GROSS ANATOMY OF THE UPPER LIMB (I)

(ANAT 201 FOR MBBS, BSc ANATOMY AND PHYSIOLOGY)

By
Dr. Nura Bello Kaura
Department of Anatomy
Federal University Birnin Kebbi
Kebbi State
Nigeria
2025-03-22 1
 OUTLINE
 Introduction
 Pectoral region
 Axilla
 Brachial plexus
 Arm
 Forearm
 Hand
 Neurovascular supply of the upper limb
 Lymphatic drainage of the upper limb
 Conclusion

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 INTRODUCTION
 The upper limb comprises of four parts: the shoulder, the arm, forearm and the hand.

 The shoulder region is made up of the pectoral or breast region, the axilla or the armpit, and
scapular region that forms the part around the scapula.

 The arm (brachium) extends from the shoulder to the elbow or the cubitus and centred around the
humerus

 The forearm (antebrachium) extending form the elbow to the wrist joint contains the ulna and
radius

 The hand is made up of the wrist, the palm, dorsum of the hand and the digits.

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 THE SHOULDER REGION

THE PECTORAL REGION

 The pectoral region lies on the front of the chest.

 The region is marked superiorly by the clavicle, medially (from

above downwards) by the jugular notch, manubrium sternii, sternal
angle (angle of Louis), body of the sternum, the xiphoid process,
the nipple and upper four ribs.

 The superficial fascia contains moderate amount of fat.

 Mammary gland is an important content of the fascia supported by

the septa given off by the fascia.

 Also contains cutaneous nerves, vessels, and the platysma.

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 Pectoral region ctn

 The cutaneous nerves are:

(i) Lateral, medial, and intermediate supraclavicular nerves from cervical
plexus (C3, C4)
• They supply the skin over the clavicle to the second rib and the skin over
the upper half of the deltoid muscle
(ii) Anterior and lateral cutaneous (T3-T6) branches of the second to sixth
intercostal nerves.
• They supply the skin below the level of the second rib

 The cutaneous vessels are:

(i) Perforating branch of internal thoracic artery
• Accompanying the anterior cutaneous nerves
(ii) Lateral cutaneous branches of posterior intercostal arteries
• Accompanying the lateral cutaneous nerves

 Platysma
• Is thin, broad and sheet-like muscle overlapping the sternocleidomastoid
muscle and covers the anterior aspect of the neck superficially.
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 Pectoral region ctn
• Origin – deep fascia covering the pectoralis major and deltoid muscles. The
fibres runs upwards and medially crossing the clavicle and covering the
anterolateral side of the neck
• Insertion – base of the mandible and the skin on the lower part of the face
• Nerve supply - supplied by facial nerve
• Action – when the muscle contracts, it depresses the mandible in opening the
mouth

THE BREAST/MAMMARY GLAND

 Is an important content of the pectoral region lying within the superficial

fascia

2nd
 It is a modified sweat gland and serve as an accessory reproductive organs
in females.

 It is rudimentary in males
sternum Midaxillary

LOCATION/EXTENSION
 Lies in the superficial fascia extending vertically from 2 nd to 6th rib and 6th
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horizontally form the lateral border of the sternum to the midaxillary line.
 Pectoral region ctn
 A small portion from its upper outer quadrant pierces the deep
fascia and lies in the axilla, called the axillary tail of spence.

DEEP RELATIONS
 Lies on the deep fascia covering the pectoralis major separated
from it by loose areolar tissue called retromammary space. This
allows free movement of the normal breast.

 Other deeper structures are parts of serratus anterior muscle, rectus

sheath and the external oblique muscle of the abdomen.

STRUCTURE
The skin
 The breast is completely covered by the skin with a conical
projection just below the centre called the nipple.

 The nipple is rich in nerve supply contains, circular and

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longitudinal smooth muscle responsible for its erection .
 Pectoral region ctn

 Some 15 to 20 lactiferous duct pierces the nipple each draining a lobe of

breast and converge to open at the tip.

 The pigmented round area at the base of the nipple is called the areola.

