 ) companies with thoracodorsal a. Subscapular n. 肩胛下神经 ( 肩胛下肌和大圆肌 ), 不与肩胛下动脉伴行 35

36 Axillary n. 腋神经 Origin: Arises from posterior cord. Course: Passes backward and enters the quadrilateral foramen with the posterior circumflex humeral a. Distribution: Deltoid and teres minor; shoulder joint; skin over deltoid and upper posterior aspect of arm (superior lateral brachial cutaneous n.) Injury: result in deltoid and teres minor paralysis (loss of shoulder abdcution and weak external rotation) with loss of sensation over the deltoid. square shoulder 36

37 Axillary lymph nodes Axillary lns vary in size from a pin-head to a large bean. They are arranged in five groups. 外侧 前 后 中央 尖 Lateral lns Pectoral lns( 前群 ) Subscapular lns( 后群 ) Central lns Apical lns 37

38 Axillary lymph nodes Central ln. Apical ln. Subclavian trunk Pectoral ln. Lateral ln. Subscapular ln. 38

39 乳房淋巴回流 主要注入腋淋巴结, 引流方向有 : 外侧部和中央部的淋巴管 胸肌淋巴结 这是乳房淋巴回流的主要途径 上部的淋巴管 尖淋巴结和锁骨上淋巴结 内侧部的淋巴管 胸骨旁淋巴结 深部的淋巴管穿胸大肌 胸肌间淋巴结或尖淋巴结 内侧部的浅淋巴管与对侧乳房淋巴管相交通 内下部的淋巴管通过腹壁和膈下淋巴管与肝的淋巴管相交通 乳癌时 - 桔皮样变,why? 39

40 乳腺癌 : 威胁女性健康的 第一杀手, 并且呈年轻化发展趋势 64 岁 42 岁 歌手叶凡,37 岁 姚贝娜,34 岁 40

41 10 月, 国际乳癌防治月 粉红丝带乳腺癌防治运动是全球最有影响力的乳腺癌防治活动 每年十月, 世界各国的政要 名流 影视明星佩戴活动标志的 粉红丝带 出席各种公众活动, 呼吁大家关注女性, 关注乳房健康 41

42 (a) In mammography, the breast is placed alternately on a metal plate and radiographed from above and from the side. 钼靶摄片 超声 钼靶 核磁共振动态光学乳腺成像 (b) A mammogram of a patient with carcinoma of the breast. 42

43 Axillary sheath 腋鞘 Extension of deep cervical fascia of the neck, forming a tubular sheath that surrounds axillary a. & v., and brachial plexus. 43

44 deltoid region, scapular region 44

45 Scapular arterial network Note: dorsal scapular a. is also named descending scapular a. / deep br. of transverse cervical a. 45

46 肩胛背动脉 肩胛上动脉 旋肩胛动脉 肩胛动脉网 46

47 Axillary a. Thoracoacromial a. Lateral pectoral n. Musculocutaneous n. Medial antebrachial cutaneous n. Median n. Ulnar n. Medial brachial cutaneous n. Intercostobrachial n. Thoracodorsal n. & a. Long thoracic n. & lateral thoracic a. 47

48 You must identify follow structures! 锁胸筋膜及穿行结构腋动脉的 6 个分支胸外侧神经胸内侧神经胸长神经胸外侧动脉腋神经旋肱后动脉胸背神经胸背动脉肩胛下神经 重点总结 运动肩关节的肌肉腋动脉分支臂丛及其分支腋淋巴结 肌皮神经 正中神经 尺神经 桡神经 臂及前臂内侧皮神经等可暂缓 48