 The area contains some sebaceous glands called the areola glands that
enlarges during pregnancy called tubercles of Montgomery.

The parenchyma
 The breast is formed of 15 to 20 lobes.

 Each lobe is formed by a cluster of alveoli (acini) and is drained by a

lactiferous duct.

 Near the end of the duct, a dilatation appears called lactiferous sinus.
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 Pectoral region ctn
 Passage of milk from the alveoli to the lactiferous duct and sinus is
enhanced by myoepitheliocytes found around the alveoli, the duct,
epithelium and the basement membrane.

The stroma
 Forms the supportive frame work of the breast.

 It is partly fatty (main bulk of the breast) and fatly fibrous distributed
throughout the breast tissue except at the nipple and areola

 The fibrous stroma sends multiple septa across the breast called
suspensory ligament anchoring the skin and the gland to the deep pectoral
fascia thereby keeping the breast suspended.

BLOOD SUPPLY
 Has rich blood supply through the following arteries
• Internal thoracic artery which is a branch of subclavian artery
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 Pectoral region ctn
• Lateral thoracic, superior thoracic and acromiothoracic
(thoracoacromial) arteries which are all branches of the axillary
artery.
• Lateral branches of posterior intercostal arteries.

 The veins followed the arteries and converge towards the nipple
forming an anastomotic venous circle running in superficial and
deep set.
• The superficial veins drains in to the internal thoracic vein and the
superficial veins of the lower part of the neck.
• The deep veins drains in to the internal thoracic, axillary and
posterior thoracic veins.

NERVE SUPPLY
 By the anterior and lateral cutaneous branches of the 4th and 6th
intercostal nerves.

 The nerves gives sensory supply to the skin and autonomic fibres
to the smooth muscles and blood vessels
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 Pectoral region

LYMPHATIC DRAINAGE
 Importance because of the spread of breast cancer

 The superficial lymphatics drain the skin over the breast except for the areola and the nipple. The
vessels passes radially to the surrounding lymph nodes (axillary, internal mammary,
supraclavicular and cephalic)

 The deep lymphatic vessels drain the parenchyma, the nipple and areola

 The axillary lymph nodes, receive about 75% of the lymph from the breast, 20% goes to the
internal mammary lymph nodes, and 5% to the posterior intercostal nodes.

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 Pectoral region

DEEP PECTORAL FASCIA

 This is thin and deep fascia attached to the pectoralis

major

 It has the following attachments

o Superiorly – the clavicle
o Inferiorly – blend with the fascia of the chest and the
rectus sheath of the abdomen.
o Medially – to the sternum
o Superolaterally- - is continuous with the deltoid fascia,
passing over the infraclavicular fossa and deltopectoral
groove.
o Inferolaterally – curves around the lower border of the
pectoralis major to become continuous with the axillary
fascia.
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 Pectoral region ctn

MUSCLES OF THE PECTORAL REGION

PECTORALIS MAJOR
 Is a large triangular or fan-shaped muscle that converge on the
upper end of the humerus folding on itself by forming a bilaminar
tendon.
Origin
 1. Clavicular head - from the anterior surface of the medial half
of the clavicle
 2. Sternocostal head – from the lateral half of the anterior surface
of the manubrium and the body of the sternum.
- from 2nd to 6th costal cartilages
- aponeurosis of the external oblique muscle

Insertion
 Inserted by a bilaminar tendon in to the lateral lip of the bicipital
groove
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 Pectoral region ctn

Nerve supply
• Medial and lateral pectoral nerves

Action
• Adduction and medial rotation of the arm
• Flexion at the shoulder joint

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 Pectoral region ctn
PECTORALIS MINOR
• Small triangular muscle undercover of p. major

Origin
• From 3rd, 4th and 5th rib near the costochondral junction

Insertion
• Medial border and upper surface of the coracoid process

Nerve supply
• Medial pectoral nerve

Action
• Together with serratus anterior, p minor protracts the scapula
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 Pectoral region ctn
SUBCLAVIUS
Origin
• From the first rib, at its costochondral junction

Insertion
• Subclavian groove on the inferior surface of the
clavicle

Nerve supply
• Nerve to subclavius (C5, 6) from the upper trunk of the
brachial plexus

Action
• Stabilises the clavicle during the movement of the
shoulder girdle.
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 Pectoral region
CLAVIPECTORAL FASCIA
 Is a strong fibrous fascia situated deep to the clavicular head of p.
major in a space between the pectoralis minor and the clavicle.

 It extends from the clavicle above to the axillary fascia below

 Attachments
• Above - to the edges of the subclavian groove
• Below – continues with the axillary fascia (attached to the dome) as
the suspensory ligaments
• Medially – to the first rib
• Laterally – to the coracoid process

 Superiorly, the fascia splits to enclose the subclavius, after which it

fuse together to form the costocoracoid ligament.

 Inferiorly, it splits to enclose the p. minor

 Pierced by the following structures:

• Lateral pectoral nerve
• Thoracoacromial artery
• Cephalic vein
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• lymphatics
 AXILLA
 The axilla is a four sided pyramidal space between
the arm and the side of the chest wall.

 It has apex, base (floor) and 4 walls: anterior,

posterior (forms their respective folds), medial and
lateral walls.

 The apex is directed obliquely, upward and

medially communicating with posterior triangle of
the neck.

BOUNDARIES
 Apex
• Anteriorly – the clavicle
• Posteriorly – upper border of the scapula
• Medially
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– outer border of the first rib 18
 The axilla
 floor
• Directed downwards, formed by the skin and the
axillary fascia extending from the anterior to
posterior folds

 Anterior wall
• P. major
• P, minor
• Subclavius
• Clavipectoral fascia

 Posterior wall
• Subscapularis above
• Teres major below
• Tendon of latissimus dorsi winding round the above
muscles
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 The axilla
 Medial wall
• Upper part of serratus anterior
• Upper four ribs and their intercostal muscles

 Lateral wall
• Upper part of the shaft of the humerus
• Coracobrachialis
• Short head of biceps

CONTENTS
• Axillary artery and its branches
• Axillary vein and its tributaries
• Brachial plexus (infraclavicular part)
• Lymph nodes
• Pad of fat
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 The axilla
AXILLARY ARTERY

 Starts at the outer border of the first rib as the continuation of

the third part of the subclavian artery.

 Enters the axilla by passing behind the midpoint of the clavicle

 Ends at the lower border of teres major where it continues as

brachial artery.

 The artery together with the cords of brachial plexus are

enclosed within the axillary sheath.

 It is crossed in front by p. minor, thereby dividing it in to three

parts: first part (above the muscle), second part (behind the
muscle), third part (below the muscle).
21
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 The axilla

RELATIONS
First part
 Anteriorly
• Skin
• Fascia
• Deep pectoral fascia
• P. major
• Clavipectoral fascia and structures piercing it

 Posteriorly
• First intercostal space and muscle
• First and second digitations of serratus anterior
• Medial cord of brachial plexus

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 The axilla
 Laterally
• Lateral and posterior cords of brachial plexus

 Medially
• Axillary vein

Second part
 Anteriorly
• As first part
• Pectoralis minor

 Posteriorly
• Coracobrachialis
• Posterior cord of brachial plexus
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 The axilla
 Medially
• Axillary vein
• Medial cord of brachial plexus
• Medial pectoral nerve

 Laterally
• Lateral cord of brachial plexus

Third part
 Anteriorly
• As the first part
• Medial root of the median nerve

 Posteriorly
• Radial nerve
• Axillary nerve and subscapularis in the upper part
• Tendons of latissimus dorsi and teres major in the upper part
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 The axilla

 Laterally
• Coracobrachialis
• Musculocutaneous nerve and lateral pectoral nerve in the upper part
• Trunk of the median nerve in the lower part

 Medially
• Axillary vein
• Medial cutaneous nerve of the forearm and ulnar nerve between the artery and the vein
• Medial cutaneous nerve of the arm, medial to the axillary vein.

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 The axilla
BRANCHES
 Gives six branches (1 from the first part, 2 from the
second part and 3 from the third part)

From the first part

 Superior thoracic artery
• Is a small branch that arises closes to the subclavius, it
runs downwards, forward and medially between the two
pectoral muscles to supply thoracic wall and the muscles.

Form the second part

 Thoracoacromial artery
• Emerges at the upper border of the p. minor and pierces
the clavipectoral fascia to give its terminal branches:
- Pectoral branch
- Deltoid branch
- Acromial branch
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- Clavicular branch
 The axilla
 Lateral thoracic artery
• Emerges at the lower border of p. minor
and runs along the border to give off the
lateral mammary branches of the breast in
females.
• It also supply branches to the pectoralis
and serratus anterior

From the third part

 Subscapular artery
• Is the largest branch of the axillary artery
• Runs along the lower border of the
subscapularis to terminate at the inferior
angle of the scapula
• It gives off a dorsal branch called the
circumflex scapula artery that takes part in
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anastomosis around the scapula. 27
 The axilla

 Anterior circumflex humeral artery

• Emerges at the lower border of subscapularis
• Passes laterally crossing the intertubercular sulcus
• Anastomose with the posterior circumflex humeral artery to
form a circular anastomoses around the surgical neck of the
humerus
• It gives an ascending branch that ascends upward in the
intertubercular groove to supply the head of the humerus and
the shoulder joint

 Posterior circumflex humeral artery

• Arises at the lower border of the subscapularis
• Runs backward accompanied by the axillary nerve to pass
through the quadrangular space
• End by anastomosing with the anterior circumflex humeral
artery around the surgical neck of the humerus
• It supplies the shoulder joint, deltoid and the muscles of the
quadrangular space
• It gives
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off a descending branch that anastomose with the 28
 The axilla

AXILLARY VEIN

 Begins at the lower border of the teres major as a continuation of basilic vein

 It ends at the outer border of the first rib where it becomes the subclavian vein

 It lies medial to the axillary artery

 It is joined by the venae comitantes of the brachial artery a little above its beginning

 It receives tributaries corresponding to the branches of the axillary artery, and the cephalic vein in its
upper part as well

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 The axilla
BRACHIAL PLEXUS

 The plexus consist of roots, trunks, divisions and cords

 The roots and trunks lie in the neck, while divisions and cords are found in the axilla

FORMATION
 The roots is formed by the anterior primary rami of C5, 6, 7, 8.and T1. Sometimes with
contribution form C4 and T2

 There are three trunks: upper (formed by the union of C5, 7), middle (formed by C7) and lower
(formed by the union of C8, and T1)

 Each of the trunks divide in to ventral and dorsal divisions

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 The axilla

 The cords are formed by the union of the ventral and dorsal division as follows;
• Lateral cord formed by the union of ventral divisions of upper and middle trunks
• Medial cord is by ventral division of lower trunk
• Posterior cord is formed by the union of dorsal division of all the three trunk

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2025-03-22 32
 The axilla

BRANCHES
 From the roots Medial cord
• Long thoracic nerve (C5, 6, 7) • Medial pectoral nerve (C8, T1)
• Dorsal scapula nerve (C5) • Medial root of the median nerve (C8, T1)
• Medial cutaneous nerve of the arm (C8, T1)
 From the trunks • Medial cutaneous nerve of the forearm (C8, T1)

• Suprascapular nerve (C5, 6) • Ulnar nerve

• Nerve to subclavius (C5, 6)

Posterior cord
 From the cords • Upper subscapular nerve (C5, 6)
• Lower subscapular nerve (C5, 6)
Lateral cord
• Thoracodorsal nerve (C6, 7, 8)
• Lateral pectoral nerve (C5, 6, 7)
• Axillary nerve (C5, 6)
• Lateral roots of the median nerve (C5, 6, 7)
• Radial nerve (C5, 6, 7, 8, T1)
• Musculocutaneous nerve (C5, 6, 7)
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